A Shared Decision Making Intervention for Diabetes Prevention in Women with a History of Gestational Diabetes Mellitus.

项目摘要/摘要 有妊娠期糖尿病(GDM)病史的女性患2型糖尿病的风险很高 (T2 DM)。糖尿病预防项目的证据表明，生活方式的改变和二甲双胍的使用 这些人群在临床上是相同的，每个人将T2 DM的发病率降低约50% 有GDM病史的女性。这些女性面临着一个对偏好敏感的决定，在基于证据的 另类选择。在这种情况下，共享决策制定(SDM)是一种有吸引力的方法，它使用决策辅助来 明确决策，均衡描述可用选项，引出患者偏好，并提供帮助 患者会在知情的情况下做出适合自己的决定。据我们所知，目前还没有研究 评价SDM在有妊娠期糖尿病病史的妇女中预防糖尿病的作用。 我们的团队在以团队为基础的糖尿病预防SDM方法方面拥有丰富的经验，我们之前的 研究表明，这种方法会增加对循证糖尿病预防策略的接受 (生活方式改变，二甲双胍或两者兼而有之)，以及在更广泛的12个月随访中持续减肥 有糖尿病前期的人群。我们还在33名患有妊娠期糖尿病的妇女中完成了SDM的初步测试 历史，证明了可行性和可接受性。在这项提案中，我们的目标是评估SDM对糖尿病的疗效 在两个卫生系统(加州大学洛杉矶分校和加州大学洛杉矶分校)内预防有妊娠期糖尿病和糖尿病前期病史的妇女 山间)。药剂师将在加州大学洛杉矶分校实施干预措施，临床护理经理将实施 在InterMountain的干预行动。我们的具体目标如下：测试RCT的有效性 对有糖尿病病史的超重/肥胖女性进行SDM预防糖尿病1)体重减轻的评估 妊娠期糖尿病和血红蛋白A1c在5.7-6.4%之间，2)改变生活方式和/或使用二甲双胍，患者- 报告结果(体力活动、饮食模式、患者活力、与健康相关的生活质量)，年度 进展为T2 DM的随访筛查，以及再次怀孕时GDM的发生率(探索性 结果)，以及3)评估每名有以下历史的妇女执行方案的增量成本 GDM和Hb A1c在5.7-6.4%之间，成功启动生活方式改变和/或二甲双胍。我们的 应用程序提供了一个独特的机会来实施严格的项目，以解决尚未满足的关键领域 有妊娠期糖尿病病史的妇女在预防糖尿病方面的需求，利用我们的卫生系统基础设施和 我们的协作、多学科团队在糖尿病预防方面取得了很好的成绩。这 工作将提供务实、有效和可持续的方法来增加循证糖尿病 为有妊娠期糖尿病病史的妇女制定可在其他卫生系统中轻易采用的预防战略。

PROJECT SUMMARY/ABSTRACT Women with a history of gestational diabetes mellitus (GDM) are at high risk of developing type 2 diabetes (T2DM). Evidence from the Diabetes Prevention Program indicates that lifestyle change and metformin use in this population are clinically equivalent, each reducing the incidence of T2DM by approximately 50% among women with a GDM history. These women face a preference-sensitive decision between the evidence-based alternatives. Shared decision making (SDM) is an attractive approach in this situation, using a decision aid to make the decision explicit, describe the available options with equipoise, elicit patient preferences, and help patients make an informed decision that is right for them. To our knowledge, there are no existing studies evaluating SDM for diabetes prevention among women with a history of GDM. Our team has extensive experience with a team-based SDM approach for diabetes prevention, and our prior work showed that this approach leads to increased uptake of an evidence-based diabetes prevention strategy (lifestyle change, metformin or both) as well as sustained weight loss at 12-month follow-up in a broader population with prediabetes. We have also completed a pilot test of SDM among 33 women with a GDM history, demonstrating feasibility and acceptability. In this proposal, we aim to evaluate SDM for diabetes prevention among women with a history of GDM and prediabetes within two health systems (UCLA and Intermountain). Pharmacists will implement the intervention at UCLA, and clinic care managers will implement the intervention at Intermountain. Our Specific Aims are as follows: To test the effectiveness of an RCT evaluating SDM for diabetes prevention on 1) weight loss among overweight/obese women with a history of GDM and hemoglobin A1c between 5.7-6.4%, 2) uptake of lifestyle change and/or metformin use, patient- reported outcomes (physical activity, eating patterns, patient activation, health-related quality of life), annual follow-up screening for progression to T2DM, and rates of GDM in a subsequent pregnancy (exploratory outcome), and 3) to evaluate the incremental cost of program implementation per woman with a history of GDM and hemoglobin A1c between 5.7-6.4% who successfully initiates lifestyle change and/or metformin. Our application presents a unique opportunity to implement a rigorous project addressing a critical area of unmet need in diabetes prevention for women with history of GDM, leveraging our health system infrastructure and our collaborative, multidisciplinary team with a strong record of accomplishment in diabetes prevention. This work will provide pragmatic, effective and sustainable approaches to increase evidence-based diabetes prevention strategies for women with a history of GDM that can be readily adopted in other health systems.