UCSF Center for Vulnerable Populationsat San Francisco General Hospital and

Trauma Center

2009 Annual Report

UCSF Center for Vulnerable Populationsat San Francisco General Hospital and

Trauma Center

2009 Annual Report

Table of Contents

I. Executive Summary…………………………………………………………………………….. 2

II. Background and Introduction……………………………………………………………….. 5

III. Center Plans and Development……………………………………………………………. 5

IV. CVP Research Projects…………………………………………………………………………. 7

V. Dissemination…………………………………………………………………………............. 14

VI. CVP Awards and Recognition……………………………………………………………… 25

VII. Policy Impacts…………………………………………………………………………………….. 25

VIII. Appendices…………………………………………………………………………………………. 28

I. CVP ANNUAL REPORT EXECUTIVE SUMMARY

The UCSF Center for Vulnerable Populations (CVP), directed by Dean Schillinger, MD (Director) and Kirsten Bibbins-Domingo MD, PHD, MAS (co-Director) was founded in 2006 and is the only UCSF research center dedicated to chronic disease.  Its mission is to carry out innovative research to prevent and treat chronic disease in populations for whom social conditions often conspire to both promote chronic disease and make its management more challenging. CVP is based within the UCSF Department of Medicine located on the campus of San Francisco General Hospital and Trauma Center, the public health hospital of the City and County of San Francisco.

CVP has distinguished itself as a practice-based research center whose work has helped translate research into community and public health practice, as well as infuse local practice back into research. CVP faculty has coordinated 7 randomized trials in community settings. Beyond the local communities it serves, CVP is nationally and internationally known for its research in health communication and health policy to reduce health disparities, with special expertise in the social determinants of health, including literacy, food policy, poverty and minority status, and with a focus on the clinical conditions of pre-diabetes, diabetes, and cardiovascular disease, including hypertension, chronic kidney disease and heart failure.

In 2009, the CVP successfully recruited new faculty and staff and launched a new website http://cvp.ucsf.edu. In addition, thanks to the vision of the San Francisco General Hospital Foundation and a gift from an individual donor, we developed space plans for a 2600 square foot space to permanently house the CVP and its two future programs--Health Communications and Health Policy and Chronic Disease Prevention. The CVP has now grown to include 8 multidisciplinary faculty investigators, 3 biostatisticians, 1 mathematician a Center manager, project coordinator and 6 research and administrative staff.

During 2009, the CVP received several prestigious awards including the 14th Annual George Engel Award for Outstanding Research Contributing to the Theory, Practice and Teaching of Effective Health Care Communication and Related Skills awarded to Dr. Dean Schillinger. CVP faculty and staff were also recognized as Quality Leaders from the California Association of Public Hospitals/Safety Net Institute (CAPH/SNI) for the “Automated Telephone Self-Management Support Model for Diabetes Project”.

In 2009 alone, CVP faculty 1st-authored 15 peer-reviewed papers and co-authored 36 more, in several prestigious journals that include the New England Journal of Medicine, Annals of Internal Medicine, and American Journal of Public Health and broadened dissemination efforts to reach diverse audiences including the Spanish-language radio station Radio Bilingüe; an NBC-affiliated show, Comunidad del Valle; a CBS local station, KTVU, and through the ethnic media consortium, New America Media. The CVP also created and distributed fact sheets that highlighted key research findings to diverse groups.

This year the CVP further expanded its research portfolio with grants from the Center for Disease Control and Prevention, the National Institutes of Health (National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and Kidney Diseases), the American Heart Association, the Robert Wood Johnson Foundation, the California Program on Access to Care, the California Endowment and others that contribute to a research portfolio of over $10 million. The CVP embarked on several pioneering research projects including partnering with the San Francisco Health Plan in a scaled-up automated

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telephone diabetes management program; adapting a heart disease policy model to explore impacts on minorities and the poor; assessing chronic disease risk in young adults; exploring the relationship between food insecurity and chronic disease; and strengthening binational disease prevention efforts between US and Mexico.

The CVP also continues to play an active role in translating research into public policy. Dr. Schillinger continues his role as Chief of the California Diabetes Prevention and Control Program; Dr. Bibbins-Domingo has worked with the Center for Disease Control and other state and local agencies to advise on policies related to salt intake in the US diet; she is also a member of an Institute of Medicine Committee making recommendations on vaccine safety; Dr Urmimala Sarkar serves in an advisory capacity for the National Patient Safety Foundation; and Dr. Seligman advances policies around food insecurity by participating in the Food Security Task Force and the Southeast Food Access Program of the City and County of San Francisco.

The CVP spent much of last year strengthening and forming new partnerships both within and beyond UCSF. The CVP continues to play leadership roles in UCSF’s Clinical and Translational Sciences Institute (CTSI), advancing community engagement and dissemination sciences, helping direct the training program for the CTSI mentored scientist awards, and participating in the San Francisco Health Improvement Project to improve collaborations between UCSF, local health departments and the broader community.  The CVP also collaborated with UCSF Global Health Sciences to pilot a medical residency exchange program in Tanzania, Africa. Lastly, CVP is collaborating on a planning process to improve collaborations between UCSF faculty based at SFGH and the San Francisco Unified School District.

The CVP is building momentum to generate even broader impact in 2010. The Center will focus programmatic efforts on space renovation and fundraising, and will refine and further realize our vision for two new CVP programs in Health Communications and Health Policy and Chronic Disease Prevention. The CVP will also increase its visibility and impact by 1) launching a UCSF Health Communications Research Seminar series; 2) coordinating a larger initiative to bring together research expertise on the SFGH campus to improve the health of vulnerable populations; and 3) holding symposia that showcase work related to vulnerable populations both at SFGH and in the larger UCSF community. The CVP is expanding its role as a premier translational research home for a range of trans-disciplinary scientists dedicated to reducing the burden of chronic disease in vulnerable populations.

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Annual Report Section Summary

Faculty 20 Faculty and Staff Members-1 Constance B. Wofsy Professor-1 Professor-1 Associate Professor -5 Assistant Professors-3 Biostatisticians-1 Mathematician-1 Center Manager-1 Project coordinator-1 Administrative Assistant-5 Staff Research Associates

Research projects CVP faculty members are principal investigators or co-investigators on 24 projects. The projects with CVP faculty as PIs represent $10,103,799 in total costs

Publications 51 peer-reviewed articles in 31 academic journals17 additional research abstracts 7 non-peer reviewed publications

Presentations/Symposia 52 Presentations and Invited Lectures-19 national -28 regional -5 international

Awards and recognition 5 Awards or nominations-1 national award-1 program award-1 abstract finalist-1 abstract award-1 national research award finalist

Research mentoring and training

27 Mentees -14 Faculty members

-Primary mentorship on two K Awards-Secondary mentorship on VACD Award-Secondary mentorship on K Award-Secondary mentorship on ACR junior faculty award

-11 Postdoctoral fellows and residents - 2 Predoctoral students

II. BACKGROUND AND INTRODUCTION

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Established in October 2006, the UCSF Center for Vulnerable Populations (CVP http://cvp.ucsf.edu) is the only research center at UCSF dedicated to chronic disease. With its academic home in the UCSF Department of Medicine, its mission is to carry out innovative research to prevent and treat chronic disease in populations for whom social conditions often conspire to promote chronic disease and make its management more challenging. CVP has distinguished itself as a practice-based research center whose work has helped translate research into community and public health practice, as well as infuse local practice back into research. Beyond the local communities it serves, CVP is nationally and internationally known for its research in health communication and health policy to reduce health disparities, with special expertise in the social determinants of health, including literacy and language, food policy, poverty and minority status, and a focus on the clinical conditions of pre-diabetes, diabetes, hypertension and heart failure. The following report focuses on CVP activities and accomplishments for 2009 only. We will present an overview of the Center’s infrastructure development; current research projects and grants; dissemination efforts; and policy impacts.

III. CENTER PLANS AND DEVELOPMENTA. NEW DESIGNATED SPACE

The CVP recently secured a 2,600 square foot shell space on 25th Street and Potrero Avenue (two blocks south of the hospital) to renovate and house the CVP. This new space will allow the CVP to support and centralize its current operations and house two new programs--Health Communications and Health Policy and Chronic Disease Prevention--that further the CVP mission of translating innovative research into effective clinical and public health practice.

The CVP Health Communications Program is dedicated to improving health communications science for the most vulnerable populations. This program incorporates health information technology, media production, telemedicine, disciplinary collaborations and policy/advocacy to improve health outcomes for vulnerable groups. Research projects include San Francisco Health Plan “Smart Steps” Project on Improving Diabetes Self-Management for High Risk Patients with Diabetes; Interactive Health IT to Promote Ambulatory Safety among Vulnerable Diabetes Patients; and Development of an Instrument to Measure Health Literacy.

Health Policy and Chronic Disease Prevention Program will focus on health policy prevention efforts to reduce chronic disease in the most vulnerable groups. Research projects in this program focus on three main areas: 1) examining the biological, behavioral, environmental, and health systems factors that place vulnerable groups at high risk for chronic illness, 2) evaluating policy interventions for their impact on the development of chronic illness in these groups, and 3) designing new policy interventions aimed at chronic disease prevention.

The space will also be a planning and management hub for a larger initiative at San Francisco General Hospital and Trauma Center that brings together different disciplines on campus with innovative and synergistic approaches to improving health for vulnerable populations. This includes laboratory researchers engaged in discovery related to mechanisms of diseases in vulnerable patients treated at SFGH and clinical researchers engaged in behavioral interventions for diverse patients.

During 2009, with support from an individual donor we met with architects (Tsao Designs) and engineers to develop space design plans. The new space will house 7 offices and 8 work stations, and have a multi-media conference room. Please see Appendix A for space plans.

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B. NEW WEBSITEThe CVP collaborated with the Elfenworks Foundation to create a new website http://cvp.ucsf.edu highlighting CVP projects, new publications, faculty and staff profiles, and important links and resources.  The Elfenworks Foundation provided critical expertise in website design development and overall implementation for this project.

C. FACULTY AND STAFF ADDITIONSThe CVP has prioritized creating and expanding a cadre of top-notch clinical scientists from Medicine and related disciplines dedicated to generating new knowledge to improve the health for vulnerable populations. In 2009, Dr. Neil Powe, MD, MPH, MBA, joined UCSF as the Constance B. Wofsy Distinguished Professor, Vice-Chair of Medicine at the University of California San Francisco and Chief of Medical Services at San Francisco General Hospital and Trauma Center. Formerly, Dr. Powe was the director of the Welch Center for Prevention, Epidemiology and Clinical Research at Johns Hopkins University. We are excited and humbled to have Dr. Powe’s guidance, stewardship and membership with the CVP. Laura Plantinga, ScM, also joined the CVP as Assistant Adjunct Professor of Medicine. Ms. Plantinga brings expertise in processes and quality of care, patient outcomes and quality of life, and epidemiology of chronic disease, particularly related to chronic kidney disease.

Additionally, the CVP filled two staff research associates to support new research projects. New staff and faculty bios are included in Appendix B along with a complete list of CVP faculty and staff.

C. MENTORING AND TRAININGThe CVP recognizes the importance of training new leaders to help meet its larger goals. Drs. Bibbins-Domingo and Schillinger have devoted much of their time to mentoring junior faculty, fellows, residents and other emerging leaders in research, practice and policy related to vulnerable populations, and they play key roles in UCSF’s clinical research training programs. Their teaching portfolio has included areas like designing clinical research, dissemination and implementation sciences, epidemiology, and health communication. Dr. Handley is director of the Training Program in Implementation and Dissemination Sciences, which focus on the art and science of translating evidence into practice, policy and public health. Please see Appendix C for a list of teaching and mentoring responsibilities during 2009.

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IV. CVP PROJECTS In 2009, CVP researchers were involved in 10 innovative research projects ranging from developing communication tools to improving diabetes management, advancing health literacy, creating a policy model to monitor and reduce disparities in heart disease, developing community education to prevent lead poisoning, and piloting innovative surveillance strategies for ambulatory diabetes patients. Faculty was also involved in a number of other UCSF and multi-site projects as co-investigators (information available upon request). CVP-directed projects and their associated Principal Investigators (PIs) are designated in bold.

1. Promoting Lead Education to High Risk Community Members through a Community-Based Participatory Education and Dissemination Model PIs: Margaret Handley, PhD, MPH Maricel Santos (SF State, and Paul Heavenridge, Literacyworks)Funder: Public Health Trust; 10/1/08-6/30/10

The goals of this project are to develop a regional dissemination model to integrate existing county-level community education programs (ESL, Cooperative Extension and Library-Based Adult Literacy programs) with health communication expertise, to promote community-developed lead educational materials. These materials will then be disseminated to diverse communities in a high risk county for lead poisoning using epidemiological strategies to identify community ‘hot spots’. The investigators will develop a state-wide plan to scale up this model across state chapters of the local community education programs and other environmental justice coalitions.

2. Interactive Health IT to Promote Ambulatory Safety among Vulnerable Diabetes PatientsPI: Urmimala Sarkar, MD, MPHFunder: Agency for Health Research Quality (K-08)9/30/2008-9/29/13

This career development award aims to support Dr Sarkar in her progress to become an independent investigator in the areas of ambulatory patient safety in chronic diseases among vulnerable populations. Her projects will leverage self-management support technology for diabetes to assess patient safety between visits for ambulatory patients, and to compare this to other surveillance strategies.

3. Adapting the Coronary Heart Disease Policy Model to Address Disparities in Heart DiseasePI: Kirsten Bibbins-Domingo, PhD, MDFunder: UCSF CTSI Resource Allocation Program9/1/08-6/30/09

This pilot project will seeks to develop race/ethnic and income stratified versions of the Coronary Heart Disease Policy Model, a computer simulation of heart disease among adults in the US and to use this Model to examine the impact of public health interventions on cardiovascular health in US minority populations.

4. Chronic Kidney Disease and Cardiovascular Risk in Young Adults PI: Kirsten Bibbins-Domingo, PhD, MDFunder: National Institute of Diabetic and Digestive and Kidney Disease (R-01)8/1/08-7/31/11

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This project examines the role of early declines in kidney function and the development of cardiovascular risk using a longitudinal study of cardiovascular disease development in young adults and cystatin C as a marker of kidney function.

5. Evaluating the Missouri Health Literacy and Diabetes Communication InitiativePI: Dean Schillinger, MDCVP Co-Investigator: Hilary Seligman, MD, MASFunder: American College of Physicians Foundation11/1/07-10/30/10

This project will implement and evaluate the effects of a patient centered diabetes guide among diabetes patients in Missouri community health centers.

6. San Francisco Health Plan “Smart Steps” Project on Improving Diabetes Self-Management for High Risk Patients with DiabetesPI: Dean Schillinger, MDCVP Co-Investigators: Margaret Handley, PhD, MPH, Neda Ratanawongsa, MD, MPHFunder: Agency for Healthcare Research and Quality (AHRQ)9/01/07 – 8/31/11

This is an evaluation of a large Automated Telephone Self Management/health IT initiative at the San Francisco Health Plan (SFHP) among 500 English, Chinese, and Spanish speaking patients with diabetes. The evaluation will focus on the effects of health IT on both patient-centered and clinical outcomes through a “real-world” effectiveness study, as well as explore impacts on patient safety. This project builds on a prior CVP study, the IDEALL Project, which demonstrated the value of automated telephone self-management support for high risk populations.

7. Biomarkers for the diagnosis of heart failure in young African Americans. PI: Kirsten Bibbins-Domingo, PhD, MDFunder: Hellman Family Award1/1/07 – 12/31/08 NCE

Goal: To explore the role of novel prognostic markers to aid in the diagnosis of heart failure among young African Americans.

8. Health Literacy and Self-Management in Heart FailureSite PI: Dean Schillinger, MDCVP Co-Investigator: Kirsten Bibbins-Domingo, PhD, MDFunder: NIH/National Heart Lung and Blood Institute (NHLBI)9/1/06 – 5/31/11 To conduct a multi-site randomized controlled trial of a diuretic self-management intervention among a sample of 660 English and Spanish speaking patients with heart failure and limited health literacy.

Grants with CVP faculty as Co-investigators1. Coronary Artery Risk Development In young Adults (CARDIA)PI: Steve Sidney; CVP Co-Investigator: Kirsten Bibbins-Domingo, PhD, MDFunder: National Heart Lung and Blood Institute Kaiser Oakland Field Center10/1/08-9/30/13

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This project will examine the development of cardiovascular risk in black and white young adults.

2. Clinical and Translational Science InstitutePI: Mike McCune; CVP Co-Investigators: Kirsten Bibbins-Domingo, PhD, MD and Dean Schillinger MDFunder: Clinical and Translational Science Institute9/30/06 – 6/30/11

To create an integrated academic home that transforms training in and conduct of clinical and translational research at UCSF and the greater Bay Area community.  Components of the CTSI include formal didactic programs, career development, consultative and technical cores, and community outreach.

V. NEW GRANTSIn 2009, CVP researchers successfully competed for 14 additional grants either as principal investigators or co-investigators. These grants cover a range of areas including modifying a heart disease policy model, assessing chronic disease risk in young adults, exploring the relationship between food insecurity and chronic disease, and strengthening binational disease prevention efforts. These projects involve collaborations with a range of investigators across UCSF Divisions, Departments and Schools, and also involve multiple disciplines from other universities and community groups. Below is the list of grants that were awarded to CVP faculty in 2009.

1. Cardiovascular Risk Reduction in Diabetes Care Among Vulnerable PopulationsPI: Dean Schillinger, MDCo-Investigator: Neda Ratanawongsa, MD, MPH Funder: San Francisco General Hospital Foundation (McKesson Foundation Award)1/1/10 – 12/31/10

This grant will help identify factors affecting patient preferences for cardiovascular risk reduction therapies, evaluate patient and provider decisions about medication adherence, and identify outcomes of a telephone diabetes self-care management program vs. counseling.

