This document summarizes an evaluation of five programs funded by The Merck Company Foundation to reduce disparities in diabetes care. The programs implemented multicomponent interventions including patient education, clinician cultural competency training, and health system changes. Data was collected from over 1,000 patients and showed significant improvements in clinical measures like HbA1c and blood pressure, as well as patient-reported outcomes regarding diabetes competence, self-management, and self-care. While not randomized trials, the results suggest these types of multilevel interventions can effectively improve outcomes and reduce disparities for those with diabetes.

1. Evaluation of Multicomponent Interventions to Enhance Outcomes and Reduce
Disparities among Diverse Patient Populations
1 1 2 3 4 5 6 7 1
Megan A. Lewis, Pamela A. Williams, Jeffrey Brenner, Patria Johnson, Kathy Langwell, Monica Peek, James Walton, Noreen M. Clark, and Douglas Kamerow *
Abstract 2. Interventions 3. Cross-Site Evaluation (continued) 4. Preliminary Results (continued) 5. Discussion
The Alliance to Reduce Disparities in Diabetes, sponsored by The Merck Although the interventions vary across the programs, the focus is on three Program Participants Table 3. Patient-Reported Measures Aggregated Across All Grantees Although these five programs are not randomized controlled trials,
Company Foundation, is a consortium of five grantees, a National Program core components: comparisons of clinical and patient-reported measures from baseline to
Office, and an external evaluator. The Alliance integrates innovative Table 1 presents the demographic characteristics for program participants Number t-test follow-up show improvements across almost all measures, including both
■■ Patient Component: Patient education included community, small who currently have baseline and follow-up measures, and are included Outcome of Sites Time Mean N Min Max (p-value)
professional and patient education and quality of care improvements clinical and behavioral outcomes.
group, and individual materials, classes, and discussions. Curricula in the cohort analysis. The average time between baseline and cohort
aimed at vulnerable patients, and focuses on reducing disparities in 3 Baseline 5.2 126 1.0 7.0
included topics such as the basics of diabetes; food diary instructions measures is 1 year. Diabetes Competence
diabetes care and enhancing outcomes through clinical and community 3 Follow-up 5.9 126 1.4 7.0 0.000
and healthy eating tips; physical activity and exercise; goal setting; “I think the fact that they were able to go [work out] together
interventions. Five project sites involving key community stakeholders in
glucose monitoring; fat and calorie education; HbA1c, BP, and cholesterol Table 1. Demographic Characteristics of Program Participants in Resources and 2 Baseline 2.6 38 1.0 4.0 and sort of have partners and that they have this resource that
reducing disparities are based in Chicago, IL, Camden, NJ, Wind River Indian
education; managing high and low glucose; checking blood sugar levels; the Cohort Support for Self- was free in the community … was really exciting. … So it was a
Reservation, WY, Dallas, TX, and Memphis, TN. Across the Alliance sites a
smoking and alcohol; long-term complications; and treatment options. management 2 Follow-up 2.9 38 1.0 4.0 0.004 really nice example of the education and the social support and
multiracial patient group was enrolled and sites implemented multilevel and Unweighted
multicomponent interventions to enhance patient skills, clinician cultural Quality of Life (VR-12) the community resources that our project brings together, really
Characteristic N Percent helping a couple of these patients become empowered and take
competencies, and health care systems changes to address disparities and “The patient classes are diabetes education and then patient/ 4 Baseline 40.1 167 18.8 59.9
enhance care. Each grantee provided clinical (hemoglobin A1c [HbA1c], Physical control of their health.” — Site Project Manager
provider communication around shared decision making. … Cohort 1,143 100.0 4 Follow-up 41.2 167 18.1 64.4 0.019
blood pressure [BP]) and patient-reported outcomes (diabetes competence, Patients are educated on how to take care of themselves and
quality of life, resources and supports for self-management, and diabetes a lot of that requires what you eat and what you do, which Male 417 37.0 4 Baseline 44.6 167 11.5 69.5
Gender Mental This evaluation suggests that the Alliance is demonstrating that diabetes
self-care behaviors) for program participants to the Alliance’s external means that they need to be aware of community resources that 4 Follow-up 45.6 167 20.4 69.6 0.090
evaluator. Baseline and follow-up clinical data are reported for more than Female 710 63.0 outcomes can be improved and disparities potentially decreased in groups
can help them with eating better and having better physical Diabetes Self-care
1,000 patients, with a decrease of mean HbA1c values from 8.5% to 7.9% and most burdened by diabetes management by using multifocal interventions
activity.” — Site PI White 91 8.0
a decrease in BP from 132/80 to 129/78, both significant at the p < .001 level. 4 Baseline 3.6 162 0.0 7.0 that include patient, provider, and system components. Analyses specifically
General diet comparing racial differences did not emerge as significant. These findings
Multivariable regression analysis showed that patients who participated in African American 300 26.3 4 Follow-up 4.5 162 0.0 7.0 0.000
more than half of the program had greater changes in both HbA1c and BP are likely attributable to the fact that the Alliance programs sought to serve
■■ Clinician Component: Provider education included cultural competency 4 Baseline 4.0 165 0.0 7.0
over time, controlling for age and gender. Analyses of the patient-reported Native American 34 3.0 Specific diet low-income and underserved adults with type 2 diabetes regardless of race,
training and behavioral change education about communicating
4 Follow-up 4.4 165 0.5 7.0 0.000 although these programs have successfully served a large multi-ethnic and
survey measures also showed significant improvements in perceived effectively with patients and facilitating lifestyle improvements.
