Reducing Emergency Diabetes Care for Older African Americans

患有糖尿病(DM)的非裔美国人(AA)寻求急诊科(ED)治疗的频率是白人的两倍。 约40%的患有糖尿病的AA每年都会去急诊室就诊，24%的人将急诊室作为他们通常的护理场所(与 13%的白人)。ED使用的种族差异的原因是复杂的，但科学的前提是 建议的随机对照试验(RCT)是获得初级保健的机会较少和糖尿病自我护理能力较差的主要原因 在伴有糖尿病的腹主动脉硬化患者中使用高ED。减轻这些因素的与文化相关的干预可能会减少 在这一高危人群中需要使用ED。这项RCT将比较COPDE(社区护理)的疗效 预防糖尿病突发事件)与加强日常护理(EUC)相比，减少糖尿病相关急诊和/或 在急诊科就诊后，230名50岁及以上糖尿病患者的住院时间超过12个月(主要结果)。 COPDE是初级保健医生(PCPS)、DM护士教育者和 从教育署延伸到社区的社区卫生工作者(CHW)。社区卫生服务将：1)提供 在家进行DM教育，以增加参与者管理DM的知识和技能；2)使用DM特定的 行为激活以加强糖尿病自我护理；以及3)促进与儿科医生和糖尿病护士的远程医疗访问 教育工作者增加获得护理的机会。对照治疗，EUC，是通常的医疗护理，通过 DM自我护理教育。EUC在治疗强度(即，在家治疗的次数和持续时间)方面与COPDE匹配 访问)和提供糖尿病自我护理教育，但不包括COPDE的其他积极因素(即， 行为激活和远程健康)。治疗比较将确定COPDE的特定疗效 以及在EUC之上。我们假设COPDE将使糖尿病相关急诊就诊和/或事件发生率减半 与EUC相关的住院率。三个次要结果是：1)对获得 2)DM质量指标(即已实现的护理机会的客观指标)的接收；以及3)DM自我护理。 中介分析将确定这些变量中的一个或多个的变化是否解释COPDE的有效性。 探索性目标将：1)确定COPDE是否减少“所有原因”急诊/住院；2)确定是否 社区需要指数得分(反映护理的经济和结构性障碍的程度)、识字、 年龄和/或性别适度的治疗效果；3)确定COPDE是否改善了血糖控制，影响了DM- 相关的健康信念，减少抑郁，和/或提高生活质量；4)确定COPDE治疗 具有文化相关性的特点；以及5)估计COPDE的成本和净财务收益。本RCT是 重要的是因为糖尿病患者的肾上腺皮质激素使用率正在迅速上升，治疗这一高风险的新方法 人口是需要的。这项随机对照试验的创新之处在于：1)它测试了第一个ED到社区干预 旨在减少糖尿病AAS患者使用ED的需要，以及2)它确定居住在高海拔地区的参与者 需求社区和低需求社区同样受益。如果成功，COPDE将在2020年前与健康人相遇--S 降低糖尿病的个人和社会成本和实现所有美国人的健康公平的双重目标。

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.