DIABETES IN RURAL AMERICA
by Betty Dabney and Annie Gosschalk
SCOPE OF PROBLEM
- Diabetes mellitus was
the sixth ranking leading cause of death in 1999.78
- Diabetes is an “ambulatory-care-sensitive”
condition.77
GOALS AND OBJECTIVES
America is in the midst of an epidemic of diabetes.
Approximately 17 million Americans, 6 percent of the population, are diabetic,
with another estimated 16 million having “pre-diabetes.”1-3 Type 2 diabetes
(formerly termed adult onset or non-insulin dependent) accounts for 90 to 95
percent of all cases and is primarily responsible for the increase in
prevalence over the past 10 years. Because the U.S. population is steadily aging
and is also disproportionately increasing in high-risk groups, the prevalence
of diabetes is expected to double by 2050.4
The nation’s vested interest
in addressing this public health crisis is articulated as follows in the
Healthy People 2010 goal relating to diabetes: “Through prevention programs,
reduce the disease and economic burden of diabetes, and improve the quality of
life for all persons who have or are at risk for diabetes.”5 Those at risk
include rural Americans by virtue of their unique demographic profile.
According to the Rural Healthy People 2010 survey, diabetes was identified as
the third highest-ranking rural health concern after access and heart disease
and stroke.6 Diabetes was consistently among the top five priorities in all
four geographic regions. The South, more than the other three
regions, rated diabetes as a priority¾the second-ranked rural priority in the
South. The difference across the regions fell just short of statistical
significance.7
This diabetes section
emphasizes the following HP2010 objectives:
- 5-1.
Increase the proportion of persons with diabetes who receive formal
diabetes education.
- 5-2.
Prevent new cases of diabetes.
- 5-3.
Reduce the overall rate of diabetes that is clinically diagnosed.
- 5-4.
Increase the proportion of adults with diabetes whose condition has been
diagnosed.
- 5-5.
Reduce the diabetes death rate.
- 5-6.
Reduce diabetes-related deaths among persons with diabetes.
- 5-7.
Reduce deaths from cardiovascular disease in persons with diabetes.
PREVALENCE
Diabetes impacts every area
of society. It occurs across all racial/ethnic and socioeconomic groups, but it
is two to five times more common in African Americans, Hispanics, Native
Americans, Pacific Islanders, and Asians.8-12 The
prevalence of diabetes varies by urbanicity and
degree of rurality. In 1995, the self-reported
prevalence of diabetes in non-metropolitan statistical areas (MSAs) of the U.S. was 17 percent higher than in central
cities and 11.7 percent higher than all MSAs (3.6
percent, 3.19 percent, and 3.24 percent, respectively).13 The prevalence of
diabetes may vary significantly across different rural regions of the country.
It is generally more common in the Southeast and Southwest.12, 14-16 Migrant farmworkers, estimated at 750,000 to 5 million, are also at risk. According to two studies of this group,
diabetes rose in rank from the sixth most frequent diagnosis or reason for
physician visits in 1980 to first place in 1986-1987.17, 18
The issue of rural-urban
disparities for diabetes is quite complex. Typically, diabetes is a more
serious problem in rural areas as they adopt a more “developed” or urban
lifestyle.19-21 As the differences between rural and urban lifestyles
disappear, higher rural prevalences may reflect
differences in socioeconomic, racial/ethnic, or age status, more so than rurality per se. However, rural-urban disparities in
diabetes are more pronounced for African Americans.22
IMPACT
Diabetes was the sixth
leading cause of death in the U.S. for the year 2000, accounting for a
preliminary 68,662 deaths in 2000.23 Death rates for diabetics are two times
higher than for non-diabetics and higher for both genders and for all ages and
races.24 Diabetics are two to four times more likely to die from heart disease;
those with pre-diabetes are twice as likely to die from heart disease.3, 25
Diabetes is the leading cause of deaths from kidney disease.26
Mortality from diabetes is
not geographically uniform and follows a similar pattern to prevalence rates,
with age-adjusted death rates generally highest in the Southeast and
Southwest.27 As with prevalence, racial/ethnic differences account for much
larger differences in mortality from diabetes than rural-urban differences.28,
29
Diabetes is the sixth leading
cause of hospitalization in the U.S. for men at least 45 years old and the
seventh overall cause for women of comparable ages.30 In 1996, diabetes
accounted for 3.8 million hospital discharges, 64 million physician office
visits, 1.2 million emergency room visits, 14 million work-loss days, and 88
million disability days.31
Diabetes also has major
consequences for virtually every system in the body that may become chronic,
debilitating, and costly to the health care system and to quality of life. Besides
cardiovascular disease, diabetes is a major risk factor for end-stage renal
disease, peripheral neuropathy, nontraumatic limb
amputations, blindness, lipid abnormalities, impotence, periodontal disease,
infections, and depression.25, 26, 32-35 The duration
of the disease is a major factor for development of complications.36-38 This is
a major concern for the increasingly younger age of onset of type 2 diabetes.