diabetes compe­ ence, resources and supports for self-management, and
t Race/Ethnicity Hispanic 627 54.9 4 Baseline 2.8 166 0.0 7.0 multiracial group of program participants.
Exercise
self-care behaviors. We conclude that multicomponent programs can reduce 4 Follow-up 3.3 166 0.0 7.0 0.000
disparities and improve outcomes for people with diabetes. “Before I used to focus only on numbers. Now I understand that Asian/Pacific 16 1.4
it’s not all about that. Those [numbers] are important but also 4 Baseline 4.2 168 0.0 7.0
Other 16 1.4 Blood-glucose testing
taking into account what the patients are going through in 4 Follow-up 5.0 168 0.0 7.0 0.000
“It combines the strengths of the healthcare system, the
6. Next Steps
their houses and with their family, it has a great effect, too.” — Unknown 59 5.2 4 Baseline 4.0 167 0.0 7.0
strengths of the community, and there haven’t been a lot of Diabetes Health Promoter Foot care
projects like this in [our city]. … I think it’s a positive in terms 4 Follow-up 5.0 167 0.0 7.0 0.000 Next steps in the cross-site evaluation include additional data collection,
18–44 345 30.5
of doing these collaborations across the five centers and the Note: VR-12 = Veterans RAND 12 Item Health Survey such as a comparison cohort, that will allow us to determine whether
partnership, which, again, has not traditionally happened. So ■■ System Change Component: Diabetes management via systems changes Age 45–54 398 35.2 disparities in diabetes were reduced. In addition, a final site visit with
it’s fun.” — Site Co-PI included care coordination, use of diabetes registries, nurse or community To further understand the potential impact of the grantee programs on grantees at the end of their intervention programs will allow us to better
health worker participation in care management, enhanced community 55 or older 388 34.3 understand program process improvements over the course of the
changes over time, we regressed each of the changes in clinical measures
partnerships, and policy changes. All of these elements focused on on selected characteristics, including age (under 55 years vs. 55 or older), initiative that may have helped contribute to program success.
improving care for and self-management by patients with diabetes. gender (male vs. female), and race (any underrepresented race vs. White),
and program participation status (high intensity vs. low intensity). High-
intensity program participants were those who attended over half of the
1. Background “We reach out as far as like system level, to the community, from program sessions that composed the Alliance programs; low-intensity
the patient and the provider. It’s like multifaceted and all of 4. Preliminary Results References
program participants were those who attended less than half of the
those areas together, like one is no more important than the sessions. The results appear in Table 4.
To address the growing problem of health care disparities in the context of other, you can’t subtract one for another, they all need to work
type 2 diabetes in the United States among low-income and underserved
Results for Clinical and Patient-Reported Outcomes 1. Williams, G. C., McGregor, H. A., Zeldman, A., Freedman, Z.R., & Deci, E. L. (2004).
together and that’s what we’re doing.” — Site Project Manager Table 4. Results of Clinical Measures Regressed on Patient Testing a self-determination theory process model for promoting glycemic control
adult populations, The Merck Company Foundation—the philanthropic arm of For the participant cohort, we used t-tests and multivariable regression through diabetes self-management. Health Psychology, 23(1), 58–66.
Merck & Co., Inc.—launched the Alliance to Reduce Disparities in Diabetes. The Characteristics and Program Participation Status
analyses to understand how health and diabetes outcomes changed over 2. McCormack L. A., Williams-Piehota, P. A., Bann, C. M., Burton, J., Kamerow, D. B.,
Alliance aims to help decrease diabetes disparities and enhance the quality time because of program participation. Table 2 presents the descriptive Regression Coefficients Squire, C., … Glasgow R. E. (2008). Development and validation of an instrument to
of health care by improving prevention and management services. Through statistics for the baseline and follow-up clinical measures, and indicates measure resources and support for chronic illness self-management: a model using
HbA1c BP LDL
grants to five organizations, The Merck Company Foundation supports significant differences. Both HbA1c and BP improved from baseline to diabetes. Diabetes Education, 34(4), 707–718.
