Susan Enguidanos, MPH, PhD
Assistant Professor, University of Southern California Davis School of Gerontology
|ADA Research Funding|
Clinical Translational Research Award
Getting out of the hospital may be less dramatic than landing in it, but it brings its own dangers. For people hospitalized because of complications from diabetes, the transition from being taken care of by a staff of medical professionals to fending for themselves at home is even more perilous, according to research. That’s further compounded when patients are unable to read the doctor’s instructions, forget to schedule the right follow-up appointments, or don’t understand what medications they’re supposed to take, and how.
Many people in America at the highest risk for diabetic complications face exactly those challenges—and more. For example, more than 10 percent of Latinos over the age of 20 in the United States have diabetes, and Latinos are nearly twice as likely to develop diabetes as non-Hispanic whites. At care centers that serve mostly high-risk minority populations, the chances that patients will wind up back in the hospital are higher.
Susan Enguidanos, MPH, PhD, a social and behavioral researcher at the University of Southern California, is trying to understand the forces behind these trends in the hopes that they can be turned around. “We wanted to focus on the hospital-to-home transition, which is always dangerous,” Enguidanos says. People with diabetes “especially are at higher risk because of these poor transitions.”
Enguidanos is looking at a specific set of high-risk patients: Latinos with diabetes. For reasons ranging from communication to culture, Latinos who have been hospitalized with complications from diabetes are particularly likely to wind up back in the hospital. Breaking that cycle would undoubtedly be good for patients, but there’s a growing body of research showing that it might also benefit hospitals and insurers.
As part of new health care regulations going into effect in 2012, for example, hospitals will be penalized if too many patients have to be readmitted for the same medical problems within 30 days—a sign, regulators say, that the hospital didn’t do the job right the first time. In one 2007 study, researchers estimated that three-quarters of these short-term readmissions were preventable. “For the first time, hospitals are taking action, because they’re going to be [accountable],” Enguidanos says.
To see how to improve the post-hospitalization care of Latinos with diabetes, Enguidanos set up an experiment with funding from the California Community Foundation and the American Diabetes Association. She divided participants, who come originally from Mexico, Cuba, and just about every country in Central and South America, into two groups. Members of one group got standard hospital care at two Los Angeles facilities. The other participants were assigned to two specially trained diabetes educators who spoke Spanish and grew up in the L.A. area.
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Enguidanos says initial observations suggest that communication is a huge barrier to recovery and health. Of the people she enrolled in the study, 90 percent spoke only Spanish. Yet 100 percent of them were given hospital discharge papers in English. “Language is a huge factor that’s setting them into a higher-risk category,” Enguidanos says. “We have found there are huge systemic issues preventing good care.”
Language may have been the biggest barrier, but it wasn’t the only one. For participants in the study group, follow-up care often fell apart not long after they got out of the hospital. “There are people who get discharged and go to Mexico to be taken care of by family, people who don’t get their prescriptions filled,” or people who wind up taking the same medicines twice, Enguidanos says.
The educators made two or three home visits in the month after patients got out of the hospital and followed up on the phone. “It was meant to be a brief intervention and focused on establishing a connection to regular medical care,” Enguidanos says.
Still, the educators often had to start nearly from scratch. Sometimes patients were confused as to what kind of doctor they should see: One had to be convinced to see a podiatrist for follow-up care after a toe amputation. Another was doubling up on her medication because she couldn’t read the labels on the bottles. Often, patients don’t know much about their diabetes to begin with. “Overall, this group hasn’t received a lot of information on self-management,” Enguidanos says. “And they really don’t want us to tell them how to change their lifestyle.”
That doesn’t mean the experiment’s health educators don’t try. In addition to helping participants in the study arrange for follow-up care, they talk to families about what they can do to help manage diabetes. “Once we get in the home, we rally the troops and talk about diet and exercise,” Enguidanos says. “It doesn’t help to just educate older men. If you don’t educate the wife who does all the cooking, nothing’s going to change. You have to bring in the whole family.”
Enguidanos is still recruiting people for her study. She’s hoping the group receiving post-hospitalization help will prove to have better health outcomes, saving lives—and money—in the long run.