Home Center Cores & Projects About the Center Faculty & Personnel News Contact Us  
 

Project 1:

Northern Manhattan Diabetes Community Outreach Project

 

NOCHOP team

Northern Manhattan Diabetes Community Outreach Project (NOCHOP; clinicaltrials.gov identifier NCT00787475) was originally designed and co-lead by Olveen Carrasquillo, MD, and Walter Palmas, MD. Dr Palmas has led NOCHOP since Dr. Carrasquillo’s departure to become the Chief of General Internal Medicine at the University of Miami in May of 2009.

Project background and description: Traditional medical models of diabetes control have had limited success among Latinos. One promising strategy is the use of community health workers (CHWs). However, because of limited effectiveness data, the adoption of the CHW model has been limited both nationally and locally. The goal of NOCHOP was to examine the effectiveness of a community based community health worker (CHW) intervention in addressing the ABCs of diabetes care (HgA1c, BP, Cholesterol) among Latinos of Caribbean descent with poorly controlled diabetes. The study was a randomized controlled trial (RCT) of 360 Latino patients with poorly controlled (Hg A1C > 8 %) Type 2 diabetes aged 35-70 years. Patients were randomized into either the intervention (CHW) or to enhanced usual care (EUC) and followed for one year. Details of the study can be found in our protocol manuscript published in BMJ open (1).

The primary aim was to determine if, at twelve months, the CHW intervention results in improvements in glycemic control as measured by HgA1c. Secondary objectives were to examine for improvements in cholesterol and BP. The expected improvement in glycemic status over baseline was at least a 0.5 reduction in HgA1C.

The last NOCHOP participant was followed in September of 2013. We found that there was a modest improvement in A1c levels in the intervention group, as compared to usual care, but it lacked statistical significance (p= 0.131 for the cluster-adjusted comparison). There was no improvement in the secondary outcomes of blood pressure and LDL-cholesterol levels; there was actually a non-significant trend towards an increase in LDL cholesterol levels and SBP in the intervention arm.  Sensitivity analyses modeling for missing data showed similar results. Intervention fidelity, measured as the number of contacts in the intervention arm (visits, phone contacts, group support, and nutritional education), showed a borderline association with greater A1c reduction (p= 0.054). The CHW intervention failed to achieve a statistically significant A1c reduction, as compared to usual care. However, greater intervention fidelity may be related to better glycemic control and future studies should aim to improve intervention fidelity. We published our finding in Diabetes Care in 2014 (2).

One of the important findings in NOCHOP was that there was prevalence of depressive symptoms (3). We planned an intervention that addresses the “ABCs” of diabetes as in NOCHOP but additional addresses “D” (depression) and have applied for funding to conduct this study.

In 2014 we conducted a meta-analysis to review the efficacy of Community Health Worker (CHW) interventions to improve glycemia in people with diabetes including NOCHOP.
Data sources for this meta-analysis included the Cochrane Central Register of Controlled Trials, Medline, clinicaltrials.gov, Google Scholar, and reference lists of previous publications. We reviewed randomized controlled trials (RCTs) that assessed the efficacy of CHW interventions, as compared to usual care, to lower hemoglobin A1c (A1c). Two investigators independently reviewed the RCTs and assessed their quality. Only RCTs with a follow-up of at least 12 months were meta-analyzed.  A random effects model was used to estimate, from unadjusted within-group mean reductions, the standardized mean difference (SMD) in A1c achieved by the CHW intervention, beyond usual care.

Thirteen RCTs were included in the narrative review, and nine of them, which had at least 12 months of follow-up, were included in the meta-analysis. Publication bias could not be ruled-out due to the small number of trials. Outcome heterogeneity was moderate (I2= 37%). The SMD in A1c (95% confidence interval) was 0.21 (0.11-0.32). Meta-regression showed an association between higher baseline A1c and a larger effect size.  We concluded that CHW interventions showed a modest reduction in A1c compared to usual care and that A1c reduction was larger in studies with higher mean baseline A1c. However, caution is warranted given the small number of studies.

Publications

  1. Palmas W, Teresi JA, Findley S, Mejia M, Batista M, Kong J, Silver S, Luchsinger JA, Carrasquillo O. Protocol for the Northern Manhattan Diabetes Community Outreach Project. A randomised trial of a community health worker intervention to improve diabetes care in Hispanic adults. BMJ Open. 2012 Mar 26;2(2):e001051. doi: 10.1136/bmjopen-2012-001051. Print 2012. PubMed PMID:22454189; PubMed Central PMCID: PMC3330252.
  2. Palmas W, Findley SE, Mejia M, Batista M, Teresi J, Kong J, Silver S, Fleck EM, Luchsinger JA, Carrasquillo O. Results of the northern Manhattan diabetes community outreach project: a randomized trial studying a community health worker intervention to improve diabetes care in Hispanic adults. Diabetes Care. 2014 Apr;37(4):963-9. doi: 10.2337/dc13-2142. Epub 2014 Feb 4. PubMed PMID: 24496805; PubMed Central PMCID: PMC3964489.
  3. March D, Luchsinger JA, Teresi JA, Eimicke JP, Findley SE, Carrasquillo O, Palmas W. High rates of depressive symptoms in low-income urban Hispanics of Caribbean origin with poorly controlled diabetes: correlates and risk factors. J  Health Care Poor Underserved. 2014 Feb;25(1):321-31. doi: 10.1353/hpu.2014.0027.  PubMed PMID: 24509029.
  4. Palmas W, March D, Darakjy S, Findley SE, Teresi J, Carrasquillo O, Luchsinger JA. Community Health Worker Interventions to Improve Glycemic Control in People with Diabetes: A Systematic Review and Meta-Analysis. J Gen Intern Med. 2015 Mar  4. [Epub ahead of print] PubMed PMID: 25735938.

 

 
 
NOCHOP, COACH and address
link to NOCHOP link to COACH email link rc2415@cumc.columbia.edu