Publications by authors named "Jane N Bolin"

36 Publications

Racial, Rural, and Regional Disparities in Diabetes-Related Lower-Extremity Amputation Rates, 2009-2017.

Diabetes Care 2021 Jul 22. Epub 2021 Jul 22.

Department of Health Policy & Management, Texas A&M University, College Station, TX.

Objective: To examine the racial/ethnic, rural-urban, and regional variations in the trends of diabetes-related lower-extremity amputations (LEAs) among hospitalized U.S. adults from 2009 to 2017.

Research Design And Methods: We used the National Inpatient Sample (NIS) (2009-2017) to identify trends in LEA rates among those primarily hospitalized for diabetes in the U.S. We conducted multivariable logistic regressions to identify individuals at risk for LEA based on race/ethnicity, census region location (North, Midwest, South, and West), and rurality of residence.

Results: From 2009 to 2017, the rates of minor LEAs increased across all racial/ethnic, rural/urban, and census region categories. The increase in minor LEAs was driven by Native Americans (annual percent change [APC] 7.1%, < 0.001) and Asians/Pacific Islanders (APC 7.8%, < 0.001). Residents of non-core (APC 5.4%, < 0.001) and large central metropolitan areas (APC 5.5%, < 0.001) experienced the highest increases over time in minor LEA rates. Among Whites and residents of the Midwest and non-core and small metropolitan areas there was a significant increase in major LEAs. Regression findings showed that Native Americans and Hispanics were more likely to have a minor or major LEA compared with Whites. The odds of a major LEA increased with rurality and was also higher among residents of the South than among those of the Northeast. A steep decline in major-to-minor amputation ratios was observed, especially among Native Americans.

Conclusions: Despite increased risk of diabetes-related lower-limb amputations in underserved groups, our findings are promising when the major-to-minor amputation ratio is considered.
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http://dx.doi.org/10.2337/dc20-3135DOI Listing
July 2021

Factors Affecting Adoption of a Technology-Based Tool for Diabetes Self-Management Education and Support Among Adult Patients with Type 2 Diabetes in South Texas.

Sci Diabetes Self Manag Care 2021 Jun 17;47(3):189-198. Epub 2021 Apr 17.

Center for Outcomes Research, Houston Methodist, Houston, Texas.

Purpose: The purpose of this study is to describe a novel computerized diabetes education tool and explore factors influencing self-selection and use among primarily Hispanic patients diagnosed with type 2 diabetes in south Texas.

Methods: Study participants included 953 adult patients with type 2 diabetes enrolled in a diabetes education program between July 1, 2016, and June 30, 2017. Participants were asked to choose either a new technology-based diabetes education tool with a touch-screen device or a traditional face-to-face education method. Multivariate logistic regression analysis was applied to identify factors associated with adopting the computerized diabetes education tool among the patients.

Results: When comparing technology-based tool adopters and nonadopters, several demographic and health-related factors differentiated technology use in bivariate analyses. The multivariate logistic regression model showed that Hispanic patients were less likely to choose a technology-based tool. Patients who perceived their health status as excellent/good were more likely to adopt the technologic education method than those with fair/poor perceived health status. A1C level was negatively associated with self-selection of technology.

Conclusions: Specific demographic and health-related characteristics are significant contributing factors to patients' adoption of a technology-based diabetes education tool. Health care providers can utilize these findings to target and refer specific patients to a computerized diabetes education tool for more effective diabetes care and to optimize technology adoption success.
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http://dx.doi.org/10.1177/26350106211004885DOI Listing
June 2021

Factors affecting the likelihood of a hospitalization following a diabetes-related emergency department visit: A regional and urban-rural analysis.

J Diabetes 2020 Sep 27;12(9):686-696. Epub 2020 Jun 27.

Department of Health Policy & Management, Texas A&M University, School of Public Health, College Station, Texas, USA.

Background: The objective of this study is to examine place-based and individual-level predictors of diabetes-related hospitalizations that stem from emergency department (ED) visits.

Methods: We conducted a pooled cross-sectional analysis of the National Inpatient Sample (NIS) for 2009 to 2014 to identify ED-initiated hospitalizations that were driven by the need for diabetes care. The odds of an ED-initiated diabetes-related hospitalization were assessed for the United States as a whole and separately for each census region.

Results: Nationally, residents of noncore areas (odds ratio [OR] 1.10; CI 1.08, 1.12), the South (OR 8.03; CI 6.84, 9.42), Blacks (OR 2.49; CI 2.47, 2.52), Hispanics (OR 2.32; CI 2.29, 2.35), Asians or Pacific Islanders (OR 1.20; CI 1.16, 1.23), Native Americans (OR 2.18; CI 2.10, 2.27), and the uninsured (OR 2.14; CI 2.11, 2.27) were significantly more likely to experience an ED-initiated hospitalization for diabetes care. Census region-stratified models showed that noncore residents of the South (OR 1.17; CI 1.14, 1.20) and Midwest (OR 1.06; CI 1.02, 1.11) had higher odds of a diabetes-related ED-initiated hospitalization.

Conclusions: As continued efforts are made to reduce place-based disparities in diabetes care and management, targeted focus should be placed on residents of noncore areas in the South and Midwest, racial and ethnic minorities, as well as the uninsured population.
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http://dx.doi.org/10.1111/1753-0407.13066DOI Listing
September 2020

Effect of Study Design and Survey Instrument to Identify the Association Between Depressive Symptoms and Physical Activity in Type 2 Diabetes, 2000-2018: A Systematic Review.

Diabetes Educ 2020 02 24;46(1):28-45. Epub 2019 Dec 24.

Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, Texas.

Introduction: Previous studies have used a variety of survey measurement options for evaluating the association between physical activity (PA) and depressive symptoms, raising questions about the types of instruments and their effect on the association. This study aimed to identify measures of PA and depressive symptoms and findings of their association given diverse instruments and study characteristics in type 2 diabetes (T2DM).

Methods: Online databases, Medline, Embase, CINAHL, and PsycINFO were searched on July 20, 2018, and January 8, 2019. Our systematic review included observational studies from 2000 to 2018 that investigated the association between PA and depressive symptoms in T2DM.

Results: Of 2294 retrieved articles, 28 studies were retained in a focused examination and comparison of the instruments used. There were a range of standard measures, 10 for depressive symptoms and 7 for PA, respectively. Patient Health Questionnaire (PHQ) for depressive symptoms and study-specific methods for PA were the most popular. Overall, 71.9% found a significant association between PA and depressive symptoms. Among studies classified as high quality or reliability, the figure was 81.8%.

Conclusion: A majority of the sample found an association between depressive symptoms and PA, which is fairly consistent across study characteristics. The findings provide the evidence for the health benefits of PA on reducing depressive symptoms in persons with T2DM, suggesting active engagement in PA for effective diabetes management. However, guidelines for objective measurements and well-designed prospective studies are needed to strengthen the evidence base and rigor for the association and its directionality.
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http://dx.doi.org/10.1177/0145721719893359DOI Listing
February 2020

The Impact of Medicaid Expansion on Diabetes Management.

Diabetes Care 2020 05 24;43(5):1094-1101. Epub 2019 Oct 24.

Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX.

Objective: Diabetes is a chronic health condition contributing to a substantial burden of disease. According to the Robert Wood Johnson Foundation, 10.9 million people were newly insured by Medicaid between 2013 and 2016. Considering this coverage expansion, the Affordable Care Act (ACA) could significantly affect people with diabetes in their management of the disease. This study evaluates the impact of the Medicaid expansion under the ACA on diabetes management.

Research Design And Methods: This study includes 22,335 individuals with diagnosed diabetes from the 2011 to 2016 Behavioral Risk Factor Surveillance System. It uses a difference-in-differences approach to evaluate the impact of the Medicaid expansion on self-reported access to health care, self-reported diabetes management, and self-reported health status. Additionally, it performs a triple-differences analysis to compare the impact between Medicaid expansion and nonexpansion states considering diabetes rates of the states.

Results: Significant improvements in Medicaid expansion states as compared with non-Medicaid expansion states were evident in self-reported access to health care (0.09 score; = 0.023), diabetes management (1.91 score; = 0.001), and health status (0.10 score; = 0.026). Among states with large populations with diabetes, states that expanded Medicaid reported substantial improvements in these areas in comparison with those that did not expand.

Conclusions: The Medicaid expansion has significant positive effects on self-reported diabetes management. While states with large diabetes populations that expanded Medicaid have experienced substantial improvements in self-reported diabetes management, non-Medicaid expansion states with high diabetes rates may be facing health inequalities. The findings provide policy implications for the diabetes care community and policy makers.
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http://dx.doi.org/10.2337/dc19-1173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171935PMC
May 2020

The impact of interprofessional education on family nurse practitioner students' and family medicine residents' knowledge and confidence in screening for breast and cervical cancer.

J Am Assoc Nurse Pract 2018 Sep;30(9):511-518

Department of Health Policy & Management, Texas A&M University School of Public Health, College Station, Texas.

Background And Purpose: This study determined the impact of an interprofessional education (IPE) simulation on family nurse practitioner (FNP) students' and family medicine residents' (FMRs) self-reported confidence in counseling women reluctant to engage in cancer screening or evaluation and assessed knowledge of breast and cervical cancer risk factors.

Method: A multi-item knowledge survey on breast and cervical cancer risk factors was administered to 76 FNP students and FMRs followed by an IPE simulation with a pre-/postsurvey of self-reported confidence in counseling a woman reluctant to have breast and cervical cancer screening and evaluation.

Discussion: Data demonstrated knowledge deficits in breast and cervical cancer risk factors in both disciplines with the average risk factor knowledge score of 8.5/12 for breast cancer and 7.8/12 for cervical cancer. Following IPE simulation, confidence in counseling women reluctant to have breast or cervical cancer screening improved across both disciplines (p < .05) and debrief feedback findings suggest improved attitudes toward collegiality, communication, and understanding of other interprofessional roles among both disciplines.

Conclusion: Knowledge gaps exist among both FNP students and FMRs in breast and cervical cancer risk factors. This study suggests IPE simulation is effective in building individual provider confidence and team collegiality.
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http://dx.doi.org/10.1097/JXX.0000000000000072DOI Listing
September 2018

Cervical Cancer Screening Barriers and Risk Factor Knowledge Among Uninsured Women.

J Community Health 2017 Aug;42(4):770-778

Department of Clinical Translational Medicine, College of Medicine, Texas A&M Health Science Center, 2900 E. 29th Street, Bryan, TX, 77802, USA.

