The Improving Primary Care of African Americans with Diabetes (IPCAAD) project

Abstract

African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.

Introduction

African Americans have a high prevalence of diabetes, primarily type 2 diabetes (T2DM). The prevalence of diabetes in African Americans has nearly tripled over the past 30 years 1, 2. Diabetes is present in 25% of African Americans 65 to 74 years of age [3]. The impact of diabetes is exacerbated by diabetes-related morbidity and mortality, which are higher than in the Caucasian population 4, 5. Moreover, the increased morbidity of diabetes for African Americans remains after adjusting for the effects of concomitant hypertension [6].

Although diabetes clinical outcomes are improved by good metabolic control, diabetes in African-American patients is often poorly controlled 7, 8, 9. A survey of 19 clinics in Florida revealed that African-American women were more than twice as likely as Caucasian women to have an HbA1c over 8.0%; these differences persisted after adjustment for age, type of treatment, time since diagnosis and obesity [10]. Significant racial differences were also found in North Carolina and South Carolina 11, 12. The care of urban patients appears to be particularly difficult, even in specialized diabetes units; in studies from Atlanta and Memphis reported in 1984, there was no significant improvement in metabolic control over a 10-year period [13]. Thus, increased diabetes morbidity in African Americans can be attributed largely to poor metabolic control 14, 15.

Such findings may reflect barriers to care such as poverty, limited access to care, family responsibilities that limit time for self-care, and instructional materials that may be inappropriate for patients with limited education and literacy 16, 17, 18, 19. Moreover, urban African-American patients may have difficulty in following diets with nontraditional foods and in understanding the usual “exchange” diets [20]. There may also be little family tradition of health-oriented behavior such as utilization of medical resources to optimize long-term health prospects [21].