Research Article
Telephone Intervention to Improve Diabetes Control: A Randomized Trial in the New York City A1c Registry

https://doi.org/10.1016/j.amepre.2015.04.016Get rights and content

Introduction

Scalable self-management interventions are necessary to address suboptimal diabetes control, especially among minority populations. The study tested the effectiveness of a telephone behavioral intervention in improving glycemic control among adults with diabetes in the New York City A1c Registry.

Design

RCT comparing a telephone intervention to print-only intervention in the context of the A1c Registry program.

Setting/participants

Nine hundred forty-one adults with diabetes and hemoglobin A1c (A1c) >7% from a low-income, predominantly Latino population in the South Bronx were recruited from the A1c Registry.

Intervention

All study participants were mailed print diabetes self-management materials at baseline and modest lifestyle incentives quarterly. Only the telephone participants received four calls from health educators evenly spaced over 1 year if baseline A1c was >7%–9%, or eight calls if baseline A1c was >9%. Medication adherence was the main behavioral focus and, secondarily, nutrition and exercise.

Main outcome measures

Primary outcome was difference between two study arms in change in A1c from baseline to 1 year. Secondary outcomes included diabetes self-care activities, including self-reported medication adherence. Data were collected in 2008–2012 and analyzed in 2012–2014.

Results

Participants were predominantly Latino (67.7%) or non-Latino black (28%), with 69.7% foreign-born and 55.1% Spanish-speaking. Among 694 (74%) participants with follow-up A1c, mean A1c decreased by 0.9 (SD=0.1) among the telephone group compared with 0.5 (SD=0.1) among the print-only group, a difference of 0.4 (95% CI=0.09, 0.74, p=0.01). The intervention had significant effect when baseline A1c was >9%. Both groups experienced similar improvements in self-care activities, medication adherence, and intensification.

Conclusions

A telephone intervention delivered by health educators can be a clinically effective tool to improve diabetes control in diverse populations, specifically for those with worse metabolic control identified using a registry. This public health approach could be adopted by health systems supported by electronic record capabilities.

ClinicalTrials.gov Registration

NCT00797888.

Introduction

The prevalence of diabetes in New York City (NYC) increased from 4.2% in the early 1990s to 9.2% in 2004.1 Faced with increasing diabetes prevalence and suboptimal control of diabetes,2, 3 the NYC Department of Health and Mental Hygiene (DOHMH) expanded existing community programs and policy approaches to diabetes prevention and control by creating an A1c Registry (Registry). The Registry was created in 2006 following an amendment to the NYC Health Code mandating laboratories to report hemoglobin A1c (A1c) test results for NYC residents to the DOHMH. Using information in the Registry, the DOHMH planned to follow trends in glycemic control while providing broad-reaching, low-intensity Registry services to providers and patients across the city to support diabetes management.4 These services consisted of quarterly mailing of reports to healthcare facilities and providers containing a summary of glycemic control in their population compared with a citywide benchmark, a list of their patients stratified by A1c level for panel management, and motivational letters mailed to patients with high A1c values or who were overdue for an A1c test. These free services were initially offered to providers serving the South Bronx because of the high prevalence of diabetes in this predominantly Latino and lower-income neighborhood. The program was expanded over time, ultimately reaching up to 150 healthcare facilities serving approximately 20% of residents with diabetes.

Although provider performance feedback, panel management, and patient reminders such as those provided in the Registry program are components of effective quality improvement interventions,5, 6, 7 self-management support is an aspect of diabetes management that is essential in any environment.8 Previous research3, 9, 10 has found that self-management support delivered in person or by telephone can improve diabetes outcomes and may be delivered effectively by clinical11, 12 or community13, 14, 15, 16 providers. Telephone interventions are particularly appealing as they are relatively low cost, easily accommodated around individuals’ schedules, and may ameliorate health literacy challenges of print interventions. Given DOHMH’s interest in high-need South Bronx residents and under-representation of low-income Latino and black populations in RCTs, identification of a low-cost, community-based intervention to complement existing clinical management of diabetes and the DOHMH’s Registry program was important. We designed a study, “Bronx A1c,” to test the effectiveness of a tiered, tailored telephone intervention to improve glycemic control in adults with diabetes identified through the Registry. This report describes the main results of this study.

Section snippets

Methods

As previously described,17 eligible study participants were non-pregnant adults with type 1 or type 2 diabetes, aged >18 years, who had a recent A1c test >7.0%, had not opted out of receiving communications from the Registry, and lived in one of the ten ZIP codes of the South Bronx. The estimated number of people with diabetes living in the South Bronx at the start of recruitment was 35,000.18 Between September 2008 and October 2010, adults with an A1c test result >7.0% in the previous 3–6

Results

A total of 941 adults with diabetes were randomized, 31 of whom either died or withdrew informed consent (Figure 1). Study participants were: 67.7% Latino and 28.0% non-Latino black, with 69.7% being foreign-born (86.5% of Latinos and 31.5% of non-Latino blacks) and 55.1% Spanish-speaking; mean age was 56.3 years. The majority (77%) had an annual household income of <$20,000, and 91% of participants reported at least some healthcare coverage. There were no substantial differences at baseline in

Discussion

This report provides the main results of a telephone behavioral intervention to improve diabetes control in a predominately Latino, urban, low-income population living in the South Bronx, New York. The telephone intervention, incorporating print diabetes self-management materials, was associated with a significant decrease of 0.4% A1c more than the print intervention alone. These results compare favorably in terms of A1c lowering to monotherapy with some pharmacologic agents approved to treat

Acknowledgments

This study was funded by R18 DK 078077 and partially by P60 DK 020541. We acknowledge the outstanding contributions of our New York City Department of Health and Mental Hygiene (NYC DOHMH) health educators who contributed to study design and data collection, Giovanna DiFrancesca, BA, Danielle Powell, MPH, and Rosa Rosen, JD; NYC DOHMH Registry staff, Anita Richichi, MPA, who contributed grant management, Angela Merges, MPH, who supported recruitment activities, and Qun Jiang, MS, for assisting

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