Reducing Emergency Diabetes Care for Older African Americans

患有糖尿病的非裔美国人（AAs）寻求急诊科（ED）护理的频率是白人的两倍。

African Americans (AAs) with diabetes (DM) seek emergency department (ED) care twice as often as Whites. About 40% of AAs with DM have an ED visit each year, and 24% use the ED as their usual place of care (vs. 13% of Whites). The reasons for these racial disparities in ED use are complex, but the scientific premise of the proposed randomized controlled trial (RCT) is that poor access to primary care and poor DM self-care lead to high ED use in AAs with DM. A culturally relevant intervention that mitigates these factors may reduce the need for ED use in this high risk population. This RCT will compare the efficacy of COPDE (COmmunity Care to Prevent Diabetes Emergencies) vs. Enhanced Usual Care (EUC) to reduce DM-related ED visits and/or hospitalizations over 12 months (primary outcome) in 230 AAs with DM, 50 years and older, after an ED visit. COPDE is a collaborative intervention of Primary Care Physicians, (PCPs), a DM nurse educator, and Community Health Workers (CHWs) that extends from the ED into the community. The CHWs will: 1) deliver in-home DM education to increase participants’ knowledge and skills to manage DM; 2) use DM-specific Behavioral Activation to reinforce DM self-care; and 3) facilitate telehealth visits with PCPs and a DM nurse educator to increase access to care. The control treatment, EUC, is usual medical care that is enhanced with DM self-care education. EUC matches COPDE in treatment intensity (i.e., number and duration of in-home visits) and delivery of DM self-care education, but does not include COPDE’s other active elements (i.e., Behavioral Activation and telehealth). The treatment comparison will identify COPDE’s specific efficacy over and above EUC. We hypothesize that COPDE will halve the rate of incident DM-related ED visits and/or hospitalizations relative to EUC. The three secondary outcomes are: 1) subjective perceptions of access to care; 2) receipt of DM Quality Metrics (i.e., objective indicators of realized access to care); and 3) DM self-care. A mediation analysis will determine if changes in one or more of these variables explain COPDE’s efficacy. Exploratory Aims will: 1) determine if COPDE reduces “all cause” ED visits/hospitalizations; 2) determine if Community Need Index scores (which reflect the extent of economic and structural barriers to care), literacy, age, and/or sex moderate treatment effects; 3) determine if COPDE improves glycemic control, impacts DM- related health beliefs, reduces depression, and/or improves quality-of-life; 4) identify COPDE treatment features that confer cultural relevance; and 5) estimate COPDE’s costs and net financial benefits. This RCT is significant because rates of ED use among AAs with DM are rapidly rising, and new ways to treat this high risk population are needed. This RCT is innovative because: 1) it tests the first ED-to-community intervention designed to reduce the need for ED use in AAs with DM, and 2) it determines if participants who reside in high- need as well as low-need communities equally benefit. If successful, COPDE will meet Healthy People 2020’s twin goals of reducing the personal and societal costs of DM and achieve health equity for all Americans.