Gestational diabetes is
associated with pregnancy complications, increased neonatal morbidity and
mortality, birth defects, and increased risk for developing diabetes in both
mother and child.1, 25, 39, 40
Type 2 diabetes is closely
associated with obesity, and the sedentary, high-fat American lifestyle is
thought to be largely responsible for the epidemic sweeping the world.41
Obesity and lack of leisure activity are also more common in rural than in
urban areas.30
Other factors contributing to
development of type 2 diabetes are genetics,42-45
lower socioeconomic status,9, 11, 12, 46-49 belonging to a minority group or
the female gender, gestational diabetes, lack of early detection,50-52 acanthosis nigricans,53 and possibly exposure to certain
environmental chemicals.54-56
BARRIERS
The American health care
system has not been very effective in preventing, diagnosing, or managing
diabetes, especially in rural and low-income patients.31, 57-61 Rural residents
are less likely to visit doctors and to receive specialized care or adequate posthospital home health care.57, 62-66 Rural residence is
also a significant risk factor for never receiving an ophthalmic examination,65 which can detect early signs of diabetic retinopathy.
Other challenges to slowing the epidemic, irrespective of location, include
personal lifestyle choices relating to diet and exercise (see the Nutrition and
Overweight section).49
PROPOSED SOLUTIONS
While improving all detection
and treatment methods in rural areas is desirable, the Diabetes Prevention
Program Research Group recommends prevention as the preferable approach.67 The
onset and progression of type 2 diabetes and its complications can be delayed
or prevented by significant changes in lifestyle that are feasible to implement
in rural communities, including modest exercise and weight loss.67-69
Where prevention has not been
possible, the risk of developing complications can be minimized by effective
metabolic control, regular examinations, and patient education.25, 26, 70-72
Based on strict review of published studies, the HHS Task Force on Community
Preventive Services recommends four types of interventions for reducing
morbidity and mortality from diabetes. These are case and disease management by
health care providers, community-based self-management education programs for
adults with type 2 diabetes, and home-based programs for children and
adolescents with type 1 diabetes.73
Most published community
studies address only one component of diabetes education, prevention,
detection, and care. While many innovative programs record short-term success,
few demonstrate long-term improvement in clinical outcomes.74 New
cost-effective approaches need to be developed around a chronic disease
model,75, 76 using the existing health care and public health infrastructure,
and based upon preventive and routine patient care clustered at the community
level by allied health professionals.
Summary and Conclusions
The prevalence of diabetes is
somewhat higher in rural than in urban areas, but racial/ethnic, socioeconomic,
and lifestyle factors appear to be stronger risk factors for diabetes than
rural residence. Compounding the problem in rural areas are limited resources
to effectively diagnose and manage diabetes, reinforcing the need for an
emphasis on prevention efforts. All types of prevention have a place in
management of diabetes from a medical and public health perspective, but
primary prevention is ultimately the most cost effective and the most desirable
from an ethical standpoint. Unchecked, the diabetes epidemic will produce an
intolerable burden on the health system and quality of life over the next
generation.
MODELS FOR PRACTICE
The following models for
practice are examples of programs utilized to address this rural health issue.
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MODELS FOR
PRACTICE
FOCUS AREA: DIABETES
Program Name: Diabetes Collaborative
Location:
Laurel Health System, Wellsboro, Pennsylvania (Tioga
County)
Problem Addressed: Diabetes and Access to Primary Care
Healthy People 2010 Objective: 1-9
Web Address:
http://www.laurelhs.org; http://www.tiogapartners.org
The Laurel Health System (LHS), with its six
Federally Qualified Health Centers (FQHCs), is a
participant in a national diabetes collaborative. The
collaborative supports a systematic approach to diabetes care and management
and development of an electronic registry of patient data in the primary care
environment.
