Results Summary
What was the research about?
Type 2 diabetes is a long-term health problem that can be hard to manage. Latino patients from low-income households have high rates of diabetes.
In this study, the research team compared two programs adapted to help Latino patients from low-income households manage their diabetes:
- Diabetes Self-Management Support Empowerment Model, or DSMS. Doctors referred patients to the program. Over six weeks, patients had nine hours of group sessions in English at a hospital. Topics included how to change eating and activity habits, self-monitor their diabetes, and manage stress. Patients also met with a diabetes educator for one-on-one support.
- Chronic Care Model, or CCM. Doctors and community health workers, or CHWs, referred patients to the program. CHWs are community members trained to teach about health. CHWs led the program at a community health center in English and Spanish. The program helps patients get care, make decisions, coordinate care, and access community resources.
What were the results?
After one year, patients in the two programs didn’t differ in:
- Knowledge about diabetes.
- Confidence to manage diabetes.
- Blood sugar levels.
- Body mass index, or BMI. BMI is a measure of a person’s body fat based on their height and weight.
Patients in CCM had a greater decrease in depression symptoms than patients in DSMS.
Patients in both programs knew more about diabetes and had higher confidence to manage diabetes, a slight decrease in blood sugar levels, and no change in BMI.
Who was in the study?
The study included 226 pairs of Latino patients with diabetes or prediabetes who were in DSMS or CCM and each patient’s social support person. This person was a life partner, family member, friend, or neighbor. The average patient age was 52, and 73 percent were women. Patients were from low-income households. The programs took place at hospitals and health centers in Albuquerque, New Mexico.
What did the research team do?
The research team surveyed patients at the start of the study and one year later about diabetes knowledge, confidence to manage diabetes, and depression. Support persons completed surveys about their perceptions of the patient’s confidence and depression. The team hired and trained patients with diabetes who were not in the study to ask survey questions, take blood samples, and measure BMI.
Latino patients with diabetes, caregivers, CHWs, and diabetes educators provided input during the study.
What were the limits of the study?
The study didn’t assign patients by chance to a program. As a result, findings may be due to factors other than the programs. Also, at the start of the study, patients in the two programs differed in blood sugar levels and depression symptoms. The research team couldn’t completely account for these differences in the analysis.
Future research could look at reasons why depression symptoms improved in CCM.
How can people use the results?
Health centers that serve Latino patients can use the results when considering ways to help patients manage their diabetes.
Professional Abstract
Objective
To compare the effectiveness of the Diabetes Self-Management Empowerment Model (DSMS) versus the Chronic Care Model (CCM) on improving diabetes self-management among Latino patients with type 2 diabetes from low-income households
Study Design
| Design Element | Description |
|---|---|
| Design | Quasi-experimental study |
| Population | 226 pairs of Latino patients with type 2 diabetes or prediabetes from low-income households and their social support partners, such as life partners, family members, friends, or neighbors, who provided support in managing the patients’ diabetes |
| Interventions/ Comparators |
|
| Outcomes |
Primary: diabetes knowledge; patient activation, which is the skills and confidence for diabetes self-management Secondary: hemoglobin A1c (HbA1c) levels, BMI, depression index score |
| Timeframe | 1-year follow-up for primary outcomes |
This quasi-experimental study compared the effectiveness of two culturally adapted programs for improving diabetes knowledge and patient activation among Latino patients. Latinos who are from low-income households are at high risk for type 2 diabetes.
Researchers compared ongoing interventions at two sites in Albuquerque, New Mexico, that serve Latino patients with diabetes who are from low-income households:
- DSMS. Doctors referred patients to the program. Over six weeks, patients completed nine hours of classes in English at a hospital about changing eating and physical activity behaviors, self-monitoring of diabetes, and stress management. Patients also met with a certified diabetes educator for personalized support.
- CCM. Doctors and community health workers (CHWs) referred patients to CCM. Community health workers are community members who are trained to teach about health. They offered the program in English or Spanish at a community health clinic. CHWs taught patients ways to manage diabetes, helped coordinate care, and provided access to community services.
The study included 226 pairs of Latino patients with diabetes or prediabetes and their social support partners. Patients were from low-income households. The average patient age was 52, and 73% were female.
Before the program and again 3, 6, and 12 months later, patients completed surveys about diabetes knowledge, patient activation, and depression levels. Support partners completed surveys about their perceptions of the patient’s activation and depression levels. Researchers hired and trained patient advisors to ask survey questions, take patient blood samples for HbA1c levels, and measure body mass index (BMI) for the study.
