David G. Marrero

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https://hdl.handle.net/1805/6601

The 2013 inaugural recipient of the Bantz-Petronio Translating Research into Practice Award, David G. Marrero is the J.O. Ritchey Endowed Professor of Medicine, Indiana University School of Medicine. His translational research into diabetes identification and management has shown that improving risk factors depends upon tailoring disease management programs to specific populations to better address health disparities. In a practical application of this work, he and his colleagues have developed a tablet-based program that explains what risks of cardiovascular disease an individual person has and then educates on reducing those risks. He also implemented an innovative and successful program at the YMCA to assist in the identification of persons at risk for diabetes followed by educational and behavioral interventions focused on diet and exercise. This program is now the subject of a CMS demonstration project.

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Nutrition Management of Type 2 Diabetes by Primary Care Physicians
(2000-11) Marrero, David G.; Kraft, Stephanie Kakos; Mayfield, Jennifer; Wheeler, Madelyn L.; Fineberg, Naomi
A survey was mailed to a probability sample of primary care physicians in Indiana to assess their use of and barriers to nutritional therapy for patients with type 2 diabetes. Most (62%) primary care physicians reported referring their type 2 diabetes patients for nutrition counseling, while 38% reported providing counseling themselves. Patient-centered barriers were most frequently cited as reasons for poor effectiveness of nutrition therapy. This differs from previous research that cites system-level factors as barriers.
A Spatial Analysis of Obesogenic Environments for Children
(2002) Liu, Gilbert C.; Cunningham, Cynthia; Downs, Stephen M.; Marrero, David G.; Fineberg, Naomi
In this study, we use spatial analysis techniques to explore environmental and social predictors of obesity in children. We constructed a merged database, incorporating clinical data from an electronic medical record system, the Regenstrief Medical Record System (RMRS) and societal & environmental data from a geographical information system, the Social Assets and Vulnerabilities Indicators (SAVI) Project. We used the RMRS to identify cohorts of children that were normal weight, overweight, or obese. The RMRS records were geocoded and merged into the SAVI database. Using the merged databases, we analyzed the relationships between markers of socioeconomic status and obesity outcomes in children. Our preliminary analyses show that markers of low socioeconomic status at the census tract level correlate with both overweight and obese outcomes in our study population. Utilization of geographic information systems (GIS) for the study of health epidemiology is discussed.
Issues in Conducting Randomized Controlled Trials of Health Services Research Interventions in Nonacademic Practice Settings: The Case of Retail Pharmacies
(2002-08) Weinberger, Morris; Murray, Michael D.; Marrero, David G.; Brewer, Nancy; Lykens, Michael; Harris, Lisa E.; Newell, A Jeffrey; Collins, Joyce; Tierney, William M.
Objective. To describe unexpected challenges and strategies to overcome them when conducting randomized controlled trials (RCT) of health services research interventions in retail pharmacies. Study Setting. Thirty-six retail drug stores in Indianapolis. Study Design. We conducted an RCT to evaluate the effectiveness of an intervention to increase pharmacists’ involvement in caring for customers. We describe: (1) our RCT as originally designed, (2) unexpected challenges we faced; and (3) how we resolved those challenges. Data Collection/Extraction Methods. Randomized controlled trial. Principal Findings. Major modifications in research design were necessitated by factors such as corporate restructuring, heightened sensitivity to patient confidentiality, and difficulties altering employees’ behavior. We overcame these barriers by conducting research that is consistent with corporate goals, involving appropriate corporate administrators and technical personnel early in the process, and being flexible. Conclusions. Health services researchers should conduct RCTs in a variety of nonacademic practice settings to increase generalizability and better reflect the true impact of interventions. Pragmatic problems, although significant, can be successfully overcome.
Referral management and the care of patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) study.
(2004-02) Kim, Catherine; Williamson, David F.; Herman, William H.; Safford, Monika M.; Selby, Joseph V.; Marrero, David G.; Curb, David; Thompson, Theodore J.; Narayan, KM Venkat; Mangione, Carol M.
OBJECTIVE: To examine the effect of referral management on diabetes care. STUDY DESIGN: Cross-sectional analysis. PATIENTS AND METHODS: Translating Research Into Action for Diabetes (TRIAD) is a multicenter study of managed care enrollees with diabetes. Prospective referral management was defined as "gatekeeping" and mandatory preauthorization from a utilization management office, and retrospective referral management as referral profiling and appropriateness reviews. Outcomes included dilated eye exam; self-reported visit to specialists; and perception of difficulty in getting referrals. Hierarchical models adjusted for clustering and patient age, gender, race, ethnicity, type and duration of diabetes treatment, education, income, health status, and comorbidity. RESULTS: Referral management was commonly used by health plans (55%) and provider groups (52%). In adjusted analyses, we found no association between any referral management strategies and any of the outcome measures. CONCLUSIONS: Referral management does not appear to have an impact on referrals or perception of referrals related to diabetes care.
