The Effects of a Nurse Case Manager and a Community Health Worker Team on Diabetic Control, Emergency Department Visits, and Hospitalizations Among Urban African Americans With Type 2 Diabetes Mellitus

Abstract

Background Although African American adults bear a disproportionate burden from diabetes mellitus (DM), few randomized controlled trials have tested culturally appropriate interventions to improve DM care. Methods We randomly assigned 542 African Americans with type 2 DM enrolled in an urban managed care organization to either an intensive or minimal intervention group. The intensive intervention group consisted of all components of the minimal intervention plus individualized, culturally tailored care provided by a nurse case manager (NCM) and a community health worker (CHW), using evidence-based clinical algorithms with feedback to primary care providers (eg, physicians, nurse practitioners, or physician assistants). The minimal intervention consisted of mailings and telephone calls every 6 months to remind participants about preventive screenings. Data on diabetic control were collected at baseline and at 24 months by blind observers; data emergency department (ER) visits and hospitalizations were assessed using administrative data. Results At baseline, participants had a mean age of 58 years, 73% were women, and 50% were living in poverty. At 24 months, compared with the minimal intervention group, those in the intensive intervention group were 23% less likely to have ER visits (rate difference [RD], −14.5; adjusted rate ratio [RR], 0.77; 95% confidence interval [CI], 0.59-1.00). In on-treatment analyses, the rate reduction was strongest for patients who received the most NCM and CHW visits (RD, −31.0; adjusted RR, 0.66; 95% CI, 0.43–1.00; rate reduction ↓ 34%). Conclusion These data suggest that a culturally tailored intervention conducted by an NCM/CHW team reduced ER visits in urban African Americans with type 2 DM.

Community Health Worker Interventions to Improve Glycemic Control in People with Diabetes: A Systematic Review and Meta-Analysis

“…Participant attrition rates were high in some studies, reaching 50 % in the usual care (control) group of the trial performed by Babamoto et al 14 Only nine trials had a clinically meaningful follow-up of at least 12 months. [10][11][12][13][20][21][22][23][24] Of note, those nine studies also exhibited higher quality, and substantially lower risk of bias, than shorter-term studies. For example, all of them described the standardized method applied to measure A1c, and they all followed the intention to treat principle to analyze A1c changes.…”

“…[8][9][10][11][12][13][14][19][20][21][22][23][24] Table 1 describes the basic characteristics of those thirteen trials, including the setting for participant recruitment, duration of the study, and ethnicity of the study populations. Most of them studied minority populations, either AfricanAmerican, 13 Hispanics, 9,10,12,14,19,21,23,24 or both. 8 Allen et al recruited some White participants (21 % of their study sample), but the majority of their participants were AfricanAmerican.…”

“…19 The study by Babamoto et al had two control arms: in one control arm, the participants were managed by a diabetes nurse, and in the other control arm, participants continued to receive usual care from their primary care providers. 14 In three of the longer studies, the usual care provided by primary care providers was Benhanced^by either feedback to participants and PCP, 11 or regular telephone and mail contact with participants, with 13 or without 21 feedback to the PCP. In the two-year-long MATCH study, participants in the control arm were mailed 36 monthly issues of a diabetes education newsletter.…”

“…In eight of the studies, the CHWs worked on their own, whereas in the remaining cases, the CHW worked with either a certified diabetes educator, 19 a nurse and a dietician, 10 a nurse practitioner, 11 or a nurse case manager. 13,20 As described in Table 2, in all the studies, CHWs worked for a local non-profit organization. In most cases, they had received formal training in preparation for the study, and followed a well-defined intervention protocol.…”

“…Some trials showed a significant reduction in A1c, [8][9][10][11][12] while other trials did not. 13,14 Of note, there was methodological variability across studies, including sample size, target population, intervention protocols, and length of follow-up.…”