Social virtual reality and diabetes management: Extending the clinical encounter

描述（由申请人提供）：在美国有超过2400万人受糖尿病影响。这些人中的大多数由初级保健提供者（PCP）而不是专家照顾。我们对理想的患者和供应商糖尿病管理实践的理解和阐述有了显着的改善。然而，由于提供者和患者面临的环境和心理障碍，这些最佳的糖尿病护理行为在真实的世界临床经验中通常无法实现。最佳提供者实践和最佳患者自我管理和方案依从性的一个重要障碍是“面对面时间”-患者和提供者参与任何给定临床遭遇的时间量。典型的初级保健患者-提供者互动（PPI）的持续时间短，加上其相对不频繁和不稳定的时间安排，对实现理想的糖尿病管理实践构成了相当大的障碍。特别是，对PCP施加的极端时间压力和普遍缺乏支持结构，通常导致糖尿病PPI的重点从重要但时间密集的自我管理要素（如生活方式改变和行为改变支持）转向更狭隘的强调“固定数字”，可能因此，绝大多数患者没有得到目标治疗。此外，不频繁的糖尿病PPI等同于收集患者结局数据点的机会较少：提供者收到的关于其患者状态的数据较少且频率较低，因此，对健康状态进展的了解较少，并且更不能够修改方案以实现最佳管理。对于患者而言，与医疗保健系统的不频繁和不稳定的接触可能导致次优的糖尿病自我管理，这是由于关于他们的药物方案的反馈和加强的机会相对不一致，以及他们的生活方式改变和行为改变努力。理想情况下，这种情况可以通过为PCP提供更多的糖尿病PPI时间来补救;但是，由于各种社会技术原因，在美国医疗保健系统的结构和压力下，这种情况不太可能发生。因此，必须探索在不增加提供者和患者负担的情况下实现更佳结果的其他方法。增加PPI的频率和持续时间的一种创新方法是使用基于网络的交互式技术（包括社交虚拟现实环境（SVRE））来延长这种“面对面时间”。通过SVRE，可以在面对面PPI之前、之后和之间进行理想的患者和提供者糖尿病管理实践的各个方面，这些方面要么被省略，要么以次优频率发生。这种临床接触的扩展将代表常规护理的有价值的增强，增加患者结局跟踪、反馈和强化的机会，从而潜在地改善依从性，减少管理不善和后遗症，并改善患者结局和生活质量。利用AEI的媒体，教育和性能支持的经验与广泛的行为改变和PCP支持的努力和IUSOM的糖尿病转化研究中心的专业知识在糖尿病护理，获得糖尿病PCP供应商和患者，和众所周知的电子记录系统，拟议的努力将检查使用SVRE的影响，以增加日常护理。这项工作将通过建立以用户为中心的迭代开发方法，精心创建PCP糖尿病护理SVRE，从而将理想的PCP糖尿病管理护理转化为SVRE。将在一项对照、混合方法、多变量、重复测量的现场试验中检查所得SVRE的可接受性、效用和影响，并在IUSOM医疗保健系统内的糖尿病患者和提供者中进行随访。最佳提供者实践和最佳糖尿病管理的一个重要障碍是“面对面时间”-患者和提供者参与任何给定临床接触的时间量。增加PPI的频率和持续时间的一种可能方法是使用基于网络的交互式技术（包括社交虚拟现实环境（SVRE））来延长这种“面对面时间”。这种临床接触的扩展将代表常规护理的有价值的增强，增加患者结局跟踪、反馈和强化的机会，从而潜在地改善依从性，减少管理不善和后遗症，并改善患者结局和生活质量。关于SVRE在糖尿病患者中的可接受性和影响知之甚少，关于患者与实时和模拟提供者化身交互的效用更是知之甚少。通过开发PCP糖尿病护理SVRE，检查患者对环境的满意度，并将SVRE增强的常规护理中的患者结局与常规护理中的患者结局进行比较，所提出的努力将填补我们理解中的这一空白，提供与该竞技场中的最佳实践相关的可推广的发现，并可能导致用于改善糖尿病患者护理、结局和生活质量的可推广工具。

DESCRIPTION (provided by applicant): There are over 24 million individuals affected by diabetes in the United States. The majority of these individuals are cared for by primary care providers (PCPs) rather than specialists. There has been significant improvement in our understanding and articulation of ideal patient and provider diabetes management practices. However, these optimal diabetes care behaviors are often not achieved in real world clinical experiences as a result of environmental and psychosocial barriers faced by providers and by patients. A significant barrier both to optimal provider practice and to optimal patient self-management and regimen adherence is "face time"-the amount of time available to the patient and provider to engage in any given clinical encounter. The short duration of typical primary care patient-provider interactions (PPIs), coupled with their relatively infrequency and erratic scheduling, presents a considerable barrier to achieving ideal diabetes management practices. In particular, extreme time pressures placed upon PCP and the common lack of support structures, often cause the focus of the diabetic PPI to shift away from important but time-intensive elements of self- management, such as lifestyle change and behavioral modification support, toward a more narrow emphasis on "fixing the numbers," with, perhaps as a result, the vast majority of patients not being treated to target. Additionally, infrequent diabetic PPIs equate to fewer opportunities to gather patient outcomes data points: providers receive less, and less frequent, data regarding their patients status and, as a result, are both less informed regarding health status progression and less able to modify the regimen for optimal management. For patients, infrequent and erratic contact with the health care system may lead to suboptimal diabetes self- management