Evaluating the implementation of the diabetes prevention program in an integrated health system

项目摘要/摘要：超过三分之一的60岁以上成年人患有肥胖症，50% 有糖尿病前驱症状。糖尿病预防计划(DPP)的临床试验表明， 生活方式干预可以减少2型糖尿病的发生率，并导致临床上显著的体重 损失，特别是在老年人中。有几项研究探讨了如何将民进党转化为社区- 基于环境和初级保健，但这些都受到样本量小、缺乏对照的限制 群体，以及极少的老年人。需要更大、更高质量的语用研究来确定如何 将这些发现转化为实践。最近，基督教青年会证明了民进党可以成功 提供给患有糖尿病前期的联邦医疗保险受益人，并导致临床上显著的体重减轻和成本 积蓄。根据这些发现，从2018年1月开始，医疗保险和医疗补助服务中心 (CMS)计划为联邦医疗保险受益人提供为期12个月的DPP计划。然而，这一计划的可行性 以所需的规模实施这一计划仍不清楚。而联邦医疗保险将亲自资助DPP或 在网上，任何一种形式在老年人中的覆盖面和有效性都需要确定。此外，我们 对影响项目参与度的行为和心理社会因素知之甚少 在这群人中。 我们建议严格评估Kaiser Permanente西北地区医疗保险DPP的实施情况 (KPNW)，一个大型的综合医疗保健系统，以确定提供 民进党当面或在线。KPNW将于2017年实施为期12个月的医疗保险DPP，并将随机化 6000名2型糖尿病高危受益者接受以下四种治疗方式之一：1)面对面的DPP；2)DPP 在线；3)患者在DPP面对面或在线之间进行选择；或4)常规护理。我们将检查计划的覆盖范围 (比较面对面和在线形式的征聘和保留率以及会议出勤率)， 比较治疗臂的临床指标(从电子健康中提取的体重和HbA1c 记录)，并检查与计划有效性和参与度相关的因素。我们还将 比较四个治疗组在6岁和12岁时饮食摄入量和体力活动分钟数的变化 几个月，以及抑郁症、生活质量、压力、社会支持和动机的测量 基线和六个月。将进行定性访谈，以探索与以下因素相关的因素 课程注册、满意度和持续参与。最后，我们将对成本效益进行比较 民进党面对面、民进党在线、民进党选择。简而言之，这项务实的研究将决定最好、最 为这些高风险的医疗保险人群提供这些服务的经济有效的方法。

PROJECT SUMMARY/ABSTRACT: More than one-third of adults over age 60 have obesity and 50% have prediabetes. The Diabetes Prevention Program (DPP) clinical trial demonstrated that a behavioral lifestyle intervention could reduce the incidence of type 2 diabetes and lead to clinically significant weight loss, particularly among older adults. Several studies have examined how to translate DPP into community- based settings and primary care, but these have been limited by small sample sizes, absence of a control group, and very few older adults. Larger, higher-quality pragmatic studies are needed to determine how to translate these findings into practice. Recently, YMCA demonstrated that DPP could be successfully delivered to Medicare beneficiaries with prediabetes and lead to clinically significant weight loss and cost savings. Based on these findings, starting in January 2018 the Centers for Medicare & Medicaid Services (CMS) plans to cover a 12-month DPP program for Medicare beneficiaries. Yet, the feasibility of implementing this program at the required scale remains unclear. While Medicare will fund DPP in-person or online, the reach and effectiveness of either format among older adults needs to be determined. Further, we have limited knowledge about the behavioral and psychosocial factors that influence program engagement in this group. We propose to rigorously evaluate the implementation of Medicare DPP at Kaiser Permanente Northwest (KPNW), a large, integrated health care system, to determine the feasibility and effectiveness of delivering DPP in-person or online. KPNW will implement the 12-month Medicare DPP in 2017, and will randomize 6000 beneficiaries at high risk for type 2 diabetes to one of four treatment arms: 1) DPP in-person; 2) DPP online; 3) patient choice between DPP in-person or online; or 4) Usual care. We will examine program reach (comparing in-person and online formats on recruitment and retention rates and session attendance), compare treatment arms on clinical measures (weight and HbA1c extracted from the electronic health records), and examine factors associated with program effectiveness and engagement. We will also compare the four treatment arms on change in dietary intake and minutes of physical activity at six and 12 months, as well as on measures of depression, quality of life, stress, social support, and motivation at baseline and at six months. Qualitative interviews will be conducted to explore factors associated with program enrollment, satisfaction, and continued participation. Finally, we will compare the cost-effectiveness of DPP in-person, DPP online, and DPP choice. In short, this pragmatic study will determine the best, most cost-effective methods for delivering these services to this high risk Medicare population.