Diabetes in Latinos in USA

Send This

Download

Comment

Favourite

more

Rating :

Rate It:

Embed :

Post a comment

Post Comment on Twitter Post Comment on SlideWorld

Comments:

Subscribe to follow-up comments

Notes

Hide Notes

Slide 1 :

Diabetes in the Hispanic/Latino Population in the United States:The Georgia Latino Diabetes Education Program Guillermo E. Umpierrez, MD, FACP, FACEAssociate Professor of Medicine Associate Director Clinical Research Center Emory University School of Medicine Director, Diabetes & Endocrinology Grady Health System

Slide 2 :

Agenda: Areas of interest would be: specific epidemiologic, ethnic or cultural issues we should know to optimally manage the Latino patient drug therapy management of Latino diabetes patients, counseling of patients, challenges with drug therapy adherence, how to communicate most effectively, Does that help? Becky Hamilton

Slide 3 :

The Economist, February 17th -23rd, 2007 DIABETES: AN AMERICAN EPIDEMIC

Slide 4 :

N Engl J Med 356: 214, 2007 Projected Increase in the Incidence of Diabetes from 2000 to 2010

Slide 5 :

U.S. Diabetes Prevalence20 Years or Older, by Race/Ethnicity, 2005 NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.

Slide 6 :

Slide 7 :

NEW PATIENTS WITH DIABETES New patient each 21 seconds = 3 per minute 1440 minutes per day x 3 = 4,320 patients per day 365 days per year x 4,320 = 1,576,800 new patients with diabetes per year

Slide :

Slide 9 :

Estimated lifetime risks for diabetes African-Americans and Latinos: 1 in 2 Number of People in the United States With Diagnosed Diabetes Narajan et al, JAMA 290:1884-90, 2003

Slide 10 :

Diabetes in Latinos Higher prevalence - Why so much disease? Higher rates of complications – What explains the disparity? Barriers to care – Georgia Latino Diabetes Education Program

Slide 11 :

Harris MI, et al. Diabetes Care. 1998;21(4):518-524. Prevalence of Diagnosed Diabetes in Mexican Americans, NHANES III United States, 1988-1994 ?

Slide 12 :

Diabetes in US Latinos Higher prevalence - Why so much disease? Genetic Factors: The “thrifty gene” Medical and Lifestyle Factors: Dietary changes Obesity Physical inactivity

Slide 13 :

The Thrifty Gene Hypothesis Populations exposed to periodic famines, through natural selection increase frequency of ‘protective genes’ These genes allows efficient energy conservation and fat Storage In the presence of food abundance, these genes become disadvantageous predisposing to obesity and diabetes Neel JV. Am J Human Genetics 14:353, 1962

Slide 14 :

Prevalence of Diabetes in Minority Populations Rate in country of origin compared with rate in the U.S. Ann Intern Med 125(3):221-232, 1996

Slide :

Slide 16 :

Obesity Trends 1990 2001 Diabetes Trends 1990 2001 CDC, BRFSS, 1990- 2001

Slide :

Slide 18 :

Leisure-Time Physical Activity Among US Latinos: NHNES III Age (years) % Leisure time physical activity: light-moderate physical activity > 30 min 5 or more times per week or vigorous exercise = 20 min 3 or more times per week ~45% ~33% ~26% ~15% Adapted from: Crespo CJ, Arch Int Med 156:93-98, 1996

Slide 19 :

Diabetes Complication Rates in Minorities and Caucasians Black Persons Hispanics Nephropathy ESRD Greater Greater Proteinuria Greater Greater Retinopathy Greater Greater Lower-extremity Greater Greater amputations Carte et al, Ann Int Med 125:221, 1996

Slide 20 :

Retinopathy* in Type 2 DiabetesPrevalence in U.S. Adults Aged ?40 Years * Any retinopathy in patients with diagnosed type 2 diabetes. Harris MI, et al. Diabetes Care. 1998;21(8):1230-1235. NHANES III, 1988–1994N = 1,180 Prevalence (%)