A steady decline in cervical cancer incidence and mortality in the United States has been attributed to increased uptake of cervical cancer screening tests such as Papanicolau (Pap) tests. However, disparities in Pap test compliance exist, and may be due in part to perceived barriers or lack of knowledge about risk factors for cervical cancer. This study aimed to assess correlates of cervical cancer risk factor knowledge and examine socio-demographic predictors of self-reported barriers to screening among a group of low-income uninsured women. Survey and procedure data from 433 women, who received grant-funded cervical cancer screenings over a span of 33 months, were examined for this project. Data included demographics, knowledge of risk factors, and agreement on potential barriers to screening. Descriptive analysis showed significant correlation between educational attainment and knowledge of risk factors (r = 0.1381, P < 0.01). Multivariate analyses revealed that compared to Whites, Hispanics had increased odds of identifying fear of finding cancer (OR 1.56, 95% CI 1.00-2.43), language barriers (OR 4.72, 95% CI 2.62-8.50), and male physicians (OR 2.16, 95% CI 1.32-3.55) as barriers. Hispanics (OR 1.99, 95% CI 1.16-3.44) and Blacks (OR 2.06, 95% CI 1.15-3.68) had a two-fold increase in odds of agreeing that lack of knowledge was a barrier. Identified barriers varied with age, marital status and previous screening. Programs aimed at conducting free or subsidized screenings for medically underserved women should include culturally relevant education and patient care in order to reduce barriers and improve screening compliance for safety-net populations.
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http://dx.doi.org/10.1007/s10900-017-0316-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494033PMC
August 2017

Determinants of HPV vaccine awareness and healthcare providers' discussion of HPV vaccine among females.

Prev Med Rep 2017 Mar 16;5:257-262. Epub 2017 Jan 16.

Department of Health Policy and Management, Texas A&M Health School of Public Health, College Station, TX 77843-1266, USA.

Two human papillomavirus (HPV) vaccines are available and can prevent 98% of HPV 16 and 18 infections. This study aimed to explore determinants of 1) HPV vaccine awareness among a cohort of low-income women participating in a cancer prevention program in Central Texas and compare them to United States residents; 2) determinants of healthcare providers' discussion of HPV vaccine among female residents of the United States. Bivariate and multivariable analysis of HPV vaccine awareness using survey data (n = 359) collected between 2014 and 2016 in Central Texas, and the Health Information and Nutrition Survey (HINTS) data which is a nationally representative dataset (unweighted n = 1214) collected in 2013 were conducted. Bivariate and multivariable regression analyses of healthcare providers' discussion of the HPV vaccine using the HINTS survey data were also conducted. Compared to non-Hispanic Whites, there was a decreased likelihood of HPV vaccine awareness among non-Hispanic Blacks (OR = 0.50; 95% CI = 0.28-0.90) and Hispanics (OR = 0.55; 95% CI = 0.30-0.99) in the grant funded program, as well as non-Hispanic Blacks (OR = 0.28; 95% CI = 0.14-0.58) and Hispanics (OR = 0.22; 95% CI = 0.12-0.41) in the HINTS data. There was also a decreased likelihood of healthcare providers discussing the HPV vaccine with respondents who were 35-49 years (OR = 0.50; 95% CI = 0.30-0.84), 50-64 years (OR = 0.26; 95% CI = 0.14-0.49) or ≥ 65 years compared to those who were 18-34 years among the HINTS data respondents. Interventions to increase HPV awareness among non-Hispanic Blacks and Hispanics, as well as encourage healthcare providers' discussion of the HPV vaccination during patient encounters regardless of the patient's age are needed.
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http://dx.doi.org/10.1016/j.pmedr.2017.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5262500PMC
March 2017

Disparities in Surgical Treatment of Early-Stage Breast Cancer Among Female Residents of Texas: The Role of Racial Residential Segregation.

Clin Breast Cancer 2017 04 19;17(2):e43-e52. Epub 2016 Oct 19.

Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX.

Introduction: Early-stage breast cancer can be surgically treated by using mastectomy or breast-conserving surgery and adjuvant radiotherapy, also known as breast-conserving therapy (BCT). Little is known about the association between racial residential segregation, year of diagnosis, and surgical treatment of early-stage breast cancer, and whether racial residential segregation influences the association between other demographic characteristics and disparities in surgical treatment.

Methods: This was a retrospective study using data from the Texas Cancer Registry composed of individuals diagnosed with breast cancer between 1995 and 2012. The dependent variable was treatment using mastectomy or BCT (M/BCT) and the independent variables of interest (IVs) were racial residential segregation and year of diagnosis. The covariates were race, residence, ethnicity, tumor grade, census tract (CT) poverty level, age at diagnosis, stage at diagnosis, and year of diagnosis. Bivariate and multivariable multilevel logistic regression models were estimated. The final sample size was 69,824 individuals nested within 4335 CTs.

Results: Adjusting for the IVs and all covariates, there were significantly decreased odds of treatment using M/BCT, as racial residential segregation increased from 0 to 1 (odds ratio [OR] 0.47; 95% confidence interval [CI], 0.41-0.54). There was also an increased likelihood of treatment using M/BCT with increasing year of diagnosis (OR 1.14; 95% CI, 1.13-1.16). A positive interaction effect between racial residential segregation and race was observed (OR 0.56; 95% CI, 0.36-0.88).

Conclusion: Residents of areas with high indices of racial residential segregation were less likely to be treated with M/BCT. Racial disparities in treatment using M/BCT increased with increasing racial residential segregation.
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http://dx.doi.org/10.1016/j.clbc.2016.10.006DOI Listing
April 2017

Physician Recommendation of Diabetes Clinical Protocols.

Hosp Top 2016 ;94(1):15-21

a School of Public Health, Texas A&M Health Science Center, College Station , Texas , USA.

