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Health Disparities in Diabetes

Health Disparities in Diabetes. Jim Holt, MD February 11, 2009. Poll. Consider your patients in the clinic. In what ways is their health adversely affected by--

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Health Disparities in Diabetes

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  1. Health Disparities in Diabetes Jim Holt, MD February 11, 2009

  2. Poll • Consider your patients in the clinic. In what ways is their health adversely affected by-- 1) The prevailing culture? Does the Appalachian area accept more: sedentary lifestyles/obesity, poor diets, smoking, and ignorance of general health recommendations? 2) Inability to access all needed care? 3) Inadequate resources for care? 4) Other factors?

  3. County-level Estimates of Diagnosed Diabetes for Adults aged ≥ 20 years: United States 2005

  4. Unsubstantiated Local Data • 100,000 diabetics in East Tennessee region • Average HbA1c 9.4% vs. national 7.8% • Average BMI of East TN diabetics: 34 • There are 3 pediatric endocrinologists in the East TN region. Half of the children they saw in 2007 have Type 2 diabetes. In 1992, 10% of the children they saw had Type 2 DM. • Data from a Knoxville pediatric endocrinologist

  5. CDC Co. Prevalence Data

  6. TN 2007 County Health Snapshot

  7. Sullivan & Washington Cos.

  8. Other Regional Counties

  9. Adjacent Counties (Cont.)

  10. “Double Disparity” • Groups which are disadvantaged in general settings might suffer from additional hardship in areas experiencing health disparities. • Example: the documentary “Conocimiento”, a brief film produced by an interdisciplinary team at ETSU in 2006, notes particular hardships Mexican mothers faced in complicated deliveries at local hospitals with inadequate availability of Spanish translators.

  11. Other Disparities • Higher obesity rates in Appalachia • Higher tobacco smoking rates • Sedentary activity much more prevalent • Insurance coverage trend to lower percentage • Higher hospitalization rate for DM2 in SW VA

  12. Small Group Activity • Count off for groups of 4 or 5 • Each group takes 1 case • May have 2 groups working on the same case • Answer questions within 15 minutes • Select spokesperson, to report to the large group

  13. Questions for Cases • Which disparities are most relevant in this case? • What barriers exist to optimal care of the DM? • What are the group’s recommendations to significantly improve the patient’s care? • What additional resources would improve this patient’s care, or the care of similar patients?

  14. Disparities in Diabetes Case # 1 PC is a 52 year-old white female who presents to Diabetes Clinic. She reports onset of Type 2 Diabetes at age 31, when her sugars remained abnormal following the birth of her second (and last) child. PC reports great difficulty controlling binge eating, and consistently poor blood sugar readings over the course of her illness. She has burning pain and numbness in her legs constantly, up to the thighs. She’s had a small MI in the past year, and a “TIA” 3 years ago, which left her with mild weakness in the left hand. Her vision is “only fair”. She is 61 inches tall, and 185 lbs.; her BMI is 35.

  15. Disparities in Diabetes Case # 2 LB is a 12 year-old white female with a 4 year history of Type 1 Diabetes. She initially presented to the office with F/U care on a Salter I fracture of her ankle; after 2 visits of mother requesting pain meds, suspicion of drug abuse by mother is confirmed by DCS. Father is in prison, but a release date is approaching. LB presents to Diabetes Clinic, reporting resentment of her twin sister’s ability to live “normally”. LB admits to daily binge eating, with blood sugars ranging from mid-100’s to mid-400’s nearly every day.

  16. Disparities in Diabetes Case # 3 RF is a 56 year-old white male with DM2 for 12 years, HTN for 25 years, and OSA diagnosed concurrently with COPD 2 years ago. He tolerates CPAP poorly, and often doesn’t wear it. He stays sleepy and sluggish most of the time. He has gained 50 lbs. in the past 26 months; during that time, his diabetic control has deteriorated from HbA1c’s in the 7 to 8% range, to 13.5% today. He is still gaining weight. He presents to the Diabetes Clinic saying, “I don’t really see the point of trying too hard to control this disease. It’s pretty obvious to me that I’m going to die soon.”

  17. Disparities in Diabetes Case # 4 DE is a 61 year-old white male from Elizabethton, who presents to Diabetes Clinic. He is “tired”, since he walked from Elizabethton: his truck is old and not running, and he can’t afford to get it fixed. He has no income and no prospects; he gets food through church charity programs. His food is usually canned vegetables and fruits, and a large block of cheese monthly. He loves the cheese, so he eats it 3 times/day until it runs out in 2 weeks. His blood pressure is 130/80, his BMI is 29%, but his HbA1c is 14%. Talking to him, you get the impression that he may have mild mental retardation.

  18. Possible Approaches to Addressing Disparities • EMR with functional registry (apparently rare) and prevention/CDM prompts • Case management • Group classes • Use of chronic care model: planned visits, EBM at point of care, improved systems of care delivery in the 3 programs/”lean thinking”, support for self-management by patients, and tap into community systems--effective programs

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