Clinic-Based Versus Outsourced Implementation of a Diabetes Health Literacy Intervention
ABSTRACT We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers.
A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes.
Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm (p < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients (p < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c (β = -0.31, 95 % CI -0.56 to -0.06, p = 0.02), systolic blood pressure (β = -3.65, 95 % CI -6.39 to -0.90, p = 0.01), and low-density lipoprotein (LDL) cholesterol (β = -7.96, 95 % CI -10.08 to -5.83, p < 0.001) at 6 months.
An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.
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ABSTRACT: This study was conducted to validate a shortened version of the Rapid Estimate of Adult Literacy in Medicine (REALM). This screening instrument is designed to be used in public health and primary care settings to identify patients with low reading levels. It provides reading grade estimates for patients who read below a ninth-grade level. The REALM can be administered in one to two minutes by personnel with minimal training. Two hundred and three patients in four university hospital clinics (internal medicine, family practice, ambulatory care, and obstetrics/gynecology) were given the REALM and three other standardized reading tests: the reading recognition section of the Peabody Individual Achievement Test-Revised (PIAT-R), the Wide Range Achievement Test-Revised (WRAT-R), and the Slosson Oral Reading Test-Revised (SORT-R). One hundred inmates at a state prison were also given the REALM twice, one week apart, to determine test-retest reliability. The REALM correlated well with the three other tests. (Correlation coefficients were 0.97 [PIAT-R], 0.96 [SORT-R], and 0.88 [WRAT-R].) All correlations were significant at P < .0001. Test-retest reliability was 0.99 (P < .001). The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.Family medicine 06/1993; 25(6):391-5. · 0.85 Impact Factor
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ABSTRACT: Health literacy is a measure of patients' ability to read, comprehend, and act on medical instructions. Poor health literacy is common among racial and ethnic minorities, elderly persons, and patients with chronic conditions, particularly in public-sector settings. Little is known about the extent to which health literacy affects clinical health outcomes. To examine the association between health literacy and diabetes outcomes among patients with type 2 diabetes. Cross-sectional observational study of 408 English- and Spanish-speaking patients who were older than 30 years and had type 2 diabetes identified from the clinical database of 2 primary care clinics of a university-affiliated public hospital in San Francisco, Calif. Participants were enrolled and completed questionnaires between June and December 2000. We assessed patients' health literacy by using the short-form Test of Functional Health Literacy in Adults (s-TOFHLA) in English or Spanish. Most recent hemoglobin A(1c) (HbA(1c)) level. Patients were classified as having tight glycemic control if their HbA(1c) was in the lowest quartile and poor control if it was in the highest quartile. We also measured the presence of self-reported diabetes complications. After adjusting for patients' sociodemographic characteristics, depressive symptoms, social support, treatment regimen, and years with diabetes, for each 1-point decrement in s-TOFHLA score, the HbA(1c) value increased by 0.02 (P =.02). Patients with inadequate health literacy were less likely than patients with adequate health literacy to achieve tight glycemic control (HbA(1c) < or = 7.2%; adjusted odds ratio [OR], 0.57; 95% confidence interval [CI], 0.32-1.00; P =.05) and were more likely to have poor glycemic control (HbA(1c) > or = 9.5%; adjusted OR, 2.03; 95% CI, 1.11-3.73; P =.02) and to report having retinopathy (adjusted OR, 2.33; 95% CI, 1.19-4.57; P =.01). Among primary care patients with type 2 diabetes, inadequate health literacy is independently associated with worse glycemic control and higher rates of retinopathy. Inadequate health literacy may contribute to the disproportionate burden of diabetes-related problems among disadvantaged populations. Efforts should focus on developing and evaluating interventions to improve diabetes outcomes among patients with inadequate health literacy.JAMA The Journal of the American Medical Association 01/2002; 288(4):475-82. · 30.39 Impact Factor
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ABSTRACT: The objective of this study was to evaluate the concordance of self-report measures of medication adherence (interview, diary, or questionnaire) with nonself-report measures of adherence (administrative claims, pill count or canister weight, plasma drug concentration, electronic monitors, or clinical opinion). A literature search was conducted to identify published reports in which self-report and nonself-report measures of adherence were used within the same study. The concordance of measures within each study was categorized as high, moderate, or low based on a comparison of the adherence estimates. Eight-six comparisons of self-report to nonself-report measures of adherence were identified. Thirty-seven of the 86 comparisons (43%) were categorized as highly concordant. However, concordance varied substantially by type of self-report measure and nonself-report measure. Self-report measures, in general, were highly concordant with electronic measures in only 17% of comparisons, whereas they were highly concordant with other types of nonself-report measures in 58% of comparisons (chi-square = 14.30, P <0.01). When comparing self-report measures, interviews had significantly lower concordance with nonself-report measures as compared with questionnaires or diaries (chi-square = 8.47, P = 0.01). In 15 comparisons of interviews with electronic measures, none of the comparisons were highly concordant, whereas questionnaires and diaries had moderate-to-high concordance with electronic measures in 12 of 16 comparisons (75%). The concordance of self-report and other measures of medication adherence varies widely based on the type of measures used. Questionnaires and diaries tend to have moderate-to-high concordance with other measures of medication adherence. However, interview-based self-reports are not concordant with electronic measures. Questionnaire and diary methods could be preferable to interviews for self-reported medication adherence.Medical Care 07/2004; 42(7):649-52. DOI:10.1097/01.mlr.0000129496.05898.02 · 2.94 Impact Factor