A multi-level intervention to increase access and use of patient portals for diabetes management in community health centers (MAP)

摘要 在美国，2型糖尿病的患病率、发病率和死亡率存在显著的卫生保健差异 2型糖尿病（T2 D）在种族和少数民族人群。增加患者门户的使用，例如访问医疗 记录和与提供者的安全消息传递有可能改善与护理和糖尿病的接触 健康成果。然而，不同种族/民族的成年人在门户网站的使用方面存在很大差异 而且社会经济资源有限。美国有1,400多个社区卫生中心（CHC）， 为服务不足社区的不同种族和民族的成年人提供全面的医疗保健， 在解决T2 D护理中的健康不平等方面发挥关键作用。我们建议发展多层次的干预措施， 增加社区卫生中心糖尿病管理患者门户网站（MAP）的访问和使用 与世界卫生组织（世卫组织）健康公平的社会决定因素框架保持一致。的 干预措施将：1）免费提供平板电脑和互联网（物质环境）; 2）技术培训 （3）评估健康的社会决定因素，并向社区 资源（物质环境）;和，4）支持糖尿病自我管理行为和参考诊所 服务（行为和生物因素）。MAP将由社区卫生工作者（CHW）提供， 护士已经嵌入CHCs（医疗保健系统）。本研究的目的是：1）优化的组成部分， 通过开展焦点小组/访谈，对在CHCs接受医疗保健的T2 D成人进行MAP干预 使用已建立的定性方法，与来自两个CHC的T2 D成人和卫生保健提供者（n=24）进行比较; 和2）确定在两个CHC（n=36）的T2 D成人患者中使用MAP对主要结局的效应量 门静脉使用和A1 C的次要结局：a）患者参与护理，T2 D自我管理，以及 心理社会结果。使用受试者内、前后设计，我们将在以下T2 D成人患者中试用MAP： 门户幼稚。我们将使用广义线性混合模型（GLMM），将重复之间的相关性 测量（基线、3个月和6个月）以分析数据。我们将评估门户网站的使用因素， 在结果上有所改善。我们将严格评估MAP的可行性（可接受性，需求， 实施、调整和整合）。最后，我们将 探索成人T2 D患者在互联网上使用公开的糖尿病和健康资源， 提供平板电脑和互联网接入。这项研究的结果将对潜在的 在CHC中提供一种新型多水平干预，以改善患者门户网站的使用、糖尿病自我管理，以及 不同种族/民族的社会经济资源有限的成人血糖控制。

Abstract In the US, there are significant health care disparities in the prevalence, morbidity, and mortality of type 2 diabetes (T2D) in racial and ethnic minority populations. Increased patient portal use, such as accessing medical records and secure messaging with providers has the potential to improve engagement with care and diabetes health outcomes. Yet, there are substantial disparities in portal use by adults who are of diverse race/ethnicity and with limited socioeconomic resources. Over 1,400 community health centers (CHCs) in the US provide comprehensive health care to adults of diverse races and ethnicities in underserved communities and play a critical role in addressing health inequities in T2D care. We propose to develop a multi-level intervention to increase access and use of patient portals for diabetes management (MAP) in community health centers (CHC) aligned with the World Health Organization (WHO) Social Determinants of Health Equity framework. The intervention will: 1) provide free access to tablets and internet (material circumstances); 2) technology training and ongoing support (psychosocial factors); 3) assess social determinants of health and refer to community resources (material circumstances); and, 4) support diabetes self-management behaviors and refer to clinic services (behavioral and biological factors). MAP will be delivered by community health workers (CHW) and nurses already embedded in CHCs (healthcare system). The study aims are to: 1) Optimize components of the MAP intervention for adults with T2D who access healthcare at CHCs by conducting focus groups/interviews with adults with T2D and health care providers (n=24) from two CHCs using established qualitative methods; and 2) determine the effect size of MAP use for adults with T2D at two CHCs (n=36) on the primary outcomes of portal use and A1C and secondary outcomes of: a) patient engagement with care, T2D self-management, and psychosocial outcomes. Using a within subjects, pre-post design we will pilot MAP in adults with T2D who are portal naive. We will use generalized linear mixed model (GLMM), incorporating correlations among repeated measures (baseline, 3 months, and 6 months) to analyze data. We will evaluate portal use factors associated with improvement in outcomes. We will rigorously evaluate the feasibility of MAP (acceptability, demand, implementation, adaptation, and integration) using an established framework and mixed methods. Lastly, we will explore the use of publicly available diabetes and health resources on the internet by adults with T2D when provided access to a tablet and internet. Results of this study will have important implications on the potential of a novel multi-level intervention provided in CHCs to improve patient portal use, diabetes self-management, and glycemic control in adults of diverse race/ethnicity with limited socioeconomic resources.