Faculty Bibliography

SOURCE CITATION:N Engl J Med. 2021;384:216-28. 33186492.

SOURCE CITATION/UNASSIGNED:Diabetes Obes Metab. 2020;22:1857-68. 32476254.

Racial and ethnic minorities in the U.S. experience higher incidence of and greater morbidity from chronic disease. Limited English proficiency (LEP) is a known contributor to these health disparities. The Culturally and Linguistically Appropriate Services (CLAS) standards of the U.S. Department of Health and Human Services promote health equity through the incorporation of professional interpreter services. While such services have been shown to improve quality of care, limited data exist on patient perspectives regarding these services. Better understanding patient experiences with telephone interpreter services (TIS), an increasingly used modality for professional interpretation, could elucidate ways of improving care for this population. This study explored Spanish-speaking patient experiences with TIS at an urban community clinic. Qualitative data collected via focus groups was analyzed using content analysis and grounded theory methods. Our findings suggest that TIS are generally well accepted by Spanish-speaking LEP patients. Limited relationship development with providers and physician attitudes toward TIS were among reported barriers to the use of these services.

BACKGROUND:Type 2 diabetes mellitus (DM) affects 9.4% of US adults and children, while another 33.9% of Americans are at risk of DM. Health care institutions face many barriers to systematically delivering the preventive care needed to decrease DM incidence. Community health workers (CHWs) may, as frontline public health workers bridging clinic and community, help overcome these challenges. This paper presents the protocol for a pragmatic, cluster-randomized trial integrating CHWs into two primary care clinics to support DM prevention for at-risk patients. METHODS:The trial will randomize 15 care teams, stratified by practice site (Bellevue Hospital and Manhattan VA), totaling 56 primary care physicians. The study cohort will consist of ~ 2000 patients who are 18-75 years of age, actively enrolled in a primary care team, able to speak English or Spanish, and have at least one glycosylated hemoglobin (HbA1c) result in the prediabetic range (5.7-6.4%) since 2012. Those with a current DM diagnosis or DM medication prescription (other than metformin) are ineligible. The intervention consists of four core activities - setting health goals, health education, activation for doctor's appointments, and referrals to DM prevention programs - adjustable according to the patient's needs and readiness. The primary outcome is DM incidence. Secondary outcomes include weight loss, HbA1C, and self-reported health behaviors. Clinical variables and health behaviors will be obtained through electronic medical records and surveys, respectively. Implementation outcomes, namely implementation fidelity and physicians' perspectives about CHW integration into the clinic, will be assessed using interviews and CHW activity logs and analyzed for the influence of moderating organizational factors. DISCUSSION/CONCLUSIONS:This is the first rigorous, pragmatic trial to test the effectiveness of integrating CHWs into primary care for DM prevention reaching a population-based sample. Our study's limitations include language-based eligibility and the use of HbA1c as a measure of DM risk. It will measure both clinical and implementation outcomes and potentially broaden the evidence base for CHWs and patient-centered medical home implementation. Further, the intervention's unique features, notably patient-level personalization and referral to existing programs, may offer a scalable model to benefit patients at-risk of DM. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov NCT03006666 (Received 12/27/2016).

IN BRIEF This article reports results from a patient-centered intervention to improve management of type 2 diabetes in the New York City Bangladeshi community. The DREAM (Diabetes Research, Education, and Action for Minorities) intervention is a randomized trial among Bangladeshi immigrants with type 2 diabetes comparing those enrolled in a community health worker (CHW) intervention to those in usual care. Participants in the intervention group received five group-based educational sessions and two one-on-one visits delivered by a trained CHW, whereas those in the control group received only the first group educational session. Main outcomes include changes in A1C, systolic and diastolic blood pressure, cholesterol, triglycerides, weight, BMI, and patient-centered outcomes such as knowledge and behavior related to type 2 diabetes management.

Background: Racial and ethnic minorities in the US, a large and growing population, experience higher incidence of and greater morbidity from chronic disease. Limited English proficiency (LEP) is a known contributor to these health disparities. The Culturally & Linguistically Appropriate Services standards promote health equality through the incorporation of interpreter services (IS). IS have shown improved quality of care, but limited data exist on patient perspectives of IS; particularly telephone interpreter services (TIS), an increasingly used form of IS. Better understanding patient experiences with TIS could elucidate ways of enhancing patient-centered care for this patient population; potentially improving health outcomes. Methods: Participants were recruited via flyers, telephone, and face-to-face encounters. They completed a semi-structured questionnaire and participated in a 1-hour, audio-recorded focus group. The focus group facilitator completed field notes after each group. Audio recordings were transcribed then analyzed by content analysis approach and grounded theory. Results: Thirteen individuals participated in 4 focus groups (Group1 n = 4; Group 2 n = 3; Group 3 n = 3; Group 4 n = 3). Participants were female (n=13), ages 33-73 years (mean 55), from Mexico (n=7), Ecuador (n=2), Dominican Republic (n=3), and Columbia (n=1), and had resided in the US for an average of 22 years (range 1-38). 70% reported poor self-rated English language ability (20% fair, 10% not reported). Ten thematic codes in 3 major domains (general attitudes, facilitators, barriers) were identified. Participants reported gratitude for TIS, perceiving TIS increased access to healthcare, and preference for TIS to family members as interpreters. Barriers to the use of TIS were concerns of confidentiality, lack of interpersonal development with physicians, and preference for language-congruent providers. Facilitators to the use of TIS were positive physician attitude toward TIS, physician framing of TIS as a tool in providing quality care, and assurance of accurate communication. Conclusions: Telephone interpreter services (TIS) are generally accepted by Spanish-speaking, LEP patients, and perceived as increasing access to care and assuring accuracy of medical communication. Participants seemed to balance accessing healthcare with concerns of confidentiality when using TIS. Overall, participants fell into two groups; one prioritized access to healthcare, timely and accurate, and the other prioritized relationship building with medical providers. The later was limited in TIS based encounters. Positive physician attitudes toward TIS facilitated their use. This highlights a need for healthcare provider awareness of the impact their attitudes have on patient experiences and acceptance of TIS, and for provider training on relationship building with use of TIS. Lastly, information gathered about patient preferences for language congruent providers speaks to a need for continuing workforce diversification efforts