Slide 21 :

* Rates adjusted for age and sex. Karter AJ, et al. JAMA. 2002;287(19):2519-2527. Elevated Incidence of End-Stage Renal Disease Among Ethnic Minorities N = 39,683 N = 7,540 N = 6,202 N = 8,364

Slide 22 :

* 1993 data. † Age adjusted. ‡ P<0.001 vs Mexican Americans and non-Hispanic whites. Lavery LA, et al. South Med J. 1999;92(6):593-599. Incidence of Lower-Extremity Amputations in People with Diabetes ‡ Amputation Rates for 3 Ethnic Groups in South Texas* N = 157 N = 815 N = 71 Incidence Rate per 10,000 Persons with Diabetes†

Slide 23 :

Mortality Rate Due to Diabetes in Hispanic and Non-Hispanic White Men and Women Men Women Centers for Disease Control and Prevention. Nat’l Vital Stat Rep. 2000;48(11):1-108. United States, 1998

Slide 24 :

Diabetes in US Latinos Higher prevalence - Why so much disease? Higher rates of complications – What explains the disparity? Barriers to care Georgia Latino Education Program

Slide 25 :

M Harris et al, Diabetes Care 22:403, 1999 Mean HbA1c % 7.5 7.8 8.2 7.6 8.3 7.9 Male Female Mean HbA1c for adults with diabetes according to race or ethnicity

Slide 26 :

Diabetes Care Across Ethnic Groups: SelfMonitoring of Blood Glucose * p < 0.01 * * Harris MI. Diabetes Care. 2001 Mar;24(3):454-9. Percent

Slide 27 :

Use of Intensive Insulin Therapy Across Ethnic Groups † p < 0.01 † Harris MI. Diabetes Care. 2001 Mar;24(3):454-9. Percent

Slide 28 :

Hispanic N=156 Non-Hispanic Whites N= 149 African Americans N= 147 Bonds et al. Diabetes Care 26:1040-46, 2003 Insulin Resistance Atherosclerosis Study Diabetes control HbA1C <7% 35 48* 42 HbA1c 7-8% 22 26 18 HbA1c > 8% 44 27 40 Hypertension control BP <135/85 mm Hg 18 41† 34 BP <130-140/85-90 17 21 22 BP > 140/90 mm Hg 66 38 44 Hyperlipidemia control LDL <130 mg/dl 18 41 34 LDL > 130 mg/dl 66 38 44 Albuminuria on ACE-I (%) 27 48 28 CAD on aspirin 83 100 71 1993-1998, Los Angeles and Oakland, Ca; San Luis Valley, CO and San Antonio, TX

Slide 29 :

Barriers to Care in the Latino Population Language barriers: 25% of Latinos do not speak English 5% of doctors and 2% of nurses are Latinos Lower rate of health insurance and access to healthcare Different health care beliefs Distrust of health care providers that are not Latinos Symptom improvement equals a cure, so patients discontinue drug use More medications = worsening of the condition

Slide 30 :

Hispanic Population in Georgia U.S. Census Bureau, 2004 American Community Survey: U.S. Census Bureau, census 2000; National Council of La Raza, Statistical Brief No 7, 2005

Slide 31 :

Georgia Spanish-Speaking Population, 2004 English-Speaking Capacity % Spanish-Speaking Population (18-64 years) Speak English “very well” 29.7% Speak English “well” 17.4% Speak English “not well” 31.9% Speak English “not at all” 21% Source: Census Bureau. 2004 American Community Survey National Council of La Raza, Statistical Brief No 7, 2005

Slide 32 :

Racial and Ethnic Differences in the Healthcare Coverage for Adults > 65 yrs with Diabetes I 95% confidence interval.*Includes persons of Hispanic and nonHispanic origin.**Persons of Hispanic origin may be of any race. Source: National Health Interview Survey (NHIS), CDC, NCHS, 2000. 2010 Target 0 20 40 60 100 80 American Indian or Alaska Native* 63 Asian* 83 Hispanic or Latino** 65 Black, not Hispanic 80 White, not Hispanic 87 Total 83 AgeAdjusted Percentage 81 Native Hawaiian and other Pacific Islander*