2. Strengthening Indigenous Food Identity and Minimizing Chronic Disease Risk among Transnational Oaxacan CommunitiesPI: Margaret Handley, PhD, MPHFunder:  UC MEXUS9/1/09-8/30/10

The goals of this project are to conduct a mixed methods assessment to identify potential protective components to the Oaxacan traditional diet that can be integrated into binational disease prevention efforts.

3. Medication Communication among Vulnerable Cardiology PatientsPI: Urmimala Sarkar, MD, MPHFunder: National Institute on Aging/Center for Aging in Diverse Communities9/01/09-09/01/11

Goal: The aim of this study is to investigate the extent of medication regimen concordance between ethnically diverse patients and their providers where there are frequent medication changes; we will use previously collected data from the Video Medical Interpretation Cardiology Clinic Study, which investigated different modes of

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language interpretation in ambulatory cardiology encounters in an urban, safety-net setting.

4. Supplement to Chronic Kidney Disease and Cardiovascular Risk in Black and White Young Adults. PI: Kirsten Bibbins-Domingo, PhD, MDFunder: NIDDK8/1/09-7/31/11

Goal: To provide career development support to Dr. Vanessa Grubbs, a junior nephrologist, to conduct research with Dr.Bibbins-Domingo examining genetic factors influencing decline in early kidney function in black and white young adults in the CARDIA study.

5. Adaptation of the Coronary Heart Disease Policy Model to US SubpopulationsPI: Kirsten Bibbins-Domingo, PhD, MDFunder: American Heart Association 07/01/09-06/30/11

Goal: To adapt an established, validated computer simulation of heart disease in US adults (the CHD Policy Model) to describe differences by race/ethnicity in California and the US in order to examine disease trends in obesity and the impact of public health interventions on US Subpopulations.

6. Role of Food Insecurity as a Mediator of Socioeconomic Disparities in HealthPI: Hilary Seligman, MD, MASFunder: NIH/CTSI7/1/09-6/30/13

This career development award supports Dr. Seligman's research in the area of food insecurity, or the inability to reliably afford access to nutritious food. Using a combination of primary data collection and secondary data analysis, this project will establish the extent to which food insecurity is related to the incidence of obesity, pre-diabetes, and diabetes among young adults, and establish the extent to which food insecurity predisposes adults with diabetes to poor diabetes control.

7. A Pilot Intervention to Increase Fruit and Vegetable Intake among WIC BeneficiariesPI: Kirsten Bibbins-Domingo, PhD, MDCVP Co-Investigators: Hilary Seligman, MD, Dean Schillinger, MDFunder: Robert Wood Johnson Foundation Health and Society Scholars Program5/14/09-5/13/10

Goal: Diets high in fruit and vegetable intake are associated with lower cardiovascular disease (CVD) and cancer risk.  Fruit and vegetable-poor diets may contribute to known race/ethnic and income health disparities through a variety of mechanisms including, increasing blood pressure and increasing body weight.  This pilot study will inform the development of a larger intervention providing vouchers of varying dollar amounts redeemable for fresh fruits and vegetables to Supplemental Nutrition Program for Women, Infants, and Children (WIC) beneficiaries.  Outcomes will include fruit/vegetable intake, blood pressure, and antioxidant levels.

8. Health Literacy Team Toolkit Project PI: Hilary Seligman, MD, MASCVP Co-Investigator: Neda Ratanawongsa, MD, MPH

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Funder: American College of Physicians5/14/09 – 5/13/10

The goal is to promote patient self-management for those experiencing post myocardial infarction.

9. California Diabetes Prevention and Control Program*PI: Dean Schillinger, MDFunder: CDC4/01/09-3/28/14

* this award was processed through the UCSF Institute for Health and AgingThe goal is to work to prevent, detect, and intervene among persons at risk for diabetes mellitus and its complications to reduce the adverse personal and public impact of diabetes on California's diverse communities.

10. Diabetic retinopathy (DR) screening in California and Health Information Technology Applications- Status Review and Recommendations for Overcoming Barriers to Improving Access for Vulnerable PopulationsPI: Margaret Handley, PhD, MPHFunder: California Program on Access to Care (CPAC)3/1/09-12/30/09

Goal: Primary care-based retinal screening and eye imaging have been shown to be an effective screening method for the detection of DR. However, despite the growing evidence for digital screening and the potential to improve access, there has been limited implementation in safety net settings that disproportionately serve at risk populations. The goals of the policy paper are to describe the scope of the problem regarding an un-met need for DR screening in California among vulnerable populations receiving care in safety net settings, such as the uninsured and Medi-Cal patients and to develop recommendations to reduce the barriers to implementing primary care based DR screening in California safety net settings.

Grants with CVP faculty as Co-investigators

1. Development of a Patient-Centered, Literacy-Appropriate Self-Management Guide for Patients with Coronary Heart DiseasePI: Terry Davis (University of Louisiana Health Sciences Center, Shreveport) CVP Co-Investigator: Hilary Seligman, MD, MASFunder: American College of Physicians Foundation5/14/09-5/13/10

This project aims to produce materials for post-MI patients in a format that is easy for them to understand and follow. Our team has used many of the strategies that we will be using to accomplish this task in similar projects addressing other common diagnoses, such as diabetes and COPD. We will focus on identifying key messages by reviewing existing Post-MI self-management educational materials and consulting cardiologists. We will conduct focus groups with patients and physicians to identify key messages. We aim to understand the emotions related to coronary artery disease as well as the barriers to effective CAD management and patient-centered strategies for overcoming such barriers. Another component of making this project successful is understanding the opinions and priorities of physicians and practice work-flow issues. The information gathered will be used to develop a prototype guide. UCSF will take primary responsibility for co-

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development of the Spanish language guide. Participants will review the self-management guide and will be asked questions about its content.

2. Development of Multilingual Prescription Drug Instructions for Pharmacy PracticeCalifornia Endowment Site PI: Dean Schillinger, MDCVP Co-Investigator: Urmimala Sarkar, MD, MPH7/1/2009 – 6/30/2011

This study seeks to examine barriers pharmacies in California face in printing multilingual prescription labels and to explore the challenges associated with implementing recommendations issued in SB 472. 3. Adherence and the Economics of Colon Cancer ScreeningPI: John Inadomi, MDCVP Co-Investigator: Neda Ratanawongsa, MD, MPHFunder: National Cancer Institute9/30/09 – 9/29/11Goals: 1. Determine whether there exists heterogeneity in adherence between different CRC screening tests, 2. Utilize prospective rates of adherence to calculate the true incremental cost-effectiveness between competing CRC screening strategies, 3. Identify factors associated with non-adherence to screening.

4. Specialty Access Initiative PI: Hal Yee, MDCVP Co-Investigator: Hilary Seligman, MD, MASFunder: Kaiser Permanente Benefit Programs, Northern California Region1/1/09-12/1/10

The goal of this project is to improve access and quality of specialty care in San Francisco through the collaborative development of formalized primary/specialty care co-management strategies that will be informed by and implemented through our novel eReferral system. The current model of specialty care depends on an in-person patient visit with the specialist. Even when non-indicated or premature visits are eliminated through using eReferral, limited specialty care visit capacity represents our chief impediment to prompt quality specialty care. We hypothesize that a new specialty care model – in which formalized primary/specialty care co-management strategies informed by and implemented through eReferral largely replace the traditional face-to-face specialty visit for select medical conditions – will improve access to and quality of specialty care.

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VI. DISSEMINATIONA central part of the CVP mission is to disseminate research and innovations to clinicians and patients to improve clinical and public health practice. The CVP is also committed to disseminating key findings to diverse stakeholders including scientists, allied health professionals, policymakers, community groups and community members. During 2009, the CVP disseminated results widely through peer-reviewed publications, newsletters, and international, national, state, and local presentations. We plan to broaden our dissemination efforts for 2010 through ethnic media outlets, social marketing approaches, symposia, and community forums to better reach diverse audiences most affected by chronic disease.

A. PUBLICATIONSDuring 2009 the CVP published 51 articles in 31 peer-reviewed journals and presented 17 additional research abstracts at national meetings. Journals included New England Journal of Medicine, Archives of Internal Medicine, and American Journal of Public Health. Below is an alphabetical list of peer reviewed publications. Appendix E contains published abstracts from 2009 that are currently being prepared for publication.

Amarasingham R, Plantinga L, Diener-West M, Gaskin DJ, Powe, NR. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169:108-114.

Argyropoulos C, Chang CC, Plantinga L, Coresh J, Fink N, Powe N, Unruh M. Considerations in the statistical analysis of hemodialysis patient survival. J Am Soc Nephrol. 2009;20:2034-2043.

Barton J, Criswell L, Kaiser R, Chen Y, Schillinger D. A Systematic Review and Meta-Analysis of Patient Self-Report vs. Trained Assessor Joint Counts in Rheumatoid Arthritis. In press. J Rheumatol. 2009.

Bibbins-Domingo K, Chertow GM, Coxson PG, Moran AE, Lightwood JM, Pletcher MJ, Goldman L. Population reductions in Coronary Heart Disease and Stroke associated with modest reductions in salt intake. In Press. N Eng J Med. 2009.

Bibbins-Domingo K, Pletcher MJ, Lin F, Vittinghoff E, Gardin JM, Arynchyn A, Lewis CE, Williams OD, Hulley SB. Racial Differences in Incident Heart Failure among Young Adults. N Engl J Med. 2009 Mar 19;360(12):1179-90

Bodenheimer T, Handley MA. Goal-setting for behavior change in primary care: an exploration and status report. Patient Educ Couns. 2009 Aug;76(2): 174-80.

Casalino LP, Dunham D, Chin MH, Bielang R, Kistner EO, Karrison TG, Ong MK, Sarkar U, McLaughlin MA, Meltzer DO. Frequency of failure to inform patients of clinically significant outpatient test results. Arch Intern Med. Jun 22 2009;169(12): 1123-9

Dewalt DA, Davis TC, Wallace AS, Seligman HK, Bryant-Shilliday B, Arnold CL, Freburger J, Schillinger D. Goal setting in diabetes self-management: Taking the baby steps to success. Patient Educ Couns. 2009 Nov;77(2):218-23.

DeWalt DA, Broucksou KA, Hawk V, Baker D, Schillinger D, Ruo B, Bibbins-Domingo K, Holmes M, Weinberger M, O’Connell AM, Pignone M. Comparison of a one-time educational intervention to a teach-to-goal educational intervention for self-management

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of heart failure: Design of a randomized controlled trial. BMC Health Services Research. 2009 Jun 11;9:99.

Fagnan L, Handley M, Rollins N, Mold J. Voices from Left of the Dial: Practice-Based Research Network Clinicians’ Perspectives on Participation, Motivation and Connection. In Press. J Am Board of Family Med. 2009.

Fang M, Panguluri P, Machtinger EL, Schillinger D. Language, literarcy, and characterization of Stroke Among Patients Taking Warfarin for Stroke Prevention: Implications for Health Communication. Patient Ed Counsel. 2009 Jun;75(3):403-10.

Gozu A, Nidiry MA, Ratanawongsa N, Wright SM. Patient Factors Associated with Following a Relocated Primary Care Provider Among Older Adults. Am J Manag Care. 2009 Mar;15(3):195-200.

Handley MA, Santos M, McClellan J. Engaging learners as interpreters for developing lead poisoning prevention materials: Designing the Familias Sin Plomo English as a Second Language Curriculum Project. Glob Health Promot. 2009 Sep;16(3):53-8.

Haywood C, Lanzkron S, Ratanawongsa N, Bediako SM, Lattimer-Nelson L, Beach MC. Hospital Self-Discharge Among Adults with Sickle Cell Disease: Associations with Trust and Interpersonal Experiences with Care. Accepted for Publication. Am J Med. 2009.

Haywood C, Lanzkron S, Ratanawongsa N, Bediako SM, Lattimer-Nelson L, Beach MC. Hospital Self-Discharge Among Adults with Sickle Cell Disease: Associations with Trust and Interpersonal Experiences with Care. Accepted for publication. Journal of Hospital Medicine. 2009.

Haywood C, Lanzkron S, Ratanawongsa N, Bediako SM, Lattimer-Nelson L, Beach MC. The Association of Provider Communication with Trust Among Adults with Sickle Cell Disease. Accepted for publication. J Gen Intern Med. 2009.

He G, Sentell T, Schillinger D. A New Public Health Tool for Abnormal Glucose Risk Assessment: The AGRA-6. In press. Prev Chronic Disease. 2009.

Jaar BG, Plantinga LC, Crews DC, Fink NE, Hebah N, Coresh J, Kliger AS, Powe, NR. Timing, causes, predictors and prognosis of switching from peritoneal dialysis to hemodialysis: a prospective study. BMC Nephrol. 2009 Feb 6;10:3.

Jhamb M, Argyropoulos C, Steel JL, Plantinga L, Wu AW, Fink NE, Powe NR, Meyer KB, Unruh ML, for the Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study. Correlates and outcomes of fatigue among incident dialysis patients. In press. J Am Soc Nephrol. 2009.

Kantsiper ME, Ratanawongsa N, Wright SM, Smith CG, Levine RB. Factors That Influence Professional Satisfaction in Hospital Medicine: A Review for Prospective Hospitalists. Hospital Physician. 2009 May/June;45(4):2328.

Kalogeropoulos A, Georgiopoulou V, Kritchevsky SB, Psaty BM, Smith NL, Newman AB, Rodondi N, Satterfield S, Bauer DC, Bibbins-Domingo K, Smith AL, Wilson PWF, Vasan RS, Harris TB, Butler, J. Epidemiology of incident heart failure in a contemporary elderly cohort: The Health, Aging, and Body Composition study. Arch Intern Med. 2009;169 (7):708-15.

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Kim Y, Situ M, Handley M, McLean I, Schillinger D. Ecology Matters: Patient Perspectives of Diabetes Self-Management Support Strategies in a Safety-Net Health System. In press. Asia Pacific Journal of General Practice. 2009.

Lightwood J, Bibbins-Domingo K, Coxson P, Wang YC, Goldman L. Forecasting the future economic burden of current adolescent overweight: An estimate of the Coronary Heart Disease Policy Model. Am J Public Health. 2009 Dec;99(12):2230-7.

Lightwood J, Coxson P, Bibbins-Domingo K, Williams L, Goldman LG. Coronary heart disease attributable to passive smoking: CHD Policy Model. Am J Prev Med. 2009; 36(1):13-20.

Moffet HH, Adler N, Schillinger D, Weintraub JA, Selby JV, Liu JY, Karter AJ. Dental Insurance and Utilization Among Medically Insured Patients with Diabetes (DISTANCE). In press. Am J Prev Med. 2009.

Peralta C, Risch N, Li F, Shlipak M, Reiner A, Ziv E, Tang H, Siscovick D, Bibbins-Domingo K. The association of African ancestry and elevated creatinine in the Coronary Artery Risk Development in Young Adults (CARDIA) study. In press. Am J Nephrology. 2009.

Plantinga LC, Fink NE, Finkelstein FO, Powe NR, Jaar BG. Association of peritoneal dialysis c linic size with clinical outcomes . Perit Dial Int. 2009; 29:285-291.

Plantinga LC, Miller ER, III, Stevens LA, Saran R, Messer K, Flowers N, Geiss L, Powe NR; for the Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team. Blood pressure control among persons without and with chronic kidney disease: U.S. trends and risk factors 1999-2006. Hypertension. 2009 Jul;54(1):47-56.

Plantinga LC, Fink NE, Coresh J, Sozio SM, Parekh RS, Melamed ML, Powe NR, Jaar BG. Peripheral vascular disease-related procedures in dialysis patients: predictors and prognosis. Clin J Am Soc Nephrol. 2009; 4:1637-45.

Pletcher MJ, Lazar L, Bibbins-Domingo K, Moran A, Rodondi N, Coxson P, Lightwood J, Williams L, Goldman L. Comparing impact and cost-effectiveness of primary prevention strategies for lipid lowering. Ann Intern Med. 2009;150 (4):243-54.

Ratanawongsa N, Zikmund-Fisher BJ, Couper MP, Van Hoewyk J, Powe NR. Race, Ethnicity, and Shared Decision Making for Cardiovascular Disease Risk Reduction Treatment. Accepted for Publication. Medical Decision Making. 2009.

Sarkar U, Wachter RM, Schroeder SA, Schillinger D.Refocusing the lens: patient safety in ambulatory chronic disease care. Jt Comm J Qual Patient Saf. 2009 Jul;35(7):377-83, 341

Sarkar U, Handley M, Gupta R, Tang A, Shojania KG, Schillinger D. Opening the Black Box: Exploring Patient Safety Threats Among Ambulatory Chronic Disease Patients. In press. Int J Health Qual Safety. 2009.

Sarkar U, Ali S, Whooley MA. Self-efficacy as a marker of cardiac function and predictor of heart failure hospitalization and mortality in patients with stable coronary heart disease: findings from the Heart and Soul Study. Health Psychol. Mar 2009;28(2):166-173.

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Sarkar U, Handley M, Gupta R, Tang A, Shojainia K, Schillinger D. What Happens Between Visits? Adverse and Potential Adverse Events Among a Low-Income, Urban, Ambulatory Population with Diabetes. In press. Qual Safety Health Care. 2009.

Schenker Y, Fernandez A, Sudore R, Schillinger D. Interventions to Improve Patient Comprehension in Informed Consent for Medical and Surgical Procedures: A Systematic Review. In press. Med Dec Making. 2009.

Schenker Y, Karter A, Schillinger D, Warton EM, Adler NE, Moffett HH, Ahmed AT, Fernandez A. The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE Study. In press. Patient Educ Couns.

Schickedanz AD, Schillinger D, Landefeld CS, Knight SJ, Williams BA, Sudore RL. A clinical framework for improving the advance care planning process: start with patients' self-identified barriers. J Am Geriatr Soc. 2009 Jan;57(1):31-9.

Schillinger D, Sarkar U. Numbers don't lie, but do they tell the whole story? Diabetes Care. 2009 Sep;32(9):1746-7.

