Implementing Sustainable Diabetes Prevention and Self-Management in Primary Care

描述（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预防和延迟糖尿病前期患者的糖尿病的有效性，但最佳护理管理和预防与目前在实践中提供的内容之间存在巨大差距。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接受医疗保健，这些实践的护理提供基于由个体医生提供的急性、间歇性护理的传统模式。慢性病护理模式（CCM）为解决慢性病和预防性护理提供了一个替代框架。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，其中的做法几乎完全依赖于按服务收费的报销，已经成为一个主要障碍。支持慢性病和预防性护理的补偿战略正在出现，但尚未在按服务付费的环境中进行实践检验。因此，本提案的重点是：初级保健实践如何在以按服务付费为主的环境中为糖尿病患者和有风险的患者实施和维持CCM？在这项研究中，我们将实施CCM，重点是两个组织策略：1）临床信息系统，以提示，提醒和报告系统的决策支持，以临床医生和他们的团队，和2）护理经理，以支持病人的自我管理和预防。综合健康协会（IHA）是一个总部设在亚特兰大的医生拥有的实践集团，主要接受按服务付费。他们的10个初级保健实践将参与其中一半随机分配到干预和一半作为常规护理比较。研究目的是：1）实施CCM，重点是实施临床信息系统和护理管理，为糖尿病患者和有风险的患者提供初级保健实践，并定性和定量地描述用于实现成功整合的障碍，促进者和方法。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人员的直接成本的能力，以及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累积的收益。3)测量实践层面CCM实施对患者生理指标和健康行为的影响。主要指标包括HbA1c、血压、血脂、空腹血糖水平和BMI，与比较实践中的类似患者相比，在一年随访时。次要措施包括饮食、体育活动、酒精和烟草的使用。 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。虽然存在有效的策略来帮助糖尿病患者减少疾病的并发症，并且有风险的患者延迟或预防糖尿病的发展，但这些策略在常规初级保健医疗实践中并没有得到一致的实施。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，消除持续护理提供的障碍（包括财务可持续性），并衡量这种实施对护理流程，医疗保健成本以及患者的临床，健康行为和护理满意度结果的影响。

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.