EXpanding Technology-Enabled, Nurse-Delivered Chronic Disease Care (EXTEND)

当糖尿病、高血压等慢性病的自我管理需求超过患者的需求时， 自我管理能力差，控制环境能力差。对于许多患者来说，基于诊所的慢性病护理提供了 自我管理支持不足，导致临床难治性慢性病。例如，12%的 2型糖尿病患者尽管接受了基于临床的护理，但血红蛋白A1 c（HbA 1c）≥8.5%持续≥1年; 这被定义为“持续性控制不佳的糖尿病”（PPDM）。PPDM不响应诊所- 基于护理，因为PPDM的基础因素没有得到很好的解决， 在临床上可实现的接触。重要的是，超过85%的PPDM患者合并有高血压， 进一步加剧了这一高危人群的结局。如果没有更好的治疗选择，PPDM患者和 高血压将不可避免地产生可预防的并发症和费用。 远程保健有可能改善临床难治性慢性疾病的管理， 这是一个非常好的选择，因为它促进了患者与提供者的联系，并更好地支持自我管理。我们事先 工作表明，护士提供的远程保健干预措施，包括远程监测，自我管理， 支持和药物管理可以降低HbA 1c，即使是临床难治性PPDM患者。 令人兴奋的是，新兴的移动的监测技术可以增强临床难治性慢性疾病的远程医疗。 通过生成多个健康数据流以促进患者自我管理，或者通过 将移动的监测数据集成到护士递送的远程健康干预中。关键证据缺口 目前阻止在临床实践中使用支持移动的监测的远程保健。 目前的提案，扩展技术启用，护士提供的慢性病护理（扩展） 旨在解决目前阻碍实际使用移动的监测的障碍和证据缺口 远程保健的临床难治性慢性病，使用PPDM与共病高血压作为目标条件。 因为这一人群已经被证明对常规的临床护理难治，所以本研究提出了一种积极的治疗方法。 比较两种为期12个月的远程医疗干预措施的有效性的对照随机试验（N=220）：1） EXTEND-监测，或单独的移动的监测;和2）EXTEND-护理，护士提供的干预 整合了移动的监测、自我管理支持和药物管理。为引导 为了进一步扩大和传播“扩展”干预措施，一项严格的多方法评估将： 就实施障碍和促进因素与利益相关者进行访谈;以及（B）比较干预成本 潜在的补偿机制。最后，将来自移动的监测的数据与 将在24个月内检查队列中用于预测患者安全事件的电子健康记录。 临床难治性慢性病需要创新，以减少可预防的并发症。这么高- 影响建议将以可推广到其他条件方式解决紧急临床问题。

When the self-management demands of chronic diseases like diabetes and hypertension exceed patients’ self-management capacity, poor control ensues. For many patients, clinic-based chronic disease care provides insufficient self-management support, resulting in clinic-refractory chronic diseases. As an example, 12% of all patients with type 2 diabetes maintain a hemoglobin A1c (HbA1c) ≥8.5% for ≥1 year despite clinic-based care; this is defined as ‘persistent poorly-controlled diabetes mellitus’ (PPDM). PPDM does not respond to clinic- based care because the factors that underlie PPDM are not well-addressed with the infrequent patient-provider contact achievable in clinic. Importantly, over 85% of patients with PPDM have comorbid hypertension, which further exacerbates outcomes in this high-risk group. Without better treatment options, patients with PPDM and hypertension will inevitably accrue preventable complications and costs. Telehealth has the potential to improve management of clinic-refractory chronic diseases relative to clinic- based care alone because it facilitates patient-provider contact and better supports self-management. Our prior work shows that nurse-delivered telehealth interventions incorporating telemonitoring, self-management support, and medication management can lower HbA1c even among clinic-refractory patients with PPDM. Excitingly, emerging mobile monitoring technologies could enhance telehealth for clinic-refractory chronic diseases, either by generating multiple streams of health data to facilitate patient self-management, or by integrating mobile monitoring data into a nurse-delivered telehealth intervention. However, key evidence gaps currently prevent use of mobile monitoring-enabled telehealth in clinical practice. The current proposal, EXpanding Technology-Enabled, Nurse-Delivered Chronic Disease Care (EXTEND) seeks to address current barriers and evidence gaps preventing practical use of mobile monitoring-enabled telehealth for clinic-refractory chronic disease, using PPDM with comorbid hypertension as the target condition. Because this population has already proven refractory to usual clinic care, this study proposes an active comparator randomized trial (N=220) comparing the effectiveness of two 12-month telehealth interventions: 1) EXTEND-Monitoring, or mobile monitoring alone; and 2) EXTEND-Nursing, a nurse-delivered intervention incorporating mobile monitoring, self-management support, and medication management. In order to guide further scaling and dissemination of the EXTEND interventions, a rigorous, multi-method evaluation will: (A) interview stakeholders regarding implementation barriers and facilitators; and (B) compare intervention costs against potential reimbursement mechanisms. Finally, the value of combining data from mobile monitoring and electronic health records to predict patient safety events will be examined in the cohort over 24 months. Clinic-refractory chronic diseases demand innovation to reduce preventable complications. This high- impact proposal will address an urgent clinical problem in a manner that is generalizable to other conditions.