Enhancing Informal Caregiving to Support Diabetes Self-Management

描述（由申请人提供）：虽然家庭护理人员（ICG）有助于改善糖尿病（DM）的结局，但他们可能缺乏最佳实现这一目标所需的资源，并存在心理社会衰退和“护理人员倦怠”的风险。使问题复杂化的是，数百万患有慢性病的美国老年人独自生活，接受“远程医疗”，没有任何支持结构或资源来确保其有效性。初步数据表明，糖尿病患者将从事自动远程监护持续一段时间。由此产生的数据似乎有效地检测随着时间的推移在健康状况和自我管理的变化。我们建议将患者与愿意与患者ICG（如果存在）和临床医生密切协调支持患者健康和自我管理的非家庭成员或亲密朋友（“CarePartner;”CP）联系起来。通过自动远程监测，患者将每周提供有关其DM健康和自我管理的最新信息。将通过电子邮件向CP发送总结沿着帮助患者解决报告问题的指南;将提醒临床医生有关医学紧急问题。我们发现类似的干预措施在另一个具有挑战性的环境中是可行的，并且可能有效，即，充血性心力衰竭自我管理。对于这个提案，我们制定了DM相关的电话脚本和详细的参与者指南。在本次重新提交的资料中，我们现在纳入了试点数据，这些数据不仅表明DM患者非常容易接受干预，而且还通过表明干预不太可能产生或恶化CP、ICG和患者之间的人际冲突来解决审查者的担忧。我们现在提出一项基于社区的有效性RCT。具体目标1是比较CP干预与单独远程监测（对照）对控制不良DM患者12个月血糖控制和DM相关痛苦的影响（即，初始HbA 1c> 8.0%）。具体目标2是检查对DM自我管理、健康相关生活质量、收缩压、护理者负担、关系质量和DM护理成本的次要影响。我们已经招募了为大量低收入和保险不足的患者提供服务的临床站点，这项干预措施是专门为这些患者设计的。如果这种干预措施被证明是有效的，而不增加成本或临床医生的负担，那么它的实施可能会产生重大的公共卫生效益，特别是对脆弱和服务不足的糖尿病患者。更广泛的社会效益可能会通过增加帮助行为和加强社会联系而产生。后续工作可以调整干预措施，用于共病条件和其他需要自我管理的慢性疾病。 公共卫生相关性：尽管许多患有糖尿病的美国老年人从他们的生活伴侣那里得到了帮助，但这种情况往往会导致照顾者的压力和倦怠。许多其他糖尿病患者独自生活，但可以使用这种类型的帮助来保持健康并避免并发症。该项目通过将糖尿病患者与他们已经熟悉的家庭以外的人联系起来，并培训这个“护理伙伴”来帮助患者实现良好的糖尿病控制，从而解决了这两个问题。如果成功，该计划可以预防糖尿病并发症的成千上万的老年人谁否则将被社会孤立和医疗服务不足。

DESCRIPTION (provided by applicant): Although in-home caregivers (ICGs) help improve diabetes mellitus (DM) outcomes, they may lack the resources needed to do this optimally, and are at risk for psychosocial decline and "caregiver burnout." Complicating matters, millions of chronically-ill older Americans live alone and receive "long-distance caregiving" without any supporting structure or resources to ensure its effectiveness. Preliminary data indicate that DM patients will engage in automated telemonitoring consistently for sustained periods. The resulting data seems to validly detect changes over time in health status and self-management. We propose to link patients with a non-household family member or close friend (the "CarePartner;" CP) who is willing to support the patient's health and self-management in close coordination with the patient's ICG (if one exists) and clinician(s). Through automated telemonitoring, patients will provide weekly updates on their DM health and self-management. Summaries of this will be emailed to CPs along with guidance on helping the patient address reported problem(s); clinicians will be alerted about medically-urgent problems. We found a similar intervention to be feasible and potentially effective in another challenging setting, i.e., congestive heart failure self-management. For this proposal, we developed DM-related telephone scripts and detailed participant guidelines. In this resubmission, we now include pilot data that not only indicates that DM patients are very receptive to the intervention, but also addresses a Reviewer concerns by suggesting that the intervention is unlikely to create or worsen interpersonal conflicts between CPs, ICGs, and patients. We now propose a community-based effectiveness RCT. Specific Aim 1 is to compare the effects of CP intervention to telemonitoring alone (control) upon 12-month glycemic control and DM-related distress for patients with poorly-controlled DM (i.e., initial HbA1c > 8.0%). Specific Aim 2 is to examine secondary effects on DM self-management, health-related quality of life, systolic blood pressure, caregiver burden, relationship quality, and cost of DM care. We have already recruited clinical sites serving large numbers of low-income and underinsured patients, whom this intervention was especially designed to benefit. If this intervention proves effective without increasing costs or clinician burden, then its implementation could yield major public health benefits, especially for vulnerable and underserved DM patients. Broader societal benefit may occur through increased helping behavior and strengthened social ties. Followup work could adapt the intervention for use with comorbid conditions and other chronic conditions requiring self-management. PUBLIC HEALTH RELEVANCE: Although many older Americans with diabetes receive caregiving assistance from someone they live with, this situation often leads to caregiver stress and burnout. Many other diabetes patients live by themselves, but could use this type of assistance to remain healthy and avoid complications. This project addresses both problems by linking diabetes patients with someone from outside their home who they already know well, and training this "CarePartner" to help the patient achieve good diabetes control. If successful, this program could prevent diabetes complications for many thousands of older Americans who would otherwise be socially isolated and medically under-served.