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In response to the study, the NYC Department of Health is pursuing large-scale implementation of this approach, targeting diabetes hot spots across the city through public health messaging, mailed print materials, and Care Calls.
A study presented at the virtual American Diabetes Association 80th Annual Scientific Sessions reported success in decreasing A1c levels in individuals living in New York City’s poverty areas through self-management support.
The study’s author, Jeffrey Gonzalez, PhD, professor of psychology and medicine at Albert Einstein College of Medicine and director of New York Regional Center for Diabetes Translation Research, explained New York City’s distinct socioeconomic layout, noting that the city bears huge disparities between rich and poor.
While Manhattan houses much of the affluent NYC population, South Bronx, as well as the border of Brooklyn and Queens, have the highest rates of poverty in the city. Gonzalez overlaid a poverty distribution map with another depicting areas with the highest diabetes prevalence, showing that NYC regions with the highest rates of poverty also show highest diabetes prevalence. Manhattan diabetes prevalence exists at a 4.1% to 8.9% rate, but rates in South Bronx and other impoverished areas were much higher at 13.6% 14.6%, according to the study.
Not only are high poverty areas associated with prevalence of diabetes, those living with diabetes in these regions are also more likely to have poor glycemic control. Gonzalez presented a NYC map showing areas with poor A1c control, as well as a map that showed increased emergency department use and indicated the same poverty areas.
The study used NYC’s A1c registry, a resource that Gonzalez said was unique for such a large city, to identify individuals with poor A1c control. The study implemented self-management support initiatives in 2 randomized control arms: 1 arm received print resource materials and the other received telephonic intervention.
Demographic data of the 841 participants found a predominantly Latino and Black population, with the majority of participants able to speak Spanish. Sixty-nine percent were born outside of the United States, and 76% had household incomes of less than $20,000.
Only 14% of participants reported ever having any diabetes education prior to the study’s program.
Results of the study found the telephonic arm to be superior in A1c improvement. Additionally, those with A1c levels above 9% at baseline showed clinically significant improvements on the A1c scale.
Researchers also linked the participants to a statewide database that captures hospital discharges, evaluating 2 years prior to participation and 4 years post participation in the program. Individuals who received telephonic intervention showed lower all-cause hospitalizations and lower diabetes-related hospitalizations. But according to Gonzalez, these changes weren’t able to be attributed to improvement in A1c, suggesting that "some benefits of telephonic self-management intervention may go beyond A1c control."
A follow up study incorporated diabetes distress and depression levels, which Gonzalez and researchers are continuing to assess. It evaluated another high poverty area in NYC through participation of 812 adults with A1c levels above 7.5. Participants were randomized to either receive print materials by mail, or print materials along with 6 to 12 tele-SMS calls, depending on their A1c and distress levels.
In this population, 7% reported receiving prior diabetes education. Seventy-eight percent spoke Spanish, and 87% identified as Hispanic or Latino, with similarly high poverty levels.
Participants were screened for distress and stratified according to their A1c levels and distress status. Although investigators are still working through their data analysis, Gonzalez reported the A1c was significantly improved in both study arms: a -0.8% drop in the telephonic arm and a -0.7% drop in the print only arm.
Data failed to reveal any difference in diabetes distress or depression, something that Gonzalez said might hint that there was some mismatch between the distress protocol and the needs of their patients.
The NYC DOH has decided to disseminate the study’s Care Calls telephonic approach in several ways. They have begun a pilot and feasibility study to train medical assistants in NYC Care Calls delivery. In the midst of the pandemic, they’re also conducting telephonic outreach to adults with chronic illness using the NYC Care Calls protocol, Gonzalez said.
The study intends pursue further augmentation to incorporate social determinants of health and stronger collaboration between health care providers and coaches.