A Home-Based Educational Intervention Improves Patient Activation Measures and Diabetes Health Indicators among Zuni Indians.

INTRODUCTION: One in three people will be diagnosed with diabetes by 2050, and the proportion will likely be higher among Native Americans. Diabetes control is currently suboptimal in underserved populations despite a plethora of new therapies. Patient empowerment is a key determinant of diabetes control, but such empowerment can be difficult to achieve due to resource limitation and cultural, language and health literacy barriers. We describe a home-based educational intervention using Community Health Representatives (CHRs), leading to improvement in Patient Activation Measures scores and clinical indicators of diabetes control. METHODS: Sixty participants with type 2 diabetes (T2D) completed a baseline evaluation including physical exam, Point of Care (POC) testing, and the Patient Activation Measure (PAM) survey. Participants then underwent a one hour group didactic session led by Community Health Representatives (CHRs) who subsequently carried out monthly home-based educational interventions to encourage healthy lifestyles, including diet, exercise, and alcohol and cigarette avoidance until follow up at 6 months, when clinical phenotyping and the PAM survey were repeated. RESULTS: PAM scores were increased by at least one level in 35 (58%) participants, while 24 participants who started at higher baseline score did not change. Six months after intervention, mean levels of A1C decreased by 0.7 ± 1.2%; fasting blood glucose decreased by 24.0 ± 38.0 mg/dl; BMI decreased by 1.5 ± 2.1 kg/m2; total cholesterol decreased by 12.0 ± 28.0 mg/dl; and triglycerides decreased by 52.0 ± 71.0 mg/dl. All of these changes were statistically significant (p < 0.05). CONCLUSION: This six month, CHR led and community-oriented educational intervention helps inform standards of practice for the management of diabetes, engages diabetic populations in their own care, and reduces health disparities for the underserved population of Zuni Indians. TRIAL REGISTRATION: ClinicalTrials.gov NCT02339311.

Building capacity to reduce disparities in diabetes: training community health workers using an integrated distance learning model.

PURPOSE: The purpose of this study is to determine whether an innovative interactive distance training program is an effective modality to train community health workers (CHWs) to become members of the diabetes health care team. The University of New Mexico Health Sciences Center has developed a rigorous diabetes training program for CHWs involving both distance and hands-on learning as part of Project ECHO™ (Extension for Community Healthcare Outcomes). METHODS: Twenty-three diverse CHW participants from across New Mexico were enrolled in the first training session. Participants completed surveys at baseline and at the end of the program. They attended a 3-day hands-on training session, followed by weekly participation in tele/video conferences for 6 months. Wilcoxon signed-rank statistics were used to compare pre- and posttest results. RESULTS: Participants demonstrated significant improvements in diabetes knowledge (P = .002), diabetes attitudes (P = .04) and confidence in both clinical and nonclinical skills (P < .001 and P = .04, respectively). Additionally, during focus group discussions, participants reported numerous benefits from participation in the program. CONCLUSIONS: Community health worker participation in the Project ECHO diabetes training program resulted in significant increases in knowledge, confidence, and attitudes in providing care to patients with diabetes. Studies are ongoing to determine whether the training has a positive impact on patient outcomes.

Partnering urban academic medical centers and rural primary care clinicians to provide complex chronic disease care.

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.

Expanding access to hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care.

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team-based interdisciplinary development. Using state-of-the-art telehealth technology, best practice protocols, and case-based learning, ECHO trains and supports primary care providers to develop knowledge and self-efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment-induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self-efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self-efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence.

Disparities in cardiovascular disease risk and treatment: demographic comparison.

