Internet Intervention For Improving Rural Diabetes Care

描述（由申请人提供）： 背景亚拉巴马的糖尿病患病率已增至10.5%，是所有州中最高的之一。我们提出了一项为期4年的随机试验，以提高亚拉巴马农村医生对2型糖尿病成人患者的指南依从性的基于互联网的干预。农村亚拉巴马有许多弱势和少数民族患者有限的医疗保健。与城市患者相比，亚拉巴马农村的糖尿病患者接受的护理质量较差，结局更差。 目标. (1)评估糖尿病指南实施的障碍，并通过焦点小组和基于病例的小插曲调查确定解决方案;（2）开发和实施交互式互联网干预，包括个性化的医生表现反馈;（3）在随机对照试验中评估干预;（4）一旦反馈停止，检查改善指南依从性的可持续性。 方法.我们与亚拉巴马大学农村医学项目合作，将200个农村医生诊所随机分配到干预或比较组。我们的18个月干预，实时为每个医生定制，包括基于案例的教育，绩效反馈和基准的互联网学习模块。对照组将收到一份以文字为基础的非交互式因特网公布的公开资源。研究医生办公室的执业护士和医生助理也可以参加互联网模块。结果将基于先前开发和验证的糖尿病质量指标。干预措施将包括筛查、诊断、治疗和预防。性能反馈将包括每位介入医生的15个图表。在医生层面进行的主要分析将比较研究组之间指南依从性的差异改善。辅助分析将检查医生特征、办公室中的其他提供者和患者特征（例如，合并症、种族、性别、年龄和社会经济地位）。多变量技术将调整重复测量，医生内的患者集群，以及单个办公室内的多个提供者。 意义这项研究提供了一种技术先进，理论为基础的干预措施，以改善高风险，服务不足的人群的护理。凭借将研究转化为实践，农村医学，行为医学，健康信息学和临床糖尿病的专业知识，我们的多学科团队拥有经过验证的合作记录。该项目将产生一种循证和可复制的干预措施，这种干预措施可以在“真实的世界”中持续，并很容易针对其他疾病进行修改。在作出第二次审查建议的重要修改后，该项目得到了很大改进。

DESCRIPTION (provided by applicant): Background. The prevalence of diabetes in Alabama has increased to 10.5 %, one of the highest among all states. We propose a 4-year randomized trial of an Internet-based intervention for improving guideline adherence by rural Alabama physicians caring for adult patients with type 2 diabetes. Rural Alabama has many disadvantaged and minority patients with limited health care access. Patients with diabetes in rural Alabama receive poorer quality of care and have worse outcomes compared to urban patients. Objectives. (1) Assess barriers to implementation of diabetes guidelines and identify solutions through focus groups and case-based vignette surveys; (2) Develop and implement an interactive Internet intervention including individualized physician performance feedback; (3) Evaluate the intervention in a randomized controlled trial; and (4) Examine the sustainability of improved guideline adherence once feedback ceases. Methods. In partnership with the University of Alabama rural medicine program, we will randomize 200 rural physician offices to an intervention or comparison arm. Our 18-month intervention, customized to the individual physician in real-time, consists of Internet learning modules with case-based education, performance feedback, and benchmarks. The comparison group will receive a text-based, non-interactive Internet posting of publicly available resources. Nurse practitioners and physician assistants from the offices of study physicians may also participate in the Internet modules. Outcomes will be based on previously developed and validated quality measures for diabetes. The intervention will cover screening, diagnosis, treatment, and prevention. Performance feedback will include 15 charts per intervention physician. The main analysis, conducted at the physician level, will compare differential improvement in guideline adherence between the study arms. Ancillary analyses will examine the effects of physician characteristics, other providers in the office, and patient characteristics (e.g., comorbidities, ethnicity, gender, age, and socioeconomic status). Multivariable techniques will adjust for repeated measures, clustering of patients within physicians, and multiple providers within a single office. Significance. This study offers a technologically advanced, theory-grounded intervention for improving care of a high-risk, underserved population. With expertise in translating research into practice, rural medicine, behavioral medicine, health informatics, and clinical diabetes, our multidisciplinary team has a proven record of collaboration. This project will produce an evidence-based and replicable intervention that can be sustained in the "real world," and easily modified for other diseases. This project is substantially improved after making important changes recommended in the second review.