Improved Outcomes in Diabetes Care for Rural African Americans

As a physician who leads group diabetes visits for a similar patient population and team composition (nurse case manager, pharmacist, dietician), I was pleased to see the statistically significant reductions in HgbA1c and percentage of patients meeting systolic blood pressure goals. We have been able to demonstrate increased patient satisfaction, increased knowledge about diabetes, and an increased sense of empowerment in patients attending group diabetes group visits, but we have not yet attempted to quantify improvements in HgbA1c.

In UKPDS a 1% decline in HgbA1c over a ten year period reduced the risk for microvascular complications, myocardial infarction, and diabetes- related deaths by 37%, 14%, and 21% respectively. A 0.5% average reduction in HgbA1c, as described by Bray and colleagues may not be clinically significant enough to justify the expenses incurred in group intervention without determining which components of team based care contribute greatest to the change. In a two year long study to evaluate the clinical outcomes of pharmacist interventions, HgbA1C values declined by 2.7% compared with 1.1% in a usual care group. This additional 1.6% decrease in HgbA1c was both statistically and clinically significant, while the 2.7% drop in HgbA1c is eye-popping. The patients in both Bray and Johnson's studies were from low-income populations. In contrast, however, the patients in Johnson's study were urban, and predominantly Hispanic/Latino, not rural and African American. It is difficult to determine if the difference is secondary to geographic location, ethnic group, socioeconomic group or inclusion criteria. Bray and colleagues included patients with a HgA1C > 7.5 while Johnson and colleagues included patients with HgA1C > 9.0. The difference creates a "floor effect" as it is more difficult to reduce HgA1c below 7.5.

I would like further studies to parse which components of the intervention are essential to achieve maximum success in this sub- population. Is it the nurse care manager providing encouragement to follow up to get labs drawn and to make appointments in a rural community? Is it the dietician providing culturally relevant dietary advice? Or is it the pharmacist helping the providers overcome clinical inertia?

I commend Dr. Bray and colleagues for demonstrating that their intervention was successful in African American rural communities and would like to see further research on this topic. I, in particular, look forward to future research to determine which interventions are most beneficial in populations with large health care disparities.

Lenny Salzberg, MD Director, Faculty Development Fellowship 1601 Owen Drive, Fayetteville NC 28304 Phone: 910-678-7203 Fax: 910-678-0115 lenny.salzberg@sr-ahec.org

Competing interests:   None declared