Using CERs to Optimize Quality of Life for Persons with Diabetes and Chronic Pain

描述(由申请人提供)：比较有效性研究结果，例如AHRQ的比较有效性审查(CER)，应该惠及所有美国人，甚至是难以接触到的弱势群体。我们建议在阿拉巴马州黑带进行一项研究，其中包括主要是非洲裔美国人(AA)，他们中有三分之一生活在联邦贫困线以下，在接受医疗服务方面面临距离、成本和不信任障碍。我们的目标是需要提高质量的一个非常常见的临床问题：慢性疼痛、骨关节炎(OA)和糖尿病(DM)患者。虽然药物管理，包括CER内容，是OA和DM治疗的支柱，但基于认知-行为治疗(CBT)原则的生物心理社会方法可以改善功能，减少对药物的依赖，这对DM患者有风险。我们将在测试社区卫生工作者(CHW)提供的改善功能状态和DM代谢参数的计划的有效性的过程中，检查五个CER在临床决策中的实施情况。为了验证干预组患者将比对照组患者有更好的结果的假设，我们的目标是：1：调整五个关于OA和DM的CER，以提高在决策中的使用和价值，使用形成性评估来评估需求。我们将与(1)初级保健提供者合作，将适应的材料纳入最先进的互动、多模式继续医学教育计划；(2)与黑带居民合作，开发与文化相关的患者教育材料，并将其纳入CHW提供的DM-疼痛干预，旨在基于CBT原则赋予患者权力和激活患者。2：在一组随机试验中测试CHW提供的为期16周的干预措施，该试验包括400名慢性疼痛、骨关节炎和糖尿病患者。该试验将有80%的能力检测功能状态评分低至0.7，A1c和Gt；0.4%，收缩压4 mm Hg和低密度脂蛋白胆固醇6 mg/dl(主要结果)的差异。次要结果包括CER在临床决策、疼痛和自我护理行为中的应用。这两个部门的供应商都将在CER上获得CME。干预ARM患者将接受CHW赋权干预疼痛和DM自我护理，整合CER内容，而注意力控制ARM患者将接受不赋权的指导性健康教育计划。3：通过AHRQ和UAB CME部门向全国医生传播这项研究的CER产品，并通过UAB护理学院的在线课程向世界各地的护士传播。传播产品包括(1)关于CHW是否改善了难以接触到的弱势群体的CER实施情况的有力证据；(2)针对初级保健医生和护士的关于五个CER主题的在线继续医学教育；(3)在线CHW培训课程，以改善患有慢性疼痛、骨关节炎和糖尿病的个人的健康结果；(4)关于五个CER主题的针对南方农村AA社区的消费者信息材料。该试验利用了一项正在进行的研究的工具和基础设施，并将为有关CHW的政策决策提供信息。 公共卫生相关性：我们建议进行一项随机试验，以测试社区卫生工作者(CHW)的干预措施，以改善居住在阿拉巴马州农村和贫困黑带的脆弱、难以接触到的疼痛、糖尿病和骨关节炎患者的慢性疼痛和糖尿病。这项试验将测试CHW干预是否比仅仅提供教育的影响更大。在试验过程中，我们将研究如何调整五项比较有效性审查，以最大限度地影响临床决策，以改善健康结果。

DESCRIPTION (provided by applicant): Comparative effectiveness research results, such as AHRQ's Comparative Effectiveness Reviews (CER), should reach all Americans, even hard-to-reach vulnerable groups. We propose a study in the Alabama Black Belt, which includes mostly African Americans (AA), 1/3 living below the Federal poverty line and facing distance, cost and mistrust barriers to receiving healthcare services. We target a very common clinical problem in need of quality improvement: patients with chronic pain, osteoarthritis (OA) and diabetes (DM). While medication management, including CER content, is a mainstay of OA and DM therapy, biopsychosocial approaches based on cognitive-behavioral therapy (CBT) principles can improve functioning and reduce reliance on medications, which have risks for DM patients. We will examine the implementation of five CERs in clinical decision-making in the course of testing the effectiveness of a community health worker (CHW)- delivered program to improve functional status and DM metabolic parameters. To test the hypothesis that intervention group patients will have improved outcomes compared with controls, we aim to: 1: ADAPT Five CERs on OA and DM to enhance use and value in decision-making, using formative evaluation to assess needs. We will work iteratively with (1) primary care providers, to incorporate adapted materials into a state-of-the-art interactive, multimodal CME program; and (2) with Black Belt residents, to develop culturally relevant patient education materials, and incorporate them into a CHW-delivered DM-pain intervention designed to empower and activate patients, based on CBT principles. 2: TEST the CHW-delivered 16-week intervention in a group randomized trial including 400 patients with chronic pain, OA and DM. The trial will have 80% power to detect differences in functional status scores as low as 0.7, A1c >0.4%, systolic blood pressure >4 mmHg, and low density lipoprotein cholesterol >6 mg/dl (primary outcomes). Secondary outcomes include CER utilization in clinical decision-making, pain, and self- care behaviors. Providers in both arms will receive CME on the CERs. Intervention arm patients will receive the CHW empowerment intervention on pain and DM self-care with integrated CER content, and "attention" control arm patients will receive a didactic health education program without empowerment. 3: DISSEMINATE the CER products of the study through AHRQ and the UAB CME department to physicians nationally, and through the UAB School of Nursing's on-line curriculum to nurses worldwide. Dissemination products include (1) Robust evidence on whether CHWs improve CER implementation in a hard-to-reach vulnerable group; (2) On-line CME for primary care physicians and nurses on five CER topics; (3) On-line CHW training curriculum to improve health outcomes for individuals with chronic pain, OA and DM; (4) Consumer information materials tailored for southern rural AA communities on five CER topics. The trial leverages tools and infrastructure of an ongoing study and will inform policy decisions on CHWs. PUBLIC HEALTH RELEVANCE: We propose a randomized trial to test a Community Health Worker (CHW) intervention to improve chronic pain and diabetes for patients with pain, diabetes and osteoarthritis in vulnerable, hard-to-reach patients living in Alabama's rural and impoverished Black Belt. The trial will test whether the CHW intervention has greater impact than provider education alone. In the course of the trial, we will examine how five Comparative Effectiveness Reviews can be adapted to best impact clinical decision-making to improve health outcomes.