ACCTiVATE: Achieving Chronic Care equiTy by leVeraging the Telehealth Ecosystem

项目总结/摘要 高血压、糖尿病和慢性肾病等慢性疾病造成大量死亡， 严重的不平等影响到种族和族裔少数群体。2019冠状病毒病疫情促使 慢性病管理迅速转向远程保健护理，包括患者门户、远程医疗 视频访问和远程患者监控。然而，有大量的种族/民族和社会经济因素， 美国慢性病管理的卫生信息技术接入差距。这是由于患者水平 设备和互联网接入不公平、数字素养较低以及诊所层面的障碍 例如，对获取数字技术和技能的支持不足，卫生信息技术的提供不公平， 缺乏注重公平的分层远程保健数据。少数群体中远程保健的使用日益增加， 减少慢性病健康结果差异的潜力。 我们提出了一项2x2随机对照试验，题为“通过杠杆老化实现慢性护理平等”， 远程保健生态系统”（ACCTiVATE），我们将研究多层次干预的影响， 解决患者和诊所层面的障碍，以增加慢性病卫生信息技术的公平使用 管理患者层面的干预结合了数字健康导航员和慢性病的作用 健康教练，以促进获得设备和宽带，提供数字技能培训，并提供长期 疾病保健辅导侧重于远程保健方式。临床层面的干预包括实践 通过学习协作、诊所特定社区咨询委员会和电子“远程医疗”提供便利 公平仪表板”显示按种族/族裔分层的远程保健利用情况。 我们将随机抽取600名讲英语和西班牙语的高血压未得到控制的成年人， 联邦合格的健康中心，以数字教练与常规护理。10个健康中心将 随机分为练习引导组和常规护理组。在目标1中，我们将评估多层次 收缩压的干预（指导结合练习促进，单独使用每只手臂） （主要结局），血红蛋白A1 c和微量白蛋白尿，以及黑人和拉丁裔患者。在 目标2，我们将评估对远程医疗疾病管理过程措施的影响（数字素养， 药物依从性，与健康IT的接触）。在目标3中，我们将进行混合方法评估， 通过应用RE-AIM框架来识别成功采用所需的关键功能， 通过保健网络传播。一个多学科的利益攸关方咨询委员会将就所有目标提供咨询意见。 拟议的干预措施认识到使数字鸿沟长期存在的多层次决定因素， 大流行期间慢性病护理恶化。这种干预的影响将导致一个有效的， 以用户为中心的多层次干预，以改善远程医疗参与、药物依从性和数字化 扫盲，这些都是改善慢性病结果的关键驱动因素。

PROJECT SUMMARY/ABSTRACT Chronic diseases such as hypertension, diabetes and chronic kidney disease cause significant mortality, with stark inequities impacting racially and ethnically minoritized populations. The COVID-19 pandemic prompted a rapid shift in chronic disease management to telehealth-based care, including patient portals, telemedicine video visits, and remote patient monitoring. However, there are substantial racial/ethnic and socioeconomic disparities in health IT access for chronic disease management in the United States. This is due to patient-level barriers such as inequitable device and internet access and lower digital literacy, as well as clinic-level barriers such as inadequate support to access digital technologies and skills, inequitable offering of health IT, and a lack of equity-focused, stratified telehealth data. Increasing telehealth use among minority populations has the potential to lessen disparities in chronic disease health outcomes. We propose a 2x2 randomized controlled trial entitled “Achieving Chronic Care equiTy by leVerAging the Telehealth Ecosystem” (ACCTiVATE), in which we will examine the impact of a multi-level intervention that tackles patient-level and clinic-level barriers to increase the equitable use of health IT for chronic disease management. The patient-level intervention combines the role of digital health navigator and chronic disease health coach to facilitate access to devices and broadband, offer digital skills training, and provide chronic disease health coaching focused on telehealth modalities. The clinic-level intervention includes Practice Facilitation with a learning collaborative, clinic-specific Community Advisory Boards, and electronic “Telehealth Equity Dashboards” that display telehealth utilization stratified by race/ethnicity. We will randomize 600 English- and Spanish-speaking adults with uncontrolled hypertension across 10 federally qualified health centers to digital coaching versus usual care. The 10 health centers will be randomized to Practice Facilitation versus usual care. In Aim 1, we will assess the impact of the multi-level intervention (coaching combined with practice facilitation, and each arm alone) on systolic blood pressure (primary outcome), hemoglobin A1c, and microalbuminuria overall, and among Black and Latinx patients. In Aim 2, we will assess impacts on process measures of telehealth disease management (digital literacy, medication adherence, engagement with health IT). In Aim 3, we will conduct a mixed methods evaluation of implementation by applying the RE-AIM framework to identify key features needed for successful adoption and dissemination by healthcare networks. A multidisciplinary Stakeholder Advisory Board will advise on all Aims. The proposed intervention recognizes the multilevel determinants that have perpetuated the digital divide, worsening chronic disease care during the pandemic. The impact of this intervention will result in an efficient, user-centered multilevel intervention for improved telehealth engagement, medication adherence, and digital literacy, which are all key drivers of improved chronic disease outcomes.