Latino patients with diabetes, caregivers, CHWs, and diabetes educators provided input throughout the study.
Results
After one year, patients in the two programs did not differ significantly in diabetes knowledge, patient activation, HbA1c levels, or BMI. In both programs, patients’ diabetes knowledge and patient activation increased (both programs, p<0.05), HbA1c levels decreased slightly (both programs, p<0.05), and BMI did not change. Patients in CCM had greater decreases in depression symptoms than patients in DSMS (p=0.006).
Limitations
Because researchers did not randomly assign patients to the two programs, differences seen across programs may be due to differences in sites or patient populations. For example, DSMS required insurance or self-pay while CCM took place at a community clinic that did not accept insurance and had nominal fees. Also, patients in the two programs had differences at baseline that researchers could not completely adjust in their analysis, including in HbA1c levels and depression symptoms.
Conclusions and Relevance
In this study, the CCM and DSMS programs did not differ in how much they improved diabetes knowledge or patient activation of diabetes self-care. Both programs improved diabetes self-management among Latino patients. Patients in the CCM program showed greater improvements in depression symptoms.
Future Research Needs
Future research could explore factors contributing to depression symptom improvement in the CCM program.
Final Research Report
This project's final research report is expected to be available by July 2023.
Journal Citations
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers felt that the report’s assertion regarding the superiority of the Chronic Care Model (CCM) was too strong and asked the research to take a more cautious approach given the limited positive results. The researchers revised the report to more clearly acknowledge the limited statistically significant differences in the primary and secondary outcomes.
- The reviewers also noted that the report did not adequately consider the post-hoc nature of the association between the CCM arm and greater A1c reduction for participants with poor glycemic control. The reviewers asked the researchers to present this result with caution and clearly acknowledging that the results should be considered exploratory. The researchers revised their abstract and conclusions by describing these results as being based on an exploratory subgroup analysis.
- The reviewers asked the researchers to provide more detail on the self-management interventions, indicating that the descriptions were not sufficient for replication and did not address any measures of adherence or intervention fidelity. The researchers added more detail about the interventions to the report.
- The reviewers questioned the study’s inclusion of participants with pre-diabetes, given that interventions such as those presented in this study are usually only covered by insurance for people with diabetes. The researchers explained that their stakeholder partners requested the inclusion given the apparent acceleration in people with pre-diabetes being diagnosed with diabetes. The stakeholders believed that it would be important to know what kinds of interventions would work best for people at risk of developing diabetes. Further, the researchers explained that both programs offered free services to patients with pre-diabetes.
- The reviewers asked the researchers to discuss in greater detail the generalizability of the results given the limited availability of the CCM program in US medical practices. The researchers revised their discussion to note the alignment of their findings with the broader literature but also acknowledged that the CCM model is a high-intensity intervention that may be challenging for many communities to implement.
Conflict of Interest Disclosures
Project Information
Patient / Caregiver Partners
- Esperanza Perez, Patient Advisory Board Member and Patient Research Team Liaison
- Guadalupe Fuentes, Patient Advisory Board Member
- Sofia Hernandez, Patient Advisory Board Member
- Maria Gonzalez, Patient Advisory Board Member
- Hector Capistran, Patient Advisory Board Member
- Pablo Muniz, Patient Advisory Board Member
- Blanca Pedigo, Patient Advisory Board Member and Research Team Member
- Virginia Sandova, Research Team Member
- Lidia Regino, Co-PI, Patient
- One Hope Centro de Vida Health Center
Other Stakeholder Partners
- Maria Tellez, One Hope Centro de Vida Health Center
- Karla Castaneda, One Hope Centro de Vida Health Center
- Mary Lynn Johnston, University of New Mexico Diabetes Education Program
- Sara Nelson, Soda Creek Consulting Media Specialist
- Will Kaufman, First Choice Community Health Care
- Janet Page-Reeves, University of New Mexico (PI)
- Mark Burge, University of New Mexico
- Shiraz Mishra, University of New Mexico
- Elaine Bearer, University of New Mexico
- Cristina Murray-Krezan, University of New Mexico
- Erik Erhardt, University of New Mexico
- Molly Bleecker, University of New Mexico
- Courtney FitzGerald, University of New Mexico