Slide 33 :

Rate of Non-elderly Uninsured by Race/Ethnicity in Georgia, 2002-2003 White, 15% Black 24% Hispanic, 43% Other, 31% Source: Urban Institute and Kaiser Comission on Medicaid and the uninsured estimates based on pooled March 2003 and 2004 Current Population Surveys

Slide 34 :

Appointment Keeping and EthnicityGrady Diabetes Clinic, 2000-2004 % Blacks Latinos Whites % patients returning at 6 months % patients returning at 12 months 78.7 68.9 75.7 44.6 24.6 42.6 Umpierrez et al, Am J Med Sci, in press

Slide 35 :

Appointment Keeping and A1C level Among Different Ethnic GroupsGrady Diabetes Clinic, 2000-2004 A1C % Blacks Latinos Whites 8.7 9.1 8.4 7.6 7.9 7.3 Baseline 6 months 12 months 7.4 7.5 7.3 Umpierrez et al, Am J Med Sci, in press

Slide 36 :

What can we do? The vast majority of patients with T2DM (< 10%) are not treated by specialists We must educate primary care providers to do a better job Use culturally sensitive materials, and be culturally sensitive yourself Nurse-directed diabetes care following protocols and algorithms and supervised by a diabetologist

Slide 37 :

NURSE-DIRECTED DIABETES CARE Specially trained registered nurse followed detailed treatment algorithms Endocrinologist (MBD) available by phone Endocrinologist met with nurse once per week to sign charts and review any problems (mostly administrative) Clinics two evenings and Saturday mornings Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 38 :

DEMOGRAPHICS Number of Patients – 367 Age – 51.2 ± 10.6 years Disease Duration – 6.9 ± 6.6 years Females – 71% Race/Ethnicity African-American - 80 (22%) Caucasian - 2 (0.5%) Latino - 283 (77%) Asian - 2 (0.5%) Type 1 diabetes – 2 (0.5%) Type 2 diabetes – 365 (99.5) Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 39 :

EDUCATION AND INCOME LEVELS Education (n=102) – 73% had 6th grade or less Household Income (n=63) – 95% <$25,000 Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 40 :

OUTCOME MEASURES (Hb A1C - %) Usual Care* Nurse-Directed Care P Value (n=303) (n=364)+ Initial 9.3 ± 2.5 8.8 ± 2.5 <0.001 Final 8.7 ± 2.4 7.0 ± 1.3 <0.001 Change -0.6 ± 2.8 -1.8 ± 2.6‡ <0.001 P Value <0.001 <0.001 *Prior year +3 patients had hemoglobinopathies ‡ n= 361 (3 patients had only one test) Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 41 :

A1C LEVELS 9.3 +2.6 8.8 +2.5 7.0 +1.3 8.8 8.4 P <0.001 for similarly marked comparisons, * and ** 6.7 Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 42 :

OUTCOME MEASURES(Hb A1C – % meeting goal of <7.0%) Usual Care* Nurse-Directed Care P Value (n=303) (n=361) Initial 17% 28% <0.001 Final 28% 59% <0.001 P value <0.001 <0.001 * Prior year Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 43 :

OUTCOME MEASURES(LDL Cholesterol – % meeting goal*) Usual Care** Nurse-Directed Care P Value (n=244) (n=366) Initial 51% 50% NS Final 50% 82%** <0.001 P Value NS <0.001 *Goal <130 mg/dl in year 1 and <100 mg/dl in years 2 and 3 **Prior year **352 patients had at least 2 values Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 44 :

TOTAL URGENT CARE AND EMERGENCY ROOM VISITS AND HOSPITALIZATIONS Year Prior Nurse-Directed Care Urgent Care 30 19 ER 49 25 Hospitalizations 16 8 Total 95 52 45% reduction (P <0.001) Davidson M et al, Diabetes Care 30:224–227, 2007

