MARCO LEGAL

P9.01

The Progression From Prediabetes to Diabetes –– Impact of Social Determinants of Health

June O’Leary,1 _{Ning Fu,}1 _{Glenn Melnick,}1 _Joyce

LaMori,2 _{Janelle Howe,}3 _{Jeremy Rich}4

1_{University of Southern California, Los Angeles, CA;} 2_{Janssen Scientific Affairs, LLC, Los Angeles, CA;} 3_DaVita

HealthCare Partners, El Segundo, CA; 4_HealthCare

Partners Institute for Applied Research and Education, El Segundo, CA

Background: It has been said “your zip code matters more than your genetic code” when discussing the impact of a person’s neighborhood on life expectancy in the U.S. This

finding is embedded in the social determinants of health

–– factors like education, income, and race, which impact where people live and their health outcomes. There is limited evidence of the importance of social determinants of health to the risk for developing type 2 diabetes. Methodological

limitations and varying endpoints make it difficult to

generalize or reach clear conclusions regarding the relative importance of different factors. We utilize a large and diverse sample of patients from an integrated care system in the greater Los Angeles area (DaVita HealthCare Partners) to investigate the impact of several social determinants of health on the likelihood of transitioning from prediabetes to diabetes. Prediabetes, in which blood glucose levels are elevated above normal levels but not quite high enough to be considered diabetes, is a high-risk state for developing diabetes. It was recently estimated that one-third of younger adult Californians, those age 18–39 years, have prediabetes.

Methods: Using Census zip code-level data from the

American Community Survey, we identified 10 social

determinants of health that have been found to be associated with type 2 diabetes. These zip code-level variables were included in a multivariate regression model of the transition from prediabetes to diabetes, controlling for several individual-level risk factors.

Results: For 2007, 19,021 patients were identified with a

an additional 12,673 were identified. Descriptive analysis

of zip codes suggested that higher rates of transition over

the 10-year study period occurred in less affluent, Hispanic

neighborhoods. After controlling for multiple individual- level risk factors, our preliminary analysis indicated small

but statistically significant associations between transitioning

from prediabetes to diabetes with neighborhood educational attainment, household income level, and home value.

Conclusion: Further investigation into the social determinants of health and their role in the development and progression of diabetes may provide opportunities for the health care system to cost-effectively target resources.

Keywords: geographic/spatial factors, social determinants of health, diabetes, small-area analysis

P9.02

Understanding Diabetes Management Among Hispanics at Kaiser Permanente Northwest

Dea Papajorgji-Taylor,1 _{Jennifer Schneider,}1 _Inga

Gruss,1 _{David Mosen,}1 _{Nangel Lindberg}1

1_{Kaiser Permanente Center for Health Research, Portland,}

OR

Background: The Kaiser Permanente Northwest (KPNW) region has reported a 12.6% gap in rates of glycemic control between Hispanic and non-Hispanic white patients, with a lower proportion of Hispanic patients showing adequate levels of glycemic control (A1c > 8%). While recognizing that the term “Hispanic” is used to describe a highly heterogeneous population of diverse sociocultural backgrounds, it is critical to identify nuanced and contextualized factors that contribute to this gap in health outcomes, particularly in the context of a comprehensive medical care organization. Relying on qualitative data collection, this study explores sociocultural factors that might help explain suboptimal levels of diabetes control in this population. The goal is to identify actionable elements to improve care and support for patient self-care.

Methods: The study team has partnered with a KPNW primary care provider (PCP) panel serving Hispanic patients diagnosed with type 2 diabetes to conduct a qualitative pilot study. From the PCP’s Hispanic patient panel, individuals with A1c > 8% will be invited to participate, which involves direct observation of medical encounters between PCPs and patients as well as individual in-depth telephone interviews with both patients and PCPs. Observations and interviews

will center on identification of factors that may help optimize

patient-provider communication and patient adherence to diabetes self-care recommendations.

Results: This is an ongoing study. By the expected completion date (December 31, 2017), we hope to provide thematic summaries regarding Hispanic patients’ experience in receiving diabetes care at KPNW, barriers and facilitators of optimal patient-provider communication, patient diabetes self-care, and adherence to treatment recommendations.

Conclusion: Conclusions from this study will identify gaps in equitable care and inform efforts to improve culturally competent practice in diabetes care.

Keywords: cardiovascular disease, observational study, primary care, patient-provider communication, engagement of stakeholders, racial/ethnic differences, social determinants of health, diabetes, qualitative research, chronic disease, patient experience/satisfaction

P9.03

Use of Interpreter Flag in Determining Eligibility for Studies Conducted at Kaiser Permanente Washington Health Research Institute: Mining Information From the Survey Research Program

Paula Sandler,1 _{Luesa Jordan,}1 _{Matthew Nguyen,}1

Megan Baldwin1

1_{Kaiser Permanente Washington Health Research Institute,}

Seattle, WA

Background: As a shared resource for Kaiser Permanente Washington Health Research Institute, the Survey Research Program (SRP) contacts thousands of participants annually via phone, mail, and web-based surveys. Inevitably, there are participants unable to participate either because they are non-English speaking or hearing impaired. Since 2014,

only one of more than 50 fielded phone room studies

used Spanish-bilingual interviewers. Teletypewriter and/ or video relay services are available to participants with a hearing impairment, but the participant must initiate use of the technology. The electronic health record (EHR) has an

“Interpreter flag” field that identifies members requiring an

interpreter, including American Sign Language. Some studies

utilize the Interpreter flag as an exclusion criterion. Together,

this tells us that non-English speaking and hearing-impaired individuals may not be invited to participate in studies or, if invited, not able to participate. Using data in the SRP database, augmented by information from the virtual data warehouse (VDW), we will investigate how the Interpreter

flag is currently used and how to better utilize it in the future.