Depression Symptoms and Antidepressant Medicine Use in Diabetes Prevention Program Participants
(2005-04) Rubin, Richard R.; Knowler, William C.; Ma, Yong; Marrero, David G.; Edelstein, Sharon L.; Walker, Elizabeth A.; Garfield, Sanford A.; Fisher, Edwin B.; The Diabetes Prevention Program Research Group
OBJECTIVE: To assess depression markers (symptoms and antidepressant medicine use) in Diabetes Prevention Program (DPP) participants and to determine whether changes in depression markers during the course of the study were associated with treatment arm, weight change, physical activity level, or participant demographic characteristics. RESEARCH DESIGN AND METHODS: DPP participants (n = 3,187) in three treatment arms (intensive lifestyle, metformin, and placebo) completed the Beck Depression Inventory (BDI) and reported on use of antidepressant medicines at randomization and subsequently at each annual visit (average duration in study 3.2 years). RESULTS: On study entry, 10.3% of participants had BDI scores > or =11, which was used as a threshold for mild depression, 5.7% took antidepressant medicines, and 0.9% had both depression markers. During the DPP, the proportion of participants with elevated BDI scores declined (from 10.3% at baseline to 8.4% at year 3), while the proportion taking antidepressant medicines increased (from 5.7% at baseline to 8.7% at year 3), leaving the proportion with either marker unchanged. These time trends were not significantly associated with the DPP treatment arm. Depression markers throughout the study were associated with some participant demographic factors, adjusted for other factors. Men were less likely to have elevated depression scores and less likely to use antidepressant medicine at baseline (9.0% of men and 17.9% of women had at least one marker of depression) and throughout the study (P <0.0001). Those with more education were less likely to have elevated symptom scores (P = 0.0007) but more likely to be taking antidepressant medicine (P = 0.002). Non-Hispanic white participants were less likely than African Americans to have BDI scores > or =11 (P = 0.03), but white participants were more likely to be taking antidepressant medicine than any other racial/ethnic group (P <0.0001). CONCLUSIONS: DPP participation was not associated with changes in levels of depression. Countervailing trends in the proportion of DPP participants with elevated depression symptoms and the proportion taking antidepressant medicine resulted in no significant change in the proportion with either marker. The finding that those taking antidepressant medicine often do not have elevated depression symptoms indicates the value of assessing both markers when estimating overall depression rates.
A Critical Dialogue: Communicating with Type 2 Diabetes Patients about Cardiovascular Risk
(2005-12) Roach, Paris; Marrero, David G.
Patients with type 2 diabetes mellitus (DM) are at increased risk for cardiovascular disease (CVD), and many patients are inadequately treated for risk factors such as hyperglycemia, hyperlipidemia, hypertension, and smoking. Providing individualized risk information in a clear and engaging manner may serve to encourage both patients and their physicians to intensify risk-reducing behaviors and therapies. This review outlines simple and effective methods for making CVD risk infomation understandable to persons of all levels of literacy and mathematical ability. To allow the patient to understand what might happen and how, personal risk factors should be clearly communicated and the potential consequences of a CVD event should be presented in a graphic but factual manner. Risk calculation software can provide CVD risk estimates, and the resulting information can be made understandable by assigning risk severity (eg, “high”) by comparing clinical parameters with accepted treatment targets and by comparing the individual's risk with that of the “average” person. Patients must also be informed about how they might reduce their CVD risk and be supported in these efforts. Thoughtful risk communication using these techniques can improve access to health information for individuals of low literacy, especially when interactive computer technology is employed. Research is needed to find the best methods for communicating risk in daily clinical practice.
Validation of a Scale to Measure Patient-Perceived Barriers to Medication Use
(International Society for Quality of Life Research, 2006) Marrero, David G.; Monahan, Patrick O.; Lane, Kathleen A.; Hayes, Risa P.
