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Traumatic Brain Injury (TBI) has gained attention in the past decade as a "signature injury" in the conflicts in Iraq and Afghanistan. TBI is a major burden for both the military and civilian population in the US and worldwide. It is a leading cause of death and disability in the US and a major health services resource burden. We seek to answer two questions. What is the evidence regarding the association of TBI with health services utilization and costs in the US and worldwide? What is the evidence regarding racial/ethnic, gender, geographic, socio-economic and other disparities in health services utilization and cost in the US and worldwide? To attain this goal we searched several databases using key words to perform a systematic review of the literature since 2000. We found 36 articles to be eligible for inclusion in the review. The evidence demonstrates a wide variation in health services utilization and costs depending on population of study and severity of TBI. The evidence also supports the existence of racial/ethnic, gender, insurance, geographic disparities in the US as well as other unique disparities worldwide.

PurposeNeighborhood factors such as crime, discrimination, and violence are increasingly recognized as correlates of poor glycemic control. However, pathways for these relationships are unclear. This study examined stress and self-efficacy as potential pathways for the relationship between neighborhood factors and glycemic control in adults with type 2 diabetes.DesignCross-sectional study.SettingTwo primary care clinics in southeastern US.Participants615 adults aged 18 years and older.MeasuresValidated measures were used to capture neighborhood factors, stress, and self-efficacy, while hemoglobin A1c (HbA1c) was abstracted from the electronic health record.AnalysisPath analysis was used to investigate direct and indirect relationships between neighborhood factors, stress, self-efficacy, and glycemic control.ResultsIn the final model, violence (r = .17, P = .024), discrimination (r = .46, P < .001), and crime (r = .36, P = .046) were directly associated with higher perceived stress. Stress (r = −.5, P < .001) was directly associated with lower self-efficacy. Self-efficacy was directly associated with better general diet (r = .12, P < .001), better specific diet (r = .04, P < .001), more exercise (r = .08, P < .001), and lower HbA1c (r = −.11, P < .001). Stress (r = .05, P < .001), crime (r = .20, P < .001), and discrimination (r = .08, P < .001) were indirectly associated with higher HbA1c.ConclusionStress and self-efficacy are potential pathways for the relationship between neighborhood factors like violence, discrimination, and crime and glycemic control. Interventions aimed at mitigating stress and improving self-efficacy may improve self-care behaviors and glycemic control.

Purpose: Despite evidence that food insecure African Americans with type 2 diabetes are at particularly high risk for poor health outcomes, there is currently a lack of information on their lived experience. This qualitative study aimed to identify chal­lenges, facilitators, and barriers to effective diabetes care for food insecure African Americans with type 2 diabetes residing in an inner city.Methods: In fall 2018, we conducted two focus groups attended by a total of 16 food insecure adults with type 2 diabetes residing in the inner city of Milwaukee, Wisconsin. A standardized moderator guide included questions to explore the role of food inse­curity in managing diabetes, and facilitators that improve diabetes management within the context of food insecurity. Focus groups were audio recorded and recordings were transcribed by a professional transcription service. A grounded theory approach was used for analysis.Results: Six major challenges existed at the individual level (diet/nutrition, exercise, dia­betes knowledge and skills, complications from diabetes, a family history of diabe­tes, and a preoccupation with food). Five major barriers and facilitators existed both internally and externally to the individuals (access to food, medications, stress, cost of health-related needs and religion/spiritual­ity).Conclusions: This study identified multiple challenges, barriers, and facilitators to effec­tive care for food insecure African American adults with type 2 diabetes. It is impera­tive to incorporate this understanding in future work by using an ecological approach to investigate strategies to address food insecurity beyond a singular focus on access to food. Ethn Dis. 2021;31(4):527-536; doi:10.18865/ed.31.4.527

Purpose: Evaluate cost-effectiveness of a telephone-delivered education and behav­ioral skills intervention in reducing glycemic control (HbA1c) and decreasing risk of complications.Methods: Data from a randomized con­trolled trial, conducted from August 1, 2008 – June 30, 2010 and using a 2x2 factorial design delivered to 255 African American adults not meeting glycemic targets for dia­betes were used. Though the primary aim found no significant differences in HbA1c between groups, there was an overall drop in HbA1c across arms and differential cost. Primary clinical outcome was HbA1c measured at 12-months. Costs were esti­mated based on self-reported utilization of primary care, emergency, and other health care. Costs due to lost wages were calcu­lated based on self-reported days of work missed due to illness. The Michigan Model for Diabetes was used to estimate 10-year probability of developing congestive heart failure, cardiovascular disease, end stage renal disease, stroke, myocardial infarction, all cause death, and CVD death. Total cost per patient and clinical outcomes were used to estimate an incremental cost effective­ness ratio (ICER) using non-parametric bootstrapping.Results: ICERs indicated combined educa­tion and skills intervention was $3,630 less expensive than usual care to achieve a 0.6% decrease in HbA1c and was between $34,000 and $95,000 less expensive than usual care to reduce risk of complications. The knowledge only intervention was $661 less expensive than usual care and the behavioral skills only intervention did not indicate cost effectiveness.Conclusion: The combined intervention ICER for HbA1c is comparable to other education programs and the ICER to reduce the probability of complications falls below previously recommended long-term cut-off of $100,000, suggesting cost-effectiveness in an African American population.Ethn Dis. 2021;31(2):217-226; doi:10.18865/ed.31.2.217