Internet Intervention For Improving Rural Diabetes Care

描述(由申请人提供)： 背景资料。阿拉巴马州的糖尿病患病率已经上升到10.5%，是所有州中发病率最高的州之一。我们提出了一项为期4年的基于互联网的干预措施的随机试验，以改善阿拉巴马州乡村医生对成年2型糖尿病患者的指南遵从性。阿拉巴马州的农村有许多弱势群体和少数族裔患者，他们获得的医疗保健机会有限。与城市患者相比，阿拉巴马州农村的糖尿病患者接受的护理质量较差，结果也更差。 目标。(1)评估实施糖尿病指南的障碍，并通过焦点小组和基于病例的小插曲调查确定解决方案；(2)开发和实施交互式互联网干预措施，包括个性化的医生表现反馈；(3)在随机对照试验中评估干预措施；以及(4)在反馈停止后检查改善指南遵守情况的可持续性。 方法：研究方法。我们将与阿拉巴马大学乡村医学项目合作，将200个乡村医生办公室随机分配到一个干预或比较小组。我们为期18个月的干预是为个别医生实时定制的，包括基于案例的教育、绩效反馈和基准的互联网学习模块。比较组将收到以文本为基础、非互动的公开可用资源的互联网公告。来自学习医生办公室的执业护士和医生助理也可以参加互联网模块。结果将基于以前开发和验证的糖尿病质量衡量标准。干预措施将包括筛查、诊断、治疗和预防。绩效反馈将包括每个干预医生的15个图表。主要的分析是在医生层面进行的，将比较研究部门之间在指南遵从性方面的差异改善。辅助分析将检查医生特征、办公室其他提供者和患者特征(例如，共病、种族、性别、年龄和社会经济地位)的影响。多变量技术将根据重复测量、医生内部的患者聚集以及单个办公室内的多个提供者进行调整。 意义重大。这项研究提供了一种技术先进的、以理论为基础的干预措施，以改善对高危、服务不足人群的护理。我们的多学科团队在将研究转化为实践、农村医学、行为医学、健康信息学和临床糖尿病方面拥有专业知识，具有良好的合作记录。该项目将产生一种以证据为基础的、可复制的干预措施，它可以在“真实世界”中持续存在，并且很容易针对其他疾病进行修改。在进行了第二次审查中建议的重要修改后，该项目有了很大改进。

DESCRIPTION (provided by applicant): Background. The prevalence of diabetes in Alabama has increased to 10.5 %, one of the highest among all states. We propose a 4-year randomized trial of an Internet-based intervention for improving guideline adherence by rural Alabama physicians caring for adult patients with type 2 diabetes. Rural Alabama has many disadvantaged and minority patients with limited health care access. Patients with diabetes in rural Alabama receive poorer quality of care and have worse outcomes compared to urban patients. Objectives. (1) Assess barriers to implementation of diabetes guidelines and identify solutions through focus groups and case-based vignette surveys; (2) Develop and implement an interactive Internet intervention including individualized physician performance feedback; (3) Evaluate the intervention in a randomized controlled trial; and (4) Examine the sustainability of improved guideline adherence once feedback ceases. Methods. In partnership with the University of Alabama rural medicine program, we will randomize 200 rural physician offices to an intervention or comparison arm. Our 18-month intervention, customized to the individual physician in real-time, consists of Internet learning modules with case-based education, performance feedback, and benchmarks. The comparison group will receive a text-based, non-interactive Internet posting of publicly available resources. Nurse practitioners and physician assistants from the offices of study physicians may also participate in the Internet modules. Outcomes will be based on previously developed and validated quality measures for diabetes. The intervention will cover screening, diagnosis, treatment, and prevention. Performance feedback will include 15 charts per intervention physician. The main analysis, conducted at the physician level, will compare differential improvement in guideline adherence between the study arms. Ancillary analyses will examine the effects of physician characteristics, other providers in the office, and patient characteristics (e.g., comorbidities, ethnicity, gender, age, and socioeconomic status). Multivariable techniques will adjust for repeated measures, clustering of patients within physicians, and multiple providers within a single office. Significance. This study offers a technologically advanced, theory-grounded intervention for improving care of a high-risk, underserved population. With expertise in translating research into practice, rural medicine, behavioral medicine, health informatics, and clinical diabetes, our multidisciplinary team has a proven record of collaboration. This project will produce an evidence-based and replicable intervention that can be sustained in the "real world," and easily modified for other diseases. This project is substantially improved after making important changes recommended in the second review.