Schillinger D, Handley M, Wang F, Hammer H. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Diabetes Care. 2009 Apr;32(4):559-66.

Seligman HK, Laraia BA, Kushel MB.Food Insecurity Is Associated with Chronic Disease among Low-Income NHANES Participants. J Nutr. 2009 Dec 23.

Seligman HK, Grossman MD, Bera N, Stewart AL. Improving physical activity resource guides to bridge the divide between the clinic and the community. Prev Chronic Dis. 2009 Jan;6(1):A18

Singh HS, Bibbins-Domingo K, Ali S, Wu AHB, Schiller NB, Whooley MA. N-terminal pro-B-type Natriuretic Peptide and inducible ischemia in the Heart and Soul Study. Clin Cardiol. 2009;32(8):447-53.

Steinman MA, Schillinger D. Drug Detailing in Academic Medical Centers: Regulating for the Right Reasons, with the Right Evidence, at the Right Time. Response to Open Peer Commentary “The Pitfalls of Deducing Ethics from Behavioral Economics: Why the Association of American Medical Colleges is Wrong about Pharmaceutical Detailing”. Am J Bioeth. 2010 Jan;10(1):21-3.

Sudore RL, Landefeld CS, Pérez-Stable EJ, Bibbins-Domingo K, Williams BA, Schillinger D. Unraveling the relationship between literacy, language proficiency, and patient-physician communication. Patient Educ Couns. 2009 Jun;75(3):398-402.

Sudore R, Schillinger D. Interventions to Improve Care for Patients with Limited Health Literacy. J Clin Outcomes Manag. 2009 Jan;16(1):20-9.

Taché S, Schillinger D. Health worker migration: time for the global justice approach. Am J Bioeth. 2009 Mar;9(3):12-4.

Villalobos M, Merino-Sánchez C, Hall C, Grieshop J, Gutiérrez-Ruiz M.E, Handley M. Lead (II) detection and contamination routes in environmental sources, cookware and home

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prepared foods from Zimatlan, Oaxaca, Mexico. Sci Total Environ. 2009 Apr 1;407(8):2836-44.

Wallace AS, Seligman HK, Davis TC, Schillinger D, Arnold CL, Bryant-Shilliday B, Freburger JK, DeWalt DA. Literacy-appropriate educational materials and brief counseling improve diabetes self-management. Patient Educ Couns. 2009 Jun;75(3):328-33.

Wang E, Pletcher MJ, Vittinghoff E, Kertesz SG, Kiefe CI, Bibbins-Domingo K. Incarceration, incident hypertension, and access to health care: Findings from the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Arch Intern Med. 2009;169(7):687-93.

Westfall JM, Fagnan LJ, Handley MA, Salsberg J, McGinnis P, Zittleman LK, Macaulay AC. Practice-Based Research is Community Engagement. J Am Board Fam Med. 2009 Jul-Aug;22(4):423-7.

Non-peer reviewed publications

1. Dean Schillinger, MD and Hliary Seligman, MD, MAS helped develop a Living with Diabetes Guide supported by the American College of Physician (ACP) Foundation. Over 1,000,000 copies of these guides have been distributed and are available through ordering at the following link:http://foundation.acponline.org/hl/diabguide.htm

Hilary Seligman appears on the video highlighting this work.http://foundation.acponline.org/hl/diabguide.htm

2. Seligman H, Davis T, and Kalmbach L. Living with COPD: An Everyday Guide for You and Your Family.  Published by the American College of Physicians Foundation.

3. Handley M, Schillinger D, Cu C, Richardson V, He G, Cuadros J. Diabetic Retinopathy In California – A Status Report And Review Of Telemedicine Strategies To Overcome Health Disparities In Type II Diabetes-Related Vision Loss. 

4. Handley, M, Potter, M, & Goldstein, E. Community-Engaged Research with Community-Based Clinicians.http://ctsi.ucsf.edu/files/CE/manual_for_researchers_clinicians.pdf

5. Sarkar U, Schillinger D. Health Literacy Chapter UpToDate. Waltham, MA: UpToDate; 2009. Available at www.utdol.com.

6. Through a grant from the Public Health Trust, Dr. Margaret Handley, local community-based organizations and residents in Monterey/Santa Cruz Counties created a fotonovela highlighting lead poisoning prevention for vulnerable populations in Monterey and Santa Cruz counties http://cemonterey.ucdavis.edu/EFNEP122/_b__i_Fotonovelas__b___i_.htm.

7. Research from the CVP was referenced in a Robert Wood Johnson Foundation Commission to Build a Healthier America report entitled Education Matters for Health. The report highlights educational attainment as a key social determinant of health, with references to CVP research on health literacy (17 and 24). http://www.commissiononhealth.org/PDF/c270deb3-ba42-4fbd-baeb-2cd65956f00e/Issue%20Brief%206%20Sept%2009%20-%20Education%20and%20Health.pdf

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 B. PRESENTATIONS

In 2009, CVP faculty delivered 52 presentations to research, policy, and community audiences.

Kirsten Bibbins-Domingo

National1. University of Texas Health Science Center, San Antonio, Fredic C. Bartter Visiting

Professorship2. American Heart Association Epidemiology Council Annual Meeting, Tampa, Florida.

Finalist for the Sandra Daugherty Award for Hypertension Research. Population wide reductions in dietary salt and resulting reductions in coronary heart disease.

3. American Heart Association Annual Conference, Orlando, Florida. Best Imaging Abstract Award: Echocardiographic Predictors of Incident Heart Failure in Young Black Adults: The CARDIA Study

Regional1. Thinking Outside the Box: New Ideas for Changing Times: Targeting Salt Reduction

to Prevent Chronic Disease. California Diabetes Leadership Summit, Sacramento, CA.

2. Global Health Implications of Chronic Disease. UCSF Global Women’s Health NIH Presentation.

3. UCSF Center on Social Disparities and Health--Chronic Disease in Young and Middle Aged Adults.

Margaret Handley

International 1. Linking practice-based research with implementation sciences: Which approaches

can lead to best practices for CTSA and community partnerships? North American Primary Care Research Group, Montreal, QU. 

2. Getting the ’Community’ out of Community-based participatory research. North American Primary Care Research Group, Montreal, QU. 

3. Integrated Primary Health Care and Workforce Training in Zomba District Malawi – Health Systems Strengthening. 

4. Meeting on Population Health Implementation and Training Partnerships-Doris Duke Foundation, Zomba, Malawi

 Regional

1. From Immigrant Stories to Collaborative Action: A Case Study in Community Wellness, Culture and Transnational Identity. San Francisco State University Community-based Participatory Research Symposium.

2. California Diabetes Summit Presentation:  Promising Approaches to Integrating Tele-Health Initiatives into Primary-Care Services for Patients with Diabetes.

3. 3rd Annual UCSF Health Disparities Symposium Poster Presentation: Staying healthy, staying connected: An empirical study of transnational health perspectives in English as a Second Language (ESL) and community high school programs

Laura Plantinga

Regional

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3rd Annual UCSF Health Disparities Symposium Presentation: Lower Income Is Independently Associated with Disability among Persons with Chronic Kidney Disease in the United States

Neda Ratanawongsa

National

Ratanawongsa N, Dean C, Rand C, Powe NR, Zimmet JM. “Knowledge and Attitudes about Dual Antiplatelet Therapy Among Patients Receiving Cardiac Catheterization.” 2009 International Conference on Communication in Healthcare, Miami, FL.

Regional

1. 3rd Annual UCSF Health Disparities Symposium Poster Presentation: Using Health Information Technology to Triangulate the Contributions of Patient Preferences, Non-Adherence, and Need for Treatment Intensification in the Achievement of Diabetes Goals in a Vulnerable Population.

2. Davis E, Alpers L, Duffy K, Harleman E, Gelason N, Maldonado A, Jagannathan P, Komisarjevsky V, Seligman H, Newbold E, Tayo-Samoni D, Winston L, Ratanawongsa N. Teaching Residents the Value of Caring for Patients Awaiting Placement. Society of General Internal Medicine Annual Meeting, Miami, FL.

3. Ratanawongsa N, Sarkar U, Quan J, Handley M, Soria C, Tan S, Lau O, Lum A, Pfeifer K, Schillinger D. Using Health Information Technology to Triangulate the Contributions of Patient Preferences,  Non-Adherence, and Need for Treatment Intensification in the Achievement of Diabetes Goals in a Vulnerable Population. 2009 AHRQ Annual Conference, Bethesda, MD; 2009 UCSF Disparities Symposium, San Francisco, CA.

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Urmimala Sarkar

National

1. Monitoring Patient Safety for Vulnerable Diabetes Patients using Automated Telephone Self-Management Support. National Partnership for Action to End Health Disparities, National Leadership Summit, Office of Minority Health, Washington, DC.

2. Ambulatory Safety Surveillance using Automated Telephone Technology for Vulnerable Diabetes Patients. Society of General Internal Medicine National Meeting, Miami, FL.

3. Monitoring Medication Safety via an Enhanced Personal Health Record in an Urban, Diverse, HIV Positive Population. Society of General Internal Medicine National Meeting, Miami, FL.

Regional

1. Heart to heart: Inadequate Patient-Clinician Communication in Ambulatory Cardiac Care. 3rd Annual UCSF Health Disparities Symposium Poster Presentation.

2. Patient Safety in the Ambulatory Setting. San Francisco General Hospital and Trauma Center Medical Grand Rounds.

Dean Schillinger

International1. Addressing the Co-Epidemics of TB and Diabetes: International Web-Based

Seminar, Francis J. Curry National TB Center, San Francisco, CA

National1. Proactive Outreach Using Telephone Technology. Right Care Initiative. CA Dept of

Managed Healthcare. Los Angeles CA.2. Preventing Readmissions: Employing the “Teach-Method” at the Systems Level.

Florida Hospital Association Collaborative.3. Health Literacy and Diabetes Prevention and Control. CDC Division of Diabetes

Translation. Long Beach, CA.4. Health Literacy and Diabetes Prevention and Control. Diabetes Coalition of

California. Sacramento CA.5. What Will it Take to Fight Diabetes in California? California Diabetes Leadership

Summit, Sacramento CA.6. Addressing Social Determinants in Diabetes: What is Our Role? California Diabetes

Leadership Summit, Sacramento CA.7. A Framework for Patient Safety in the Ambulatory Setting. U Colorado Health

Sciences Denver CO.8. Literacy, Health Communication and Diabetes Disparities. U Colorado Health

Sciences Grand Rounds, Denver CO.9. Overcoming Diabetes Disparities in Safety Net Health Systems. CA Primary Care

Assn Annual Conference Keynote Address.10.Harnessing Health IT for Advancing Public Health: Populations with Limited Health

Literacy. Health Literacy Annual Research Conference, Washington DC.

Regional

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1. UCSF Center for Social Disparities in Health Seminar Literacy, Health Communication, and Chronic Illness to the Center on Social Disparities and Health.

2. Kaiser-Permanente Care Management Institute. 3. Asian Health Services, Oakland CA.4. Alta Bates Ethnic Health Institute, Oakland CA.5. Guest speaker, Radio Bilingue Nacional (Linea Abierta): Diabetes Prevention in

Latinos. [http://www.radiobilingue.org/blogairelibre/blogairelibre.htm] [http://www.archivosderb.org/?q=es/node/2267]

6. Diabetes Center Retreat: Health Services Research: Diabetes in Underserved Populations

Hilary Seligman 

National1. Davis E, Alpers L, Duffy K, Harleman E, Gleason N, Maldonado AM, Jagannathan P,

Komisarjevsky V, Seligman H, Newbold E, Tayo-Samoni E, Winston L, Ratanawongsa N. Poster presentation. Teaching Residents the Value of Caring For Patients Awaiting Placement. Society of General Internal Medicine, Miami, FL, May 2009.

2. Maldonado AM, Gleason N, Davis E, Irby R, Shao L, Seligman H. Poster presentation. Nothing to Do, Awaiting Placement: Teaching the Prevention of Hospital Acquired Complications in Pts with Prolonged Hospitalizations, A Multidisciplinary Resident Integrated Approach. Society of General Internal Medicine, Miami, FL.

Regional

1. Plenary Presentation. Improving Health Promotion Counseling for Patients with Limited Health Literacy. Regional Diabetes Collaborative (RDC) of Monterey, San Benito and Santa Cruz Counties, Diabetes Forum, Watsonville, CA.

2. Invited Lecture. Health and Hunger in America. Mission Mental Health Clinic, noon conference for providers, San Francisco, CA.

3. Plenary Presentation. Health and Hunger in America. Bi-Annual Professional Practice Group Conference, San Francisco, CA.

4. Riley L, Saad N, Seligman HK. Poster Presentation. Postpartum Diabetes Insipidus: An Interesting Path to a Rare Diagnosis. Society of General Internal Medicine Regional Meeting.

5. Riley L, Saad N, Seligman HK. Poster Presentation. Postpartum Diabetes Insipidus: An Interesting Path to a Rare Diagnosis. American College of Physicians Foundation.

6. Invited Lecture. How I Became an Expert in Food Insecurity, or How to Become an Activist Leader in 5 Steps. Social Activism in Medicine Class, UCSF, San Francisco, CA.

7. Invited Lecture. Food Insecurity. UC-Berkeley, Nutritional Epidemiology (Public Health 206C), San Francisco, CA.

8. 3rd Annual UCSF Health Disparities Symposium Poster Presentation: Food Insecurity is a Risk Factor for Poor Diabetes Self-Management

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9. Health and Hunger in America. SFGH and Moffit-Long Hospital-Medical Grand Rounds on February 10, 2009.

10. Guest interview appearance, Hunger in America on KTVU Channel 2.

C. COMMUNITY FORUMS/Town Hall Meetings

a. KTVU: Hunger in America

Hilary Seligman, MD, MAS was interviewed for a news piece on how America could be simultaneously facing an epidemic of obesity and an epidemic of hunger.  The interview was broadcast on KTVU Channel 2 news on December 24, 2009.

b. World Diabetes Day

Dr. Dean Schillinger, Chief of the California Diabetes Program and Director of the Center for Vulnerable Populations was a speaker for World Diabetes Day, on November 14th, 2009 in Sacramento, CA.  This event was co-hosted by the California Diabetes Program and gathered a global and local community around diabetes prevention. Dr. Schillinger was interviewed on the Channel 13 News.

c. UCSF Third Annual Health Disparities Symposium

CVP investigators presented during the third annual UCSF Annual Health Disparities Symposium on October 23, 2009. Laura Plantinga, ScM, gave a presentation entitled Lower Income is Independently Associated with Disability among Persons with Chronic Kidney Disease in the United States. Posters were presented by Margaret Handley, PhD, “Staying healthy, staying connected: An empirical study of transnational health perspectives in English as a Second Language (ESL) and community high school programs”; Neda Ratanawongsa, MD, MPH “Using Health Information Technology to Triangulate the Contributions of Patient Preferences, Non-Adherence, and Need for Treatment Intensification in the Achievement of Diabetes Goals in a Vulnerable Population”; Urmimala Sarkar, MD, MPH “Heart to heart: Inadequate Patient-Clinician Communication in Ambulatory Cardiac Care”; and Hilary Seligman, MD, MAS “Food Insecurity is a Risk Factor for Poor Diabetes Self-Management”.

d. California Diabetes Leadership Summit, Sacramento, CA

CVP researchers presented at the first annual California Diabetes Leadership Summit. Dr. Dean Schillinger who is also the Chief of the California Diabetes Program gave a talk entitled “What Will it Take to Fight Diabetes in California?” Dr. Schillinger also facilitated a discussion with Linda Rudolph, MD, MPH, Deputy Director, California Department of Public Health, Center for Chronic Disease Prevention and Health Promotion during a session entitled “Addressing Social Determinants in Diabetes: What is Our Role?”

CVP researchers presented during a break out session entitled Thinking Outside the Box: New Ideas for Changing Times: Dr. Kirsten Bibbins-Domingo gave a talk entitled “Targeting Salt Reduction to Prevent Chronic Disease” and Dr. Margaret Handley gave a talk entitled “Promising Approaches to Integrating Tele-Health Initiatives into Primary-Care Services for Patients with Diabetes.”

e. Drs. Schillinger and Handley were interviewed on a Bay Area-wide television program, Comunidad del Valle, which reaches a primarily English-speaking audience whose influence reaches large segments of the Latino community. The interview focused on the

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work at the Center for Vulnerable Populations that centers on innovative communication strategies between primary care centers and vulnerable populations in the community who don’t receive the information they need to manage chronic illnesses, due to such factors as limited literacy, language barriers and lack of health insurance.

f. Radio Bilingüe - Living with Diabetes; Innovative Communication Strategies. Dr. Dean Schillinger was featured on the Radio Bilingüe program, Linea Abierta, a non-profit radio network with Latino control and leadership that is the only national distributor of Spanish-language programming in public radio.  The shows featured a panel of patients sharing their experiences living with diabetes.  Dr. Schillinger discussed health promoting behaviors to prevent and control diabetes, the type 2 diabetes epidemic as it affects Latinos and effective tools to improve communication between doctors and diabetes patients. There was also a Q and A period at the end where callers joined the discussion from Merced, Bakersfield, Chicago, Washington State and other areas.

Below are links to two shows conducted in Spanish

archivosderb.org - June 18, 2009 archivosderb.org - July 23, 2009

6. Special Medical Grand Rounds: Health Inequities for Undocumented Immigrants. Co-sponsored by the UCSF Medical Humanities Initiative, the CVP hosted a Medical Grand Rounds featuring attorney, acclaimed writer and San Francisco State University associate professor, Peter Orner. Orner discussed health inequities raised by the Voices of Witness oral history book “Underground America” which tells the stories of “illegal” immigrants in the U.S. Orner was joined by LA Times journalist Sandra Hernandez and, via satellite, by one of the undocumented immigrants depicted in the book. Topics covered included health and human rights in prison, occupational injuries and social vulnerabilities (e.g. overcrowded living environments, food scarcity, violence, social isolation, and delayed medical care due to lack of health insurance and immigration-related fears).