BACKGROUND: Cardiovascular morbidity and mortality can be prevented by identification and modification of specific risk factors. Ethnic minorities have a higher incidence of cardiovascular risk factors. Additionally, ethnic minorities often reside in medically underserved areas and are subject to health care disparities. We hypothesized that ethnic minorities residing in medically underserved areas would experience greater health care disparities related to cardiovascular disease (CVD) prevention and treatment compared with those residing near an urban academic medical center. METHODS: We performed a retrospective chart review (N = 200) comparing an urban academic medical center with a rural community center. We evaluated the effects of ethnicity, demographics, and the absence or presence of CVD on cardiovascular risk factor prevalence, risk factor reduction, and CVD prevention and treatment. RESULTS: We found that Hispanics had more cardiovascular risk factors, including diabetes mellitus and low high-density lipoprotein cholesterol, compared with non-Hispanic whites. However, there were no ethnically based differences in risk factor prevalence by location. Additionally, ethnicity had no impact on the management of cardiovascular risk factors. However, patients with CVD residing in the rural location, regardless of ethnicity, received significantly fewer secondary prevention treatments compared with patients residing near the urban academic medical center, including aspirin or antiplatelets (p < .0001); beta-blockers or calcium channel blockers (p < or = .0001); diuretics, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers (p = .014); and statins (p < or = .0001). CONCLUSIONS: Hispanics have more CVD risk factors than non-Hispanic whites but receive equivalent prevention initiatives. Residing in a rural, medically underserved area, regardless of ethnicity, was associated with the largest CVD treatment and health care disparity.

Rimonabant: a novel approach for the treatment of obesity and cardiometabolic risk by blockade of the endocannabinoid system.

Obesity, the metabolic syndrome, diabetes and cardiometabolic risk are increasing at epidemic rates worldwide. Without interventions, the healthcare ramifications and costs of this epidemic will be astronomical. Current available treatment modalities have demonstrated limited effectiveness to deal with this metabolic epidemic. A novel metabolic pathway, the endocannabinoid system, plays a significant and direct role in appetite regulation, glucose homeostasis and lipid metabolism. Activation of the endocannabinoid system increases hunger and decreases satiety, and promotes insulin resistance and lipogenesis. Studies indicate that the endocannabinoid system is chronically activated in abdominal obesity and Type 2 diabetes. Additionally, blockade of the endocannabiniod receptor type-1 improves multiple cardiometabolic parameters and may represent a potential mechanism to combat obesity, metabolic syndrome, diabetes and other cardiometabolic risks. Rimonabant, a novel agent, blocks the endocannabinoid-receptor type 1, and results in weight loss, decreases in abdominal adiposity, improvement in glucose and lipid homeostasis and decreases components of the metabolic syndrome. It is the first therapeutic agent that inhibits the endocannabiniod system and improves multiple cardiometabolic parameters.

Reification of abstract concepts to improve comprehension using interactive virtual environments and a knowledge-based design: a renal physiology model.

Several abstract concepts in medical education are difficult to teach and comprehend. In order to address this challenge, we have been applying the approach of reification of abstract concepts using interactive virtual environments and a knowledge-based design. Reification is the process of making abstract concepts and events, beyond the realm of direct human experience, concrete and accessible to teachers and learners. Entering virtual worlds and simulations not otherwise easily accessible provides an opportunity to create, study, and evaluate the emergence of knowledge and comprehension from the direct interaction of learners with otherwise complex abstract ideas and principles by bringing them to life. Using a knowledge-based design process and appropriate subject matter experts, knowledge structure methods are applied in order to prioritize, characterize important relationships, and create a concept map that can be integrated into the reified models that are subsequently developed. Applying these principles, our interdisciplinary team has been developing a reified model of the nephron into which important physiologic functions can be integrated and rendered into a three dimensional virtual environment called Flatland, a virtual environments development software tool, within which a learners can interact using off-the-shelf hardware. The nephron model can be driven dynamically by a rules-based artificial intelligence engine, applying the rules and concepts developed in conjunction with the subject matter experts. In the future, the nephron model can be used to interactively demonstrate a number of physiologic principles or a variety of pathological processes that may be difficult to teach and understand. In addition, this approach to reification can be applied to a host of other physiologic and pathological concepts in other systems. These methods will require further evaluation to determine their impact and role in learning.

Patient knowledge improves glycemic control: is it time to go back to the classroom?