The authors examined the responses of 63 primary care physicians to diabetes clinical protocols (DCPs) for the management of type II diabetes (T2DM). We measured physician demographics, current diabetes patient loads, and responses to DCPs (physician attitudes, physician familiarity, and physician recommendation of DCPs) using a 20-question electronic survey. Results of the survey indicate that primary care physicians may be unfamiliar with the benefits of diabetes clinical protocols for the self-management of T2DM. Given the importance of diabetes self-management education in controlling T2DM, those interested in implementing DCPs should address the beliefs and attitudes of primary care physicians.
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http://dx.doi.org/10.1080/00185868.2016.1142313DOI Listing
March 2017

The cost-effectiveness of training US primary care physicians to conduct colorectal cancer screening in family medicine residency programs.

Prev Med 2016 Apr 10;85:98-105. Epub 2016 Feb 10.

School of Public Health; Texas A&M Health Science Center, College Station, United States.

Background: Demand for a wide array of colorectal cancer screening strategies continues to outpace supply. One strategy to reduce this deficit is to dramatically increase the number of primary care physicians who are trained and supportive of performing office-based colonoscopies or flexible sigmoidoscopies. This study evaluates the clinical and economic implications of training primary care physicians via family medicine residency programs to offer colorectal cancer screening services as an in-office procedure.

Methods: Using previously established clinical and economic assumptions from existing literature and budget data from a local grant (2013), incremental cost-effectiveness ratios are calculated that incorporate the costs of a proposed national training program and subsequent improvements in patient compliance. Sensitivity analyses are also conducted.

Results: Baseline assumptions suggest that the intervention would produce 2394 newly trained residents who could perform 71,820 additional colonoscopies or 119,700 additional flexible sigmoidoscopies after ten years. Despite high costs associated with the national training program, incremental cost-effectiveness ratios remain well below standard willingness-to-pay thresholds under base case assumptions. Interestingly, the status quo hierarchy of preferred screening strategies is disrupted by the proposed intervention.

Conclusions: A national overhaul of family medicine residency programs offering training for colorectal cancer screening yields satisfactory incremental cost-effectiveness ratios. However, the model places high expectations on primary care physicians to improve current compliance levels in the US.
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http://dx.doi.org/10.1016/j.ypmed.2016.02.007DOI Listing
April 2016

The role of health literacy and communication habits on previous colorectal cancer screening among low-income and uninsured patients.

Prev Med Rep 2015 24;2:158-63. Epub 2015 Feb 24.

Department of Health Promotion and Community Health Sciences, Texas A&M Health Science Center School of Public Health, College Station, TX 77843-1266, USA.

Objective: To determine the association between health literacy, communication habits and colorectal cancer (CRC) screening among low-income patients.

Methods: Survey responses of patients who received financial assistance for colonoscopy between 2011 and 2014 at a family medicine residency clinic were analyzed using multivariate logistic regression (n = 456). There were two dependent variables: (1) previous CRC screening and (2) CRC screening adherence. Our independent variables of interest were health literacy and communication habits.

Results: Over two-thirds (67.13%) of respondents had not been previously screened for CRC. Multivariate analysis showed a decreased likelihood of previous CRC screening among those who had marginal (OR = 0.52; 95% CI = 0.29-0.92) or inadequate health literacy (OR = 0.49; 95% CI = 0.27-0.87) compared to those with adequate health literacy. Controlling for health literacy, the significant association between educational attainment and previous CRC screening was eliminated. Thus, health literacy mediated the relationship between educational attainment and previous CRC screening. There was no significant association between communication habits and previous CRC screening. There was no significant association between screening guideline adherence, and health literacy or communication.

Conclusion: Limited health literacy is a potential barrier to CRC screening. Suboptimal CRC screening rates reported among those with lower educational attainment may be mediated by limited health literacy.
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http://dx.doi.org/10.1016/j.pmedr.2015.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4721377PMC
February 2016

Expanding Access to Colorectal Cancer Screening: Benchmarking Quality Indicators in a Primary Care Colonoscopy Program.

J Am Board Fam Med 2015 Nov-Dec;28(6):713-21

From the Department of Clinical & Translational Medicine, College of Medicine, Texas A&M University, Bryan (DAM, RP, JS, KF, AR); Texas A&M Physicians Family Medicine Residency, Texas A&M University, Bryan (DAM, RP, JS, KF, AR, PN); the Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station (COO, JWH, JNB); and the Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University, College Station (MGO).

Background: An inadequate supply of physicians who perform colonoscopies contributes to suboptimal screening rates, especially among the underserved. This shortage could be reduced if primary care physicians perform colonoscopies. This purpose of this article is to report quality indicators from colonoscopy procedures performed by family medicine physicians as part of a colorectal cancer prevention program targeting uninsured, low-income individuals.

Methods: A grant-funded colorectal cancer screening program was implemented to increase access to affordable colonoscopies for underinsured or uninsured residents of target counties while providing colonoscopy training to family medicine resident physicians. Colonoscopies were performed or supervised by 4 board-certified family physicians. Data were collected between 2011 and 2014.

Results: A total of 1155 colonoscopies were performed on 1101 individuals over a 3-year period. Cecal intubation rate was 96.25%. Adenoma detection rates among men and women >50 years old were 38.15% and 25.96%, respectively. There was 1 perforation, which was referred to a hospital, and 1 instance of postprocedural bleeding, which spontaneously resolved.

Conclusions: Primary care physicians performing colonoscopies met the recommended quality indicators set forth by the American Society for Gastrointestinal Endoscopy.
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http://dx.doi.org/10.3122/jabfm.2015.06.140342DOI Listing
September 2016

Rural Healthy People 2020: New Decade, Same Challenges.

J Rural Health 2015 7;31(3):326-33. Epub 2015 May 7.

Department of Health Policy & Management, Texas A&M School of Public Health, College Station, Texas.