7. Margaret Handley, PhD, MPH presented at the Meeting on Population Health Implementation and Training Partnerships-Doris Duke Foundation, iZomba, Malawi (February, 2009) to an audience of NGOs.

8. Margaret Handley, PhD, MPH gave a presentation at San Francisco State University for the spring series of Community Engaged Scholarship/Community-based Participatory Research. The presentation was entitled “From Immigrant Stories to Collaborative Action: A Case Study in Community Wellness, Culture and Transnational Identity”.

Dr. Handley’s presentation explored the power of stories as a vehicle for community-based research around immigrant wellness. Dr. Handley co-presented an adult ESL case study that highlighted new stories on immigrant identity in which struggles to stay healthy are in unintentional conflict with hopes to stay connected to the home culture. A collaborative project between adult ESL practitioners and public health researchers working on sources of lead poisoning within Latino immigrant communities in Northern California, this case study embeds community literacy practices, and a community strengths approach to boost the likelihood that environmental health messages and research designs will respect cultural practices around food and support immigrants in their efforts to preserve ties to home.

VII. AWARDS AND RECOGNITION23

Below is a list of awards and recognition presented to CVP faculty and staff in 2009.

1. CVP team members were honored with the 2009 California Association of Public Hospitals and Health Systems/ Safety Net Institute (CAPH/SNI) Award. This award recognizes innovative programs developed by California’s public hospitals and health systems to meet the needs of the communities they serve.  The CVP team received this award for work on the “Automated Telephone Self-Management Support Model for Diabetes Project” presented on Thursday, December 3, 2009 during the CAPH Annual Conference.

2. Dean Schillinger, MD was selected as the recipient of the 14th Annual George Engel Award for Outstanding Research Contributing to the Theory, Practice and Teaching of Effective Health Care Communication and Related Skills. This award was presented during the International Conference in Communication in Healthcare in Miami Beach, Fl on October 2nd-3rd, 2009. The American Academy on Communication in Healthcare presents this award in honor of Dr. George L. Engel, an internist with psychoanalytic training whose articulation of the "biopsychosocial model" in the 1970s and widespread recognition in the 1980s had a profound impact on the clinical approach to patients, the medical interview, and the patient-doctor relationship. The Academy’s mission is to foster “best patient care by advocating a relationship centered approach to healthcare communication, education and research.”

3. Pam Coxson, PhD, presented the abstract “Sugar-Sweetened Beverage Consumption and the Attributable Burden of Diabetes and Coronary Heart Disease” at the Bay Area Clinical Research Conference on October 28th, 2009. The abstract was a finalist for the best abstract by a junior investigator award.

4. Kirsten Bibbins-Domingo, PhD, MD, MAS was a finalist Sandra Daugherty Award for Research, American Heart Association and was honored with the Best Imaging Abstract (Mentee J. Ho) during the American Heart Association Scientific Session.

VIII. POLICY IMPACTSThe CVP recognizes policy as a critically important vehicle to address the burden of chronic disease for vulnerable populations. Below are some examples of ways in which the CVP has advanced the public policy agenda for vulnerable populations faced with chronic disease and in support of the practitioners and systems that disproportionately serve these populations.

Kirsten Bibbins-Domingo

1. CVP co-director, Dr. Kirsten Bibbins-Domingo is conducting a study entitled Adapting the Coronary Heart Disease Policy Model to Address Disparities in Heart Disease. This study has great potential to drive public policy because national, state and local health policy is often evaluated for the ability to eliminate health disparities between different sub-populations. This study will be adapting the Coronary Heart Disease Policy Model to examine coronary heart disease rates by race/ethnicity and income level which will enable a more accurate description of disease trends over diverse populations and evaluation of interventions that target vulnerable groups.

2. Dr. Bibbins-Domingo presented salt policy work to the California Department of Public Health. Drs. Bibbins-Domingo delivered a talk entitled “Targeting Salt Reduction to Prevent Chronic Disease and Death”.

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3. Dr. Bibbins-Domingo served as co-chair for a NIH Office of Research on Women’s Health session. This session focused on global health and chronic disease during a scientific workshop to update the NIH Women’s Health Research Agenda NIH Office of Research on Women’s Health event.

4. Dr. Bibbins-Domingo was appointed to an Institute of Medicine Committee evaluating policies to compensate those with adverse side-effects from vaccinations.

Margaret Handley

1. Dr. Handley has worked on a grant from the California Program on Access to Care in collaboration with the State Diabetes Program, Medi-Cal, and optometrists at UC Berkeley to assess barriers to screening for diabetic retinopathy among vulnerable populations in California. A policy brief is being drafted for widespread dissemination.

Dean Schillinger1. Dr. Dean Schillinger gave testimony to California Legislature: Protecting the Health of Children and Adolescents with Diabetes in California Schools

2. Dr. Schillinger appeared in the California Association of Public Hospitals (CAPH) Diabetes Issues Brief, December 2009. He was quoted about the role of public hospital systems in caring for vulnerable populations with diabetes.

3. The Agency for Health Research Quality and Safety (AHRQ) interviewed Dr. Dean Schillinger on his role as a practicing clinician at a safety net hospital (San Francisco General Hospital and Trauma Center). Dr. Schillinger discussed challenges in a safety-net hospital including limited literacy and non-English communication barriers http://www.webmm.ahrq.gov/audio.aspx

4. The Improving Diabetes Efforts across Language and Literacy (IDEALL) project, led by Dean Schillinger and CVP faculty received widespread local, state, and national attention.

a. The Agency for Health Research Quality (AHRQ) highlighted the IDEALL project in the Patient Safety and Health IT Professional Literature. They circulated the following citation for the IDEALL project in their Patient Safety and Health Information Technology E-Newsletter:

Handley MA, Shumway M, Schillinger D. Cost-Effectiveness of Automated Telephone Self-Management Support with Nurse Care Management Among Patients with Diabetes. Ann Fam Med 2008 Nov-Dec;6(6):512-8. Select to access the abstract.

b. The IDEALL project was sited as a national model in Mitch Katz, MD director’s report for the San Francisco Department of Public Health.

c. California Safety Net Institute highlighted the IDEALL project in their bulletin. Please see Appendix D for this piece.

d. The National Association of Chronic Disease Directors highlighted the IDEALL project in their December ebulletin

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5. Dean Schillinger, MD, co-authored a California Department of Public Health report entitled Diabetes in California Counties, Issued April 2009. This document provides background information, facts, and statistics about diabetes across California counties, through data collected from the 2005 California Health Interview Survey. The information can be used by county health departments, community-based organizations, and those providing clinical services to make strategic decisions about their current and future activities. http://www.caldiabetes.org/content_display.cfm?ContentID=1160

Urmimala Sarkar1. Dr. Urmimala Sarkar was invited to the Advisory Council for its Ambulatory Stand Up for Patient Safety (ASUPS) program by the National Patient Safety Foundation.  This program is designed to deliver to its members an ongoing stream of tools and information of relevance to the patient safety work and is organized around competencies.  As a leader in the patient safety field, Dr. Sarkar will share her expertise and help us identify emerging information and tools to keep the content current.

2. Dr. Sarkar was also featured on a blog for the Joint Commission Journal for Quality and Patient Safety. In this blog, she reflects on the origins of her article entitled “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care,” (published July 2009) and on the need to engage patients, especially the large population of patients with chronic conditions, in improving safety. http://www.jcrinc.com/Blog/2009/7/2/Thinking-about-Patient-Safety-for-Chronically-Ill-Outpatients/

3. Dr. Urmimala Sarkar serves on a national committee entitled the National Collaborative for Health Information Technology for Underserved Populations.  She leads the dissemination group for the Education and Outreach Workgroup, whose charge is to “Identify and develop effective practices for communicating HIT benefits to diverse underserved populations; identify or create models, practices or activities utilizing health IT; and identify/create and distribute materials to these communities that are culturally/linguistically appropriate. A focus of this task force will be educating individuals on HIT to improve health self-management and support consumer empowerment.”

4. Dr. Sarkar has also partnered with the California Diabetes Program to assess of practices and policies of state diabetes public health programs across the US regarding clinical guidelines for diabetes management.

Hilary Seligman1. Dr. Hilary Seligman works with the American College of Physicians Foundation to develop and enhance the quality of physician counseling about chronic disease. This work has included the development of patient education guides targeted toward patients with limited health literacy. Almost a million copies of the diabetes guide have been distributed throughout the country to HMOs (including Kaiser and Blue Cross), Medicaid Programs, VA Medical Centers, hospital settings, and community health centers.  2. Dr. Seligman is also active in policy work in the area of food insecurity. She participates in a number of local organizations, such as the Food Security Task Force and the Southeast Food Access Program of the City and County of San Francisco.  She has worked on developing a resolution to nominate San Francisco County as a candidate for the Healthy Purchase Pilot program, which would incentivize Supplemental Nutrition Assistance (formerly Food Stamps) participants to purchase more fruits and vegetables. She has prepared an Issues Brief for the California Department of Public Health regarding the implications of food insecurity on diabetes prevention and control efforts.

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Laura Plantinga

Laura Plantinga, ScM works with the Centers for Disease Control and Prevention (CDC) in the development and maintenance of a surveillance system for chronic kidney disease (CKD) in the United States. The data from this project, including data on the disproportionate development and progression of CKD among vulnerable groups, will provide the informational backbone for the CDC website on CKD, which will be launched in early 2010. Additionally, she also works with CDC and other partners in creating a national CKD fact sheet for use by both the public and policy makers. She has produced several papers that have influenced policy in CKD, including assessments of: awareness of CKD among those with the disease in the community, which was featured on the CDC website as part of World Kidney Day 2009 (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5808a1.htm); blood pressure control according to clinical practice guidelines for those with CKD; the association of physician visit frequency with dialysis patient outcomes; and the association of patient outcomes with attainment of clinical performance targets for dialysis patients set forth by the National Kidney Foundation. She has also published an invited commentary on prevention of repeat hospitalizations in dialysis patients.

IX. NEXT STEPSThe CVP team is excited to build on its momentum and make more strides toward becoming a premier research center dedicated to health communications and health policy. The goal of the center is to translate research into greater community health, and to infuse community needs into research. The Center will focus programmatic efforts on the new CVP space renovation by articulating our vision for the two new CVP programs in Health Communications and Health Policy and Chronic Disease Prevention and raising funds for this new space. The CVP will also increase its visibility by 1) launching a Health Communications Research Seminar series; 2) coordinating a larger initiative to bring together expertise on the SFGH campus that relate to the health of vulnerable populations; and 3) holding symposia that showcase work related to vulnerable populations both at SFGH and in the larger UCSF community. The CVP is expanding its role as a premier research home for a range of trans-disciplinary scientists dedicated to reducing the burden of chronic disease in vulnerable populations.

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APPENDIX A CVP SPACE PLANS—2789 25th Street

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APPENDIX B

2009 FACULTY AND STAFF ADDITIONS

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Laura Plantinga, ScM, is Assistant Adjunct Professor in the Department of Medicine, Division of General Internal Medicine. Her primary research interests include processes and quality of care, patient outcomes and quality of life, and epidemiology of chronic disease, particularly related to chronic kidney disease (CKD). Ms. Plantinga serves as a co-investigator and project director for a CDC-funded effort to establish a CKD surveillance system in the United States. She has several published and in-press articles generated from this project, including an article on CKD awareness in the United States. Ms. Plantinga continues to work with nephrologists and fellows on on-going projects related to the CHOICE (Choices for Healthy Outcomes in Caring for ESRD) study of patient outcomes in end-stage renal disease, from which she and collaborators continue to generate published manuscripts. Additionally, Ms. Plantinga continues to mentor residents and fellows in appropriate clinical research practice, particularly analysis and presentation of study results.

Neil R. Powe, MD, MPH, MBA is the Constance B. Wofsy Distinguished Professor, Vice-Chair of Medicine at the University of California San Francisco and Chief of Medical Services at San Francisco General Hospital and Trauma Center. Dr. Powe's research unites medicine and public health with the goals of saving and improving quality of human lives. It involves the knowledge of fundamental discoveries in biology and clinical medicine to advance the health of patients who ultimately make up a larger population of patients affected by a disease. Dr. Powe studies chronic kidney disease as well as many important diseases with substantial morbidity in areas of prevention and screening, clinical epidemiology, patient outcomes research, technology assessment, and cost-effectiveness analysis. He has extensive experience in developing and measuring outcomes in kidney disease using data from prospective studies, the United States Renal Data System, Medicare records, and patient surveys.

Dr. Powe is principal investigator of a Center for Disease Control and Prevention sponsored study to establish a national surveillance system for chronic kidney disease in the United States. He also leads the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) study, a national study of patient outcomes in the treatment of chronic kidney disease funded by the agency for Healthcare Research and Quality and the National Institute of Diabetes and Digestive and Kidney Diseases. This was one of the first large prospective studies of incident dialysis patients. In his most recent NIH grant supporting the CHOICE cohort he is examining the role of small organic solutes retained after hemodialysis and their effect on patient outcomes. This project seeks to identify substances that lead to toxicity and poor outcomes in end stage renal disease. Dr. Powe also conducts projects on health disparities, care management, access to care, quality of care and resource allocation.

Andrea Lopez currently serves as a CVP research associate, working with Drs. Urmimala Sarkar and Hilary Seligman on patient safety, food insecurity, and health access related research.  Prior to joining the Division of General and Internal Medicine and CVP team, Andrea worked for Communities for a Better Environment as the coordinator of a community-based health survey in Richmond, CA. Andrea graduated from Brown University with a B.Sc. in Human Biology, where she worked on university-community partnerships in health.

Phiona Tan, BS is a bilingual (Cantonese/English) research assistant working on the Self-Management Automated Real Time Telephone Support (SMART Steps) program. She is also fluent in Mandarin and Toisanese. Prior to joining the Division of General and Internal Medicine and CVP team, she worked with Dr. Chesla and Dr. Chun for 4 years on a qualitative study on Chinese American with diabetes at UCSF School of Nursing. Phiona graduated from UC Davis with a B.S. in Bio-Psychology

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CVP FACULTY AND STAFF

Dean Schillinger, MD Director, CVP, Professor of Medicine

Kirsten Bibbins-Domingo, MD, PhD, MAS Co-Director, CVP Associate Professor of Medicine, Epidemiology, and Biostatistics

Margaret Handley, PhD Assistant Professor

Laura Plantinga, ScM Assistant Professor

Neil R. Powe, MD, MPH, MBA Constance B. Wofsy Distinguished Professor, Vice-Chair of Medicine at the University of California San Francisco and Chief of Medical Services

Neda Ratanawongsa, MD, MPH Assistant Professor of Medicine

Urmimala Sarkar, MD, MPH Assistant Professor of Medicine

Hillary Seligman, MD Assistant Professor of Medicine

Natalie Collins, MSW Center Manager

Pam Coxson, PhD Mathematician

Lauren Davidson Administrative Assistant

David Guzman, MSPH Senior biostatistician

Aurora Hernandez Research Associate

Andrea Lopez Research Associate

Tekeshe Mekonnen, MS Project Coordinator

Matt Ong, MPH Biostatistician

Judy Quan, PhD Biostatistician

Zenelia Roman Research Associate

Catalina Soria Research Associate

Phiona Tan Research Associate

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APPENDIX C

CURRENT CVP RESEARCH MENTORING AND TEACHING ACTIVITIES

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Kirsten Bibbins-DomingoDr. Bibbins-Domingo is the Associate Director of the Clinical and Translational Sciences Institute's Multidisciplinary K Scholars program.  This program provides competitive career development awards to promising junior faculty from across all five schools at UCSF.  The program includes career mentorship, epidemiological and statistical support, works-in-progress seminars, and methodological seminars over a 4-5 year period.

