Implementing Sustainable Diabetes Prevention and Self-Management in Primary Care

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型糖尿病管理和生活方式干预对糖尿病前期患者预防和延迟糖尿病的有效性，但在最佳护理管理和预防与目前在实践中提供的服务之间存在很大差距。无论是糖尿病患者还是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，而初级保健实践的基础是由个别医生提供急性、偶发护理的传统模式。慢性护理模式（CCM）提供了另一种框架来解决慢性和预防性护理。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存在一个主要障碍，因为初级保健的实践几乎完全依赖于按服务收费的报销。支持慢性和预防性保健的报销策略正在出现，但尚未在按服务收费的支付环境中在实践层面进行测试。因此，本提案的重点是：在以服务收费为主的支付环境中，初级保健实践如何对糖尿病患者和有糖尿病风险的患者实施和维持CCM ？在本研究中，我们将以两种组织策略为重点实施CCM: 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的决策支持；2)护理管理者支持患者自我管理和预防。综合健康协会（IHA）是一家总部位于密歇根州的医生所有的实践集团，主要收取按服务收费的费用。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组，一半作为常规护理组进行比较。研究的目的是：1)实施CCM，重点关注临床信息系统和护理管理的实施，针对患有糖尿病和有糖尿病风险的患者，纳入初级保健实践，并定性和定量地描述成功整合所使用的障碍、促进因素和方法。2)在两个层面上识别和衡量CCM实施的财务可持续性：a)干预实践产生新收入来源的能力，以支付临床信息系统和护理管理人员的直接成本；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)衡量实践层面CCM实施对患者生理指标和健康行为的影响。在一年的随访中，主要测量指标包括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。次要措施包括饮食、身体活动、酒精和烟草使用。

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.