This model reflects improved access to quality
primary care addressing medical conditions (such as diabetes, hypertension, and
asthma) for which improved primary care management results in reduced
hospitalization. It includes a diabetes electronic management system that:
The model enhances clinical care enhancement and
promotes the effective use of a countywide health partnership to extend
effective prevention and primary care interventions for diabetes to other
providers and to people in the community.
Blueprint: Beginning in January 2000, LHS’s health centers were accepted for participation in the
National Diabetes Collaborative. By participating, the health centers were able
to establish a systematic approach to diabetes treatment and electronic
management of patient data. Beginning with the patients in one of the six FQHCs, the program was implemented at all six centers over
the next nine months. A key element in the program, the Diabetes Electronic
Management System (DEMS), is a registry for all Laurel Health
Center patients with
diabetes. When a patient with diabetes schedules an appointment, a DEMS report
is printed, attached to the patient’s chart, and employed by the nurse or
clinician with the patient in reviewing the patient’s condition and engaging
the patient in continuing self-management of diabetes. The registry supports
ongoing analysis of the impact of this program upon patients’ health status and
cost of treatment. This analysis is supported by IMPACT software specially
designed for organizations participating in the diabetes collaborative program.
The diabetes collaborative model, fully implemented at LHS’s
FQHCs, is currently being extended, under the
sponsorship of the countywide health partnership and regional Area Health
Education Center (AHEC), to other primary care providers in this rural county.
Making a Difference: Beginning in January 2000, the use
of DEMS and education for clinicians and office staff on diabetes management
produced immediate small improvements in diabetes outcomes. These improvements increased and
affected more patients as the program was extended to all of the six health centers
over the next nine months. The program collects the following data on patients
with diabetes: percent with HbA1c measured yearly; percent
maintaining HbA1c <8 percent, percent with annual foot exam,
percent with influenza and pneumovax immunizations,
percent controlling blood pressure at <135/85, and percent with an annual
lipid profile performed. As of April 2002, there is documentation of an average
Hemoglobin A1c (HbA1c) of 7.1 in a population of 622
diabetic patients, with an average total cholesterol
of 201 and an average LDL of 110. These factors have been demonstrated to
decrease diabetic morbidity and mortality from secondary end organ failure
(such as renal failure or heart failure secondary to diabetes). Cost savings
for averted stroke, myocardial infarction, or coronary artery bypass graft are
estimated at between $10,000 and $20,000 for each occurrence. Conversely,
primary care revenue increased as a result of the more aggressive disease
management in the first year of the program. The population of focus, 116
patients in the pre-collaborative year, yielded 115 diabetic patient visits
with a revenue of $5,410 compared to 550 visits and
$27,827 in the first year of the collaborative.
Beginnings: The
model grew out of a community needs assessment sponsored by the countywide
Tioga County Partnership for Community Health (TCPCH) in 1994. The assessment
found the self-reported diabetes rate in Tioga County
to be one-quarter higher than the national average (8 percent versus 6 percent,
nationally). The 1998 county mortality rate for diabetes at 20.2/100,000 was 45
percent higher than the state average. Beginning in 1995, patient education and
community health education components for diabetes were implemented by LHS, a
local integrated rural health system within the county. LHS’s
Laurel Health Center Diabetes Education and Nutrition Counseling program was
launched shortly after the local study. In 1996, a few providers from among the
six FQHCs began ongoing evaluation of HbA1c levels
and provision of specified care.
Challenges and Solutions: The diabetes collaborative is
associated with a northeast regional cluster of such initiatives supported by
U.S. Health Resources and Services Administration’s Bureau of Primary Health
Care. The program has become institutionalized in diabetes treatment within the
LHS FQHCs. At the same time, additional grant funding
has been attained from the Pennsylvania Department of Health by the county
partnership (TCPCH) to extend the LHS diabetes collaborative model to other
primary care providers inside the county but outside the LHS umbrella. The
success of the diabetes collaborative has led LHS to seek similar benefits for
other conditions. It recently became a participant in the national
cardiovascular collaborative.