Mentoring Positions1) Attending physician – Medicine Service – SFGH 2003-present2) Attending physician – Medicine Consult Service – SFGH 2003-present3) Attending physician – General Medicine Clinic – SFGH 2006-present4) Course director– Designing Clinical Research for Predoctoral students – 2005-

present5) Lecturer – SFGH Core clinical curriculum for medical students – 2008-present6) Associate Director – CTSI KL2 Multidisciplinary Scholars Program – 2007-present 7) Research mentor/career mentor – medical students – 2005-present8) Research mentor – residents/fellows/junior faculty DGIM and CTSI-KL2 – 2006-

presentRECENT PREDOCTORAL STUDENTS AND MEDICAL RESIDENTS MENTOREDDates Name School Role Current Position2009-present

Margarite Changala

Undergraduate UCB

Career and project mentoring

UCB Undergraduate

2009-present

Antoinette Mason

Undergraduate – UC Davis

Career and project mentoring

UC Davis Undergraduate

2008-present

Litsa Lambrakos Resident-Medicine

Supervised research project

Resident

2008-present

Melissa Burroughs

Resident - Medicine

Supervised research project

Resident

RECENT POSTDOCTORAL STUDENTS MENTOREDDates Name Fellow Role Current Position2006-present

Stacey Jolly General Medicine

Supervised research project

Assistant Professor Cleveland Clinic

2006-present

Emily Wang General Medicine

Supervised research project

Assistant ProfessorYale

2008-present

Eveline Oestricher

Medicine - Cardiology

Supervised research project

Fellow

2008-present

Jennifer Ho Medicine-Cardiology

Supervised research project

Fellow – Framingham Heart Study

2008-present

Erica Wang OB-GYN Supervised research project

Fellow

2009-present

Michelle Odden Medicine- DGIM

Supervised research project

Fellow

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2009-

Maya Vijayaraghavan, MD

Medicine - DGIM Research mentor Fellow

2008-present

Vanessa Grubbs Medicine-Nephrology

Supervised research project

Assistant Professor - UCSF

RECENT JUNIOR FACULTY MENTOREDDates Name School –

ProgramRole Current Position

2007-present

Kristine Madsen Medicine –CTSI-KL2

Career development and project mentoring

Assistant Professor

2007-present

Carmen Peralta Medicine –CTSI-KL2

Career development and project mentoring

Assistant Professor

2007-present

Hilary Seligman Medicine - DGIM Career development and project mentoring

Assistant Professor

2007-present

Andrew Choi Medicine - Nephrology

Career development and project mentoring

Assistant Professor

2008- Christine Dehlendorf MD

Medicine – Family Community Medicine

Career development and project mentoring

Assistant Professor

2009-present

Andrew Choi Medicine - Nephrology

Career development and project mentoring

Assistant Professor

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Dean Schillinger

Over the past few years, Dr. Schillinger has taken on increasing responsibilities for mentoring research fellows and faculty in their clinical research. This has predominantly taken place in the form of one on one counseling, project management, manuscript preparation, and grant-writing, including helping with career development awards. This work has focused on UCSF faculty, but also for non-UCSF faculty, including an International Harkness Policy Research Fellow. Additionally, Dr. Schillinger also participates in the monthly faculty research works-in-progress sessions at SFGH. In his CTSI role, Dr. Schillinger is taking increasing responsibility for fostering research capacity at UCSF in communication and dissemination sciences. He is currently the primary mentor for 2 faculty-level K awardees, and the secondary mentor for 3 others.Mentoring and Training Positions

1. Attending physician – SFGH inpatient – 1995-present2. Attending physician – SFGH outpatient – 1995-present3. Attending physician – and medical consultation services –1995-present4. Lecturer – USCF/SFGH Primary Care Core Curriculum –1995-present5. Lecturer– SFGH Primary Care Residency Program & Health Equities Residency track6. Lecturer – ATCR course on Translational and Implementation Sciences (Epi 245):

taught seminar on Case Studies in Implementation Research (Course taught by R Gonzales and M Handley) – 2008- present

7. Facilitator – Primary Care Journal Club – 1995-presentRECENT POSTDOCTORAL FELLOWS AND RESIDENTS DIRECTLY SUPERVISED OR MENTOREDDates Name Position while

MentoredMentoring Role Current Position

2008-Yael Schenker MD

Research fellow Research mentor

HRSA Fellow, DGIM, UCSF

2009-

Maya Vijayaraghavan, MD

Research fellow Research mentor

HRSA Fellow, DGIM, UCSF

2009-David Moskowitz, MD

Research fellow Research mentor

HRSA Fellow, DGIM, UCSF

2009-Pamela Stoddard PhD

Research fellow Research mentor

Philip Lee Institute for Health Policy Studies

RECENT JUNIOR FACULTY MENTORING 2007- Maricel Santos,

PhDJunior Faculty, SFSU

Research mentorRIMI Fellow

Asst Prof, SFSU Dept of English 2nd Language

2008- Christina Dehlendorf MD

Junior Faculty Research mentor Asst Prof, UCSF Dept of Fam and Comm Med

2008- Urmimala Sarkar, MPH, MD

Junior faculty Research mentor Asst. Prof. in Residence, Dept of Medicine, UCSF/SFGH

2008-Jennifer Barton MD MS Junior faculty Research mentor

Adjunct. Asst Prof., Dept of Medicine, UCSF/SFGH

2009-

Maria Soledad Martinez MD MPH Junior faculty Research Mentor

Fulbright Health Policy Scholar, Univ of Chile/ UC Berkeley Schools of Public Health

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APPENDIX DNEWSLETTERS AND ARTICLES

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UCSF Newsletter

December 17, 2009

UCSF/SFGH Project for Diabetes Patients Wins Award for Innovation, Quality

A UCSF project that used a novel communication tool to improve health outcomes among

diabetes patients was honored recently with a quality leadership award from the

California Health Care Safety Net Institute.

The institute, the quality improvement partner of the California Association of Public

Hospitals and Health Systems, presents its Quality Leaders Award to innovative programs

within California’s public hospitals and health systems that aim to meet the needs of

diverse communities.

At a Dec. 3 award ceremony in Monterey, the institute honored San Francisco General

Hospital and Trauma Center (SFGH) for its Improving Diabetes Efforts Across Language

and Literacy (IDEALL) project, which ran from 2003 to 2006 and was based at the UCSF

Center for Vulnerable Populations at the UCSF-affiliated hospital.

IDEALL was designed to combine accessible, multilingual communication technology with

targeted interpersonal support, according to SFGH primary care physician Dean

Schillinger, MD, a UCSF professor of medicine who serves as both director of the Center

for Vulnerable Populations and chief of the California Diabetes Program within the

California Department of Public Health.

The project enrolled 339 patients with type 2 diabetes, many of whom had limited literacy

skills and limited English proficiency. Participants were randomly assigned to one of three

groups — automated telephone diabetes self-management, group medical visits or

standard care — and were followed for a period of one year.

Patients in the telephone group received weekly automated phone calls in their native

language, asking them about their self-care behaviors, such as medication adherence and

diet, as well as their psychological and emotional well-being. Patients responded using

touch-tone commands, and any response that raised red flags was immediately followed

by a call from a nurse care manager who spoke the patient’s primary language.

The telephone system proved superior to group-oriented support and standard care in

terms of patient engagement, improved diabetes-related health outcomes, and patient

safety, Schillinger and his team found. The technology was also highly cost-effective.

“We are extremely proud of the work done by the innovators of this project,” said Sue

Carlisle, PhD, MD, associate dean of the UCSF School of Medicine at SFGH. “This is the

kind of approach to patient care that can truly make a difference in the ability not only for

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public hospitals, but for all of our health care systems to provide improved care at lower

costs.” 

Based on the positive initial outcomes, the automated phone system is being scaled up in

collaboration with the San Francisco Health Plan, the city-sponsored local health plan.

This second-generation program, SMARTSteps (Self-Management Automated and Real-

Time Telephonic Support), is currently being implemented among an additional 500

diabetes patients.

SMARTSteps also includes access to real-time pharmacy claims data and up-to-date

clinical registry data. Those tools will enable health plan counselors to support patients in

their self-management and to assist them in sticking to — or in some cases intensifying —

their medication regimens, Schillinger said.

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UCSF TodayOctober 8, 2009

Schillinger Awarded for Outstanding Research Contributing to Effective

Communication

Dean Schillinger, MD, UCSF professor of medicine, received the 14th Annual George Engel

Award for Outstanding Research Contributing to the Theory, Practice and Teaching of

Effective Health Care Communication and Related Skills. 

He received the award during the International Conference in Communication in

Healthcare in Miami Beach, Florida on Oct. 5th.

Schillinger is the director of the UCSF Center for Vulnerable Populations (CVP) at San

Francisco General Hospital and Trauma Center (SFGH) and chief of the California Diabetes

and Prevention Program. 

CVP is a practice-based research center where scientists’ work has helped translate

research into community and public health practice, as well as infuse local practice back

into research. Beyond the local communities it serves, CVP is nationally and

internationally known for its research in health communication and health policy to

reduce health disparities.

Serving the local, regional and global communities and eliminating health disparities is

part of the vision outlined in the UCSF Strategic Plan. The plan, released in June 2007,

calls on the University to leverage UCSF’s research expertise, modeling best practices in

clinical care and integrating content on health disparities throughout the continuum of

learning.

Talmadge King, MD, chair of the Department of Medicine in the UCSF School of Medicine,

nominated Schillinger for this prestigious award in recognition of his enormous and

impactful work.

The American Academy on Communication in Healthcare presents this award in honor of

Dr. George L. Engel, an internist with psychoanalytic training whose articulation of the

“biopsychosocial model” in the 1970s and widespread recognition in the 1980s had a

profound impact on the clinical approach to patients, the medical interview, and the

patient-doctor relationship.

Making an Impact

Schillinger’s research has both defined the field of health literacy as well as advanced the

larger discipline of health communication sciences. The impact of his work includes (1)

demonstrating the disproportionately critical role that communication plays in all aspects

of health care delivery for vulnerable populations, including its contributions to access,

quality, and safety and (2) developing curricular and programmatic content for

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practitioners and health systems to improve health communication for patients with

communication barriers (e.g. language and literacy).

Schillinger’s research has demonstrated the scientific links between health

communication, health care quality, patient safety and clinical outcomes, as well as

provided evidenced-based, systems-directed solutions to improve communications for

populations with communications barriers. He has shown that for patients who are usually

considered ‘“hard-to-reach,’” developing communication expertise at the individual

clinician level, as well as communication capacity at the health system level, can yield

disproportionate gains in health for vulnerable populations, and can help sustain the

clinicians who care for them.

He has applied a range of research methods geared toward vulnerable populations to

demonstrate the effects of communication barriers and sub-optimal communication on

health care experiences and health outcomes; identify clinician communication behaviors;

and apply theory to inform literacy and language-appropriate health system

interventions. This work positions Schillinger as a key member of the “translational

research” community at UCSF. 

Schillinger’s work was one of the reasons why, in 2005, the American Medical Association

recognized SFGH for developing exemplary programs to improve communication between

health care professionals and patients.

Schillinger also has influenced practice through his efforts to advance a health

communications agenda in the health policy arena. Arguing that health literacy reflects

the balance between the communication demands of the health system and the current

capacities of the patients they serve (Am J Bioethics 2007), he has leveraged results of

his communication research to affect change to promote systems changes in quality and

patient safety at the local, state, and national levels.

For example, he provided key input to the American College of Physicians Foundation

Health Communication Initiative and co-created the limited-literacy communication,

Living Well with Diabetes Guide, which has been distributed in English and Spanish to

more than 1,000,000 people with diabetes. He has worked with public and private groups

including the National Quality Forum; the American Medical Association; the Joint

Commission on Accreditation of Healthcare Organizations; the National Association of

Public Hospital Systems; the Institute of Medicine; and the US Surgeon General. 

Dr. Schillinger also has been a mentor for more than 25 research fellows and junior

faculty at UCSF in the field of communication (in multiple disciplines including nursing,

pharmacy, adult literacy, public health and medicine), many of whom have gone on to

have successful careers in the field. He also developed curriculum and teaches medical

residents in the UCSF Primary Care Training Programs on such topics as shared decision-

making, health literacy, overcoming language barriers, and eliciting patient narratives.

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Schillinger earned his MD degree at the University of Pennsylvania’s School of Medicine in

1991. He served a residency in primary care medicine at UCSF in 1994 and became chief

medical resident at SFGH in 1995.

UCSF TodayJuly 27, 2009

UCSF team focuses on patient safety in ambulatory care system

Health care experts at the University of California, San Francisco highlight in a new report the hidden risks and complexities that compromise patient safety for ambulatory patients with chronic disease.

While most prior research in patient safety has focused on preventing medical errors during hospital stays, the UCSF team emphasizes that more attention should be paid to chronic disease patients who receive care on an outpatient basis.

The team’s analysis appears in the July 2009 edition of the Joint Commission Journal on Quality and Patient Safety in an article titled “Refocusing the Lens: Patient Safety in Ambulatory Chronic Disease Care.”  The article describes how gaps in the current health care system undermine safety in the outpatient setting, leading to preventable death and disability as well as unnecessary costs.

Unlike acute care settings, where patients receive care from trained teams of clinicians guided by protocols, the outpatient setting involves patients performing the day-to-day self-management of their chronic conditions, often in the absence of clear protocols, said lead author Urmimala Sarkar, MD, MPH, assistant professor of medicine in the UCSF Division of General Internal Medicine and the Center for Vulnerable Populations at San Francisco General Hospital Medical Center.

The authors assert that ambulatory settings present unique challenges, such as lack of communication between health systems, communities with inadequate resources, and patients struggling to manage multiple medications and complicated treatment regimens. They aim to refocus attention on the issue of ambulatory patient safety, because they have seen the adverse effects of medical errors in their own outpatient practices.

“As a resident, I saw one of my patients who had just been discharged from the hospital,” said Sarkar, “and I found that she was taking literally four times the maximum dose of her blood pressure medication. The medication overdose gave her kidney failure, and I had to send her right back to the hospital.”

The article, which appears in the journal’s “Forum” section, is the first to present a conceptual framework for advancing the field of ambulatory patient safety in chronic disease management.  It uses actual clinical cases to illustrate the interrelated ways that

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communities and health systems, patient-provider interactions, and health behaviors all impact patient safety.

To improve safety for chronic disease populations, the authors advocate first to improve patients’ and caregivers’ capacity for self-management.  This includes targeting safety promotion efforts to those most at risk, including individuals with limited English proficiency, limited health literacy, and those with other social vulnerabilities, such as poverty and food insecurity.  The team notes that patients with limited health literacy and language barriers report greater problems across a range of communications issues, including informed consent, shared decision making, and addressing health concerns with their providers.

The authors also recommend that clinicians in ambulatory health systems develop more robust health information technology systems, especially for safety surveillance; improve communication among providers and patients, especially for transitions in care; and develop and implement interventions to better prepare and support patients to safely manage their chronic disease at home. Moreover, clinicians should weigh the risk of intensifying treatment regimens with potential risks and adverse events that could arise in the ambulatory setting, according to the authors.

Co-authors of the article are Robert M. Wachter, MD, Lynne and Marc Benioff endowed chair in hospital medicine, chief of the Division of Hospital Medicine, and chief of the Medical Service, UCSF Medical Center; Steven A. Schroeder, MD, distinguished professor of health and health care, UCSF Department of Medicine; and Dean Schillinger, MD, professor of medicine at UCSF, director of the Center for Vulnerable Populations at SFGH, and program chief of the California Diabetes Program.

Sarkar’s work is supported by a grant from the Agency for Healthcare Research and Quality. Schillinger’s work is supported by a grant from the Agency for Healthcare Research and Quality and a National Institutes of Health Clinical and Translational Science Award.

The UCSF Center for Vulnerable Populations is part of the Department of Medicine at SFGH. Founded in 2006, its mission is to carry out innovative research to prevent and treat chronic disease in populations for whom social conditions often conspire to both promote chronic disease and make its management more challenging. CVP is nationally and internationally known for its research in health communication and health policy to reduce health disparities.

UCSF is a leading university dedicated to promoting health worldwide through advanced

biomedical research, graduate-level education in the life sciences and health professions,

and excellence in patient care

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National Heart, Lung, and Blood Institute

http://www.nhlbi.nih.gov

______________________________________________________________________Embargoed For Release Contact: NHLBI Communications OfficeWednesday, March 18, 2009 (301) 496-42365 p.m. ET NHLBI_news@nhlbi.nih.gov

Heart Failure Before Age 50 Substantially More Common in Blacks Disease Linked to Untreated Risk Factors in Second and Third Decades of Life

As many as 1 in 100 black men and women develop heart failure before the age of 50, 20 times the rate in whites in this age group, according to new findings from the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. In the study, heart failure developed in black participants at an average age of 39, often preceded by risk factors such as high blood pressure, obesity, and chronic kidney disease 10 to 20 years earlier.

Findings from the 20-year observational study Coronary Artery Risk Development in Young Adults study (CARDIA) are published in the March 19 issue of the New England Journal of Medicine.

By the tenth year of the study, when participants were between ages 28 and 40, 87 percent of black participants who later developed heart failure had untreated or poorly controlled high blood pressure. Black participants who developed heart failure were also more likely in their young adulthood to be obese and have diabetes and chronic kidney disease. Furthermore, 10 years before developing heart failure, they were more likely already to have some level of systolic dysfunction, or impairment in the ability of the heart muscle to contract, visible on echocardiograms.

“The disproportionate rate at which heart failure impacts relatively young African-Americans in this country underscores the importance of recognizing and treating risk factors for heart disease,” said Elizabeth G. Nabel, M.D., director, NHLBI.

With heart failure, the heart loses its ability to pump enough blood through the body. The life-threatening condition usually develops over several years. The leading causes of heart failure are coronary artery disease, high blood pressure, and diabetes. About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year.

CARDIA includes 5,115 black and white men and women (52 percent black, 55 percent women) who were age 18-30 at the start of the study in 1985 and 1986, recruited from Birmingham, Ala., Chicago, Minneapolis, and Oakland, Calif. Participants were followed for 20 years, with physical exams conducted every few years and telephone interviews every

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six months. Twenty-seven men and women developed heart failure; all but one were black.

Higher blood pressure, greater body mass index, lower HDL (or “good” cholesterol), and chronic kidney disease were all independent predictors at ages 18 to 30 of heart failure developing 15 years later.

“Through this long-term study, we saw the clear links between the development of risk factors and the onset of disease one to two decades later. Targeting these risk factors for screening and treatment during young adulthood could be important for heart failure prevention,” said Kirsten Bibbins-Domingo, PhD, MD, study author, University of California, San Francisco.

The study found that each 10 mmHg increase in diastolic blood pressure among blacks in their 20s doubles the likelihood of developing heart failure 10 to 20 years later.

“This study shows how devastating high blood pressure in young adulthood, especially if uncontrolled, can be for developing heart failure later on. Unfortunately, we know from national data that younger adults with high blood pressure are often unaware that they have the condition, and even when they are aware, their blood pressure is often not controlled,” said Gina Wei, MD, medical officer, CARDIA study, NHLBI.

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NYC takes lead in setting next food target — salt

By STEPHANIE NANOAssociated PressThursday, April 23, 2009

NEW YORK — First, it was a ban on artery-clogging trans fats. Then calories were posted on menus. Now the New York City health department is taking on salt.

City officials are meeting with food makers and restaurants to discuss reducing the amount of salt in common foods such as soup, pasta sauce, salad dressing and bread.

