Learnings in Diabetes Prevention from an Integrated Delivery System

项目摘要/摘要Kaiser Permanente Northern California （KPNC）及其研究部（DOR）提出了一套KPNC系统级努力的三个评估，以预防高危成员的糖尿病发展。这些研究中的一个或多个将非常适合与该研究网络中其他系统的类似干预措施的数据汇集。申请人研究团队在与KPNC临床和业务领导者合作评估糖尿病护理的自然实验方面经验丰富，包括最近作为CDC/ niddk赞助的TRIAD研究的一部分进行的评估。我们相信这是一个检验对糖尿病患者有效的人群治疗方法是否适用于支持高风险糖尿病前期患者改变生活方式和预防糖尿病进展的好时机。主要评估是KP -雇主伙伴关系，该伙伴关系调整了其工作场所健康计划，使用电子健康记录（EHR）数据对所有员工进行风险分层，并使用密集的推广、激励和指导（网络、电话或面对面）来支持高危员工改变生活方式。干预和控制雇主地点的选择将与加州公务员退休基金协商，这是一个代表多家雇主的大型福利管理组织。我们希望在每个站点确定大约750名高风险员工。将使用电子病历和患者调查（在基线和12个月时通过邮件、电话或互联网）来评估影响，以测量体重指数（BMI）、身体活动、血压和脂质水平的变化。第一项辅助研究评估了2010年1月建立的电话健康指导项目。它旨在成为指导支持组合的一部分，该组合还包括在线和面对面的服务。它由KPNC的区域卫生教育部门（RHE）运营，全面实施后，每年将针对多达10 000名高危人群。我们将与RHE合作，根据电子病历或健康风险评估数据，或两者结合，评估项目对高风险成员的影响。基线和12个月的调查将再次测量BMI、体力活动、血压和血脂的变化。我们还将评估改变的准备程度，对教练类型的偏好，以及这些偏好的相关性。第二项辅助研究检查了2006年实施的一项区域性项目，该项目旨在确保所有妊娠期糖尿病（GDM）妇女使用75克口服葡萄糖耐量试验进行产后糖尿病筛查。该项目向那些在测试中被证明患有糖尿病前期的人提供服务。该项目将通过检查2001- 2005年与2006-2010年所有GDM妇女队列中人群发病率（产后5年以上）的变化来评估（每个队列中n=12,000）。发病率将分为较轻（通常筛查检测到）和较严重（糖化血红蛋白达到8%或需要两种药物治疗）。我们假设，该计划将导致更严重的糖尿病患者减少，但轻度糖尿病患者增加。我们还列出了一些我们能够评估的糖尿病护理的自然实验。

DESCRIPTION (provided by applicant): Project Summary / Abstract Kaiser Permanente Northern California (KPNC) and its Division of Research (DOR) propose a set of three evaluations of KPNC system-level efforts to prevent development of diabetes in high-risk members. One or more of these studies would be well-suited for pooling with data from other systems in this research network on similar interventions. The applicant research team is highly experienced in working with KPNC clinical and operational leaders to evaluate natural experiments in diabetes care, including recent evaluations as part of the CDC/NIDDK-sponsored TRIAD study. We believe this is an is an opportune moment to examine whether the population approaches that have been effective for patients with diabetes can be adapted to support high-risk pre-diabetic patients to modify lifestyles and prevent progression to diabetes. The primary evaluation is of a KP - employer partnership that has adapted its worksite wellness program to risk stratify all employees using electronic health record (EHR) data and to use intensive outreach, incentives, and coaching (web, telephone, or in-person) to support lifestyle change in high-risk employees. Intervention and control employer sites will be selected in consultation with CalPERS, a large benefits management group representing multiple employers. We expect to identify approximately 750 high-risk employees at each site. Impact will be assessed using both EHR and patient surveys (via mail, phone, or internet at baseline and 12 months) to measure changes in body mass index (BMI), physical activity, blood pressure and lipid levels. The first ancillary study evaluates a telephonic wellness coaching program established in January 2010. It is intended to be part of a portfolio of coaching support that also includes online and in-person services. It is operated by KPNC's Regional Health Education Department (RHE), and will target as many as 10,000 high risk persons per year when fully implemented. We will work with RHE to evaluate program impact among high risk members identified either from EHR or health risk appraisal data, or from a combination. Surveys at baseline and 12 months will again measure changes in BMI, physical activity, blood pressure and lipids. We will also assess readiness to change, preferences for type of coaching, and correlates of these preferences. A second ancillary study examines a regionwide program implemented in 2006 that aims to ensure postpartum screening for diabetes, using a 75-gram oral glucose tolerance test, in all women with gestational diabetes mellitus (GDM). The program conducts outreach to those who prove to have pre-diabetes at testing. The program will be evaluated by examining changes in population incidence (over 5 years postpartum) in cohorts of all women with GDM from 2001-05 vs 2006-2010 (n=12,000 in each cohort). Incidence will be divided into less severe (often screen-detected) and more severe (with A1c >8% or requiring two medications). We hypothesize that the program will lead to decreases in more severe diabetes but to increases in milder disease. We also list a number of natural experiments in diabetes care that we would be able to evaluate.