Local Community Program Fights Diabetes Among Latinos and Others in San Diego

In the nation’s war against type 2 diabetes (T2D), the search for the “magic bullet” primarily targets drug development. However, one community-based program has been winning the battle—achieving patient outcomes that exceed the National Council for Quality Assurance’s benchmarks in T2D care—through a systematic, evidence-based, culturally sensitive approach to patient care that emphasizes self-empowerment.

The 14-year-old program, Project Dulce, has served 18,000 patients at San Diego’s community health clinics who are Latinos and members of other ethnic groups that are characterized by low income, inadequate insurance, and disproportionate rates of such T2D complications as kidney disease.

Because its clinical, behavioral, and economic outcomes have been so impressive, Project Dulce has been a model for similar community-based diabetes management programs in the United States. It now is being evaluated in selected T2D patients at Scripps Health, one of the top 10 health systems in the United States, according to Thomson Reuters. The patients in this pilot study have commercial medical insurance coverage but, like the Project Dulce patients, are at high risk for the development of disease complications.

“Project Dulce is the model that recent health care reform initiatives have been looking for,” said Scripps Health endocrinologist Athena Philis-Tsimikas, MD, whose leadership of Project Dulce was recognized with the Outstanding Service Award for the Promotion of Endocrine Health of an Underserved Population at the annual meeting of the American Association of Clinical Endocrinologists in April 2011.

In addition to improving T2D patients’ HbA1c, blood pressure, and lipid parameters, Project Dulce achieves “lower total cost of care due to consistent reduction in hospitalizations,” said Philis-Tsimikas, chief medical officer and corporate vice president of the Scripps Whittier Diabetes Institute, one of the largest diabetes education programs accredited by the American Diabetes Association (ADA) in the United States.

The site of the pilot study is the Scripps Health clinic in Rancho Bernardo, a master-planned community in San Diego that is home to residences and regional offices of Sony Electronics and several other corporations.

Like Project Dulce, the pilot study follows the chronic care model, emphasizing productive interactions between patients and their registered nurses and case managers who collaborate with the patients’ physicians.

“Because standardized orders are followed, the care process is allowed to move along more efficiently,” explained Philis-Tsimikas, who is certified by the American Board of Internal Medicine in the subspecialty of diabetes and endocrinology.

Project Dulce’s registered nurses and case managers are certified diabetes educators trained by endocrinologists on the Staged Diabetes Management protocols for stepped-care pharmacologic treatment of glucose and lipid levels and hypertension. Project Dulce’s bilingual and bicultural care teams also include medical assistants and registered dieticians.

When Project Dulce began, community health clinic physicians were reluctant to work so collaboratively with the nurses/case managers. However, after two weeks, they were uniformly enthusiastic, Philis-Tsimikas noted. In addition to enhancing the quality of patient care, the nurses/case managers saved physicians time by taking responsibility for the instruction of patients about measuring glucose and achieving target levels by adjusting diet and medication.

In the Project Dulce model, new patients participate in eight weekly two-hour group classes taught by peer educators (promotoras), members of the patients’ ethnic group who effectively manage their T2D and have completed three months of training in the ADA-certified curriculum program. In the pilot study, group classes also will be given.

“The promotoras, who are supervised by a health educator, take on the traditional role of the nurse in educating the patient,” said Philis-Tsimikas. As trusted sources of information, the promotoras persuade the Project Dulce patients to follow the prescribed medical therapy rather than use home remedies such as eating nopales to cure diabetes.

“In the Hispanic/Latino community, people tend to follow those who relate to them. They think, ‘This person is one of my people,’” said Betsy Rodríguez, senior deputy director, National Diabetes Education Program of the U.S. Centers for Disease Control.

Promotoras also can help patients to “unlearn” cultural beliefs—for example, that extreme emotional stress causes diabetes, Rodriguez added.

Or that T2D complications are inevitable. Philis-Tsimikas recalled one patient, José, who came to Project Dulce after experiencing vision loss, coronary artery bypass surgery, and metatarsal amputation.

“His grandmother, mother, and brother all had similar complications. So why shouldn’t he? Wasn’t that just part of the disease?” said Philis-Tsimikas.

When José enrolled in Project Dulce, his creatinine level was 2.8 mg/dL. Although he learned how to make adjustments in his medications and diet, and achieved normal ranges for blood glucose and low-density lipoprotein, his kidney function continued to worsen, requiring dialysis.

José “exemplifies what is happening to so many people with diabetes in our nation. Opportunities missed! We had opportunities to prevent his heart, vascular, and kidney disease early on,” said Philis-Tsimikas.

In 2004, she and her colleagues reported significant improvements in levels of HbA1c and total cholesterol in Project Dulce patients, and that these patients required fewer urgent care visits and hospitalizations than did patients receiving standard care. Project Dulce patients’ knowledge about T2D had increased, and their inaccurate cultural beliefs and reliance on cultural-based remedies had decreased. At the 2009 ADA scientific sessions, Philis-Tsimikas and her colleagues reported that in the peer-led educational arm (Project Dulce), glycemic control was significantly improved at the 10-month follow-up: the HbA_1c was 9.70 ± 2.00 percent in the standard group versus 8.71 ± 1.98 percent in the peer-led group (p = 0.15).

Also at the 2009 ADA meeting, they presented preliminary results in a randomized, controlled, prospective clinical study of over 200 Mexican-American T2D patients who were 21 to 75 years of age and had HbA_1c ≥8 percent (9.91 percent in the standard group vs. 10.43 percent in the peer-led group, p = 0.42). These patients had been randomly assigned to Project Dulce or to the standard diabetes care of the community health centers.

Philis-Tsimikas and her team will soon publish a paper reporting their findings, which are similar to the results presented at the ADA meeting, she said.

A previous report documented that Project Dulce is cost effective. In a 2007 Health Research and Educational Trust article, University of California San Diego health economist Todd P. Gilmer, PhD, and his colleagues analyzed data on 3893 T2D patients, 61 percent of whom were female and 48 percent of whom were Latino, and used clinical and cost data on Project Dulce as well as on commercially insured patients as inputs into a diabetes simulation model.

The incremental cost ratios per quality-adjusted life expectancy gained were $10,141 for the uninsured, $24,584 for those covered by San Diego County Medical Services, $44,941 for Medi-Cal recipients, and $69,587 for those with commercial insurance.

Scripps Health will soon complete a systemwide electronic diabetes registry, modeled on the Project Dulce registry, that will enable Philis-Tsimikas and her team to measure and monitor clinical outcomes against the ADA guidelines and stratify patients according to their HbA1c, blood pressure, and lipid parameters.

“The registry enables us to be proactive, to quickly identify patients who need extra attention because their outcomes are out of range,” said Philis-Tsimikas.