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Objective: To characterize the costs and cost-effectiveness of a telephonic behavioral intervention to promote glycemic control in the Improving Diabetes Outcomes study.Research Design and Methods: Using the provider perspective and a time horizon to the end of the 1-year intervention, we calculate the costs of a telephonic intervention by health educators compared with an active control (print) intervention to improve glycemic control in adults with type 2 diabetes. We calculate the cost-effectiveness ratios for a reduction of one percentage point in hemoglobin A(1c) (A1C), as well as for one participant to achieve an A1C <7%. Base-case and sensitivity analysis results are presented.Results: The intervention cost $176.61 per person randomized to the telephone group to achieve a mean 0.36 percentage point of A1C improvement. The incremental cost-effectiveness ratio was $490.58 per incremental percentage point of A1C improvement and $2,617.35 per person over a 1-year intervention in achieving the A1C goal. In probabilistic sensitivity analysis, the median (interquartile range) of per capita cost, cost per percentage point reduction in A1C, and cost per person achieving the A1C goal of <7% are $175.82 (147.32-203.56), $487.75 (356.50-718.32), and $2,312.88 (1,785.58-3,220.78), respectively.Conclusions: The costs of a telephonic intervention for diabetes self-management support are moderate and commensurate to the modest associated improvement in glycemic control. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of a telephonic and a print intervention over 1 year to improve diabetes control in low-income urban adults.Research Design and Methods: A randomized trial in Spanish and English comparing a telephonic intervention implemented by health educators with a print intervention. Participants (N = 526) had an A1C ≥7.5% and were prescribed one or more oral agents. All were members of a union/employer jointly sponsored health benefit plan. Health coverage included medications. Primary outcomes were A1C and pharmacy claims data; secondary outcomes included self-report of two medication adherence measures and other self-care behaviors.Results: Participants were 62% black and 23% Hispanic; 77% were foreign born, and 42% had annual family incomes <$30 thousand. Baseline median A1C was 8.6% (interquartile range 8.0-10.0). Insulin was also prescribed for 24% of participants. The telephone group had mean ± SE decline in A1C of 0.23 ± 0.11% over 1 year compared with a rise of 0.13 ± 0.13% for the print group (P = 0.04). After adjusting for baseline A1C, sex, age, and insulin use, the difference in A1C was 0.40% (95% CI 0.10-0.70, P = 0.009). Change in medication adherence measured by claims data, but not by self-report measures, was significantly associated with change in A1C (P = 0.01). Improvement in medication adherence was associated (P = 0.005) with the telephonic intervention, but only among those not taking insulin. No diabetes self-care activities were significantly correlated with the change in A1C.Conclusions: A 1-year tailored telephonic intervention implemented by health educators was successful in significantly, albeit modestly, improving diabetes control compared with a print intervention in a low-income, insured, minority population. [ABSTRACT FROM AUTHOR]

Diabet. Med. 27, 210–216 (2010) Aims To assess pharmacy claims and self-report data as measures of medication adherence and to describe baseline characteristics of subjects in the Improving Diabetes Outcomes Study. Methods Multi-ethnic, lower-income, insured adults ( n = 526) in New York City with Type 2 diabetes were enrolled in a randomized, controlled, behavioural intervention study delivered by telephone. Baseline data were examined, including glycated haemoglobin (HbA1c), objective measures of diabetes medication adherence [claims data medication possession ratio (MPR)], and two self-report measures [Morisky Medication-taking Scale and the medication-taking item of the Summary of Diabetes Self-Care Activities (SDSCA)]. Associations of highest tertile HbA1c (≥ 9.3%) with lowest tertile MPR (< 42%) were assessed with logistic regression models adjusting for potential confounders. Subset analyses were performed based on assessment of potential interaction. Results Participants (mean ± sd age 56 ± 7 years) had median (interquartile range) HbA1c 8.6% (8.0–10.0). Correlations of baseline MPR with Morisky score and SDSCA medication-taking item were strongly significant (both ρ = 0.21, P < 0.001). Lowest MPR was significantly ( P = 0.008) associated with highest HbA1c in the group as a whole and among the subset taking two or more oral glucose-lowering agents (OGLA) ( P = 0.002), but not among the subset taking only one ( P = 0.83). Self-report adherence measures were not significantly associated with HbA1c in either the whole group or either subset. Conclusions These results support the validity of MPR as an adherence measure for OGLA among insured diabetes patients with poorly controlled HbA1c, especially those taking two or more OGLA. [ABSTRACT FROM AUTHOR]

