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

描述（由申请人提供）： 比较有效性的研究结果，如AHRQ的比较有效性审查（CER），应该达到所有美国人，甚至难以达到的弱势群体。我们建议在亚拉巴马黑带，其中包括主要是非洲裔美国人（AA），1/3生活在联邦贫困线以下，面临距离，成本和不信任的障碍，接受医疗保健服务的研究。我们的目标是一个非常常见的需要质量改进的临床问题：慢性疼痛，骨关节炎（OA）和糖尿病（DM）患者。虽然药物管理，包括CER内容，是OA和DM治疗的支柱，但基于认知行为治疗（CBT）原则的生物心理社会方法可以改善功能并减少对药物的依赖，这对DM患者有风险。我们将研究在测试社区卫生工作者（CHW）提供的改善功能状态和DM代谢参数的计划的有效性的过程中，在临床决策中实施五个CER。为了检验干预组患者与对照组相比结局改善的假设，我们的目标是：1：采用形成性评价评估需求，对OA和DM进行ADAPT五项CER，以提高决策的使用和价值。我们将与（1）初级保健提供者反复合作，将改编的材料纳入最先进的互动，多模式CME计划;（2）与黑带居民一起开发文化相关的患者教育材料，并将其纳入CHW提供的DM疼痛干预措施，旨在根据CBT原则赋予患者权力和激活患者。2：在一项包括400名慢性疼痛、OA和DM患者的分组随机试验中测试CHW提供的16周干预。该试验将有80%的把握度检测功能状态评分低至0.7、A1 c> 0.4%、收缩压>4 mmHg和低密度脂蛋白胆固醇>6 mg/dl（主要结局）的差异。次要结局包括临床决策、疼痛和自我护理行为中的CER利用率。这两个部门的供应商都将获得核证的排减量。干预组患者将接受关于疼痛和DM自我护理的CHW授权干预，并整合CER内容，“注意力”对照组患者将接受无授权的教学式健康教育计划。第三章：通过AHRQ和UAB CME部门向全国医生传播本研究的CER产品，并通过UAB护理学院的在线课程向全球护士传播。传播产品包括：（1）关于社区卫生工作者是否能改善难以接触到的弱势群体的CER实施的有力证据;（2）针对初级保健医生和护士的五个CER主题的在线继续医学教育;（3）改善慢性疼痛、OA和DM患者健康结果的在线社区卫生工作者培训课程;（4）针对南部农村AA社区的五个CER主题的消费者信息材料。该试验利用了正在进行的研究的工具和基础设施，并将为有关CHW的政策决策提供信息。 公共卫生相关性：我们提出了一项随机试验，以测试社区卫生工作者（CHW）干预，以改善慢性疼痛和糖尿病患者的疼痛，糖尿病和骨关节炎在脆弱的，难以接触的患者生活在亚拉巴马的农村和贫困的黑带。该试验将测试CHW干预是否比单独提供教育具有更大的影响。在试验过程中，我们将研究如何调整五项比较有效性审查，以最大限度地影响临床决策，从而改善健康结果。

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.