About three-quarters of the salt Americans eat comes from prepared and processed food, not from the salt shaker. That’s why New York officials want the food industry to help cut back.“It’s very hard for an individual to do this on their own,” said Dr. Lynn Silver, an assistant commissioner in the health department.The department has shown its clout with bans on artificial trans fats and rules forcing chain restaurants to post calorie counts. To comply, fast food chains changed their recipes nationwide, and other cities and states have enacted similar policies.Some manufacturers said getting rid of trans fats took work, and reducing salt has its own difficulties.Unlike sugar, there’s no substitute for salt. Cream soups — like that casserole favorite cream of mushroom — are the biggest challenge, said George Dowdie, head of research and development for Campbell Soup Co. The soup maker, which has been cutting salt for years, is in the talks with New York.By fall, Campbell Soup plans to have more than 90 lower-sodium soups available. That includes its first soup, tomato, which will have almost a third less salt.The industry hopes salt reduction remains voluntary.“Literally freight cars full of salt have been removed from these products gradually over time,” said Robert Earl, vice president of science policy, nutrition and health for the Grocery Manufacturers Association. “It has to be done carefully — gradually and incremental over time.”Herbert Smith Jr. never paid much attention to how much salt was in food until he developed high blood pressure. His doctor at a Harlem health center put him on medication and told him to exercise and watch his diet.The 54-year-old church receptionist said he was alarmed to see how much salt was in the instant soup packages that he liked. He wants the food industry to cut down.“For those who want to use salt, they can add it themselves,” he said.Too much salt raises blood pressure, and high blood pressure raises the risk of heart disease. A recent analysis showed that for every gram of salt cut, as many as 250,000 cases of heart disease and 200,000 deaths could be prevented over a decade.“Very, very small changes in diet could have dramatic effects,” said Dr. Kirsten Bibbins-Domingo, a researcher with the University of California, San Francisco.For its salt initiative, New York has recruited public health agencies and medical groups across the country. The campaign — with a goal of cutting salt intake by at least 20 percent in five years — is modeled on a plan carried out in Britain. That effort set voluntary salt reduction targets for 85 categories of processed foods.“Companies have been very innovative,” said Corinne Vaughan, of Britain’s Food Standards Agency. “And they have been very good at making what are quite huge reductions in salt levels.”Salt in pasta sauces has been cut by nearly a third, and soups by about one-quarter, she said. Some foods have been more challenging, she said, citing bacon, cheeses and packaged bread. With less salt, the dough is sticky and harder to process, she said. Salt is used mostly for flavoring but can also help preserve some foods and gives others texture.Some British companies have also put “traffic light” labels on package fronts — green for low-salt, for example — so shoppers can “make a choice at a glance,” Vaughan said.Everyone needs some salt — or sodium chloride — for good health. The daily recommended amount for Americans is about a teaspoon, or 2,300 milligrams of sodium. But many people consume twice that amount. A Big Mac alone has 1,040 milligrams.A recent government report showed that seven out of 10 adults should

46

be eating even less than the recommended amount — about 1,500 milligrams. That includes anyone with high blood pressure, everyone over 40, and African-Americans, who are at greater risk than whites for high blood pressure.The prospect of government intervention bothers some, and some critics note that not everyone is sensitive to salt. A few others contend there is not enough scientific evidence that reducing salt really drives down heart problems or deaths.But many in the medical and public health field are firmly behind the idea.“When you’ve got groups … all saying we need to reduce salt, the evidence is exceedingly strong, you don’t do more trials,” said Dr. Stephen Havas, an adjunct professor at Northwestern University’s medical school and a former American Medical Association vice president.In the meantime, the Food and Drug Administration is considering a request that the government regulate salt content. An Institute of Medicine committee is also looking at ways to reduce salt consumption. The FDA says it is waiting for that committee report, due next year, before deciding the regulation issue.Bibbins-Domingo, the University of California researcher, and her colleagues say their findings support efforts to lower salt levels, either voluntarily or through regulation.She said her patients with high blood pressure struggle to cut down on salt. They give up potato chips, french fries and salty nuts, but end up eating processed foods like soups and pasta that can also have a lot of salt, she said.“I realized how hard it is for patients who want to make those changes,” she said.New York resident Kristle Thompkins, 37, has been trying to make those changes herself.She started reading labels and limiting salt a few years ago because of her high blood pressure. Now she’s adjusted to eating less salt — although she still misses potato chips.The macaroni and cheese she made for an Easter gathering now tastes “too salty.”“My salt tolerance has lowered,” Thompkins said.

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A Racial Divide Blacks experience heart failure earlier and at a far greater rate than whites.By Jesse Ellison | NEWSWEEKPublished Apr 11, 2009 Todd Bowen, a 42-year-old father of seven, has been visiting the In the Cut barbershop in Inglewood, Calif., every two weeks for seven years. He likes to look good, but he never expected his tonsorial routine to save his life. In February, Bowen arrived at the shop to find not only his barbers, but also a doctor doing on-the-spot testing for hypertension and diabetes. Bowen, who is uninsured, had never been tested for either; that day he tested positive for both, with a blood-pressure reading of 160/89. "I was all shaken up when I saw where I was on the scale and where I was supposed to be," Bowen says. "I thought I was invincible, immune. If they wouldn't have been there, I wouldn't have gotten tested. I wouldn't have went out of my way. It was God's will for that to happen to me."Undiagnosed and untreated, Bowen was at elevated risk of developing heart failure, which increasing numbers of African-American men and women are suffering at earlier and earlier ages. A study last month in The New England Journal of Medicine found that blacks under age 50 experience heart failure at 20 times the rate of whites. "To see this among people in their 30s and 40s was really quite striking to us," says Dr. Kirsten Bibbins-Domingo, co director of the UCSF Center for Vulnerable Populations at San Francisco General Hospital, and the study's lead author. Because their weakened heart muscles can't pump enough blood, people with heart failure are often too weak to work. "It's a devastating illness whenever it happens. It comes with such a high degree of disability, it could be devastating to whole communities." Exactly why these rates are so skewed is unclear, but high rates of hypertension among young African-Americans is a major culprit. Genetics, higher sensitivity to salty diets and environmental factors are also believed to play a role."The finding, while absolutely breathtaking, is not surprising," says Dr. Joseph Ravenell, a hypertension specialist and professor of medicine at New York University. "The reason it's so criminal is that hypertension is very treatable, and easy to identify. However, in order to identify it and treat it requires that black men go to the doctor. Men go to the doctor less in general, but it's a particular problem among young men of color."That's where organizations like the Black Barbershop Health Outreach Program come in. The California-based initiative, started in late 2007 by Dr. Bill Releford, has already screened more than 7,500 men around the country and plans to see another 25,000 this year alone. Last month in St. Louis, of some 550 men screened, seven had to be taken directly from the barbershop to the emergency room. And in New York's Harlem, another program, called Barbershop Quartet, is taking screening a step beyond, testing not just for hypertension and diabetes, but also for prostate and colon cancer in a mobile clinic parked in front of barbershops during the spring and summer months."The barbershop traditionally has been a place within the community where African-American men feel safe," explains Releford. "We can congregate, talk about politics, about our relationships. Now we're adding to the menu: we can talk about our health. Most black men, we're too cool to go to a health fair with balloons and things. It's just not going to happen." It's not just a matter of looking cool. For many, making the time to go to the doctor means a loss of wages. "When your primary concern is putting food on the table or keeping a roof over your head, you're not going to a doctor to get screened for anything," says Dr. Bert Petersen, founder of Barbershop Quartet. "Fundamentally, people have a desire to feel a sense of well-being. But if seeking health care is a problem, you'll put it off."That was exactly the case

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for Bowen. "The neighborhoods I'm from in South-Central, it's rough," he says. "It's survival today instead of worrying about anything else." But since his diagnosis, Bowen has replaced soda with water, and hamburgers with salads. He's losing weight, his blood pressure is dropping and he says he no longer feels sluggish when he wakes up in the morning.Bowen's diagnosis has turned his life around, but with childhood obesity rates on the rise, particularly in poor and minority communities, real change will require prevention, not just diagnosis. "Efforts to improve access to care and coverage are steps in the right direction," says Dr. David Williams, professor of public health and African-American studies at Harvard University. "However, those efforts alone are not going to be successful. Medical care as practiced in the United States is a repair shop. It takes care of us once we get sick. Addressing the problems we're talking about requires a new effort to prevent us from getting sick in the first place."

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Fact Sheet Highlights Findings from the Improving Diabetes Efforts across Language and Literacy

(IDEALL) StudyHow Can Public Health Systems Best Support People with Diabetes?Findings from the UCSF IDEALL StudyA. Overview A study published in Diabetes Care (April 2009) finds a patient-

centered approach to diabetes management using health information technology much more effective than traditional approaches for underserved populations with communication barriers like limited literacy and limited English proficiency (1). This is one of four recent articles highlighting work from the UCSF Center for Vulnerable Populations at San Francisco General Hospital which determined that automated telephone support for diabetes management improves quality of care in public “safety-net” settings; reduces patients’ symptom burden associated with diabetes; and is cost-effective (1-4). The study, directed by Dean Schillinger MD (UCSF Professor of Medicine, Director of the Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program), shows that this innovation, a product of the Improving Diabetes Efforts across Language and Literacy (IDEALL) Project, holds promise as a means to reduce diabetes-related health disparities for vulnerable populations. This project is part of the Collaborative Research Network, supported by the UCSF Clinical Translational Science Institute.B. Background and Importance Diabetes afflicts over 3 million Californians, meaning that 1 out of 10 adult Californians has diabetes. From 1998 to 2007, the prevalence of diagnosed diabetes in California rose from 5.5 to 7.6 percent, representing a 38 percent increase in one decade (5). Diabetes is a chronic illness that, if poorly controlled, significantly impairs quality of life and leads to premature death. Diabetes costs California over $24.5 billion in health care and related costs. Trends throughout the US are similar.C. Diabetes and Underserved Populations There are striking differences in diabetes rates by ethnicity and education level. Diabetes is much more common among those with less than a ninth-grade education (14 percent) compared with those with a college degree or higher (5 percent) (6). Those with less education are much more likely to have limited literacy skills (over one-third have limited literacy), which makes diabetes management in the home more challenging. Diabetes is also more common among ethnic minorities. Among Californians ages 50-64 years, 8 percent of non-Latino Whites have diagnosed diabetes, compared to 22 percent of Latinos, 18 percent of African Americans, 14 percent of American Indian/Alaskan Natives, and 13 percent of Asians (6). The rise of diabetes, coupled with the diverse representation of ethnicities and education levels within California, creates an urgent need for linguistically appropriate and cost-effective diabetes management tools accessible to individuals with limited literacy. Diabetes prevalence is higher among those with a family income below the federal poverty level (6) and who lack health insurance. More than 205,000 Californians with diabetes do not have insurance, and another 245,000 have Medi-Cal (California’s Medicaid program) (7). Many uninsured and Medi-Cal recipients receive their care at public hospitals which play a critical role in diabetes management, yet often lack vital resources for patient education, support, motivation and surveillance. Proper control and treatment of diabetes is critical to prevent serious complications—such as blindness, kidney failure, heart attack and amputations. Uninterrupted health insurance coverage, which provides access to health

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services, and a regular health care provider, who provides a connection to sources of health care, are key factors affecting whether people receive recommended diabetes-specific care. Diabetes requires patients to follow complex and expensive care regimens, communicate with providers, and manage the disease outside of the clinical environment (8-12). D. The UCSF Center for Vulnerable Populations (CVP) at San Francisco General Hospital The CVP is a pioneering center focused on improving health care for vulnerable populations, including those who lack health insurance, have limited English proficiency and limited literacy, and who face adverse social conditions like poverty and social isolation. A key focus of the CVP is to conduct and disseminate health communication and translational research like the IDEALL Project. This study compared alternate forms of diabetes support for an ethnically and socioeconomically diverse population in a large safety net clinic system. The project stemmed from a strategic initiative to improve chronic disease care in the Community Health Network of San Francisco, the integrated delivery system of the San Francisco Department of Public Health. The study was funded by the Agency for Health Research and Quality (AHRQ), the Commonwealth Fund, the California Endowment, and the California Healthcare Foundation. E. The IDEALL Project Design The IDEALL Study was a 9-month comparative effectiveness trial of two diabetes self-management support interventions compared to usual care, to determine their impact on a variety of diabetes outcomes, ranging from communication with health care providers, self-care behaviors, functional abilities, and patient safety. Over half of participants had limited English proficiency, over half had limited literacy, and half were uninsured. Participants were randomly assigned to one of the three arms listed below:1) The automated telephone self-management support system (ATSM) was developed by CVP researchers who tailored this technology to the literacy and language needs for the target population. The ATSM system provided weekly calls in patients’ native language (English, Spanish or Cantonese), regarding a number of issues including self-care (e.g., symptoms, taking medication as prescribed, diet, physical activity, self-monitoring of blood sugar, and smoking), psychological issues (e.g., coping and depressive symptoms), and referrals for preventive services (e.g., eye and foot care). Depending on their automated responses during the call, the patients then received automated health education messages and a ‘live’ telephone call back from a bilingual nurse care manager. The care manager helped patients problem-solve around disease management issues with a focus on collaborative goal setting and action plans. Patients randomized to ATSM also continued to receive their usual care with their primary care physician.2) The group medical visit support system (GMV) organized language specific monthly groups (English, Spanish or Cantonese) for nine months involving 6-10 patients per group. Each group was led by both a physician and health educator who spoke the same language as the patients. The group model provided support, education, and diabetes self-management skill-building with a focus on goal setting and action plans. Patients randomized to GMV also continued to receive their usual care with their primary care physician.3) Patients randomized to the usual care arm visited their primary care physicians for their diabetes care and received diabetes-management referrals and usual access to diabetes management resources (nutrition information, exercise resources, etc.). In comparison to the other arms,

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patients randomized to usual care did not receive an additional intervention to improve their diabetes management.F. Main Findings: Patients randomized to the ATSM arm had the following outcomes (1):Higher levels of participation compared to group medical visits, especially among those with limited English proficiency and limited literacy (2). Over 90% of participants actively engaged with the ATSM system

Better communication with providers compared to usual care and group medical visits

Significant increases in diabetes-related behavior, including physical activity (2 more hours per week related to physical activity) compared to usual care and group medical visits

Greater improvements in functional status (degree to which an individual can carry out his or her daily activities) compared to usual care and group medical visits

Fewer days spent in bed due to illness compared to usual care and group medical visits, reducing the burden of the disease on patient and family caregivers. Participants in ATSM, on average, spent 2 fewer sick days per month in bed due to diabetes compared to usual care and group medical visits participants

The ATSM technology also promoted patient safety through its surveillance function(4):

o The ATSM system identified and mitigated one or more unsafe events (e.g. hypoglycemia, medication problems, and urgent symptoms) in the majority of participants.

o Primary care physicians were unaware of the occurrence of these events, and most of these events were deemed preventable and ameliorable.

ATSM was found to be as cost-effective as other widely accepted diabetes interventions (e.g. cholesterol or glucose control and screening eye exams) targeted at preventing complications of diabetes. The investigators also calculated cost-effectiveness would further increase in a scaled-up ATSM program that served more people with diabetes (3).

G. Next Steps: Scaling It UpAfter being alerted to these positive results, the San Francisco Health Plan (SFHP), an innovative managed care MediCal program that provides healthcare coverage for over 50,000 multi-lingual San Francisco residents, contacted CVP researchers about implementing the ATSM system with their members who have diabetes. With AHRQ and William Randolph Hearst Foundation support, CVP investigators are currently partnering with SFHP to further demonstrate the ATSM systems’ “real-world” applicability. AHRQ is also highlighting ATSM as a national health information technology innovation in their Health Care Innovations Exchange website, http://www.innovations.ahrq.gov/content.aspx?id=1863.

The current project, entitled “SMART-Steps” (Self-Management Automated and Real-Time Telephonic Support), scheduled to begin in May 2009, will evaluate a scaled-up versions of the ATSM system on both patient-centered and clinical outcomes. In addition to generating local benefits, the SMART-Steps Program is expected to have far-reaching implications for priority populations disproportionately affected by chronic disease and faced with formidable communication barriers that make disease management especially challenging.

1. Schillinger, D, Handley, M, Wang, F, & Hammer, H. Effects of Self-Management Support on Structure, Process and Outcomes Among Vulnerable Patients with Diabetes: A 3-Arm Practical Clinical Trial. Diabetes Care. 2009; 32(4):559-566.

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2. Schillinger, D, Hammer, H, Wang, F, et al. Seeing in 3-D: Examining the Reach of Diabetes Self-Management Support Strategies in a Public Health Care System. Health Education and Behavior. 2008; 35(5):664-82.3. Handley, M., Shumway, M., & Schillinger D. Cost-Effectiveness of Automated Telephone Self-Management Support with Nurse Care Management Among Patients with Diabetes. Annals of Family Medicine. 2008; 6(5): 1-7.4. Sarkar, U, Handley, M, Gupta, R, et al. Use of an Interactive Telephone-based Self-Management Support Program to Identify Adverse Events Among Ambulatory Diabetes Patients. Journal of General Internal Medicine. 2007; 23(4): 459-65.5. Estimates provided by California Diabetes Program using data from California Behavioral Risk Factor Surveillance System, 1998-2007 and California Health Interview Survey, 2001-2005.6. Diamant AL, Babey SH, Hastert TA, Brown ER. Diabetes: The Growing Epidemic. Los Angeles: UCLA Center for Health Policy Research, 2007. 7. Estimates provided by California Diabetes Program using data from California Behavioral Risk Factor Surveillance System, 1998-2007 and California Health Interview Survey, 2001-2005. 8. Harris MI. Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes. Diabetes Care. 2001 Mar;24(3):454–9.9. Gary TL, Narayan KM, Gregg EW, et al. Racial/ethnic differences in the healthcare experience (coverage, utilization, and satisfaction) of US adults with diabetes. Ethn Dis. 2003 Winter;13(1):47–54.10. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002 Jul 24–31;288(4):475–82.11. Harris MI, Eastman RC, Cowie CC, et al. Racial and ethnic differences in glycemic control of adults with type 2 diabetes. Diabetes Care. 1999 Mar;22(3):403–8.12. Davis SK, Liu Y, Gibbons GH. Disparities in trends of hospitalization for potentially preventable chronic conditions among African Americans during the 1990s: implications and benchmarks. Am J Public Health. 2003 Mar;93(3):447–55. Erratum in: Am J Public Health. 2003 May;93(5):703.