AIMS: Medication adherence may explain why patients show very different clinical outcomes. Previous assessments of adherence have used refill rates and pill counts. Few studies have investigated patient-identified barriers to using medications as prescribed. This is particularly true for persons with diabetes, most of whom are using poly-pharmacy regimens. We created a questionnaire to measure patient perceptions of barriers to medication adherence (PBMA) targeting a predominately low income, inner-city minority population. METHODS: Twenty items (Likert scale) leading with "I sometimes don't take my diabetes medicines because..." were developed from 5 focus groups (N=48). A questionnaire including these items was mailed to 1000 patients who have diabetes. RESULTS: Using data from 267 respondents (Mean age=58, 74%female, 43% non-Hispanic Caucasian, 77% income<$15,000), exploratory factor analyses with varimax rotation identified 5 factors, that may contribute to poor medication adherence: personal access to medications (F1); communication with providers (F2); understanding or appropriately following the prescribed regimen (F3); side effects (F4) and system factors that inhibited access to medication (F5). Cronbach alphas ranged from .73 to .83 for the five factors and was .92 for total scale score. No relationships were found between total scores and gender, race, or income. Greater perception of barriers was significantly (p<0.01) associated with being younger (r= -0.21), being bothered more by physical (r= -0.40) and emotional side effects (r= 0.43), and less satisfaction with control of blood sugar by diabetes medications (r= 0.45). CONCLUSIONS: This instrument is reliable, factorially valid, and consistent with clinical observation regarding factors known to be associated with patient medication adherence. Although study participants were patients with diabetes, the PBMA may be applicable to other therapeutic areas.
Psychometric Properties of the Healthful Eating Belief Scales for Persons at Risk of Diabetes
(2006-05) Blue, Carolyn L.; Marrero, David G.
Objective: To examine the validity and reliability of Theory of Planned Behavior (TPB) scales for healthful eating for persons at risk for diabetes. Design: Cross-sectional, using a self-administered questionnaire. Setting: Community in the Midwest. Participants: 106 adults who self-identified based on one or more American Diabetes Association diabetes risks. Variables Measured: Behavioral, normative, and control beliefs; and attitude, subjective norm, perceived behavioral control, and intention to eat a healthful diet. Analysis: Construct validity was assessed with factor analyses and measurement and structural models using structural equation modeling. Reliability of the scales was assessed with Cronbach alpha and a 2-month test- retest. Results: Factor analysis loadings were greater than .37. Cronbach alphas for the behavioral, normative, and control belief scales were .80, .91, and .84, respectively. The measurement model revealed that the measures were significant estimates for the TPB constructs, and they fit well as indirect measures of attitude, subjective norm, and perceived behavioral control in predicting intention to eat a healthful diet. Test-retest revealed 2- month stability of the scales. Conclusions and Implications: Scales for measuring TPB behavioral, normative, and control beliefs were valid and reliable for use with adults at risk for diabetes. Further examination with minority persons is warranted.
The HealthPia GlucoPack™ Diabetes Phone: A Usability Study
(2007-04) Carroll, Aaron E.; Marrero, David G.; Downs, Stephen M.
Background: Type I diabetes is a common chronic disease of childhood. Both the growing influence of peers and the shifting away from parental influence have been implicated as prime elements contributing to poor glycemic outcomes in adolescents. Mobile technology that can be directed towards providing self-management support and modifying potentially negative child parent interaction holds promise to improve control in adolescents with diabetes. Methods: HealthPia, Inc. (Palisades Park, NJ) has developed a prototype system, the HealthPia GlucoPack™ Diabetes Monitoring System, which integrates a small blood glucose monitoring device into the battery pack of a cell phone. A pilot study used mixed quantitative and qualitative methods to evaluate user satisfaction with the integrated system, including the potential of the device to transmit self-monitoring data to a website for review and analysis by clinicians, parents, and patients. Results: Adolescents in our study liked the integration of the two technologies and agreed that the glucometer was easy to use and that the tool was useful in the management of their diabetes. Conclusions: Future work will focus on the utilization of the diabetes phone as a component of a care delivery system for adolescents with diabetes, including involvement of the health care team and enhancement of the web services that support the use of the phone.
Educational disparities in health behaviors among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study
(2007-10) Karter, Andrew J.; Stevens, Mark R.; Brown, Arleen F.; Duru, O Kenrik; Gregg, Edward W.; Gary, Tiffany L.; Beckles, Gloria L.; Tseng, Chien-Wen; Marrero, David G.; Waitzfelder, Beth; Herman, William H.; Piette, John D.; Safford, Monika M.; Ettner, Susan L.
Background Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors. Methods This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans. Results Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25–44, modest for those ages 45–64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings. Conclusion The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.

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