Reducing Emergency Diabetes Care for Older African Americans

减少老年非裔美国人的糖尿病紧急护理

• 批准号: 9915901
• 负责人: BARRY W. ROVNER
• 金额: $ 68.53万
• 依托单位: THOMAS JEFFERSON UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-05-21 至 2022-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9915901
• 关键词: Accident and Emergency department; African American; Age; American; Behavioral; Caring; Client satisfaction; Communities; Community Health Aides; Complex; Diabetes Mellitus; Economics; Education; Elements; Emergency Care; Emergency Situation; Emergency department visit; Glycosylated hemoglobin A; Goals; Health Services Accessibility; Healthcare Systems; Healthy People 2020; Home environment; Home visitation; Hospitalization; Improve Access; Income; Individual; Intervention; Knowledge; Lead; Mediating; Mediation; Medical; Mental Depression; Nursing Faculty; Participant; Patients; Perception; Primary Care Physician; Primary Health Care; Quality of life; Questionnaires; Race; Randomized Controlled Trials; Research; Self Care; Structure; Testing; Treatment outcome; Twin Multiple Birth; Visit; barrier to care; built environment; community intervention; comparative efficacy; cost; diabetes management; diabetes self-management; efficacy testing; follow-up; glycemic control; health belief; health equity; high risk population; improved; indexing; innovation; literacy; prevent; primary outcome; racial difference; racial disparity; secondary outcome; sex; skills; societal costs; socioeconomics; telehealth; therapy design; treatment as usual; treatment comparison; treatment effect

African Americans (AAs) with diabetes (DM) seek emergency department (ED) care twice as often as Whites. About 40% of AAs with DM have an ED visit each year, and 24% use the ED as their usual place of care (vs. 13% of Whites). The reasons for these racial disparities in ED use are complex, but the scientific premise of the proposed randomized controlled trial (RCT) is that poor access to primary care and poor DM self-care lead to high ED use in AAs with DM. A culturally relevant intervention that mitigates these factors may reduce the need for ED use in this high risk population. This RCT will compare the efficacy of COPDE (COmmunity Care to Prevent Diabetes Emergencies) vs. Enhanced Usual Care (EUC) to reduce DM-related ED visits and/or hospitalizations over 12 months (primary outcome) in 230 AAs with DM, 50 years and older, after an ED visit. COPDE is a collaborative intervention of Primary Care Physicians, (PCPs), a DM nurse educator, and Community Health Workers (CHWs) that extends from the ED into the community. The CHWs will: 1) deliver in-home DM education to increase participants’ knowledge and skills to manage DM; 2) use DM-specific Behavioral Activation to reinforce DM self-care; and 3) facilitate telehealth visits with PCPs and a DM nurse educator to increase access to care. The control treatment, EUC, is usual medical care that is enhanced with DM self-care education. EUC matches COPDE in treatment intensity (i.e., number and duration of in-home visits) and delivery of DM self-care education, but does not include COPDE’s other active elements (i.e., Behavioral Activation and telehealth). The treatment comparison will identify COPDE’s specific efficacy over and above EUC. We hypothesize that COPDE will halve the rate of incident DM-related ED visits and/or hospitalizations relative to EUC. The three secondary outcomes are: 1) subjective perceptions of access to care; 2) receipt of DM Quality Metrics (i.e., objective indicators of realized access to care); and 3) DM self-care. A mediation analysis will determine if changes in one or more of these variables explain COPDE’s efficacy. Exploratory Aims will: 1) determine if COPDE reduces “all cause” ED visits/hospitalizations; 2) determine if Community Need Index scores (which reflect the extent of economic and structural barriers to care), literacy, age, and/or sex moderate treatment effects; 3) determine if COPDE improves glycemic control, impacts DM- related health beliefs, reduces depression, and/or improves quality-of-life; 4) identify COPDE treatment features that confer cultural relevance; and 5) estimate COPDE’s costs and net financial benefits. This RCT is significant because rates of ED use among AAs with DM are rapidly rising, and new ways to treat this high risk population are needed. This RCT is innovative because: 1) it tests the first ED-to-community intervention designed to reduce the need for ED use in AAs with DM, and 2) it determines if participants who reside in high- need as well as low-need communities equally benefit. If successful, COPDE will meet Healthy People 2020’s twin goals of reducing the personal and societal costs of DM and achieve health equity for all Americans.

患有糖尿病（DM）的非裔美国人（AA）寻求急诊（艾德）护理的频率是白人的两倍。 大约40%的患有DM的AA每年都有艾德就诊，24%的人将艾德作为他们通常的护理场所（与 13%的白人）。艾德使用中的种族差异的原因是复杂的，但 拟议的随机对照试验（RCT）是，获得初级保健和糖尿病自我保健不良导致 高艾德使用AA与DM。减轻这些因素的文化相关干预可能会减少 需要在这一高危人群中使用艾德。本RCT将比较COPDE（社区护理） 预防糖尿病紧急情况）与减少DM相关艾德就诊的增强型糖尿病护理（EUC）和/或 230名50岁及以上患有DM的AA患者在艾德就诊后住院12个月以上（主要结局）。 COPDE是初级保健医生（PCP）、DM护士教育者和 从艾德延伸到社区的社区卫生工作者。CHW将：1）提供 家庭糖尿病教育，以提高参与者管理糖尿病的知识和技能; 2）使用糖尿病专用 行为激活，以加强糖尿病自我护理;和3）促进与PCP和糖尿病护士的远程健康访问 教育工作者增加获得护理的机会。对照治疗EUC是常规的医疗护理， DM自我护理教育EUC在治疗强度上与COPDE匹配（即，在家的次数和时间 访问）和DM自我护理教育的交付，但不包括COPDE的其他积极因素（即， 行为激活和远程保健）。治疗比较将确定COPDE的具体疗效， 及以上EUC。我们假设COPDE将使DM相关艾德就诊率减半，和/或 相对于EUC的住院治疗。三个次要结果是：1）获得的主观看法， 护理; 2）收到DM质量保证金（即，实现获得护理的客观指标）;和3）DM自我护理。 中介分析将确定这些变量中的一个或多个变量的变化是否可以解释COPDE的有效性。 探索性目的将：1）确定COPDE是否减少“全因”艾德访视/住院; 2）确定是否 社区需求指数得分（反映了护理的经济和结构性障碍的程度），识字率， 年龄和/或性别中度治疗效果; 3）确定COPDE是否改善血糖控制，影响DM- 相关的健康信念，减少抑郁症，和/或改善生活质量; 4）确定COPDE治疗 赋予文化相关性的功能;和5）估计COPDE的成本和净财务收益。该RCT是 重要的是，糖尿病AA患者中艾德的使用率正在迅速上升，治疗这种高风险的新方法 人口需要。这项随机对照试验是创新的，因为：1）它测试了第一个ED到社区干预 旨在减少患有DM的AA患者使用艾德的需求，2）确定居住在高- 需要和低需要的社区同样受益。如果成功，COPDE将满足2020年的健康人 降低糖尿病的个人和社会成本，实现所有美国人的健康公平。