Karen Usavage, RN, CRNP, Health Center
Administrator
Laurel Health System, Diabetes Collaborative
15 Meade
Street
Wellsboro, PA, 16901
Phone: (570) 724-5200
Fax: (570) 724-4885
MODELS FOR
PRACTICE
FOCUS AREA: DIABETES
Program Name: Delta
Community Partners in Care
Location: Clarksdale, Mississippi
Problem
Addressed: Diabetes/Hypertension
Healthy People 2010 Objective: 5, 12
Web Address: None
Delta Community Partners in Care (DCPIC) is a
coalition of 19 partners serving a 10-county rural area in the Mississippi
Delta region of northwest Mississippi.
This region’s economy is based primarily on agribusinesses associated with
raising soybeans, cotton, and catfish. This is a historically underserved area
for health care, where 29.5 percent of the population lives below poverty. Its
target population is the uninsured or underinsured between the ages of 21 and
64 who have a diagnosis of diabetes, hypertension, or both. The demographics
are 92.1 percent African American, 7.6 percent white, and 0.3 percent other.
DCPIC attempts to reduce the barriers affecting its
target population by providing outreach case management services. These
services include case management, financial assistance, transportation to
provider clinics for assistance, referral and follow-up of social issues
presenting barriers to a patient’s response to care, individualized health
education/self-care planning, and organized support services, such as support
groups, walking groups, etc. Community health education programs are also
provided for the community residents throughout the target area.
Blueprint: DCPIC is a 501(c)(3)
non-profit organization with a Board of Directors and elected officers. The
original stakeholders are still involved in the program. The operation has
grown to include 19 collaborative partners: four hospitals, four Federally
Qualified Community Health Centers (FQHC), three rural health centers, two
state department of health districts, one mental health center, three state
agencies, and two federally funded agencies. Currently, funding is from the
Health Resources and Services Administration (HRSA), and DCPIC has an advisory
council composed of representatives from the partnership members. The lead
agency for the HRSA grant is one of the original members and an FQHC. Staff
includes five persons at the central office and a caseworker at each of the 19
clinical sites.
DCPIC uses a community-based case management model to
improve the health status and risk factors in its target population.
Caseworkers are trained social workers, nurses, and lay health workers who work
directly with patients who have a diagnosis of diabetes, hypertension, or both.
The caseworkers use a holistic approach, and the environment is such that the
caseworkers and patients are able to learn from each other. As required by HRSA
funding, they use several prevention indicators: reminders for doctors to
perform foot checks, Hemoglobin A1c (HbA1c) tests every
six months, and annual eye exams.
Making a Difference: From its modest beginnings, DCPIC
has grown to provide comprehensive community-based education, prevention, and
treatment services for 1,570 patients. In this growth, they developed extensive tools and
materials for their program. A baseline survey provides a patient profile at
enrollment; all tracking and data collection forms are standardized, and
training materials have been developed for staff. Health status surveys,
knowledge assessments, health profiles, and patient satisfaction surveys are
used to gather information on the program’s success. Indicators employed not
only measure the effectiveness of the program but are also used to identify key
policy issues for change. These indicators are decreases in multiple clinic
utilization, emergency services utilization for primary care, the number of
nights hospitalized, and the amount of sick and bed days; an increased
knowledge of high blood pressure and diabetes, an increased utilization of
primary care, health status changes, better blood pressure and sugar control,
patient satisfaction, and improved overall health. The University of Mississippi Research Institute of Pharmaceutical Sciences
provides ongoing statistical analysis and outcomes assessments.
In their Final Outcome Evaluation in 1999, prepared
by the University of Mississippi Preventive Medicine Department,
many successful outcomes were reported. Of the clients currently enrolled at
the time the data were collected, emergency room utilization in the past year
had decreased significantly from 1.01 visits to 0.65 from time of entry into
the program to the time of the study. The number of outpatient visits in the
last year decreased from 0.68 to 0.31; and of the patients hospitalized in the
past year, the number of nights stayed decreased as well from 6.37 nights to
3.40. The number of sick days in the past year also declined, dropping from
26.74 days to 15.77. Not only did the physical health of the enrollees seem to
improve but their knowledge of their conditions did as well. Knowledge of both
hypertension and diabetes increased significantly, corresponding with an
increase of the patients’ ability to control their own blood pressure and blood
sugar. A new study is currently being planned comparing patients who have been
in the program since its inception to newer patients, for the 21 to 64-year-old
age group.
