Reducing Dirstress and Improving Self-Care in Diabetes

描述(由申请人提供)：糖尿病影响着650万至1300万美国人，与每年超过440亿美元的直接医疗费用有关。少数族裔(非洲人、亚洲人、美洲原住民、西班牙人)的流行率大约是非西班牙裔白人(Nhw)的两倍。在20%-25%的糖尿病保健员中，抑郁和高痛苦(D/D)作为共病出现，但在少数民族中，这一比例明显更高。D/D与自我护理行为减少、代谢控制不良、并发症风险增加和医疗费用增加有关。到目前为止，还没有对糖尿病患者的D/D进行全面、长期的研究，也很少有针对大多数患者得到护理的初级保健环境中的D/D和糖尿病的实际、基于证据的干预措施。鉴于D/D的普遍性以及D/D对这些患者造成的行为和生物风险的增加，这一竞争性更新应用(1)将对D/D、自我护理和代谢控制之间的相互关系的观察从18个月扩大到42个月，以评估这些过程对心血管和其他与糖尿病相关的生物行为终点的长期影响(这将是迄今为止规模最大、持续时间最长的此类研究)；(2)收集这些患者主观经历的D/D模式、原因和影响的详细定性数据；(3)利用所有这些研究结果，将现有的两种基于证据的干预措施(自动化的糖尿病专用自我护理计划与自我护理计划以及解决生活问题的痛苦减少计划与增强的常规护理计划)进行改进并有选择地结合成一项实际的三臂临床试验，其中包括一个新的高度痛苦的多种族患者样本；以及(4)使用RE-AIM框架对干预措施进行评估，通过一个全面的传播一揽子计划分享结果。这项拟议的研究对临床护理具有重大意义：(1)它将描述D/D、自我护理和代谢控制之间的关系的机制和亚组模式及其对主要的长期糖尿病相关结果的影响；(2)在不同的患者样本(种族、年龄、性别)中描述D/D对糖尿病的各种影响；(3)在随机对照试验中测试专门针对D/D和单独针对自我护理的实际、循证干预措施的相加效果；以及(4)开发一套全面的实用干预材料，用于初级保健。描述：经历高D/D水平的糖尿病患者严重疾病结局的风险增加。拟议的研究将随着时间的推移将D/D、自我护理和代谢控制的研究从18个月扩大到42个月，以确定它们对较长期的心血管和其他与糖尿病相关的终点的影响；将提供关于患者随着时间的推移对D/D的个人体验的有价值的主观信息；并将在不同的患者样本中测试和传播两种基于初级保健的干预措施的结果，这两种干预针对自我护理和D/D。

DESCRIPTION (provided by applicant): Diabetes affects between 6.5 and 13 million Americans and is associated with an expenditure of over $44 billion in direct health care costs per year. Prevalence rates for ethnic minorities (African, Asian and Native American, Hispanic) are approximately twice that of non Hispanic Whites (NHW). Depression and elevated distress (D/D) occur as co-morbid conditions in 20% -25% of NHWs with diabetes, but the rates are significantly higher among ethnic minorities. D/D is associated with decreased self-care behavior, poor metabolic control, increased risk for complications, and higher health-care costs. To date, there have been no comprehensive, long-term studies of D/D among patients with diabetes and there have been few practical, evidenced-based interventions that are directed at D/D and diabetes in primary care settings, where most patients receive care. Given the pervasiveness of D/D and the increased behavioral and biological risk that D/D poses for these patients, this competing renewal application (1) expand observation of the interrelationships among D/D, self-care and metabolic control with our existing 3-wave longitudinal cohort from 18 to 42 months to assess the longer term impact of these processes on cardiovascular and other diabetes-related bio-behavioral endpoints (this will be the largest and longest such study to date); (2) gather detailed qualitative data on the subjectively experienced patterns, causes and effects of D/D among these patients; (3) use all of these findings to refine and selectively combine two existing, evidenced-based, interventions (an automated, diabetes-specific self-care program vs. a self-care program plus a live problem solving distress-reduction program vs. enhanced usual care) into a practical, 3-arm clinical trial with a new, highly distressed, multi-ethnic patient sample; and (4) evaluate the intervention using the RE-AIM framework, sharing the results through a comprehensive dissemination package. The proposed research has major implications for clinical care: it will (1) describe the mechanisms and sub group patterns of relationships among D/D, self-care, and metabolic control and their effects on major longer-term diabetes-related outcomes; (2) describe the variety of effects of D/D on diabetes in a diverse patient sample (ethnicity, age, gender); (3) test in an RCT the additive effect of a practical, evidenced-based intervention that specifically targets D/D vs. one that addresses self-care alone; and (4) develop a comprehensive package of practical intervention materials for use in primary care. DESCRIPTION: People with diabetes who experience high levels of D/D are at increased risk for serious disease outcomes. The proposed research will expand the study of D/D, self-care and metabolic control over time from 18 to 42 months to determine their effects on longer-term cardiovascular and other diabetes-related endpoints; will provide valuable subjective information on patients' personal experience of D/D over time; and will test and disseminate the results of two primary care-based interventions that address self-care and D/D in a diverse patient sample.