as a result of relatively inconsistent opportunities for feedback regarding and reinforcement of their medication regimen, and their lifestyle change and behavioral modification efforts. Ideally, this situation would be remedied by providing PCPs with more time for diabetic PPIs; however, for a variety of sociotechnical reasons this is unlikely to occur within the structure and pressures of the US healthcare system. Therefore, other approaches to achieving more optimal outcomes, without increasing provider and patient burden, must be explored. One innovative approach to increasing the frequency and duration of the PPI is to extend such "face time" with web-based, interactive technologies, including social virtual reality environments (SVRE). Through SVRE, aspects of ideal patient and provider diabetes management practices which are either omitted or which occur with suboptimal frequency can be conducted virtually before, after, and between face-to-face PPI. Such an extension of the clinical encounter would represent a valuable augmentation of usual care, increasing opportunities for patient outcome tracking, feedback, and reinforcement, and thereby potentially improving adherence, reducing mismanagement and sequalae, and improving patient outcomes and quality of life. Drawing on AEI's media, educational and performance support experience with a wide range of behavioral change and PCP support efforts and IUSOM's Diabetes Translational Research Center's expertise in diabetes care, access to diabetes PCP providers and patients, and well-known electronic records systems, the proposed effort will examine the impact of using SVRE to augment usual care. The effort will translate aspects of ideal PCP diabetes management care to a SVRE by carefully creating a PCP diabetes care SVRE through an established iterative user-centered development methodology. The acceptability, utility, and impact of the resulting SVRE will be examined in a controlled, mixed methods, multivariate, repeated measures field trial with follow-up conducted among diabetes patients and providers within the IUSOM medical care system. A significant barrier both to optimal provider practice and to optimal diabetes management is "face time"- the amount of time available to the patient and provider to engage in any given clinical encounter. One possible approach to increasing the frequency and duration of the PPI is to extend such "face time" with web-based, interactive technologies, including social virtual reality environments (SVRE). Such an extension of the clinical encounter would represent a valuable augmentation of usual care, increasing opportunities for patient outcome tracking, feedback, and reinforcement, and thereby potentially improving adherence, reducing mismanagement and sequalae, and improving patient outcomes and quality of life. Very little is known regarding the acceptability and impact of SVRE among diabetes patients and even less regarding the utility of patients interacting with live and simulated provider avatars. By developing a PCP diabetes care SVRE, examining patient satisfaction with the environment, and comparing patient outcomes of those in SVRE- augmented usual care with those in usual care, the proposed effort will fill this gap in our understanding, provide generalizable findings related to best practices in this arena, and potentially lead to a disseminable tool for improving diabetes patient care, outcomes and quality of life.