Purpose: The health of rural America is more important than ever to the health of the United States and the world. Rural Healthy People 2020's goal is to serve as a counterpart to Healthy People 2020, providing evidence of rural stakeholders' assessment of rural health priorities and allowing national and state rural stakeholders to reflect on and measure progress in meeting those goals. The specific aim of the Rural Healthy People 2020 national survey was to identify rural health priorities from among the Healthy People 2020's (HP2020) national priorities.

Methods: Rural health stakeholders (n = 1,214) responded to a nationally disseminated web survey soliciting identification of the top 10 rural health priorities from among the HP2020 priorities. Stakeholders were also asked to identify objectives within each national HP2020 priority and express concerns or additional responses.

Findings And Conclusions: Rural health priorities have changed little in the last decade. Access to health care continues to be the most frequently identified rural health priority. Within this priority, emergency services, primary care, and insurance generate the most concern. A total of 926 respondents identified access as the no. 1 rural health priority, followed by, no. 2 nutrition and weight status (n = 661), no. 3 diabetes (n = 660), no. 4 mental health and mental disorders (n = 651), no. 5 substance abuse (n = 551), no. 6 heart disease and stroke (n = 550), no. 7 physical activity and health (n = 542), no. 8 older adults (n = 482), no. 9 maternal infant and child health (n = 449), and no. 10 tobacco use (n = 429).
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http://dx.doi.org/10.1111/jrh.12116DOI Listing
July 2016

Predictors of Colorectal Cancer Screening: Does Rurality Play a Role?

J Rural Health 2015 19;31(3):254-68. Epub 2015 Jan 19.

Department of Health Policy and Management, Texas A&M Health Science Center School of Public Health, College Station, Texas.

Purpose: The purpose of this study was to explore the associations between sociodemographic factors such as residence, health care access, and colorectal cancer (CRC) screening among residents of Texas.

Methods: Using the 2012 Behavioral Risk Factor Surveillance Survey, we performed logistic regression analyses to determine predictors of CRC screening among Texas residents, including rural versus urban differences. Our outcomes of interest were previous (1) CRC screening using any CRC test, (2) fecal occult blood test (FOBT), or (3) endoscopy, as well as up-to-date screening using (4) any CRC test, (5) FOBT, or (6) endoscopy. The independent variable of interest was rural versus urban residence; we controlled for other sociodemographic and health care access variables such as lack of health insurance.

Results: Multivariate analysis showed that individuals who were residents of a rural/non-Metropolitan Statistical Area (MSA) location (OR = 0.70, 95% CI = 0.51-0.97) or a suburban county (OR = 0.61, 95% CI = 0.39-0.95) were less likely to report ever having any CRC screening compared to residents of a center city of an MSA. Residents of a rural/non-MSA location were less likely (OR = 0.49, 95% CI = 0.28-0.87) than residents of a center city of an MSA to be up-to-date using FOBT. There was decreased likelihood of ever being screened for CRC among the uninsured (OR = 0.43, 95% CI = 0.31-0.59).

Conclusions: Effective development and implementation of strategies to improve screening rates should aim at improving access to health care, taking into account demographic characteristics such as rural versus urban residence.
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http://dx.doi.org/10.1111/jrh.12104DOI Listing
July 2016

Is diabetes color-blind? Growth of prevalence of diagnosed diabetes in children through 2030.

Popul Health Manag 2015 Jun 7;18(3):172-8. Epub 2014 Oct 7.

Diabetes knows no age and affects millions of individuals. Preventing diabetes in children is increasingly becoming a major health policy concern and focus. The objective of this study is to project the number of children, aged 0-17 years, with diagnosed diabetes in the United States through 2030, accounting for changing demography, and diabetes and obesity prevalence rates. The study team combined historic diabetes and obesity prevalence data with US child population estimates and projections. A times-series regression model was used to forecast future diabetes prevalence and to account for the relationship between the forecasted diabetes prevalence and the lagged prevalence of childhood obesity. Overall, the prevalence of diagnosed diabetes is projected to increase 67% from 0.22% in 2010 to 0.36% in 2030. Lagged obesity prevalence in Hispanic boys and non-Hispanic black girls was significantly associated with increasing future diabetes prevalence. The study results showed that a 1% increase in obesity prevalence among Hispanic boys from the previous year was significantly associated with a 0.005% increase in future prevalence of diagnosed diabetes in children (P ≤ 0.01). Likewise, a unit increase in obesity prevalence among non-Hispanic black girls was associated with a 0.003% increase in future diabetes prevalence (P < 0.05). Obesity rates for other race/ethnicity combinations were not associated with increasing future diabetes prevalence. To mitigate the continued threat posed by diabetes, serious discussions need to focus on the pediatric population, particularly non-Hispanic black girls and Hispanic boys whose obesity trends show the strongest associations with future diabetes prevalence in children.
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http://dx.doi.org/10.1089/pop.2014.0084DOI Listing
June 2015

Determinants of variations in self-reported barriers to colonoscopy among uninsured patients in a primary care setting.

