Implementing Sustainable Diabetes Prevention and Self-Management in Primary Care

在初级保健中实施可持续的糖尿病预防和自我管理

• 批准号: 8107491
• 负责人: JODI Summers HOLTROP
• 金额: $ 51.24万
• 依托单位: MICHIGAN STATE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-07-15 至 2014-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8107491
• 关键词: Acute; Address; Adult; Affect; Alcohol consumption; American; Beryllium; Blood Glucose; Blood Pressure; Body mass index; Caring; Case Manager; Cessation of life; Chronic; Chronic Care; Chronic Disease; Clinic; Clinical; Clinical Trials; Code; Communities; Cost Effectiveness Analysis; Development; Diabetes Mellitus; Diabetes prevention; Diagnosis; Diet; Direct Costs; Disease; Disease Management; Elements; Environment; Fasting; Fee-for-Service Plans; Fee-for-Service Reimbursements; Financial Support; Glucose Intolerance; Glycosylated hemoglobin A; Goals; Group Practice; Health; Health Care Costs; Health Status Indicators; Health behavior; Health system; Healthcare; Healthcare Systems; Home environment; Income; Indium; Individual; Information Systems; Intervention; Lipids; Managed Care; Measures; Medical; Methods; Michigan; Modeling; Morbidity - disease rate; Non-Insulin-Dependent Diabetes Mellitus; Obesity; Outcome; Outcome Measure; Patient Care Management; Patients; Pattern; Performance; Physical activity; Physicians; Physiological; Population; Prediabetes syndrome; Prevention; Preventive; Primary Health Care; Process; Productivity; Randomized; Relative (related person); Reporting; Research; Risk; Self Care; Self Management; Services; Source; System; Testing; Time; Tobacco use; Translating; Weight Gain; base; care delivery; chronic care model; cost; cost effectiveness; design; diabetes management; diabetes risk; diabetic patient; disability; discount; experience; follow-up; improved; lifestyle intervention; mortality; patient oriented; payment; premature; prevent; programs; research to practice; satisfaction; treatment as usual

DESCRIPTION (provided by applicant): Diabetes is a devastating disease, the complications of which result in premature death or disability for many Americans. Although clinical trials demonstrate the efficacy of type 2 diabetes management as well as lifestyle interventions to prevent and delay diabetes in those with pre-diabetes, there is a substantial gap between optimal care management and prevention and what is currently delivered in practice. Patients, both with and at-risk for diabetes, receive their health care predominantly through primary care practices, which base their care delivery on the traditional model of acute, episodic care delivered by individual physicians. The Chronic Care Model (CCM) provides an alternative framework to address chronic and preventive care. Key elements include self-management support, delivery system design, decision support and clinical information systems. Research demonstrates that the CCM improves both care delivery and outcomes for patients with diabetes, however, financial sustainability of the CCM in primary care, where practices depend almost entirely on fee-for- service reimbursement, has presented a major barrier. Reimbursement strategies supporting chronic and preventive care are emerging, but have not yet been tested at the practice level in a fee-for-service payment environment. Therefore the focus of this proposal is: How can primary care practices implement and sustain the CCM for patients with, and at-risk for, diabetes within a predominantly fee-for-service payment environment? In this study, we will implement the CCM focusing on two organizing strategies: 1) clinical information system to prompt, remind and report for systematic decision support to clinicians and their team, and 2) care managers to support patient self-management and prevention. Integrated Health Associates (IHA) is a Michigan-based, physician-owned group of practices that receive predominantly fee-for-service payment. Their ten primary care practices will participate with half randomly assigned to intervention and half as usual care comparisons. Study aims are: 1) To implement the CCM, focusing on the implementation of clinical information systems and care management, for patients having and at risk for diabetes, into primary care practices, and to describe qualitatively and quantitatively the barriers, facilitators, and methods used to accomplish successful integration. 2) To identify and measure financial sustainability of CCM implementation on two levels: a) the intervention practice's capacity to generate new sources of income to cover the direct costs of the clinical information systems and care managers and b) completing a full cost effectiveness analysis of the CCM implementation with regard to the total costs to practices, patients and the health care system versus benefits accrued by participating patients. 3) To measure outcomes of practice-level CCM implementation on patient's physiologic indicators and health behaviors. Primary measures include HbA1c, blood pressure, lipids, fasting blood sugar levels, and BMI, as compared to similar patients in comparison practices, at one year follow-up. Secondary measures include diet, physical activity, alcohol and tobacco use. PUBLIC HEALTH RELEVANCE: Diabetes is a leading cause of premature morbidity and mortality among Americans. Although effective strategies exist to help patients with diabetes reduce complications of the disease, and patients at risk to delay or prevent their development of diabetes, these strategies are not consistently implemented in routine primary care medical practice. This study seeks to implement Chronic Care Model-based diabetes prevention and self care in primary care, remove barriers to sustained care delivery (including financial sustainability), and measure the effect of this implementation on care processes, health care costs, and patient's clinical, health behavior and care satisfaction outcomes.

