The Burden of Diagnosed and Undiagnosed Diabetes in Native Hawaiian and Asian American Hospitalized Patients.

AIMS: Little is known about diabetes in hospitalized Native Hawaiians and Asian Americans. We determined the burden of diabetes (both diagnosed and undiagnosed) among hospitalized Native Hawaiian, Asian (Filipino, Chinese, Japanese), and White patients. METHODS: Diagnosed diabetes was determined from discharge data from a major medical center in Hawai'i during 2007-2008. Potentially undiagnosed diabetes was determined by Hemoglobin A1c ≥6.5% or glucose ≥200 mg/dl values for those without diagnosed diabetes. Multivariable log-binomial models predicted diabetes (potentially undiagnosed and diagnosed, separately) controlling for socio-demographic factors. RESULTS: Of 17,828 hospitalized patients, 3.4% had potentially undiagnosed diabetes and 30.5% had diagnosed diabetes. In multivariable models compared to Whites, Native Hawaiian and all Asian subgroups had significantly higher percentages of diagnosed diabetes, but not of potentially undiagnosed diabetes. Potentially undiagnosed diabetes was associated with significantly more hospitalizations during the study period compared to both those without diabetes and those with diagnosed diabetes. In all racial/ethnic groups, those with potentially undiagnosed diabetes also had the longest length of stay and were more likely to die during the hospitalization. CONCLUSIONS: Hospitalized Native Hawaiians (41%) and Asian subgroups had significantly higher overall diabetes burdens compared to Whites (23%). Potentially undiagnosed diabetes was associated with poor outcomes. Hospitalized patients, irrespective of race/ethnicity, may require more effective inpatient identification and management of previously undiagnosed diabetes to improve clinical outcomes.

Association Between Sustained Glycated Hemoglobin Control and Healthcare Costs.

OBJECTIVE: To examine the relationship between sustained glycemic control and health care costs among patients with diabetes with an initial hemoglobin A1c≥9%. STUDY DESIGN/METHODS: We conducted a retrospective analysis of administrative data from patients with diabetes and initial poor HbA1c control enrolled in a large health plan in Hawai'i (n=1304). We used propensity scores to identify a comparable cohort based on age, gender, type of coverage, diabetes duration, number of medications, location of residence, comorbidity conditions, and morbidity level. We examined the relationship between reduced A1c values and costs in the same year as well as the impact of achieving sustained A1c control (at < 7%)for three years on changes in health care costs using generalized linear models. RESULTS: In cross-sectional comparisons, the average annual direct medical costs for patients withHbA1c less than 7% was $14,821 compared to $12,108 for the matched sample of patients with A1c greater than or equal to 7%, for a difference of $2,713 95%CI[$285, $5,140]. In contrast, when we examined the change in cost from 2006 to 2009 for patients who had sustained levels of A1c at <7% for all three years, we found that total cost care for patients with sustained control decreased by $2,207 compared to a $3,006 increase for patients without sustained control, for a difference of -$5,214, 95%CI[-$10,163, -$264]. CONCLUSION: Our study suggests that while reducing hemoglobin A1c levels to target goals may not immediately result in cost reductions, sustained A1c control were associated with lower costs in a three-year time frame.

Improving patient education for patients with low literacy skills.

Patients who misunderstand their diagnosis and treatment plans usually exhibit poor compliance. The 90 million adult Americans with low literacy skills struggle to understand such essential health information as discharge instructions, consent forms, oral instructions and drug labels. The Joint Commission on Accreditation of Health Organizations (JCAHO) now requires that instructions be given on a level understandable to the patient. Most physicians tend to give too much information on too high a level for many patients to understand. Physicians who speak in simpler language, repeat their instructions and demonstrate key points, while avoiding too many directives, enhance their patients' understanding. Combining easy-to-read written patient education materials with oral instructions has been shown to greatly enhance patient understanding. To be effective with patients whose literacy skills are low, patient education materials should be short and simple, contain culturally sensitive graphics and encourage desired behavior. Compliance with therapy also may be improved by including family members in the patient education process.

Literacy and self-reported educational levels in relation to Mini-mental State Examination scores.

BACKGROUND AND OBJECTIVES: Because of its brevity and ease of use, the Mini-mental State Examination (MMSE) is commonly used to screen and follow patients with cognitive impairment. This pilot study attempted to determine the relationships between literacy, age, and self-reported educational level and the total MMSE score. METHODS: Cross-sectional analysis of all patients was followed by a family practice group at five local nursing homes. The associations between the patients' MMSE scores; literacy, as measured by the Rapid Estimate of Adult Literacy in Medicine (REALM); self-reported educational level; and age were determined using Pearson's correlation coefficient and stepwise multivariate linear regression. RESULTS: A total of 105 patients completed the study. Linear regression analysis showed that MMSE scores were significantly predicted by REALM score (P < .001) and the patient's age (P < .02). However, after accounting for REALM score and age, the self-reported educational level was not related to the MMSE score (P < .8). A significant relationship was seen between the REALM score and the subjects' self-reported educational levels (r = .44, P < .001) but not the subjects' ages (r = -.17, P < 0.09). A significant linear correlation was found between the MMSE and REALM scores (r = .71, P < .0001) and a significant inverse correlation was seen between MMSE scores and the patients' ages (r = -.28, P < .004). The correlation coefficient between the patients' MMSE scores and the self-reported educational levels was .33 (P < .0007). CONCLUSIONS: Practitioners who rely on the MMSE should be aware that patients may score in the demented range because they cannot read well enough to accurately complete the test. Literacy testing with REALM or other instruments may help identify such patients.