Predictor Variable (n=1,121) (n=1,057) (n=285)
comprehensive, multifaceted, community-based programs that address key follow-up. Table 3 presents the same information for patient-reported 3. Kazis, L. E., Miller, D. R., Skinner, K. M., Lee, A., Ren, X. S., Clark, J. A., … Fincke, B. G.
factors to improve health outcomes for people living with diabetes. 3. Cross-Site Evaluation Constant (intercept) 1
–0.28* 6.2* –7.1
outcomes. All measures show improvement from baseline to follow- (2006). Applications of methodologies of the Veterans Health Study in the VA Health
up (p < .05), except for quality of life measured by mental functioning, Age 55 or older 0.34* –0.3 –6.3 Care System: Conclusions and summary. Journal of Ambulatory Care Management,
The five programs and grantees are: 29(2), 182–188.
Methods although there was a trend toward significance for this measure (p < .10). Male –0.31* 0.4 –2.7
■■ Improving Diabetes Care and Outcomes on the South Side of Chicago, 4. Toobert, D. J., Hampson, S. E., & Glasgow, R. E. (2000).The Summary of Diabetes Self-
University of Chicago, Illinois RTI International was selected to conduct a cross-site evaluation of the African American 0.00 –1.9 8.3 Care Measure: Results from 7 studies and a revised scale. Diabetes Care, 23(7), 943–950.
Alliance. We collected clinical and patient-reported data from the five Table 2. Clinical Measures Aggregated Across All Grantees
■■ Camden Citywide Diabetes Collaborative, Camden, New Jersey Native American 0.03 –2.4 15.5
grantees four times over the past 3 years and conducted two site visits
■■ Diabetes for Life Program, Memphis, Tennessee (one virtual) to document the interventions undertaken. All data reported t-test Asian –0.33 –1.8 4.3
■■ Reducing Diabetes Disparities in American Indian Communities, Wind are aggregated across grantees to understand the net effect of the Alliance Outcome Time Mean N Min Max Median (p-value) Hispanic/Latino –0.05 –0.7 8.5
River Indian Reservation, Wyoming programs on diabetes and health outcomes. –0.75 0.1 –11.3
Baseline 8.5 1,143 4.5 15.1 8.0
Other race/ Acknowledgments
■■ The Diabetes Equity Project, Dallas, Texas HbA1c ethnicities
Measures We would like to thank the following: The Merck Company Foundation for
Unknown race/ 0.19 4.5 9.0 funding the Alliance to Reduce Disparities in Diabetes, including the cross-site
Clinical data collected across all grantees included BP calculated as mean Follow-up 7.9 1,143 5.0 18.5 7.4 0.000
ethnicity evaluation; Leslie Hardy, Vice President of The Merck Company Foundation;
arterial pressure, blood HbA1c levels, and cholesterol. the members of the cross-site evaluation team, including Connie Hobbs, Joe
Baseline 132/80 1,067 84/36 220/170 128/80 High-intensity –0.63* –9.8* –0.3
Patient-reported measures common across at least 2 grantees included: program Burton, Shawn Karns, Rebecca Moultrie, Tania Fitzgerald, and Sidney Holt; and
BP
participation National Program Office members Julie Dodge and Belinda Nelson.
Author Affiliations ■■ Perceived diabetes competence1: Average of 4 items where higher Follow-up 129/78 1,067 80/41 230/130 123/78 0.000
1
scores indicate greater confidence in managing diabetes Represents mean changes for White females under age 55 who were low-intensity participants. * p .05 level
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RTI International ■■ 2
Resources and supports for self-management : Average of 6 items Baseline 104 294 32 233 98 More Information
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Camden Coalition of Healthcare Providers where higher scores indicate more support from one’s health care team LDL *Presenting author: Dr. Douglas Kamerow
Follow-up 103 294 39 240 97 0.437 “Before the program their care was more or less just kind of up Chief Scientist, Health Services and Policy Research
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Memphis Healthy Churches in learning how to manage diabetes
to them and they’d just come in the clinic … And now with the 202.728.1959 | dkamerow@rti.org
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Sundance Research Institute ■■ Quality of life (Veterans RAND 12 Item Health Survey [VR-12])3: 12 Note: HbA1c = hemoglobin A1c; BP = blood pressure; LDL = Low-density lipoprotein cholesterol Merck grant we do a lot more home visits, we started holding
items split into 2 subscales indicating mental and physical functioning RTI International | 701 13th Street, N.W., Suite 750 | Washington, DC 20005
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University of Chicago self-management classes. And so now it kind of feels like they
(scored via algorithm) where higher scores indicate better functioning have someone that they can lean on … they don’t have to be so Presented at: The 5th Annual ADA Disparities Partnership Forum,
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Baylor Healthcare System alone.” — Diabetes Coordinator Washington, DC, October 22–23, 2012
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■■ Diabetes self-care behaviors4: Average of 2 items for each of 5
University of Michigan behaviors where higher scores indicate more frequent self-care behaviors www.rti.org RTI International is a trade name of Research Triangle Institute.