描述（由申请人提供）：糖尿病是一种毁灭性的疾病，其并发症导致许多美国人过早死亡或残疾。尽管临床试验证明了 2 型糖尿病管理以及生活方式干预对于预防和延缓糖尿病前期患者糖尿病的有效性，但最佳护理管理和预防与目前的实践之间存在很大差距。患有糖尿病和有糖尿病风险的患者主要通过初级保健实践获得医疗保健，其护理服务基于由个体医生提供的急性、间歇性护理的传统模式。慢性护理模型 (CCM) 提供了解决慢性和预防性护理问题的替代框架。关键要素包括自我管理支持、交付系统设计、决策支持和临床信息系统。研究表明，CCM 改善了糖尿病患者的护理服务和结果，然而，CCM 在初级保健中的财务可持续性（其做法几乎完全依赖于服务费用报销）构成了主要障碍。支持慢性和预防性护理的报销策略正在出现，但尚未在按服务收费的支付环境中进行实践层面的测试。因此，该提案的重点是：初级保健实践如何在主要按服务收费的支付环境中为患有糖尿病和有糖尿病风险的患者实施和维持 CCM？在本研究中，我们将实施CCM，重点关注两种组织策略：1）临床信息系统提示、提醒和报告，为临床医生及其团队提供系统决策支持；2）护理管理者支持患者自我管理和预防。 Integrated Health Associates (IHA) 是一家总部位于密歇根州、由医生拥有的诊所集团，主要收取服务费用。他们的十个初级保健机构将参与其中，一半随机分配到干预组，一半作为常规护理比较。研究目标是： 1) 实施 CCM，重点关注将患有糖尿病和有糖尿病风险的患者纳入初级保健实践的临床信息系统和护理管理的实施，并定性和定量地描述用于实现成功整合的障碍、促进因素和方法。 2) 在两个层面上确定和衡量 CCM 实施的财务可持续性：a) 干预实践产生新收入来源以支付临床信息系统和护理管理者的直接成本的能力，b) 完成 CCM 实施的全面成本效益分析，包括实践、患者和医疗保健系统的总成本与参与患者所获得的收益。 3) 衡量实践级CCM实施对患者生理指标和健康行为的结果。主要指标包括糖化血红蛋白 (HbA1c)、血压、血脂、空腹血糖水平和体重指数 (BMI)，并在一年的随访中与比较实践中的类似患者进行比较。次要措施包括饮食、体力活动、饮酒和吸烟。 公共卫生相关性：糖尿病是美国人过早发病和死亡的主要原因。尽管存在有效的策略来帮助糖尿病患者减少疾病并发症，并帮助处于延迟或预防糖尿病风险的患者，但这些策略并未在常规初级保健医疗实践中得到一致实施。本研究旨在在初级保健中实施基于慢性护理模式的糖尿病预防和自我护理，消除持续护理提供（包括财务可持续性）的障碍，并衡量这种实施对护理流程、医疗保健成本以及患者临床、健康行为和护理满意度结果的影响。