Technologically Enhanced Coaching(TEC):A Program for Improving Diabetes Outcomes

描述(由申请人提供)： 目的：提供者和患者在完成关于糖尿病治疗和自我管理任务的复杂决策所需的完整沟通方面面临障碍。提供者的时间往往有限，患者的资源也往往有限。在最近的两项退伍军人研究试验中发现，同伴指导模式在改善糖尿病高危退伍军人患者的血糖控制方面比常规护理、经济激励和护士护理管理更有效。虽然同行可以接受有效方法的培训，以支持其他退伍军人的自我管理行为，但此类教练必然缺乏糖尿病和糖尿病药物内容方面的专业知识，无法帮助退伍军人更好地与医疗保健提供者分享治疗决策和目标设定。因此，在最近的一项研究中，我们开发并测试了一种定制的、交互式的糖尿病和糖尿病药物信息工具，外展工作人员可以使用该工具来促进与患者的讨论。这些工具可以增强指导计划的可持续性和有效性，以更好地为患者设定自我管理目标、行动计划以及与提供者讨论治疗方案做好准备。由于这项干预措施解决了慢性病患者、医生和病例管理人员的疾病管理障碍，这项研究可能会对其他慢性病的管理实践产生更广泛的影响。项目方法：来自底特律退伍军人管理局的348名血糖控制较差的糖尿病患者(A1c和Gt；8.0%或A1c和Gt；如果年龄超过70岁，为8.5%)将从底特律退伍军人管理局招募，并随机接受有TEC或仅有Peer Support的Peer Support。所有参与者将被分配到87名同行教练中的一名，这些教练也是底特律退伍军人糖尿病患者，他们以前血糖控制不佳，但目前控制良好。每名同行教练将根据比赛和大约年龄被分配约4名参与者。同行教练将接受基于激励访谈的咨询方法的培训，以及如何使用iPad平台决策辅助工具的指导。在他们的基线评估之后，双方的参与者都将获得 关于他们的实验室和血压值的信息，将被随机分配到两个研究小组中的一个。被随机分配到对照组的参与者将被安排与他们的教练一起进行初步访问。然后，教练将帮助他们列出他们希望与医疗保健提供者讨论的问题和关切，练习提出他们的问题和关切，并制定行动计划，以解决他们确定的自我管理障碍。TEC ARM的参与者将被安排与他们的教练一起进行初步访问，以审查决策辅助工具，其中包含了他们的个人基线数据。然后，教练将提供与对照组相同的干预措施。在接下来的六个月里，教练将每周给他们指定的同伴打一次电话，为他们的行动步骤提供支持。这些呼叫将使用保密的IVR系统进行，该系统在不共享电话号码的情况下连接呼叫者。这项研究将衡量HbA1c、BP、以患者为中心的结果、干预效果的中介和调节器以及成本效益的变化。

DESCRIPTION (provided by applicant): Objectives: Providers and patients face barriers to accomplishing the complete communication needed to make complex decisions together about diabetes treatments and self-management tasks. Providers often have limited time and patients often have limited resources. Peer mentoring models have been found in two recent VA research trials to be more effective than usual care, financial incentives, and nurse care management in improving glycemic control in high-risk Veteran patients with diabetes. While peers can be trained in effective approaches to support other Veterans' self-management behaviors, such coaches necessarily lack diabetes and diabetes medications content expertise to help Veterans better share in treatment decisions and goal-setting with their health care providers. Accordingly, in a recent research study we developed and tested a tailored, interactive diabetes and diabetes medication information tool that outreach workers can use to facilitate discussions with patients. Such tools can enhance the sustainability and effectiveness of coaching programs to better prepare patients to set self- management goals, action plans, and to discuss treatment options with their providers. Because this intervention addresses barriers to disease management for chronically-ill patients, physicians, and case managers, the study may have broader impact on management practices for other chronic illnesses. Project Methods: 348 diabetes patients with poor glycemic control (A1c>8.0% or A1c>8.5% if older than 70) will be recruited from the Detroit VA and randomized to either Peer Support with TEC or Peer Support alone. All participants will be assigned to one of 87 peer coaches, who also are Detroit VA diabetes patients who previously had poor glycemic control but are currently in good control. Each peer coach will be assigned about 4 participants on the basis of race and approximate age. Peer coaches will undergo training in motivational interviewing-based counseling approaches and instruction in use of the iPad-platform decision aid tool. After their baseline assessment, participants in both arms will receive information on their lab and blood pressure values and will be randomized to one of the two study arms. Participants randomized to the control group will be scheduled for an initial visit wit their coach. The coach will then help them list questions and concerns they wish to discuss with their health care provider, practice raising their questions and concerns and develop an action plan to address barriers to self-management they have identified. Participants in the TEC arm will be scheduled for an initial visit with their coach to review the decision aid, which has incorporated their personal baseline data. The coach will then provide the same intervention that the Control group receives. During the next six months the coach will call their assigned peers once a week to provide support for their action steps. These calls will be placed using a confidential IVR system that connects the callers without sharing phone numbers. The research will measure changes in HbA1c, BP, patient-centered outcomes, mediators and moderators of intervention effects and cost-effectiveness.