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OPEN MINDS On-Line NewsStrategic Health Care News

Automated Telephonic Case Management Improved Diabetes Care

Patients with diabetes who participated in a pilot automated telephone self-management (ATSM) support system had better outcomes than those who participated in group medical visits (GMV) and those who received usual care. The improvement in outcomes was especially noticeable among those with limited English proficiency and limited literacy. More than 90% of those in the ATSM were actively engaged; they had better communication with providers compared to the group and usual care groups.

The ATSM group also increased their diabetes-related behaviors, such as increasing their hours of physical activity per week. The ATSM group, on average, spent two fewer sick days per month in bed due to diabetes compared to the usual care and group medical visits participants. These are findings of a report entitled “Effects of Self-Management Support on Structure, Process, and Outcomes Among Vulnerable Patients With Diabetes” by Dean Schillinger, M.D.; Margaret Handley, Ph.D.; Frances Wang, MS; and Hali Hammer, M.D.

The researchers sought to compare the effectiveness of two diabetes self-management support interventions compared to usual care, by evaluating their impact on a variety of diabetes outcomes, ranging from communication with health care providers, self-care behaviors, functional abilities, and patient safety. In the nine-month Improving Diabetes Efforts Across Language and Literacy Study more than half of the participants had limited English proficiency, over half had limited literacy, and half were uninsured. Participants were randomly assigned to one of the three groups: ATSM, GMV, or usual care.

Participants in the two intervention groups continued to receive their usual care with their primary care physician. The ATSM group received weekly automated calls. The GMV group met monthly in language-specific groups of less than 10 patients. The usual care group received no additional support, but did receive diabetes-management referrals and usual access to diabetes management resources. ATSM was developed by researchers at the Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center.

The intervention was tailored to the literacy and language needs for the target population. The automated weekly calls were in the participants’ native language English, Spanish, or Cantonese. The topics covered a number of issues including self-care and referrals for preventive services. Depending on their automated responses during the call, the patients then received automated health education messages and a ‘live’ telephone call back from a bilingual nurse care manager. The care manager helped patients problem-solve around disease management issues with a focus on collaborative goal setting and action plans. The GMV language-specific groups were led by a physician and a health coordinator fluent in the patients’ language. These groups provided support, education, and diabetes self-management skill-building with a focus on goal setting and action plans.

The researchers noted that the ATSM approach promoted patient safety through its surveillance function that identified unsafe events such as hypoglycemia, medication problems, and urgent symptoms that patients did not mention to their primary care physicians. In addition, ATSM was calculated to be as cost-effective as other diabetes interventions, such as cholesterol or glucose control and screening eye exams, at

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preventing complications of diabetes. In May 2009, the San Francisco Health Plan, a managed care MediCal program that provides health care coverage for 50,000 San Francisco residents started using ATSM in a project, called “SMART-Steps.” The project is expected to demonstrate ATSM’s real world effects. An evaluation of the project will focus on patient-centered and clinical outcomes.

The full text of “Effects of Self-Management Support on Structure, Process, and Outcomes Among Vulnerable Patients With Diabetes” was published April 2009 in Diabetes Care. An abstract may be accessed on-line at http://care.diabetesjournals.org/content/32/4/559.abstract?sid=1a20c1bb-9426-42f8-966e-8b3020cc47cc (accessed Automated Telephonic Case Management Improved Diabetes Care Page 1 of 2 http://www.openminds.com/circlehome/eprint/omol/2009/082409strat1.htm 9/14/2009 August 18, 2009). http://www.openminds.com/circlehome/eprint/omol/2009/082409strat1.htm 9/14/2009

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Managing Diabetes with a Phone Call Posted: Jun 29, 2009

New America Media, New Report, Viji Sundaram

Editor's Note: A new tool that can be used in the home could make controlling diabetes, which disproportionately affects under-served and ethnically diverse populations, a lot easier, reports NAM health editor Viji Sundaram.

SAN FRANCISCO -- Luis de Jesus, a Spanish-speaking factory worker, says he enjoys a better quality of life now than when he was first diagnosed with diabetes 10 years ago, thanks to having better control over the disease.

De Jesus enrolled in a program at San Francisco General Hospital’s (SFGH) Center for Vulnerable Population. The program is specifically tailored for “vulnerable” people like him with poor control of their diabetes and with low incomes. Although DeJesus works two jobs to support himself and his family, he has no health insurance.

“I had zero knowledge about how to control or manage diabetes prior to my participation in the project,” the 54-year-old Jesus said through an interpreter. “[The program] was so practical.”

Called Improving Diabetes Efforts Across Language and Literacy (IDEALL), the hospital's approach uses simple communication technology to help people manage their diabetes without having to make frequent hospital visits.

The IDEALL project team developed an automated telephone support system (ATSM) for diabetes management.

The system provides weekly calls in the patient’s native language--English, Spanish or Cantonese--regarding issues ranging from symptoms and taking prescribed medications, to diet, physical activity and self-monitoring of blood sugar.

The calls also offer advice about psychological issues and referrals for preventive services.

Depending on their automated responses during the call, the patient then receives automated health education messages and a “live” telephone call back from a bilingual nurse care manager. The IDEALL team found that the program could reduce diabetes-related health disparities in vulnerable populations.

“We were really impressed that diabetes patients with limited literacy and limited English proficiency, who many health care workers consider to be ‘hard to reach,’ were the most likely to use this communication tool,” said Dr. Dean Schillinger, director of the SFGH’s Center. He is also chief of the California Diabetes Program in the California Department of Public Health and head of the IDEALL team. “We found that better communication between a public health care system and the vulnerable populations they serve yielded concrete benefits,” Schillinger said.

But Schillinger warned that the program should be seen as “an adjunct” to primary care offered by physicians, not a replacement.

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“Diabetes requires daily home management by the patient and occasional visits to the clinic,” noted Susan Lopez-Payan, coordinator of the California Diabetes Program. “The IDEALL project reaches out to patients in their homes.”

An estimated 23.6 million people, or nearly 8 percent, of the U.S. population, live with diabetes. Nationally, the number of people diagnosed with type-2 diabetes has doubled over the past two decades, qualifying it as an epidemic, according to the federal Centers for Disease Control and Prevention. In California, one out of nine adults has the disease.

Diabetes is more prevalent among those without a high school education, and disproportionately affects underserved and ethnically diverse populations, including Latinos, African Americans, Native Americans and Asian and Pacific Islanders.

The correlation between the disease and educational level is in part because of the patient’s ability to read food labels, track blood sugar levels, assess insulin amounts, record meal schedules and communicate with clinicians when complications arise.

Schillinger said he hopes that the IDEALL project becomes a “standard of care” across California, given how “scaleable and cost-effective it is.”

The Center for Vulnerable Populations has received additional federal funding to scale up and adapt the ATSM system with a local Medi-Cal health plan partner, the San Francisco Health Plan.

De Jesus has nothing but praise for the program. “Had I not had this opportunity, I would have had to look for alternative programs to help me," he said. "Because of the program, I now know how to live better.”

Wednesday, June 24, 2009

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UCSF Center for Vulnerable Populations Offers Sustainable Solutions for Diabetes Patients

By Shipra Shukla

A UCSF team has found that using a simple communication technology is more effective

than traditonal methods in managing diabetes in underserved populations that have

communication barriers.

Led by Dean Schillinger, MD, UCSF professor of medicine, director of the UCSF Center for

Vulnerable Populations and chief of the California Diabetes Program in the California

Department of Public Health, the Improving Diabetes Efforts Across Language and

Literacy (IDEALL) study found that using automated telephone technology is more

effective in addressing communication barriers such as limited literacy and limited

English proficiency.

The IDEALL study was featured in the April 2009 issue of the journal Diabetes Care.

The IDEALL study team developed an automated telephone self-management support

system (ATSM) for diabetes management and found that the tool can reduce diabetes-

related health disparities in vulnerable populations.

“We were really impressed that diabetes patients with limited literacy and limited English

proficiency, who many health care workers consider to be hard to reach, were the most

likely to use this communication tool,” said Schillinger. “We found that better

communication between a public health care system and the vulnerable populations they

serve yielded concrete health benefits.”

Housed at UCSF-affiliated San Francisco General Hospital and Trauma Center, the Center

for Vulnerable Populations (CVP) is a pioneering venture focused on improving health care

for vulnerable populations. CVP’s mission is to carry out innovative research to prevent

and treat chronic disease in vulnerable populations, whose chronic disease management

is often more challenging.

CVP has distinguished itself as a practice-based research center that has helped translate

research into community benefits. Beyond the local communities it serves, CVP is

nationally and internationally known for its research in health communication and health

policy to reduce health disparities.

Diabetes and Literacy

An estimated 23.6 million people — nearly 8 percent of the population of the United

States — live with diabetes.

Nationally, the number of people diagnosed with type 2 diabetes has doubled over the

past decade, an increase the Centers for Disease Control and Prevention calls an

epidemic. In California, one out of nine adults is afflicted with diabetes.

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Diabetes is more prevalent among those without a high school education and

disproportionately affects underserved and ethnically diverse populations, including

Latinos, African Americans, Native Americans and Asian Pacific Islanders.

Diabetes control is strongly correlated with educational and literacy levels. This can be

attributed to the fact that diabetes self-management relies, in part, on the ability of the

patient to read food labels, track blood sugar levels, assess insulin amounts, record meal

schedules and communicate with clinicians when complications arise.

The increase of diabetes, coupled with the diverse ethnicities and education levels of

Californians, creates an urgent need for linguistically appropriate and cost-effective

diabetes management tools accessible to individuals with limited literacy.

“Diabetes requires daily home management by the patient and occasional visits to the

clinic,” said Susan Lopez-Payan, coordinator of the California Diabetes Program. “The

IDEALL project reaches out to patients in their homes, using an automated telephone call

in their native language. It’s so simple, it’s brilliant. Innovative, cost-effective ideas like

this show great potential for widespread implementation, saving the state money while

improving health outcomes.”

The IDEALL study demonstrates that compared with a group medical visit support system

and usual care, ATSM improves communication between patients and providers,

facilitates patients’ self-management of their diabetes, and results in significant

improvement in physical activity and overall physical and emotional function. It also

promotes patient safety and is as cost-effective as other accepted diabetes interventions,

such as lipid and blood sugar control.

Luis De Jesus, a San Francisco resident who works two jobs, lacks health insurance and is

a monolingual Spanish speaker, participated in the study. De Jesus found the telephone

interaction and support he received through the IDEALL study to be far more practical

and effective than less frequent in-person visits, he said.

For people like De Jesus, physically going to regularly scheduled appointments with

physicians who may or may not speak Spanish is not a practical solution. The IDEALL

study allowed patients like De Jesus to manage and control their diabetes through

interactions they had with health providers on the phone. Before participating in the

study, De Jesus said he felt like “a lost deer in the forest” and believes “this program,

without exaggeration, has saved my life.”

“We know that the best way to prevent and control chronic diseases is to address

individuals in the larger context of their neighborhoods and communities, and to pay

attention to the social determinants of health,” said Linda Rudolph, MD, MPH, deputy

director of the Center for Chronic Disease Prevention and Health Promotion in the

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California Department of Public Health. “This program shows how effective it is to address

two of those determinants — language and literacy.”

CVP recently received additional federal funding to scale up and adapt ATSM with a local

Medi-Cal health plan partner, the San Francisco Health Plan. “The fact that the San

Francisco Health Plan is now making this communication tool available to its members

who have diabetes suggests that CVP research has practical relevance for key community

stakeholders that influence the health of vulnerable populations. That has always been

the intent of our research,” said Schillinger.

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California Association of Public Hospitals E-bulletin

San Francisco General Hospital’s IDEALL Study looks at the Effectiveness of the Patient-Centered Approach to Diabetes Management

A study in the April issue of Diabetes Care comparing alternate forms of diabetes support for vulnerable populations with limited literacy and English proficiency determined that a patient-centered approach using health information technology is more effective than traditional diabetes management approaches. The study is one of several conducted by the Center for Vulnerable Populations (CVP) at San Francisco General Hospital as part of the Improving Diabetes Efforts across Language and Literacy (IDEALL) Project at the Community Health Network of San Francisco. Researchers found that using an automated telephone self-management support system (ATSM) for diabetes management is cost effective, reduces the burden of disease on both patient and family caregivers, and improves the quality of care in public safety-net settings. The positive results of the study have led to efforts at implementing and evaluating scaled up versions of the ATSM system.

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Central Valley hard-hit by diabetes epidemic

Posted Feb. 14, 2009By Barbara Anderson / The Fresno Bee and Natalya Shulyakovskaya / Center for California Health Care Journalism

Every week in the San Joaquin Valley, at least 19 people die of diabetes - and the death toll is rising.

The disease has reached epidemic proportions nationwide, but few places are as stricken as the Valley's eight counties, from San Joaquin to Kern. Nowhere in California are people more likely to die of diabetes than here.

The complex web of reasons include obesity and poverty.

The Valley's fast-food, car-centered culture is partly to blame, health experts say, because it packs pounds on waistlines. The agriculture-based minimum-wage job market keeps people poor and unable to afford healthier foods, they say. And a doctor shortage has stalled efforts to bring the epidemic under control.

Now the disease touches nearly one out of every 10 people who live in the Valley - compared to 1 in 13 statewide. It steals eyesight, burns nerves, disables organs. It kills. An analysis of state death records and other statistics by The Bee and the Center for California Health Care Journalism at the University of Southern California paints a vivid picture of the disproportionate toll diabetes takes here:* Minorities are up to two times as likely as whites to die from diabetes and its complications.* Less educated residents are more at risk. Almost half of those who die lack high school diplomas.* The poor - regardless of ethnic background - are more likely to get the disease than other Valley residents.

Many people don't even know their bodies are in trouble until it's too late. Symptoms start slowly, and the disease can take years to kill. So diabetes probably is a bigger health menace than anyone knows.

In fact, doctors and health officials say diabetes leads to heart attacks, strokes and high blood pressure but often is not listed as even a contributing factor on death certificates.

Recent advances in treatment are slow to reach the Valley, where doctor specialists of any type are in short supply.

The Bee's analysis shows diabetes kills people sooner here. Statewide, 27% of people killed by diabetes died before turning 65. In the Valley, the figure is 32%.

Yet despite widespread concern in the medical community about the threat of diabetes, for many patients the diagnosis still comes as a surprise.

'Oh, not me'

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When George Nunez of Fresno was younger, he ate fast food and never gave a thought to diabetes, even though it runs in his family. Today, he's legally blind because of the disease.

Nunez, 49, had a stroke about six years ago that ruined his vision and left his voice almost a whisper. He had to quit working at a bio-mass plant in 2000 and is now on disability.

For about the past nine years, he's been on dialysis. A kidney transplant in May 2008 failed after a week.

Nunez's mother has diabetes, and his father had it before he died, Nunez said last month as toxins were removed from his blood by a machine at the Community Dialysis center in Fresno.

"You don't think anything is going to happen," he said. "You know relatives have 'the sickness,' but you just think, oh, not me. And one day you wake up and you're in the same boat your family has been in."

Diabetics have too much glucose, or blood sugar, that builds up in their bodies. It attacks organs, nerves and blood vessels anywhere in the body, blocking nutrients they need to function.

Insulin regulates blood sugar. In Type 1 diabetes - the most common type among children - the body's immune system destroys pancreatic cells that make the hormone insulin.

About 90% to 95% of diabetics have Type 2, in which the body becomes resistant to insulin produced in the pancreas, and gradually the organ stops producing the hormone, allowing blood-sugar levels to rise out of control. Scientists know that genetics play a role: Type 2 diabetes runs in families and is more prevalent in African Americans, Hispanics and Native Americans, according to the federal Centers for Disease Control and Prevention.

Almost 24 million American adults have diabetes. In the Valley, almost a quarter million - 244,000 adults - have been diagnosed, according to estimates based on the 2007 California Health Interview Survey, conducted by researchers at the University of California at Los Angeles.

Diabetes is a leading cause of blindness and kidney failure. And diabetics are two to four times more likely than average to suffer strokes or heart attacks, according to the CDC.

Many people can control their diabetes with diet and exercise, but pills and insulin are a mainstay for others. And more people are on insulin every year. Diabetes rates have been increasing nationally since 1990, reaching an average of 7.5% of adults in 2007. California had a rate of 7.8%, according to the 2007 statewide health survey.

The Valley outpaces both. Here, the diabetes rate is 9.4%.

These numbers are likely underestimates. Health experts say at least a quarter of the people who have diabetes nationally don't know they have it. In its early stages, people don't feel bad.

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A web of factors

Obesity and poverty play the biggest roles in diabetes here, but the causes are complex. Many factors combine to make the Valley fertile ground for the disease.

Doctors cite urban sprawl, for example. People drive instead of walk because there's little choice. The result is inactivity, which leads to obesity - as well as air pollution. Recent research suggests air pollution could contribute to diabetes: A study at Ohio State University Medical Center found mice exposed to air pollution and fatty foods didn't process insulin as efficiently.

Experts see rising obesity as the leading cause of the proliferation of diabetes. They expect the number of diabetics worldwide at least to double in the next two decades.

California is analyzing the economic effect of obesity and diabetes, said Dr. Dean Schillinger, chief of the California Diabetes Program. He expects the price tag will be big. Among the the 2.5 million to 3 million diabetics in California, about one in 10 is covered by Medi-Cal - the federal-state insurance for the poor - and an equal number have no insurance, he said. "That poses a tremendous cost burden on the state."

Doctors refer diabetics to certified diabetes educators, but they're in short supply, too. The scarcity of Spanish speaking educators is especially troubling, said Angel Ponce, a registered dietitian and certified diabetes educator who has been working with diabetics for a decade in the Valley.

Diabetes hits minorities the hardest. Almost 8% of deaths among Native Americans were due to diabetes - twice the percentage of deaths from diabetes among whites, according to The Bee's analysis. Five percent of blacks and Asians died from it. And 6% of Hispanics died from diabetes.