Beginnings: DCPIC
began as a vision of the Northwest Mississippi Regional Medical Center (NWMRMC)
in Clarksville,
from concerns in the local medical community. Greater than expected numbers of
patients were presenting in the emergency rooms or were found to have
previously undiagnosed diabetes, were suffering strokes, or were requiring
amputations. Young patients were also developing hypertension and strokes. The
uninsured and underinsured chronically ill population faced many barriers in
accessing health care services that resulted in poor health outcomes. Community
meetings were held to identify these barriers as well as other existing
problems within the health care systems.
It was originally a grassroots operation involving
four hospitals, one community health center, three state agencies and three
rural health centers, to serve a five-county area. DCPIC received a planning
grant from the W.K. Kellogg Foundation for the period from May 1, 1994, through
April 30, 1995. The planning committee consisted of representatives from
NWMRMC, health care providers within a 15 to 30-mile radius of NWMRMC, and the
Mississippi Division of Medicaid. During the planning stage, meetings were held with providers in each county. The planning was implemented in
1996, and funding ended in 1999. DCPIC had a HRSA Community Access Program
(CAP) grant for evaluating sustainability.
Challenges and Solutions: Initial funding ended in 1999, creating a challenge to
program continuation. DCPIC is brought to the attention of potential funders through presentations at state and national
conferences as well as in published articles. Funding is continuously being
sought; however, the program has maintained its focus.
Lela Keys
Delta Community Partners in Care
P.O. Box 1218
Clarksdale, MS 38614
Phone: (662) 624-3484
Fax: (662) 624-3203
E-mail: lbkeys2@bellsouth.net
MODELS FOR PRACTICE
FOCUS AREA: DIABETES
Program Name: Holy Cross
Hospital Diabetes Self-Management Program
Location: Taos,
New Mexico
Problem Addressed: Diabetes
Healthy People 2010 Objective: 5
Web Address:
http://www.taoshospital.org
The Holy Cross Hospital (HCH) Diabetes
Self-Management Program (DSMP) is a participant in the NMMRA (New Mexico
Medical Review Association) Diabetes Collaborative. HCH DSMP offers four
curriculum visits covering 15 content areas from the National Standards and an
integration of community specialists, at no cost to the patients, to provide a
weekly exercise class, bimonthly coping skills education, a monthly diabetes
support group, and annual foot exams. HCH DSMP also has an electronic patient
registry using the DEMS-Lite software. Currently, the
Diabetes Self-Management Program at Holy
Cross Hospital
can offer 100 percent access to quality diabetes education and support
regardless of an individual’s ability to pay.
Blueprint:
Susan Kargula, RN, MSN, CDE (Certified Diabetes
Educator) began the Diabetes Self-Management Program in 1992 at Holy Cross
Hospital as one of the hospital’s community wellness programs. HCH DSMP serves
the rural area in northern New Mexico, which
encompasses Taos County (population size 26,556, population
density =12) and several surrounding smaller rural areas such as Penasco, Questa, and Angel Fire. It is estimated that 2,586
individuals within the community have diabetes, and the ethnicity of the target
population is predominately Hispanic (66.3 percent) and white. HCH DSMP offers
four curriculum visits and follow up as necessary in
an individual and group setting for adults with type 1, type 2, and gestational
diabetes. The four curriculum visits cover the 15 content areas from the
National Standards: “diabetes overview and initial assessment; blood glucose
monitoring and use of results; medications; nutrition; exercise and activity;
stress and psychosocial adjustment; family involvement and social support;
relationships among nutrition, exercise, medication, and blood glucose levels;
prevention, detection, and treatment of acute and chronic complications; foot,
skin, and dental care; behavior change strategies; goal setting and risk factor
reduction; problem solving; benefits, risks, and management options for
improving glucose control; preconception care, pregnancy, and gestational
diabetes; and use of health care systems and community resources.”
Grant awards have made it possible for weekly
exercise classes, bimonthly coping skills education, a monthly diabetes support
group, and annual foot exams to be offered to patients at no cost by a
community specialist. These community specialists include a medical director,
exercise physiologist, stress reduction specialist, and certified pedorthist (a trained professional who specializes in
designing or modifying footwear to alleviate problems associated with injury or
disease¾such
as diabetic foot). To be considered for the program, patients must have written
referrals through their primary care physician. If self-referred, a DSMP staff
member assists the individual in obtaining a written referral prior to the
initiation of services. The HCH DSMP staff also obtain
registration information, insurance prior authorizations, Medicare coverage,
and ensure coverage for uninsured patients through grants and hospital in-kind
donations. The education portion of the program is either provided
individually, or in some cases, in a group setting (e