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PAMFRI Study on Diabetes Management Programs for Economically Disadvantaged Patients Published

Dominick Frosch, Ph.D., associate investigator at PAMF Research Institute

The Archives of Internal Medicine have published three randomized controlled trials which examine the effectiveness of behavioral and educational interventions for patients with poorly controlled diabetes. One of the three research trials was directed by Dominick Frosch, Ph.D., associate investigator with the Palo Alto Medical Foundation’s (PAMF) Research Institute (PAMFRI).

The study conducted by Dr. Frosch, with colleagues from the University of California, Los Angeles, examined the effectiveness of a disease management program among socially and economically disadvantaged patients with poorly controlled diabetes.

The study included 201 patients (72 percent African American or Latino; 74 percent with annual incomes of less than or equal to $15,000) with poorly controlled diabetes. Participants were randomized to receive either an intervention package consisting of a 24-minute video behavior support intervention with a workbook and five sessions of telephone coaching by a trained diabetes nurse (treatment group), or a 20-page brochure developed by the National Diabetes Education Program (control group).

Dr. Frosch and his colleagues found that most participants in both the treatment group (94.3 percent) and control group (93.5 percent) had reviewed the assigned treatment materials and the majority (88.5 percent in the treatment group and 89.8 percent in the control group) rated the clarity of the information presented as good, very good, or excellent at the one-month follow-up.

Across treatment groups there was a significant overall reduction in average glycated hemoglobin (HbA1c) levels from study initiation to six-month follow-up, but differences between the groups were not significant.

The study also found that differences in other clinical measures (including blood lipid levels and blood pressure) and measures of diabetes knowledge and self-care behaviors were also not significant.

“More intensive and therefore more expensive interventions may be a worthwhile investment to lower the high costs associated with poorly managed diabetes in the long term. However, larger structural interventions also may be necessary to overcome the many challenges faced by these severely disadvantaged patients,” Dr. Frosch concluded.

The study, which was initiated by Dr. Frosch at University of California, Los Angeles before joining the Palo Alto Medical Foundation Research Institute in 2009, took place during one of the worst economic recessions since the Great Depression.

Dr. Frosch describes the premise and hypothesis of the study:

The costs of diabetes to society have grown enormously in recent years, owing to an increase in the incidence of the disease, driven in large part by the obesity epidemic, and the potentially severe medical complications that can result from diabetes. There is increasing interest in using disease management programs with telephone support to help patients with diabetes achieve better control of their condition and to reduce complications and suffering caused by the disease. We conducted a study to evaluate whether a video behavior support intervention combined with 5 sessions of telephone coaching could help patients from economically disadvantaged backgrounds, who were struggling to control their condition, achieve better outcomes.  The comparison group received a standardized printed brochure about diabetes management, but no telephone coaching.

Our results showed that all patients who participated in the study improved their diabetes control, but contrary to our expectations, patients who received telephone coaching did not do better than patients who did not.

 Many of the patients who enrolled in the study had lost their jobs and were struggling for basic survival. We concluded that for the most economically disadvantaged patients, who face enormous daily challenges, a modest intervention such as the one we tested may not be sufficient and that more intensive interventions appear necessary.

Even though it yielded positive insights, Dr. Frosch’s study is considered a “negative” study because the outcomes did not align with the original hypothesis that the experimental intervention would lead to more  improved health outcomes.

All three reports, including Frosch’s, are part of the journal’s Health Care Reform series. In another report, Katie Weinger, Ed.D., of the Joslin Diabetes Center, Boston, and colleagues, evaluated the efficacy of a behavioral intervention for improving glycemic control among patients with long-duration poorly controlled diabetes. In a third report, JoAnn Sperl-Hillen, M.D., of HealthPartners Research Foundation and HealthPartners Medical Group, Minneapolis, and colleagues evaluated a total of 623 adults from Minnesota and New Mexico with type 2 diabetes and glycosylated hemoglobin (HbA1c) concentrations of seven percent or higher. The authors found that individual education resulted in better glucose control in patients with established sub-optimally controlled diabetes than did group education.

NOTE: JAMA & the Archives Journals are subscription-based, but you can read the full text of the article online for free.

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