J Community Health 2015 Apr;40(2):260-70

Department of Health Policy and Management, Texas A&M Health Science Center School of Public Health, College Station, TX, 77843-1266, USA,

Colorectal cancer (CRC) is the third most common type of cancer among both males and females in the United States and the second leading cause of cancer-related deaths. Although largely preventable through screening, early detection and removal of polyps, screening rates are considered sub-optimal. Perceived barriers to screening have been reported to influence screening rates. This paper examines variations in the extent to which uninsured patients identified barriers to CRC screening using colonoscopy based on race/ethnicity, educational attainment, age, gender, marital status and prior colonoscopy. Multivariate analyses showed that compared to Caucasians, African Americans had an increased likelihood of identifying lack of transportation as a barrier [odds ratio (OR) 2.68; 95 % confidence interval (CI) 1.35-5.32] while Hispanics were more likely to identify fear of finding cancer as a barrier (OR 2.09; 95 % CI 1.19-3.66). Compared to those with more than a high school education, there was increased likelihood of identifying lack of knowledge as a barrier among individuals with high school education (OR 3.51; 95 % CI 1.94-6.36) or less than a high school education (OR 2.16; 95 % CI 1.04-4.50). Our findings suggest that strategies aimed at increasing colonoscopy screening rates among underserved populations should take into consideration race/ethnicity, educational attainment, age, and prior colonoscopy experience when developing education and outreach plans to reduce barriers to colonoscopy.
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http://dx.doi.org/10.1007/s10900-014-9925-8DOI Listing
April 2015

Impact of chronic disease self-management programs on type 2 diabetes management in primary care.

World J Diabetes 2014 Jun;5(3):407-14

Samuel N Forjuoh, Department of Family and Community Medicine, Baylor Scott and White Health, College of Medicine, Texas A&M Health Science Center, Temple, TX 76504, United States.

Aim: To assess the effectiveness of the Chronic Disease Self-Management Program (CDSMP) on glycated hemoglobin A1c (HbA1c) and selected self-reported measures.

Methods: We compared patients who received a diabetes self-care behavioral intervention, the CDSMP developed at the Stanford University, with controls who received usual care on their HbA1c and selected self-reported measures, including diabetes self-care activities, health-related quality of life (HRQOL), pain and fatigue. The subjects were a subset of participants enrolled in a randomized controlled trial that took place at seven regional clinics of a university-affiliated integrated healthcare system of a multi-specialty group practice between January 2009 and June 2011. The primary outcome was change in HbA1c from randomization to 12 mo. Data were analyzed using multilevel statistical models and linear mixed models to provide unbiased estimates of intervention effects.

Results: Demographic and baseline clinical characteristics were generally comparable between the two groups. The average baseline HbA1c values in the CDSMP and control groups were 9.4% and 9.2%, respectively. Significant reductions in HbA1c were seen at 12 mo for the two groups, with adjusted changes around 0.6% (P < 0.0001), but the reductions did not differ significantly between the two groups (P = 0.885). Few significant differences were observed in participants' diabetes self-care activities. No significant differences were observed in the participants' HRQOL, pain, or fatigue measures.

Conclusion: The CDSMP intervention may not lower HbA1c any better than good routine care in an integrated healthcare system. More research is needed to understand the benefits of self-management programs in primary care in different settings and populations.
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http://dx.doi.org/10.4239/wjd.v5.i3.407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4058746PMC
June 2014

Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: a survival analysis model.

Patient Educ Couns 2014 Apr 13;95(1):111-7. Epub 2014 Jan 13.

Department of Epidemiology & Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, USA; Department of Health Promotion & Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, USA; Department of Family & Community Medicine, Scott & White Healthcare, College of Medicine, Texas A&M Health Science Center, Temple, USA.

Objective: This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization.

Methods: Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization.

Results: Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm.

Conclusion: CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM.

Practice Implications: Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.
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http://dx.doi.org/10.1016/j.pec.2014.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009353PMC
April 2014

Behavioral and technological interventions targeting glycemic control in a racially/ethnically diverse population: a randomized controlled trial.

BMC Public Health 2014 Jan 23;14:71. Epub 2014 Jan 23.

Department of Family & Community Medicine, Scott & White Healthcare, College of Medicine, Texas A&M Health Science Center, Temple, TX, USA.

Background: Diabetes self-care by patients has been shown to assist in the reduction of disease severity and associated medical costs. We compared the effectiveness of two different diabetes self-care interventions on glycemic control in a racially/ethnically diverse population. We also explored whether reductions in glycated hemoglobin (HbA1c) will be more marked in minority persons.

Methods: We conducted an open-label randomized controlled trial of 376 patients with type 2 diabetes aged ≥18 years and whose last measured HbA1c was ≥7.5% (≥58 mmol/mol). Participants were randomized to: 1) a Chronic Disease Self-Management Program (CDSMP; n = 101); 2) a diabetes self-care software on a personal digital assistant (PDA; n = 81); 3) a combination of interventions (CDSMP + PDA; n = 99); or 4) usual care (control; n = 95). Enrollment occurred January 2009-June 2011 at seven regional clinics of a university-affiliated multi-specialty group practice. The primary outcome was change in HbA1c from randomization to 12 months. Data were analyzed using a multilevel statistical model.

Results: Average baseline HbA1c in the CDSMP, PDA, CDSMP + PDA, and control arms were 9.4%, 9.3%, 9.2%, and 9.2%, respectively. HbA1c reductions at 12 months for the groups averaged 1.1%, 0.7%, 1.1%, and 0.7%, respectively and did not differ significantly from baseline based on the model (P = .771). Besides the participants in the PDA group reporting eating more high-fat foods compared to their counterparts (P < .004), no other significant differences were observed in participants' diabetes self-care activities. Exploratory sub-analysis did not reveal any marked reductions in HbA1c for minority persons but rather modest reductions for all racial/ethnic groups.

Conclusions: Although behavioral and technological interventions can result in some modest improvements in glycemic control, these interventions did not fare significantly better than usual care in achieving glycemic control. More research is needed to understand how these interventions can be most effective in clinical practice. The reduction in HbA1c levels found in our control group that received usual care also suggests that good routine care in an integrated healthcare system can lead to better glycemic control.

