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

当糖尿病和高血压等慢性病的自我管理需求超过患者的自我管理需求时 自我管理能力差，随之而来的是控制能力差。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 尽管进行了临床治疗，2型糖尿病患者的糖化血红蛋白(HbA1c)≥仍维持在≥为8.5%的1年内； 这被定义为“持续性控制不良的糖尿病”(PPDM)。PPDM对临床没有反应- 以医疗为基础的护理，因为PPDM背后的因素没有得到很好的解决，因为很少有患者-提供者 联系可在临床上实现。重要的是，超过85%的PPDM患者合并高血压，这 进一步加剧了这一高危群体的结局。如果没有更好的治疗选择，PPDM和 高血压不可避免地会产生可预防的并发症和成本。 相对于临床，远程医疗有可能改善对临床难治性慢性病的管理。 仅基于护理，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。我们的前辈 工作表明，护士提供的远程保健干预包括远程监护、自我管理 支持和药物管理可以降低HbA1c，即使是在临床难治的PPDM患者中也是如此。 令人兴奋的是，新兴的移动监测技术可以增强临床难治性慢性疾病的远程医疗 疾病，通过生成多个健康数据流以促进患者自我管理，或通过 将移动监测数据集成到护士提供的远程健康干预中。然而，关键证据差距 目前防止在临床实践中使用启用移动监测的远程医疗。 当前的提案，扩展技术支持，护士提供的慢性病护理(扩展) 寻求解决当前阻碍启用移动监控的实际使用的障碍和证据差距 对临床难治性慢性疾病的远程保健，以PPDM合并高血压为目标条件。 由于这一人群已经被证明对常规的临床护理无效，这项研究提出了一种积极的 比较者随机试验(N=220)比较两种为期12个月的远程保健干预措施的有效性：1) 扩展-监测，或单独的移动监测；和2)扩展-护理，护士提供的干预 集移动监控、自我管理支持和药物管理于一体。为了指导 为了进一步扩大和传播扩展干预措施，严格、多方法的评估将：(A) 就实施障碍和促进者与利益攸关方进行面谈；以及(B)比较干预成本 反对潜在的补偿机制。最后，将来自移动监测的数据和 用于预测患者安全事件的电子健康记录将在24个月内进行队列检查。 临床难治性慢性病需要创新，以减少可预防的并发症。如此之高- Impact提案将以一种可推广到其他情况的方式解决紧急的临床问题。

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.