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，其并发症会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糖尿病前期患者预防和延缓糖尿病的效果，但最佳护理管理和预防与目前的实际效果之间仍有很大差距。糖尿病患者和有糖尿病风险的患者主要通过初级保健做法获得医疗保健，这些做法将他们的保健服务建立在由个别医生提供的急性间歇性护理的传统模式上。慢性护理模式(CCM)为解决慢性和预防性护理问题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提供和预后，然而，在初级保健中，CCM的财务可持续性几乎完全依赖于按服务付费的报销，这构成了一个主要障碍。支持慢性和预防性护理的报销战略正在形成，但尚未在按服务付费的环境中得到实践检验。因此，这项提案的重点是：初级保健实践如何在主要按服务付费的环境中为糖尿病患者和有糖尿病风险的患者实施和维持CCM？在这项研究中，我们将重点实施CCM的两个组织策略：1)临床信息系统，以提示、提醒和报告对临床医生及其团队的系统决策支持；2)护理经理，以支持患者的自我管理和预防。综合健康协会(IHA)是一家总部位于密歇根州的医生所有的诊所组织，主要收取服务费。他们的十个初级保健诊所将参与其中，一半随机分配到干预组，另一半与平时的护理比较。研究的目标是：1)实施CCM，重点是实施临床信息系统和护理管理，将糖尿病患者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)干预实践产生新的收入来源的能力，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，即实践、患者和医疗保健系统的总成本与参与患者积累的利益的对比。3)评估实践层面CCM实施对患者生理指标和健康行为的影响。主要测量指标包括糖化血红蛋白、血压、血脂、空腹血糖水平和体重指数，在一年的随访中与同类患者进行比较。次要措施包括饮食、体育活动、饮酒和吸烟。

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.