Trial Registration: Clinicaltrials.gov Identifier: NCT01221090.
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http://dx.doi.org/10.1186/1471-2458-14-71DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3909304PMC
January 2014

Primary care physicians' perceptions of diabetes treatment protocols.

Tex Med 2014 01 1;110(1):e1. Epub 2014 Jan 1.

Primary care physicians' perceptions of diabetes treatment protocols (DTPs) in the management of type 2 diabetes mellitus (T2DM) were examined at the individual and organizational levels. A 27-item electronic survey was administered to primary care physicians from an integrated multispecialty health care system in Texas. Information was collected on various aspects of DTPs, including attitudes toward these protocols, perceived barriers, and knowledge, as well as utilization of diabetes self-management programs. Besides quality of care, the primary care physicians surveyed generally had mixed feelings regarding DTPs' ability to contribute positively to other aspects of health care; in addition, only a small percentage were familiar with some currently available self-management programs. Given that implementation of DTPs depends on primary care physicians, we should address physicians' attitudes and perceptions toward DTPs so as to increase utilization of these helpful protocols.
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January 2014

Can chronic disease management programs for patients with type 2 diabetes reduce productivity-related indirect costs of the disease? Evidence from a randomized controlled trial.

Popul Health Manag 2014 Apr 23;17(2):112-20. Epub 2013 Oct 23.

1 Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center , College Station, Texas.

The objective was to assess the impacts of diabetes self-management programs on productivity-related indirect costs of the disease. Using an employer's perspective, this study estimated the productivity losses associated with: (1) employee absence on the job, (2) diabetes-related disability, (3) employee presence on the job, and (4) early mortality. Data were obtained from electronic medical records and survey responses of 376 adults aged ≥18 years who were enrolled in a randomized controlled trial of type 2 diabetes self-management programs. All study participants had uncontrolled diabetes and were randomized into one of 4 study arms: personal digital assistant (PDA), chronic disease self-management program (CDSMP), combined PDA and CDSMP, and usual care (UC). The human-capital approach was used to estimate lost productivity resulting from 1, 2, 3, and 4 above, which are summed to obtain total productivity loss. Using robust regression, total productivity loss was modeled as a function of the diabetes self-management programs and other identified demographic and clinical characteristics. Compared to subjects in the UC arm, there were no statistically significant differences in productivity losses among persons undergoing any of the 3 diabetes management interventions. Males were associated with higher productivity losses (+$708/year; P<0.001) and persons with greater than high school education were associated with additional productivity losses (+$758/year; P<0.001). Persons with more than 1 comorbid condition were marginally associated with lower productivity losses (-$326/year; P=0.055). No evidence was found that the chronic disease management programs examined in this trial affect indirect productivity losses.
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http://dx.doi.org/10.1089/pop.2013.0029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047841PMC
April 2014

Factors associated with successful completion of the chronic disease self-management program by adults with type 2 diabetes.

Fam Community Health 2013 Apr-Jun;36(2):147-57

Department of Health Policy & Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX 77843-1266, USA.

This study examines factors associated with completion (attendance ≥4 of 6 sessions) of the Chronic Disease Self-Management Program (CDSMP) by adults with type 2 diabetes. Patients with glycated hemoglobin ≥ 7.5 within 6 months were enrolled and completed self-report measures on demographics, health status, and self-care (n = 146). Significant differences in completion status were found for several self-care factors including healthful eating plan, spacing carbohydrates, frequent exercise, and general health. Completion was not influenced by race/ethnicity or socioeconomics. Results suggest better attention to exercise and nutrition at the start of CDSMP may be associated with completion, regardless of demographic subgroup.
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http://dx.doi.org/10.1097/FCH.0b013e318282b3d1DOI Listing
May 2013

Diabetes education kiosks in a latino community.

Diabetes Educ 2013 Mar-Apr;39(2):204-12. Epub 2013 Feb 22.

Ohio State University, Columbus, Ohio (Ms Salge)

Purpose: The purpose of this study was to examine the implementation, use, and sustainability of a computerized touch-screen diabetes education kiosk (Diosk) designed to provide "on-demand" education in a predominantly Latino community in South Texas.

Methods: A pilot study was conducted to examine the implementation, use, and sustainability of the Diosk in 5 settings (e.g., clinics, community centers, and pharmacies) serving low-income, low-literacy populations. Both quantitative and qualitative data from embedded computerized usage tracking, user surveys, and key stakeholder interviews were collected and analyzed using descriptive statistics. RESULTS; There were more than 5300 uses of the Diosk in the different sites during the 11-month study. The majority of users were female, between the ages of 36 and 64 years, and Latino, and they identified themselves as having or being at risk for type 2 diabetes. Several challenges were faced in maintaining the Diosk during the study, such as organizational capacity to host wireless Internet and establishing "office champions" responsible for overseeing the Diosk. At the end of the study, 3 of the 5 sites committed to sustaining the Diosk on their own.

Conclusions: This pilot study testing the feasibility and acceptability of the Diosk demonstrated that a Diosk can be implemented, used, and sustained in a population with high rates of diabetes and limited prior use of disease management programs. Computerized technology offers one solution to expanding the reach of diabetes education through easily accessible community and clinical settings.
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http://dx.doi.org/10.1177/0145721713476346DOI Listing
December 2013

Challenges and opportunities for implementing diabetes self-management guidelines.

J Am Board Fam Med 2013 Jan-Feb;26(1):90-2

Department of Health Promotion and Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA.

Purpose: The purpose of this article was to examine primary care providers' perceived challenges when implementing evidence-based diabetes self-management guidelines and opportunities for promoting the use of such guidelines in practice.