BACKGROUND: Over the last two decades, pharmaceutical intervention for the treatment of type 2 diabetes has expanded. Studies over this same time demonstrated the benefits of tight glycemic control. Unfortunately, despite the availability of novel therapies, glycemic control remains problematic. Nonpharmacologic interventions need to be explored, including patient empowerment. Improving patient knowledge of diabetes may ultimately improve glycemic control. To test this hypothesis, we compared patients' diabetes knowledge with their glycemic control. METHODS: The Michigan Diabetes Knowledge Test, designed by the University of Michigan, was administered to patients with type 2 diabetes at three University of New Mexico primary care clinics. Patient records were reviewed. The most recent hemoglobin A1c (HbA1c) value was recorded. The data were analyzed using linear regression analysis. RESULTS: Seventy-seven patients completed surveys and had HbA1c values available. Only questions 1 to 14 of the 23-question survey were used because they pertained specifically to type 2 diabetes. HbA1c was inversely correlated with the number of questions answered correctly on the test (r = -.337, p < .003). Using "all subsets" regression, a correct response to questions 1, 3, and 9 specifically correlated with a lower HbA1c (p < .0001). CONCLUSIONS: These results demonstrate that an inverse linear relationship exists between performance on this diabetes test and HbA1c values. Improvement in patient knowledge of diabetes and the importance of treatment may indeed improve glycemic control and ultimately decrease complications. Studies aimed at empowering patients with disease knowledge may help control the ramifications of the growing diabetes epidemic.

Methimazole-induced hypothyroidism paradoxically decreases homocysteine.

Clinical hypothyroidism is associated with hyperhomocysteinemia, whereas the opposite is seen in hyperthyroidism. The effects of mild thyroid dysfunction on homocysteine concentrations are not known. We performed the following study to investigate this. Total homocysteine, vitamins B6 and B12, folate, fibrinogen, plasminogen activator inhibitor type 1, and lipids were measured in 11 subjects at baseline and after methionine loading. Subjects began methimazole (MMI), 40 mg daily, and were restudied during 2 stages of hypothyroidism. Liothyronine was added and subjects were restudied once thyrotropin normalized. Methimazole was stopped and studies were repeated during 2 stages of hyperthyroidism. Data were analyzed using repeated-measures analysis of variance. Post-methionine homocysteine decreased in each hypothyroid study compared with baseline (28.8+/-10.7, 27.5+/-9.9 vs 34.4+/-9.2 micromol/L, respectively). In addition, both fasting and post-methionine homocysteine decreased in the euthyroid/MMI study arm compared with baseline despite equivalent thyrotropin values (fasting, 7.5+/-3.0 vs 8.8+/-3.5 micromol/L, P<.05; and post-methionine, 27.2+/-10.6 vs 34.4+/-9.2 micromol/L, P<.05, respectively). Fasting homocysteine decreased in the first hyperthyroidism study arm compared with baseline (6.6+/-2.3 vs 8.8+/-3.5 micromol/L, P<.05) and post-methionine homocysteine decreased in both hyperthyroid arms compared with baseline (25.2+/-8.1, 24.2+/-10 vs 34.4+/-9.2 micromol/L, P<.05 respectively). In conclusion, mild thyroid dysfunction changes homocysteine metabolism. Unexpectedly, our results suggest a homocysteine-lowering effect of MMI.

Potential association of thyrotoxicosis with vitamin B and folate deficiencies, resulting in risk for hyperhomocysteinemia and subsequent thromboembolic events.

OBJECTIVE: To describe a patient with severe thyrotoxicosis attributable to Graves' disease who had a thrombotic cerebrovascular accident and hyperhomocysteinuria, which resolved on correction of the thyrotoxicosis, and to present findings in a pilot study undertaken to investigate the relationship among thyrotoxicosis, homocysteine, folate, and vitamin B(12). METHODS: We present a case report of the index case, with clinical and laboratory details. For the investigative analysis, 21 patients who were 18 to 50 years old and had newly diagnosed, untreated Graves' disease and 10 age-and sex-matched euthyroid control subjects were studied. Of the patients with Graves' disease, 11 underwent studies both at diagnosis and after treatment. Fasting blood tests were performed for thyrotropin, free thyroxine, homocys-teine, vitamin B(12), folate, and methylmalonic acid, a marker of vitamin B(12) deficiency. RESULTS: Vitamin B(12), folate, homocysteine, and methylmalonic acid levels were not significantly different between the thyrotoxic and control or posttreatment groups. In patients with thyrotoxicosis, however, free thyroxine was positively correlated with both homocysteine (r = 0.67; P = 0.03) and methylmalonic acid (r = 0.89; P = 0.003). CONCLUSION: The positive correlation between free thyroxine levels and both homocysteine and methylmalonic acid suggests that thyrotoxicosis may be associated with functional vitamin B(12) deficiency. Such a deficiency may result in clinically important hyperhomocysteine-mia.