Methods: We identified approximately 50,000 unique

participant records from 24 studies in which the SRP attempted telephone contact from 2014 to present. We

used the VDW to obtain the Interpreter flag status for

our sample. We used process and outcome variables (call

disposition, study type, final status), basic demographic

variables (date of birth, gender, ethnicity, race), and

Interpreter flag (checked vs unchecked) to determine: Is the interpreter flag a predictor of final outcome? (complete vs

“ineligible: language,” “ineligible: hearing impaired,” and “refused, unable to reach”). Seven of the 24 studies used the

Interpreter flag as one of their exclusion criteria. How did

response rates differ between those studies and studies that did not use that exclusion? What is the age, race/ethnicity,

How often did SRP initiate contact with individuals who could not participate due to language barriers or hearing impairments? Could those individuals have been

preidentified by the Interpreter flag? Could study materials

or procedures be tailored to allow for individuals with these barriers to participate?

Results: Across all 24 studies, only 2.1% of the participants were determined to be ineligible for study participation

compared to 21.8% for those with an Interpreter flag. Of

the 1067 who were determined to be ineligible, 328 (30.7%) were due to hearing and language barriers. Nearly all of

those with an Interpreter flag were screened out due to

language. Completed interviews or successful recruitment

were achieved for 40.6% of those having an Interpreter flag

as compared to 44.8% of participants without. A smaller

percentage of respondents with the flag refused or were

unable to be reached, suggesting that, if enabled, they might

be more likely to participate than those without a flag.

Conclusion: Participants with an Interpreter flag were

much more likely to be determined ineligible for study

participation, and almost all of those identified as ineligible

were so due to a language barrier. While 25.3% of all participants were ineligible due to language barriers, this

was 98% of those with the Interpreter flag.

Keywords: survey research and methods, demographics, access to services

P9.04

Depression Screening and Education: Options to Reduce Barriers to Treatment (DESEO): Primary Outcomes From a Culturally Adapted Education Intervention to Increase Treatment Engagement Among Hispanics in Primary Care

Katherine Sanchez1

1_{Baylor Scott & White Health, Dallas, TX}

Background: In 2014, the Centers for Medicare & Medicaid Services’ Hispanic Health Services Research Grant Program funded the Depression Screening and Education: Options to Reduce Barriers to Treatment (DESEO) project to implement an education intervention designed to increase disease literacy and dispel myths about depression and its treatment among Hispanic patients, thus reducing stigma and increasing treatment engagement.

Methods: Universal depression screening was implemented for all adult patients during visits with their primary care providers using the 9-item Patient Health Questionnaire (PHQ-9). Depressed patients (PHQ-9 score > 10) then completed the 7-item Generalized Anxiety Disorder assessment (GAD-7) and were invited to participate in the study. DESEO utilized a one-group pretest-posttest design to assess a culturally adapted depression education intervention (a comic book-style fotonovela) within a sample of 350 depressed Hispanic patients. The Depression

Knowledge Measure (DKM) was used to evaluate the effect of the education. Three stigma measures were used to assess stigma associated with depression. Statistical tests of the demographics were completed and differences examined. Various bivariate statistical tests, including t-tests, chi- squared (𝜒2_{), and Fisher’s exact, were used for changes in}

participant-reported scores over time as well as repeated- measures analysis of variance. Multinomial logistic regression was used to test the association between the self- report measures from follow-up and the likelihood of the treatment-engagement categories.

Results: Overall, participants reported significantly lower

scores for self-reported depression, anxiety, and mental health stigma measures at second session and at 30-day follow-up compared to baseline. These changes included average PHQ-9 scores decreasing from 17.53 at baseline to 9.47 at follow-up (P<0.001), GAD-7 scores decreasing from 12.97 to 7.62 (P<0.001), and Stigma Concerns About Mental Health Care decreasing from 0.43 to 0.10 (P<0.001). Additionally, participants reported increased knowledge in depression but also greater concern and negative perceptions about antidepressant medication. Finally, a majority of participants reported entering some form of treatment at follow-up (273 of 305, 89.5%).

Conclusion: DESEO addressed the need for early

identification of depression, and the culturally adapted

education intervention increased knowledge of the disorder,

reduced stigma, and led to significant engagement in

treatment, which has implications for reducing the morbidity of related medical illnesses.

Keywords: primary care, behavioral and mental health, racial/ethnic differences, social determinants of health, social work