Using CERs to Optimize Quality of Life for Persons with Diabetes and Chronic Pain

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DESCRIPTION (provided by applicant): Comparative effectiveness research results, such as AHRQ's Comparative Effectiveness Reviews (CER), should reach all Americans, even hard-to-reach vulnerable groups. We propose a study in the Alabama Black Belt, which includes mostly African Americans (AA), 1/3 living below the Federal poverty line and facing distance, cost and mistrust barriers to receiving healthcare services. We target a very common clinical problem in need of quality improvement: patients with chronic pain, osteoarthritis (OA) and diabetes (DM). While medication management, including CER content, is a mainstay of OA and DM therapy, biopsychosocial approaches based on cognitive-behavioral therapy (CBT) principles can improve functioning and reduce reliance on medications, which have risks for DM patients. We will examine the implementation of five CERs in clinical decision-making in the course of testing the effectiveness of a community health worker (CHW)- delivered program to improve functional status and DM metabolic parameters. To test the hypothesis that intervention group patients will have improved outcomes compared with controls, we aim to: 1: ADAPT Five CERs on OA and DM to enhance use and value in decision-making, using formative evaluation to assess needs. We will work iteratively with (1) primary care providers, to incorporate adapted materials into a state-of-the-art interactive, multimodal CME program; and (2) with Black Belt residents, to develop culturally relevant patient education materials, and incorporate them into a CHW-delivered DM-pain intervention designed to empower and activate patients, based on CBT principles. 2: TEST the CHW-delivered 16-week intervention in a group randomized trial including 400 patients with chronic pain, OA and DM. The trial will have 80% power to detect differences in functional status scores as low as 0.7, A1c >0.4%, systolic blood pressure >4 mmHg, and low density lipoprotein cholesterol >6 mg/dl (primary outcomes). Secondary outcomes include CER utilization in clinical decision-making, pain, and self- care behaviors. Providers in both arms will receive CME on the CERs. Intervention arm patients will receive the CHW empowerment intervention on pain and DM self-care with integrated CER content, and "attention" control arm patients will receive a didactic health education program without empowerment. 3: DISSEMINATE the CER products of the study through AHRQ and the UAB CME department to physicians nationally, and through the UAB School of Nursing's on-line curriculum to nurses worldwide. Dissemination products include (1) Robust evidence on whether CHWs improve CER implementation in a hard-to-reach vulnerable group; (2) On-line CME for primary care physicians and nurses on five CER topics; (3) On-line CHW training curriculum to improve health outcomes for individuals with chronic pain, OA and DM; (4) Consumer information materials tailored for southern rural AA communities on five CER topics. The trial leverages tools and infrastructure of an ongoing study and will inform policy decisions on CHWs. PUBLIC HEALTH RELEVANCE: We propose a randomized trial to test a Community Health Worker (CHW) intervention to improve chronic pain and diabetes for patients with pain, diabetes and osteoarthritis in vulnerable, hard-to-reach patients living in Alabama's rural and impoverished Black Belt. The trial will test whether the CHW intervention has greater impact than provider education alone. In the course of the trial, we will examine how five Comparative Effectiveness Reviews can be adapted to best impact clinical decision-making to improve health outcomes.