Slide 45 :

EFFECT OF NURSE/PHARMACIST – DIRECTED CARE IN LOS ANGELES COUNTY CLINICS Nurse/Pharmacist Care Usual Care P Value N 120 145 Initial A1c(%) 13.3 ± 3.4 12.3 ± 3.4 <0.02 Final A1c(%) *9.8 ± 3.0 10.8 ± 3.2 <0.01 Delta* A1c(%) – 3.5 ± 3.8 -1.5 ± 2.9 <0.001 * = 6 months (Diabetes Care 26: 2281 2003)

Slide 46 :

Slide 47 :

EFFECT OF NURSE-DIRECTED CARE IN STAFF MODEL HMO N 61 66 Initial A1C (%) 9.5 ± 0.3 9.5 ± 0.3 NS Delta A1C (%)* -1.14 + 0.35 <0.01 A1C <7.5% 42.6% 24.6% <0.03 *after 1 year (Diabetes Care 26: 1058, 2003) Usual Care P Value Nurse-Directed Care

Slide 48 :

THE CALIFORNIA MEDI-CAL TYPE 2 DIABETES STUDY (Diabetes Care 27: 95, 2004)

Slide 49 :

CC - Community Clinic; UC - University Clinic; SC - Standard Care; TA - Treatment Algorithms Diabetes Care 27:1638-1646, 2004 THE CALIFORNIA MEDI-CAL TYPE 2 DIABETES STUDY

Slide 50 :

IMPORTANCE OF NURSES INDEPENDENTLY IMPLEMENTING TREATMENT Nurse? PCP a Nurse Alone b A1C (%) Control Intervention Control Intervention (n=103) (n=106) (n=29) (n=36) Baseline 9.2 9.3 10.2 10.1 Change -0.16 -0.02 -0.9c -2.1c a Am J Med 116: 732, 2004 b Am J Manag Care 11: 253, 2005 c P <0.03 } Same VA system

Slide 51 :

KEY COMPONENTS FOR GOOD DIABETES CARE Knowledgeable provider Time to interact with patient Communication with patient Educated patient Patient’s ability to carry out treatment recommendations Nurses following protocols under appropriate supervision do it better!

Slide 52 :

Project Aims: Patient Education Healthcare Provider Education Research Para-professional Education- “Promotores de Salud” or healthcare community educators Georgia Latino Diabetes Education Program

Slide 53 :

Georgia Latino Diabetes Education Program Diabetes classes: educate 400 patients/yr) - Grady Diabetes Clinic - Grady International Clinic - Grady Satellite Clinics - Saint Joseph’s Mercy Care Service Weekly classes: - Glucose monitoring - Nutrition - Physical activity - Pharmacological agents

Slide 54 :

Georgia Latino Diabetes Education Program Educational seminars for physicians and healthcare professionals (125 per yr): - Atlanta - Dalton - Gainesville - Rome, Macon Provide bilingual education materials (brochures, CD-ROM, Flip-charts) to educate Latino patients with diabetes

Slide 55 :

Literacy in native language Read in Spanish Write in Spanish

Slide 56 :

Knowledge of a second language Reading and writing in English

Slide 57 :

Georgia Latino Diabetes Education Program At Presentation (First class) At Follow up (within 6 months) 0.9%

Slide 58 :

CONCLUSION Policy makers seeking to improve diabetes care and conserve resources (especially in minority populations) should seriously consider adopting nurse-directed diabetes care. Diabetes Education: use culturally sensitive materials, and be culturally sensitive yourself

Diabetes in the New ...

Management of Diabet...

Mental Health Aspect...

Incretin Based Thera...

Diabetes

Kidney Disease and I...

Free Powerpoint Templates

	geumpie@emory.edu 5 Years ago.



1362 Views, 0 favourite
PowerPoint Slide Presentation on DM in Latinos: an overview
More By User Flag as inappropriate Select your reason for flagging this presentation as inappropriate. If needed, use the feedback form to let us know more details. Cancel