Obstacles to effective diabetes care involving patients who live in the inner city include poverty, lack of insurance, medication costs, failed appointments, attending multiple clinics, substance abuse, psychiatric illness, and budgetary pressures on physicians. In addition, language and literacy barriers may exist. Chapin and colleagues hypothesize that visual, nonverbal communication could improve diabetes control.

The authors, as part of a multidisciplinary team, designed a tool called the “Take-home Diabetes Record” (THDR) to help patients record adherence goals. The record provided visual representation of simple goals, such as taking medication, exercising, and checking glucose daily. The THDR was placed in the charts of randomized patients with brief written instructions for use, with usual care patients being the control group. Patients took home a copy, while the original was kept in the chart and updated at each visit. The end point was change in glycosylated hemoglobin (A_1c) levels.

Of 127 patients randomized over a 15-month study period, 90 patients had an initial and final A_1c separated by at least three months. Analysis of these pairs showed that control patients had an initial A_1c of 8.1, and THDR patients had an A_1c of 8.8. The controlgroup dropped 0.18 (P = .36), and the THDR group dropped 0.94 (P = .003). Fifty-one percent of THDR patients achieved a decrease inA_1c of at least 0.9 compared with 18 percent of the patients in the control group (P = .001).

The decrease in A_1c during the study periodwas similar to that associated with long-range outcomes in the United Kingdom Prospective Diabetes Study (0.9 percent). More than one half of the intervention patients using a simple visual tool achieved a drop in A_1c levels. The authors conclude that such a tool may be effective in improving diabetes control in patients who experience barriers with verbal communication.