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IIR 04-176 – HSR Study

IIR 04-176
Insulin Treatment Variation in Southwestern Diabetics - Therapeutic Decision-making
Glen H Murata, MD
New Mexico VA Health Care System, Albuquerque, NM
Albuquerque, NM
Funding Period: May 2005 - April 2008
Minority populations are disproportionately affected by type 2 diabetes mellitus (T2DM), likely due to an interaction of genetic and environmental risk factors. Several studies have documented a higher prevalence of insulin resistance, disparities in quality of care, and more microvascular and macrovascular complications in minority groups. Recent evidence by our research group indicates that insulin-using minority veterans have poorer glycemic control (as measured by HbA1c) and receive lower doses of insulin than do non-Hispanic whites.

The goal of this mixed methods descriptive, cross-sectional study is to elucidate the patient, provider and interactive patient/provider reasons for this discrepancy, to determine and validate these findings in a much larger sample, and to use what is discovered to develop strategies to remedy provider and patient behaviors in order to optimize health outcomes. The objective of this mixed method study is to unpack provider decision-making and patient self-care behaviors responsible for ethnic and racial variation in the use of insulin in veterans with T2DM receiving VA care, while adjusting for important covariates and confounders. Aim 1: Perform a qualitative provider Nominal Group Technique designed to elucidate insulin prescribing decision-making behaviors, and possible reasons for racial/ethnic variation in insulin use. Aim 2: Perform a qualitative content analysis of patient focus group data on insulin-using veterans in VA care across African American, Hispanic and non-Hispanic White (NHW) contrasts. Psychosocial determinants of self-care, diabetes care preferences, patient/provider relationship issues, and possible reasons for racial/ethnic variation in insulin use will be explored. Aim 3: Construct a) patient, and b) provider questionnaires reflective of qualitative focus group data, nominal group process and extant evidence-base findings, and Aim 4: Administer surveys to a) a racially/ethnically diverse random sample of insulin-using diabetic veterans receiving care within VISN 18, and b) their assigned primary care providers.

This is a mixed methods descriptive, cross-sectional study using 1) qualitative nominal group technique data (from providers), focus group data (from patients) and 2) provider and nested patient survey data. We will use qualitative methods to explicate and deconstruct the etiologic associations and management strategies of insulin-using patients and their providers using focus group content analytical methods. Next, we will use the extant evidence from the evidence-base, focus group data and conventional survey methods to construct two surveys-one targeted to providers and another to survey a randomly selected population of representative veterans nested within their providers VA care, following the recommendations of Hughes, O'Brien and Dillman.

233 Hispanic and 932 NHW diabetics were enrolled. Characteristics were equivalent except Hispanics were younger and had fewer years of insulin use; there was no difference in years since diagnosis across groups. Mean A1C and the proportion <8 and <7 and total insulin dose and type were equivalent. Half of Hispanics believed "only people with serious diabetic complications are started on insulin" compared to 38.8% (P = 0.001) NHW, and one-third of both groups believed "an increased insulin dose puts one at greater risk of complication". Hispanics reported greater stress and being angry or upset as reasons for high blood sugar in the past week. Hispanics also reported more social barriers, more negative attitudes toward diabetes, and more embarrassment about monitoring and injecting and certain barriers to SMBG (including Fear, Futility, and Confusion). Negative attitudes towards diabetes were associated with non-compliance with SMBG and poor glycemic control. Thirty-six percent of subjects experienced depression. Depression was significantly associated with SMBG non-compliance and higher A1C. Perceived negative relationship with providers also significantly contributed to SMBG non-compliance and higher A1C.

Sources of ethnic disparities in glycemic control and self care need to be identified. In particular, HSR&D should continue to assess the involvement of access issues, provider behaviors, and remediable patient behaviors. Many veterans on insulin have already suffered complications, lost activities of daily living, become discouraged, and do not believe that they are capable of diabetes self-care. Our study provides the motivation for a randomized trial on improving self-care based upon psychosocial profiling, quantifying patient behaviors, comparing such behaviors to similar patients, and setting goals that are consistent with the patient's attitudes and performance expectations. It is recommended that culturally-sensitive interventions be developed and tested to determine the impact on self-care behaviors and glycemic control.

External Links for this Project

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Book Chapters

  1. Shah J, Wendel CS, Mohler M, Brown V, Plummer E, Duckworth W, Murata G. Effect of attitudes, depression and provider relationships on compliance with self monitoring of blood glucose (SMBG) and glycemic control (A1c) in insulin-treated type 2 diabetic patients. In: Proceedings of the 13th International Congress of Endocrinology. 1 ed. Bologna, Italy: Medimond; 2008. [view]
Conference Presentations

  1. Wendel CS, Mohler MJ, Brown B, Plummer E, Shah JH, Duckworth WC, Lebowitz MD, Adam K, Collier K, Murata GH. Barriers to Self Monitoring of Blood Glucose in Southwestern Hispanic and non-Hispanic White Insulin-Treated Type 2 Diabetics. Paper presented at: American Diabetes Association Annual Scientific Session; 2008 Jun 6; San Francisco, CA. [view]
  2. Wendel CS, Shah J, Mohler M, Brown V, Plummer E, Duckworth W, Murata G. Barriers to Self Monitoring of Blood Glucose in Southwestern Hispanic and non-Hispanic White Insulin-Treated Type 2 Diabetics. Paper presented at: World Congress on Prevention of Diabetes and its Complications; 2010 Apr 8; Dresden, Germany. [view]
  3. Shah JH, Wendel CS, Mohler MJ, Brown V, Plummer E, Duckworth WC, Murata GH. Effect of Attitudes (ATT), Depression (DP) and Provider Relationship (PR) on Compliance with Self Monitoring of Blood Glucose (SMBG) and Glycemic Control (A1c) in Insulin-Treated Type 2 Diabetics. Paper presented at: International Society of Endocrinology International Congress of Endocrinology; 2008 Nov 1; Rio de Janeiro, Brazil. [view]
  4. Mohler MJ, Wendel CS, Brown V, Plummer E, Adam K, Collier K, Duckworth WC, Shah JH, Murata GH. Minority Disparities: A Comparison of Two Cohorts of Southwestern Insulin-Using Veterans. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 1; Baltimore, MD. [view]

DRA: Health Systems
DRE: none
Keywords: Diabetes, Research measure, Research method
MeSH Terms: none

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