Spotlight on interventions for the underserved
Project ECHO for diabetes lowered HbA1c levels in patients at federally qualified health centers, one study found, but another trial did not identify any improvements in glycemic control from providing patients on Medicaid with medically tailored meals.
Two recent studies assessed interventions for underserved patients with diabetes.
The first, published by Diabetes Care on Dec. 17, 2024, was a stepped-wedge trial of an ECHO Diabetes program in which 20 federally qualified health centers (FQHCs) across California and Florida were randomized to implement a new program in phases. The study was funded by a private charitable trust. Clinicians were invited to interactive, one-hour, bimonthly, tele-education sessions and were offered real-time support with complex medical decision-making on diabetes care; patients received access to diabetes support coaches. The total cohort included 32,796 patients (3.4% with type 1 diabetes, 96.6% with type 2); 72.7% were publicly insured or uninsured. After the intervention was implemented, the patient population had statistically significant reductions (range, 31.7% to 26.7%; P=0.033) in the proportion of patients with HbA1c levels greater than 9%. The study also looked at a subgroup of 582 patients who required multiple daily insulin injections and found significant increases in their use of continuous glucose monitoring (range, 25.1% to 36.8%; P<0.0001) and pumps (range, 15.3% to 18.3%; P<0.001). “By targeting FQHCs, we were able to recruit highly diverse and historically underrepresented cohorts of people with diabetes, and we demonstrated significant improvements within these communities,” said the study authors, who added that “these findings provide a model to improve access to diabetes technologies and medications for communities who experience structural inequities and are at greatest risk for disparate outcomes.”
The other study, published by the Journal of General Internal Medicine on Dec. 13, 2024, was a small pilot trial of medically tailored meals for patients with diabetes. All 74 study participants had an HbA1c level greater than 8% at baseline and were insured by Medicaid. Those randomized to the treatment group received home delivery of 12 medically tailored frozen meals and a fresh produce bag weekly for three months, as well as monthly calls with a registered dietitian for six months, while a control group received usual care. Overall, 77% of participants completed data collection and 86% percent of the meals were delivered. At six months, the groups had similar improvements in HbA1c level (−0.7% in the intervention group vs.−0.6% in the control group) and diabetes-related quality of life, knowledge, and self-efficacy. Changes in systolic blood pressure and body mass index also did not differ between groups at six months. However, food insecurity decreased significantly from baseline to three months in the intervention group (from 53% to 17%) compared to the controls (48% to 44%; P=0.05). The study authors noted that the lack of difference could be partly explained by patients not eating the meals and by more medication changes being made in the control group. “Overall, two-thirds of patients whose A1c was over 8% at baseline did not report any increases in their medication over 6 months, and about 20% reported taking less medication,” suggesting that the participating patients received low-quality medical care for their diabetes, according to the study authors. “More comprehensive and clinically integrated interventions are likely needed to achieve significant clinical benefits,” they wrote.