Diabet. Med. 27, 210–216 (2010) Aims To assess pharmacy claims and self-report data as measures of medication adherence and to describe baseline characteristics of subjects in the Improving Diabetes Outcomes Study. Methods Multi-ethnic, lower-income, insured adults ( n = 526) in New York City with Type 2 diabetes were enrolled in a randomized, controlled, behavioural intervention study delivered by telephone. Baseline data were examined, including glycated haemoglobin (HbA1c), objective measures of diabetes medication adherence [claims data medication possession ratio (MPR)], and two self-report measures [Morisky Medication-taking Scale and the medication-taking item of the Summary of Diabetes Self-Care Activities (SDSCA)]. Associations of highest tertile HbA1c (≥ 9.3%) with lowest tertile MPR (< 42%) were assessed with logistic regression models adjusting for potential confounders. Subset analyses were performed based on assessment of potential interaction. Results Participants (mean ± sd age 56 ± 7 years) had median (interquartile range) HbA1c 8.6% (8.0–10.0). Correlations of baseline MPR with Morisky score and SDSCA medication-taking item were strongly significant (both ρ = 0.21, P < 0.001). Lowest MPR was significantly ( P = 0.008) associated with highest HbA1c in the group as a whole and among the subset taking two or more oral glucose-lowering agents (OGLA) ( P = 0.002), but not among the subset taking only one ( P = 0.83). Self-report adherence measures were not significantly associated with HbA1c in either the whole group or either subset. Conclusions These results support the validity of MPR as an adherence measure for OGLA among insured diabetes patients with poorly controlled HbA1c, especially those taking two or more OGLA. [ABSTRACT FROM AUTHOR]

We measured patient preferences for colorectal cancer (CRC) screening strategies and actual receipt of alternative CRC screening tests among an urban minority sample participating in an intervention study. The fecal occult blood test was the most preferred test, reportedly owing to its convenience and the noninvasive nature. For individuals who obtained a test that was other than their stated preference (41.1%), reasons for this discordance may be due to physician preferences that override patient preferences. [ABSTRACT FROM AUTHOR]

Medical guidelines do not recommend prostate cancer screening, particularly without informed and shared decision making. This study investigates undisclosed opportunistic screening using prostate specific antigen (PSA) testing in black immigrant and African American men. Participants (N = 142) were insured urban men, 45- to 70-years old. Patients' reports of testing were compared with medical claims to assess undisclosed PSA testing. Most (94.4 %) men preferred to share in screening decisions, but few (46.5 %) were aware PSA testing was performed. Four factors predicted being unaware of testing: low formal education, low knowledge about prostate cancer, no intention to screen, and no physician recommendation (all p's < .05). Undisclosed PSA testing was common. Both patient and provider factors increased risk of being uninformed about prostate cancer screening. Interventions combining patient education and physician engagement in shared decision making may better align practice with current prostate cancer screening guidelines.

The study examines the role of patient colorectal cancer (CRC) screening test preference and CRC screening uptake in an insured, urban minority population. Study subjects were enrolled in a randomized controlled trial to promote CRC screening. The interventions were educational, with an emphasis on colonoscopy screening. Subjects were 50+ years of age, fully insured for CRC screening, and out of compliance with current CRC screening recommendations. This paper includes those who answered a question about CRC screening test preference and indicated that they intended to receive such a test in the coming year (n = 453). CRC screening uptake was ascertained from medical claims data. Regardless of test preference, few received CRC screening (22.3 %). Those preferring the home stool test (HST) were less likely to get tested than those preferring a colonoscopy (16.6 vs 29.9 %, χ(2) = 9.9, p = .002). Preference for HST was more strongly associated with beliefs about colonoscopy than with knowledge about colonoscopy. In the context of an RCT emphasizing colonoscopy screening for CRC, patients expressing a preference for HST are at heightened risk of remaining unscreened. Colonoscopy should be recommended as the preferred CRC test, but HSTs should be accessible and encouraged for patients who are averse to colonoscopy.Clinical trials.gov: Identifier: NCT02392143.

This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.

Background: Reducing health care costs requires the ability to identify patients most likely to incur high costs. Our objective was to evaluate the ability of the Charlson comorbidity score to predict the individuals who would incur high costs in the subsequent year and to contrast its predictive ability with other commonly used predictors., Methods: We contrasted the prior year Charlson comorbidity index, costs, Diagnostic Cost Group (DCG) and hospitalization as predictors of subsequent year costs from claims data of fund that provides comprehensive health benefits to a large union of health care workers. Total costs in the subsequent year was the principal outcome., Results: Of the 181,764 predominantly Black and Latino beneficiaries, 70% were adults (mean age 45.7 years; 62% women). As the comorbidity index increased, total yearly costs increased significantly (P<.001). At lower comorbidity, the costs were similar across different chronic diseases. Using regression to predict total costs, top 5th and 10th percentile of costs, the comorbidity index, prior costs and DCG achieved almost identical explained variance in both adults and children., Conclusions and Relevance: The comorbidity index predicted health costs in the subsequent year, performing as well as prior cost and DCG in identifying those in the top 5% or 10%. The comorbidity index can be used prospectively to identify patients who are likely to incur high costs., Trial Registration: ClinicalTrials.gov NCT01761253.