Methods: We engaged 3 group discussions with 43 key stakeholders representing family physicians, medical directors, and quality assurance leaders in a large, university-affiliated, integrated health care organization in Central Texas. Transcripts from group discussions were summarized using thematic content analysis.

Results: Key themes that emerged as challenges of implementing evidence-based diabetes self-management guidelines included lack of easily retrievable electronic patient health information, inadequate coordination with other health care providers when implementing guidelines, conflict between information in the guidelines and physicians' knowledge, and physician compensation by patient load rather than by quality of care. Two main opportunities identified were the use of health coaches or nurses trained in diabetes self-management and active collaboration between practicing providers and key stakeholders in the development and dissemination of guidelines.

Conclusion: Our study shows a need for involving front-line family physicians and other primary care providers as well as patients in the design and development of best practice guidelines to enhance implementation of diabetes self-management guidelines in primary care settings.
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http://dx.doi.org/10.3122/jabfm.2013.01.120177DOI Listing
June 2013

Factors affecting acceptability and usability of technological approaches to diabetes self-management: a case study.

Diabetes Technol Ther 2012 Dec 26;14(12):1178-82. Epub 2012 Sep 26.

Department of Epidemiology & Biostatistics, Texas A&M Health Science Center, College Station, TX, USA.

Purpose: This study explored the impact of personal digital assistant (PDA) features, users' perceptions, and other factors that may have hindered PDA acceptability and usability as technology advances in e-health diabetes self-management.

Study Design And Results: An ongoing study on PDA usage is set within the context of the advancements of Web 2.0 for type 2 diabetes mellitus (T2DM) self-management e-interventions. Advancements in technology as it relates to the future of T2DM mobile applications are discussed as possible deterrents of PDA acceptability and usability.

Conclusions: This case study illustrates the importance of addressing factors that may impede the adoption of electronic devices intended for sustained health behavior change. Recognizing the importance of individual perception within the context of rapid technological advancements is imperative for designing future health interventions. Incorporating electronic devices that individuals are more inclined to utilize, such as smartphones, as the platform for health interventions is a promising strategy to improve acceptability and usability, allowing researchers to more accurately assess the health benefits of self-management programs.
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http://dx.doi.org/10.1089/dia.2012.0139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3521137PMC
December 2012

Patient-centered medical homes: will health care reform provide new options for rural communities and providers?

Fam Community Health 2011 Apr-Jun;34(2):93-101

Department of Health Policy and Management, Texas A&M Health Science Center, School of Rural Public Health, College Station, TX 77843, USA.

Many are calling for the expansion of the patient-centered medical home model into rural and underserved populations as a transformative strategy to address issues of access, efficiency, quality, and sustainability in the delivery of health care. Patient-centered medical homes have been touted as a promising cost-saving model for comprehensive management of persons with chronic diseases and disabilities, but it is unclear how rural practitioners in medically underserved areas will implement the patient-centered medical home. This article examines how the Patient Protection & Affordable Care Act of 2010 will enhance rural providers' ability to provide patient-centered care and services contemplated under the Act in a comprehensive, coordinated, cost-effective way despite leaner budgets and health workforce shortages.
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http://dx.doi.org/10.1097/FCH.0b013e31820e0d78DOI Listing
July 2011

Forward: Contextualizing rurality for family and community health research.

Fam Community Health 2011 Apr-Jun;34(2):90-2

School of Rural Public Health, Texas A&M Health Science Center, 1266 TAMU, College Station, TX 77843, USA.

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http://dx.doi.org/10.1097/01.FCH.0000395568.99810.21DOI Listing
July 2011

Disparities in diabetes management by race or ethnicity in a primary care clinic in central Texas.

Tex Med 2010 Nov 1;106(11):e1. Epub 2010 Nov 1.

Department of Family & Community Medicine, Scott & White Santa Fe Center, 1402 W Avenue H, Temple, TX 76504, USA.

We determined the nature and magnitude of extant health disparities in patients with type 2 diabetes (T2DM) by race and ethnicity. Data were abstracted from the electronic medical records and charts of all patients 18 years or older who had been diagnosed with T2DM and seen over a 1-year period in one primary care clinic. Data abstracted included patient demographics; provision of counseling on smoking cessation, diet, exercise, and home blood glucose monitoring (HBGM); health care utilization; laboratory measures; and clinical outcomes. No significant racial or ethnic differences were found in the rate of provision of counseling on smoking cessation, diet, exercise, and HBGM, which were all suboptimal according to American Diabetes Association recommendations. In addition, no significant differences were found in the mean number of hospital admissions, emergency room visits, and referrals for specialty care. However, the mean HbA1c levels for African Americans (9.9%) and Hispanics (9.0%) were significantly higher than that of whites (8.7%; P<.0001), even after controlling for body mass index and age. Explanation of the significant racial and ethnic differences found in HbA1c levels, despite similar diabetes self-management treatment protocols or health care utilization, calls for further research.
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November 2010

Provision of counseling on diabetes self-management: are there any age disparities?

Patient Educ Couns 2011 Nov 21;85(2):133-9. Epub 2010 Sep 21.

Department of Family & Community Medicine, Scott & White, College of Medicine, Texas A&M Health Science Center, Temple, TX 76504, USA.

Objective: To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas.

Methods: EMR search from 13 primary care clinics on patients aged ≥18 years (n=1300) who had been diagnosed with type 2 diabetes.

Results: There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR=0.60; 95% CI=0.37-0.98). The mean HbA1c for patients aged ≥75 and 65-74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P<0.001).

Conclusion: While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults.

Practice Implications: Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population.
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http://dx.doi.org/10.1016/j.pec.2010.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021766PMC
November 2011
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