A financial struggle

Every month, diabetes outreach worker Maria Zapata gathers Spanish-speaking diabetics at support group meetings offered by the West Fresno Health Care Coalition. Most who attend are low-income. At some point, the conversation invariably turns to the cost of medical supplies.

"We have people who can't buy anything," Zapata said.

A diabetic needs to keep blood-sugar levels in control to avoid complications. Good control means daily checking of blood glucose levels. The goal is to keep levels as close to normal as possible.

According to the American Diabetes Association that means 70 to 130 milligrams per deciliter before meals, and less than 180 two hours after starting a meal.

To know the numbers, a diabetic pricks a finger and puts a drop of blood on a testing strip. The patient checks the blood on a glucose meter, a machine about the size of a deck of cards.

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Doctors usually recommend Type 2 diabetics check their blood sugar levels one or two times a day. Each testing strip costs $1, Zapata said.

Many of the support-group members can't afford $60 a month for test strips, she said. So they test less often and can't regulate their medications as well.

Antonia Zamora, 51, of Fresno is one. She was diagnosed with diabetes a year ago and had a blood sugar level at that time of 350, almost three times higher than the normal limit before a meal. For the past year, she's tried to check her blood sugar - but usually only once a day - when she has strips. She had none last month, when she attended the support group. "About a week without them," she said.

Zamora's husband died a year ago, and she hasn't worked as a farm laborer since that time, Zapata said, translating for Zamora, who speaks Spanish. The health care coalition provided Zamora with a glucose meter, Zapata said. But it's useless without the testing strips.

As with many in the support group, Zamora doesn't have health insurance.

Her family helps buy some of the medical supplies, and she gets low-cost health care at the Saint Agnes Holy Cross Clinic at the Poverello House.

Social disparities

Research more and more is tying diabetes to poverty, and for all too many diabetics in the Valley, poverty is a fact of life.

Four of the poorest counties in the state are in the region. Among those four, the poorest is Tulare County. Almost 24% of that county's residents lived in households with incomes below poverty level, according to the U.S. Census Bureau.

This doesn't bode well for the fight against diabetes in the Valley. Mexican-American adults are 1.7 times more likely to have diabetes than whites, according to a new state legislative task force report on diabetes and obesity. But poor whites in the Valley get diabetes as often as poor Hispanics.

Federal research shows that ethnic differences in diabetes rates tend to disappear with improvements in living standards, said Ann Albright of the CDC.

Education, which is closely linked to income, also shows up in the statistics. Those with little education are more likely to die from diabetes, an especially troubling trend since the Valley has more high-school dropouts than the state average.

Of those who died from diabetes in the Valley, 43% did not complete 12 years of schooling, The Bee's analysis of death records shows. Statewide, a third of those who died from diabetes did not finish what is considered a high-school education.

You are what you eat

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The Valley may be the fruit and vegetable basket of the country, but low-income diabetics aren't buying produce, said Ponce, the diabetes educator. That's partly why nearly two-thirds of Valley adults are obese or overweight and more vulnerable to diabetes.

"If you have limited money, you're going to buy the largest quantity of food," Ponce said. That means buying a loaf of white bread instead of whole-wheat, because white bread is cheaper. Hamburger is less expensive and more filling than lean beef or fish.

Many Valley homes rely disproportionately on foods that are cheap and high in carbohydrates, such as potatoes, beans and rice, said M. Daya Deyhim, a certified nutrition specialist at the Visalia Oak Health Center.

"I talk to some patients who say, 'I ate six tortillas this morning,'" Deyhim said.

Some of her patients only have tortillas in their cupboards, she said.

"Many times, if they are recipients of food aid, and it's the end of the month, that's all that's left in the house."

About 120,500 low-income adults in the San Joaquin Valley skipped meals and occasionally had gone to bed hungry in 2005, a UCLA report found.

Yet three balanced meals a day and exercise are key to diabetes prevention and control.

Sounds simple enough - eat right, exercise more - but nothing could be harder, said Dr. Christopher Rodarte, medical director at the Family Healthcare Network's Visalia Oak Health Center.

Rodarte has been treating diabetic patients there for a dozen years. He doesn't put much faith in diet and exercise alone to control his patient's diabetes, because most patients don't stick with it. "Maybe one of my patients a year will be successful," he said.

Deyhim said some diabetics deny they are obese rather than change their habits.

"People are surprised to find out that they're overweight," she said.

Getting diabetics to education classes can be difficult, said Dori Louie-Kai, program manager of the Community Diabetes Care Center in Fresno. Doctors will refer 20 patients, and 10 won't show, she said.

Some low-income patients don't have transportation or can't leave work, she said. But for others, "it's denial," she said. "They want to think something else is wrong."

Fear also is a factor. Some believe diabetes is an automatic death sentence, Deyhim said.

"It's just as complicated as people," Deyhim said. "There are as many reasons as people, as many perceptions and reasons for not doing things."

'I don't want to die'

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Domingo Vega, 47, of Fresno ignored his diabetes for years. When he felt bad, he blamed it on a cold.

"I thought it was going to go away like a cold," he said.

He waited years to be diagnosed. His mother had diabetes, but he didn't think he had it. He nearly passed out from high blood sugar before he went to see a doctor.

The disease has progressed in the 15 years since his diagnosis. His legs hurt most of the time from nerve damage. "It feels like they're burning," he said. He needs to use a cane or walker and sometimes a wheelchair. Six years ago he had to stop working. He had been a window washer.

When he was first diagnosed, Vega said he was given a prescription of insulin and a box of needles. The only advice he got: "Stay away from sweets."

About three months ago, he began coming to the Community Diabetes Care Center. He's learning to take care of his feet so they won't get sores that could become infected, he said. He's eating better. "Before I was drinking sodas and eating like a pig," he said. "I wasn't watching nothing. Now I'm getting better."

And he checks his blood sugar - every day or every other day. "It takes a lot of discipline being a diabetic," he said. His five children keep him motivated, he said. "I don't want to die right away."

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Health programs try to slow progression of diabetes

Posted at 08:01 PM on Sunday, Feb. 15, 2009By Barbara Anderson / The Fresno Bee and Natalya Shulyakovskaya / Center for California Health Care Journalism

At the Visalia Oak Health Center, doctors know all about diabetic patients even before examining them.

A computer tracking system alerts doctors to a patient's health needs. They know if the patient is due for a foot exam to check for nerve damage, an eye test to look at blood vessels or laboratory work to measure blood-glucose levels.

It doesn't matter if the patient is there for something else — a cough, cold or backache. The diabetes registry tells the doctor what diabetes care the patient needs.

"The goal is to prevent the progression of diabetes complications," said Erik Persell, a physician's assistant.

This is the type of program that could help bring the diabetes epidemic under control, health experts say. But the high cost of expanding programs has been a barrier. The very scope of the problem is daunting.

Diabetes is a societal disease. The fight can't be confined to treating one patient at a time. It's a battle against obesity, poverty, a doctor shortage, urban sprawl — factors found in abundance in the Valley.

"We've got to make people realize this is not simply just poor eating behaviors, poor lifestyle choices," said Rudy Ortiz, a UC Merced professor who studies obesity and diabetes. "There are issues in the workplace, in the community, in the schools that all contribute to this."

And everyone agrees more needs to be done. If things don't change, one-third of the children born in 2000 will develop the disease sometime in their lives. That puts thousands of 9-year-olds needlessly at risk of heart attack, stroke, blindness and amputations later in life.

Sounds hopeless. But each small step helps. In the waiting room

At least 25% of the patients seen at the Visalia clinic are diabetic. And half of patient visits are related to diabetes, said Dr. Christopher Rodarte, the medical director.

Diabetes requires doctors, physician assistants, diabetes educators, nutritionists, psychologists — and the patient — working together to keep a patient’s blood-sugar levels under control, he said.

Family HealthCare Network, which runs the Visalia clinic, spent nearly $50,000 on the computerized diabetes registry. The system replaces a manual registry that was time-consuming and often out of date.

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The registry has had concrete success:* A comparison of diabetes patients before and after the computer tracking found that 61%, up from 25%, had received a pneumonia vaccine. This is important because diabetes patients are more at risk of pneumonia.* Sampling suggests that nearly half of patients, up from 20%, received a retinal screening to detect eye problems. Diabetes is the leading cause of new cases of blindness among adults in the United States.

Not enough money

So far most diabetes-prevention programs have been accomplished on a shoestring budget, advocates say. That’s despite evidence that prevention programs save money.

Foot-care programs to prevent amputations reduce a diabetic’s health-care costs by about $900 over five years, according to a federal report in 2000. Blood-pressure screenings to decrease the risk of heart attack and stroke save $900 over a diabetic’s life.

Overall, every $1 spent training people to take care of their diabetes saves up to $8.76 in health-care costs, the report concluded.

But funding for diabetes prevention in California has been lacking for some time, said Lisa Murdoch of the American Diabetes Association.

The California Diabetes Program is charged with reducing the prevalence of the disease. Its $1 million annual budget is entirely funded by the federal Centers for Disease Control and Prevention.

The program has tried to distribute the people to get as much coverage statewide as possible, said Linda Rudolph, deputy director for the state’s Center of Chronic Disease Prevention and Health Promotion. Rudolph is responsible for the program.

“We’re doing the best that we can do given the economic challenges that the state is confronting,” Rudolph said.

The diabetes association worries that low-income diabetics could be hurt by California’s budget crisis, Murdoch said. California could tighten eligibility rules and limit services under Medi-Cal, the federal-state insurance plan for the poor.

Ortiz, the UC Merced professor, helped write a legislative report last month that outlines a plan to fight obesity and diabetes in California. But it counts on funding that has not been secured.

Among its recommendations: Increase meal reimbursements for schools that provide fresh fruits and vegetables to students for breakfast and lunch, and increased financial support for students enrolled in public-health degree programs.

Ortiz, an assistant professor of physiology and nutrition, recognizes the obesity and diabetes report he co-authored is hitting legislators’ desks at a bad time. But he hopes legislators will take its recommendations to heart.

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A simple plan

Agencies must look at new ways to prevent diabetes, said Dr. Dean Schillinger, who runs the California Diabetes Program. For example, he is trying to capitalize on simple technology to reach diabetics.

He is trying to get a grant for a telephone self-management support system that would be operated out of the University of California at San Francisco. Diabetics would have access to a nurse or diabetes care manager by telephone. The easy access would help them manage their disease better, Schillinger said.

A Medi-Cal managed-care health plan and a private foundation currently pay for such a program in San Francisco County, he said.

Other seemingly simple remedies can make a huge difference.

An influential 2002 study of 3,234 people with elevated blood-glucose levels showed blood-sugar levels can be brought under control if a patient loses 5% to 7% of body weight.

Participants accomplished this with a few changes: eating less fat, keeping track of what they ate, learning to handle stress, and finding time to be physically active, among others. They also exercised at least 150 minutes a week.

The exercise and weight loss were far more effective than taking pills that control blood-sugar levels, the study found.

They also save money. The state task force report says a 10% improvement in physical activity and weight could save California nearly $13 billion a year.

Another answer is to provide diabetes-education classes.

Studies in the United States and abroad have demonstrated that diabetics who have been educated about their disease do better. Their blood-sugar levels showed improvement, and they lost more weight.

But without widespread public education, many Valley residents continue to dine at fast-food outlets, eating high-fat, high-carbohydrate diets that promote weight gain and diabetes.

According to a 2007 retail-food survey by a California health advocacy group, Fresnans are more than six times as likely to be able to find a hamburger at a fast-food restaurant than to find broccoli at a grocery store or farmers market.

A foot exam

At the Oak clinic, diabetes patient Beverly Beach beamed as she walked out of an examination room recently.

The physician assistant had examined her feet for sores — which can be a sign of diabetes-related nerve damage.

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“I’d never had that done,” she said.

Beach, 59, of Visalia was diagnosed with diabetes more than a year ago.

She changed her diet and takes pills every day to control her blood sugar.

The doctor’s visit this month was the first she had had in a year.

She and her husband own a welding business, and they don’t have health insurance.

The physician’s assistant made an appointment for an eye test, she said. It has been a year since she had one, and she is due for another.

She likes knowing her doctor is keeping tabs on her diabetes. “I’m happy with the care,” she said.

She’ll return every three months now for follow-up exams, she said.

Across the clinic’s hall, physician assistant Erik Persell wants a psychologist to see a diabetic patient.

She is showing signs of depression.

He is sold on the computer-tracking system, he said.

This month, he sent a patient for an eye exam. Turns out she had eye damage from diabetes.

“We caught the problem,” Persell said, “and now we can get her into a specialist.”

It was another small step in the right direction.

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APPENDIX ERESEARCH ABSTRACTS

(CURRENTLY BEING PREPARED FOR PUBLICATION)

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RESEARCH ABSTRACTS

Jaar BG, Plantinga LC, Sozio SM, Fink NE, Coresh J, Parekh RS, Powe NR. Poster presentation of research abstract. Aspirin, mortality and cardiovascular events: a propensity-matched dialysis cohort study. American Society of Nephrology Renal Week, San Diego, CA, October 2009.

Plantinga L, Crews D, Shahinian V, Robinson B, Eggers P, Rios Burrows N, Powe N for the CDC CKD Surveillance Team. Poster presentation of research abstract. Chronic kidney disease (CKD) severity is associated with disability in the American Society of Nephrology Renal Week, San Diego, CA, October 2009.

Plantinga L, Stevens L, Saran R,Yee J, Rolka D, Sharon S, Powe N for the CDC CKD Surveillance Team. Poster presentation of research abstract. Association of sleep-related problems with chronic kidney disease (CKD) in the American Society of Nephrology Renal Week, San Diego, CA, October 2009.

Davis E, Alpers L, Duffy K, Harleman E, Gleason N, Maldonado AM, Jagannathan P, Komisarjevsky V, Seligman H, Newbold E, Tayo-Samoni D, Winston L, Ratanawongsa N. Poster presentation of research abstract. Teaching Residents the Value of Caring For Patients Awaiting Placement. Society of General Internal Medicine, Miami, FL, May 2009.

Maldonado AM, Gleason N, Davis E, Irby R, Shao L, Seligman H. Poster presentation. Nothing to Do, Awaiting Placement: Teaching the Prevention of Hospital Acquired Complications in Pts with Prolonged Hospitalizations, A Multidisciplinary Resident Integrated Approach. Society of General Internal Medicine Annual Meeting, Miami, FL, May 2009.

Sarkar U, Handley MA, Soria C, Lau O, Tan S, Pipher K, Schillinger D. Ambulatory Safety Surveillance using Automated Telephone Technology for Vulnerable Diabetes Patients. Society for General Internal Medicine National Meeting. Miami, FL, May 2009.

Sarkar U, Schillinger D, Bryant K, Nunnery T, Leasure S, Kahn JS. Monitoring Medication Safety via an Enhanced Personal Health Record in an Urban, Diverse, HIV Positive Population. Society for General Internal Medicine National Meeting, Miami, FL, May 2009.

Moore S, Bergman A, Handley M. First Nations Ethnicity is not associated with Risk Factors for Inadequate Anagesia in Patients with Isolated Long Bone Fracture. Canadian Society of Emergency Physicians, Montreal, QU, May, 2009.

Seligman H, Davis T, Bocchini M, Baily S, Davis K, Pandit A, Schillinger D, Wolf M. Poster presentation. Food Insecurity Increases Risk of Hypoglycemia: A Pilot Study. Society of General Internal Medicine, Miami, FL, May 2009.

Handley M, Santos M. Reflections on the “immigrant health paradox” and ESL health curricula. California Teachers of English to Speakers of Other Languages (CATESOL), Pasadena, CA, April 2009.

Plantinga L, Miller E, III, Stevens L, Saran R, Robinson B, Flowers N, Geiss L, Powe N. Poster presentation of research abstract. Blood pressure control in CKD by anti-hypertensive medication: NHANES 1999-2006. National Kidney Foundation Spring Clinical Meetings, Nashville, TN, March 2009.

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Plantinga LC, Crews DC, Coresh J, Saran R, Hedgeman E, Pavkov M, Eberhardt M, Powe NR. Poster presentation of research abstract. Prevalence of CKD is high in persons with undiagnosed or pre-diabetes in the United States. National Kidney Foundation Spring Clinical Meetings, Nashville, TN, March 2009.

Crews DC, Plantinga LC, Miller ER, Saran R, Hedgeman E, Saydah S, Eggers P, Powe NR. Poster presentation of research abstract. Prevalence of CKD is high in persons with undiagnosed and pre-hypertension in the National Kidney Foundation Spring Clinical Meetings, Nashville, TN, March 2009.

Riley L, Saad N, Seligman HK. Poster Presentation. Postpartum Diabetes Insipidus: An Interesting Path to a Rare Diagnosis. Society of General Internal Medicine Regional Meeting, Indian Wells, CA, October 2009.

Riley L, Saad N, Seligman HK. Poster Presentation. Postpartum Diabetes Insipidus: An Interesting Path to a Rare Diagnosis. American College of Physicians, Indian Wells, CA, October 2009.

Santos MG, McClelland J, Handley M. Situating ESL on the path to home and health: Language lessons on immigrant identity, food culture, and transnational acts of interpretation, California Teachers of English as a Second Language conference, Pasadena, CA, April 2009.

Ho JE, Foster E, Gardin JM, Hulley SB, Pletcher M, Bibbins-Domingo K. AHA 2009 Abstract Submission Final Echocardiographic Predictors of Incident Heart Failure in Young Black Adults: The CARDIA Study, Orlando, FL Nov 2009.

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For More Information and Reprint Requests Please Contact:

Natalie Collins, MSWCenter Manager, UCSF Center for Vulnerable Populations

http://cvp.ucsf.eduBldg 90, 1st Floor San Francisco General Hospital

995 Potrero Avenue, Room 128, San Francisco CA 94110Phone: 415-206-5277, Fax: 415-206-6026

UCSF Box 1364collinsnn@medsfgh.ucsf.edu

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