Methods: Suboptimal bowel preparation, present in over 20% of colonoscopies, can severely compromise the effectiveness of the colonoscopy procedure. We surveyed 93 primarily urban minority men and women who underwent asymptomatic 'screening' colonoscopy regarding their precolonoscopy bowel-preparation experience., Results: Print materials alone (39.8%) and in-person verbal instructions alone (35.5%) were reportedly the most common modes of instruction from the gastroenterologists. Liquid-containing laxative (70.6%) was the most common laxative agent; a clear liquid diet (69.6%) the most common dietary restriction. Almost half of the participants mentioned 'getting the laxative down' as one of the hardest parts of the preparation; 40.9% mentioned dietary restrictions. The 24.7% who mentioned 'understanding the instructions' as one of the hardest parts were more likely to be non-US born and to have lower education and income. There was no relationship between difficulty in understanding instructions and mode of instruction or preparation protocol. One quarter suggested that a smaller volume and/or more palatable liquid would have made the preparation easier. Three quarters agreed that it would have been helpful to have someone to guide them through the preparation process., Conclusions: These findings suggest a variety of opportunities for both physician- and patient-directed educational interventions to promote higher rates of optimal colonoscopy bowel preparation.

Background: Decision support interventions have been developed to help men clarify their values and make informed decisions about prostate cancer testing, but they seldom target high-risk black and immigrant men., Purpose: This study evaluated the efficacy of a decision support intervention focused on prostate cancer testing in a sample of predominantly immigrant black men., Methods: Black men (N = 490) were randomized to tailored telephone education about prostate cancer testing or a control condition., Results: Post-intervention, the intervention group had significantly greater knowledge, lower decision conflict, and greater likelihood of talking with their physician about prostate cancer testing than the control group. There were no significant intervention effects on prostate specific antigen testing, congruence between testing intention and behavior, or anxiety., Conclusions: A tailored telephone decision support intervention can promote informed decision making about prostate cancer testing in black and predominantly immigrant men without increasing testing or anxiety.

Objectives: We compared the effectiveness of a telephone outreach approach versus a direct mail approach in improving rates of colorectal cancer (CRC) screening in a predominantly Black population., Methods: A randomized trial was conducted between 2000 and 2003 that followed 456 participants in the New York metropolitan area who had not had recent CRC screening. The intervention group received tailored telephone outreach, and the control group received mailed printed materials. The primary outcome was medically documented CRC screening 6 months or less after randomization., Results: CRC screening was documented in 61 of 226 (27.0%) intervention participants and in 14 of 230 (6.1%) controls (prevalence rate difference=20.9%; 95% CI = 14.34, 27.46). Compared with the control group, the intervention group was 4.4 times more likely to receive CRC screening within 6 months of randomization., Conclusions: Tailored telephone outreach can increase CRC screening in an urban minority population.

Background: Colorectal cancer (CRC) is a largely preventable disease through early detection and treatment, yet screening rates remain low and mortality rates remain high, particularly among low-income, minority populations. This study was conducted to identify barriers to CRC screening., Methods: Repeated telephone contacts were conducted with 226 individuals from 52 to 80 years of age, who had not recently received CRC screening. The contacts were intended to educate and encourage participants to obtain CRC screening. Within this context, CRC screening barriers were identified and categorized using an educational diagnosis as specified in the Precede-Proceed Framework., Results: Findings showed that the most frequently observed barrier was lack of familiarity with CRC screening guidelines and tests. Availability and accessibility to screening tests was a barrier that was difficult to overcome for many participants. The majority of participants faced two or more barriers., Conclusions: This study suggests a need for public health education about CRC screening guidelines and tests and greater accessibility to CRC screening.

Eighty-one normotensive and 61 hypertensive white and nonwhite subjects were studied cross-sectionally to determine the prevalence and determinants of elevated urinary albumin levels. Twenty-four-hour urinary albumin excretion was determined by radioimmunoassay. The prevalence of elevated urinary albumin level (greater than or equal to 15 mg/24 h) was significantly greater in hypertensive than in normotensive subjects (31.1% and 8.6%). Among hypertensive subjects, a much greater proportion of whites than nonwhites had urinary albumin levels of 15 mg/24 h or greater (39.5% and 17.4%). The independent association of blood pressure with urinary albumin level was affirmed by logistic regression analyses for white normotensive and hypertensive subjects combined, and for hypertensive subjects alone. Furthermore, among hypertensive subjects, whites were five times as likely as nonwhites to have elevated urinary albumin levels. Thus, blood pressure and ethnicity were the important determinants of urinary albumin excretion among hypertensive subjects.