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Mental Health and Diabetes Control Among Vulnerable Primary Care Patients
Darrell L. Hudson, PhD, MPH; Melvin S. Blanchard, MD; Cassandra Arroyo-Johnson, PhD, MS; Laurel Milam, MA; Kimberly A. Kaphingst, ScD; and Melody S. Goodman, PhD, MS
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Mental Health and Diabetes Control Among Vulnerable Primary Care Patients

Darrell L. Hudson, PhD, MPH; Melvin S. Blanchard, MD; Cassandra Arroyo-Johnson, PhD, MS; Laurel Milam, MA; Kimberly A. Kaphingst, ScD; and Melody S. Goodman, PhD, MS
Only 19% of patients in this sample had good diabetes control based on their tested glycated hemoglobin levels. Patients diagnosed with mental health conditions in this study were more likely to have good diabetes control.

Objectives: Patients who have mental health conditions have greater difficulty managing diabetes. This study examined the association between mental health conditions and diabetes control, and medication adherence as a mediator in this relationship, among patients in a primary care setting affiliated with a large academic medical center.

Study Design: Data were drawn from questionnaires completed by patients in the waiting rooms of a primary care clinic and from patient electronic health records. Variables of interest were diagnosis of any mental health condition and diabetes control, as indicated by glycated hemoglobin (A1C) levels.

Methods: Logistic regression analyses were used to estimate the odds ratio (OR) and corresponding 95% CIs of controlled diabetes.

Results: Only 19% of patients had “good” diabetes control (A1C <6.5%). Surprisingly, better medication adherence and diagnosis of a mental health condition were significantly associated with good diabetes control, even after adjusting for known confounders in multivariable logistic regression analyses (OR, 2.4; 95% CI, 1.2-4.8).

Conclusions: These findings suggest that the identification of mental health problems among patients with diabetes is critical to improving patients’ diabetes control, particularly within settings that serve highly vulnerable patient populations.

The American Journal of Accountable Care. 2018;6(4):3-10
Diabetes is a challenging disease to manage, and patients who have comorbid mental health conditions may have even greater difficulty in managing diabetes.1-4 People with diabetes and comorbid mental health conditions routinely have less adequate self-care (eg, poorer diet, physical inactivity, poorer medication compliance, and poorer glycemic control) and poorer quality of life.5-7 Findings from previous research indicate that successful treatment of mental disorders, such as depression, improves patients’ diabetes control and adherence.7-10 However, mental health services are underutilized and mental health conditions are often undertreated, particularly in racial/ethnic minority groups, and treated less aggressively in patients with multiple comorbidities and patients with diabetes.11,12

Untreated and/or undiagnosed mental health conditions could be related to poorer diabetes management, including medication adherence, in addition to greater levels of disability and impairment associated with poor mental health.13-15 Patients with diabetes may be more likely to seek care more regularly than patients without chronic diseases, and comprehensive healthcare settings that emphasize the integration of care may be more effective in treating mental health conditions and improving diabetes control. Nonetheless, there is relatively little research regarding detection of and care for mental health conditions among vulnerable populations with diabetes in primary care settings. The goal of this study was to examine the association among mental health conditions, medication adherence, and diabetes control within a primary care clinic for the medically underserved.



This study was conducted in the primary care clinic of a large urban hospital, the Center for Outpatient Health (COH) at Barnes-Jewish Hospital in St. Louis, Missouri. The clinic serves as the site for ambulatory care training for a large internal medicine residency with about 150 residents. Trainees provide primary care to the patients and have a continuous relationship with them over their 3 years of training. The COH provides a broad range of services for patient care, including mental health, social work, pharmacy, nutrition, and foot care. In 1 year of operation, 2012-2013, the COH served 16,907 unique patients; 64% were African American and 30% were white. The majority of patients seen in that year were female (67%) and between 35 and 64 years of age (59%); about 40% of patients were covered by Medicare, 40% were covered by Medicaid, and 3% were uninsured.

Data Collection

Participants in this study were recruited in the waiting rooms of the COH. Patients were approached by trained data collectors between July 2013 and April 2014. Inclusion criteria were that participants be 18 years or older, be a patient at the COH, and speak English. Surveys were administered on different days of the week and at different times of day; data collectors approached all patients in the waiting room during their shifts. Participants were asked to complete a self-administered written questionnaire and a verbally administered component. The latter component assessed health literacy and was administered by a trained data collector who recorded responses. All participants completed a verbal consent process and signed a written consent form before completing the survey. As part of the consent process, participants could opt in to have information abstracted from their electronic health record (EHR) and merged with questionnaire data. The Institutional Review Board at Washington University School of Medicine approved this study.

Approximately 26% (n = 1111) of patients approached were ineligible to participate because they were not patients, did not speak English, or had previously taken the survey. Among eligible participants, 44% (n = 1380) agreed to participate and had their consent recorded by trained data collectors. Of the 1380 patients who consented, 1010 (73%) completed the written survey. Among those with complete written surveys, 602 (60%) completed the verbally administered component and 781 (77%) opted to have data abstracted from their EHR.

Participants completed data collection while waiting for their appointments. The primary reason for incomplete surveys was inadequate time before the clinic was ready to begin the patient evaluation. There were no significant differences in gender between individuals with complete surveys and those with incomplete surveys. African Americans made up the majority (75%) of noncompleters, a statistically higher proportion than of those completing the survey (63%; P = .003). Survey respondents were generally similar to the underlying COH primary care clinic patient population with respect to gender, age, race, and location of residence. The study population was restricted to only those patients with a diagnosis of diabetes and nonmissing values for glycated hemoglobin (A1C), providing a final sample of 275 patients.


The outcome of interest, diabetes control, was dichotomized using the A1C test, a blood test that measures the degree of diabetes control in the 3 months prior to obtaining the test. Test results were obtained from the most recent laboratory results in patients’ EHRs. Per International Diabetes Federation guidelines, patients with A1C levels below 6.5% (or 7.8 mmol/L) were categorized as having good diabetes control.16 Patients with A1C levels of 6.5% or above were categorized as having uncontrolled diabetes.

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