Peer Support to Enhance Diabetes Shared Medical Appointments: Examining Comparative Effectiveness in VA Health Systems

 描述（由申请人提供）： 项目背景：共享医疗咨询（SMA）-由多学科/多专业团队的提供者领导的具有相同医疗条件的退伍军人小组会议-目前正在全国范围内的VA设施中广泛实施。疗效试验发现，VA中的SMA增加了获得护理的机会，并改善了参与者在SMA期间和完成SMA后的自我管理、临床和以退伍军人为中心的结局。我们对通过SMA获得的收益随着时间的推移而保持的程度知之甚少，如果不是，还有什么其他可扩展的方法可以最好地保持自我管理和临床结局的改善。此外，影响有效实施SMA和后续维护计划在不同的设置的因素知之甚少。一种潜在的可扩展方法是基于电话的同伴支持，其中退伍军人彼此提供支持。由于同龄人具有相似的特征，这种方法本质上具有文化敏感性。此外，由于大多数联系都是通过电话进行的，因此那些在获得诊所护理方面面临障碍的弱势患者也可以利用电话。项目名称：因此，本混合方法的随机对照试验将评估一种新的对等支持计划-对等计划（P2P）-在维持糖尿病SMA收益方面的比较有效性和实施情况。在之前的VA疗效随机对照试验中，与常规护理管理相比，P2P改善了VA患者的糖尿病特异性社会支持、胰岛素开始和血糖控制。项目方法：P2P计划的组成部分包括至少每周一次糖尿病控制不佳的配对退伍军人之间的电话通话，这些退伍军人参加了同一个SMA组和定期的退伍军人指导组会议。参与者与另一名年龄相仿、面临类似自我管理挑战的患者相匹配。鼓励这些“同伴伙伴”至少每周通过电话交谈，以提供相互支持，分享他们的进度设置和自我管理目标的实现。其目标是通过短期糖尿病自我管理培训和临床项目（如糖尿病SMA）来加强和帮助维持所取得的改善。基于糖尿病SMAs和P2P计划的单独疗效试验的成功，本项目将研究SMAs单独、SMAs + P2P和没有这些计划的常规护理的比较有效性，并研究五个不同VA设施的七个站点的实施过程。在入组后6个月和12个月测量的结果包括：1）参与者血糖和血压控制以及他汀类药物使用的变化; 2）服务利用率; 3）对VA护理的满意度; 4）糖尿病特异性痛苦; 5）糖尿病社会支持;以及5）糖尿病自我管理行为。综合执行框架的结构已经用于在研究地点完成的执行前形成性评价，用于完善每个地点的执行计划。CFIR结构也将在实施后评估过程中使用，以确定促进广泛传播工作的建议，并为实施科学文献做出贡献。将在整个实施过程中收集有关工作人员所需努力的数据，以计算方案的成本。

 DESCRIPTION (provided by applicant): PROJECT BACKGROUND: Shared Medical Appointments (SMAs)-group sessions of Veterans with the same medical condition led by a multi-disciplinary/multi-expertise team of providers-are now being widely implemented at VA facilities nationwide. Efficacy trials have found that SMAs in VA increase access to care and improve participants' self-management, clinical, and Veteran-centered outcomes during and immediately after completion of the SMAs. Less is known about the extent to which gains achieved through SMAs are maintained over time and, if not, what additional scalable approaches can best maintain improvements in self-management and clinical outcomes. Moreover, factors influencing effective implementation of SMAs and follow-up maintenance programs in diverse settings are poorly understood. One potentially scalable approach is telephone-based peer support in which fellow Veterans provide support to each other. Because peers share similar characteristics, this approach is intrinsically culturally sensitive. Moreover, because most contacts are over the telephone, it is accessible to vulnerable patients who face obstacles to accessing clinic-based care. PROJECT OBJECTIVES: Accordingly, this mixed methods cluster randomized controlled trial will evaluate the comparative effectiveness and implementation of a novel reciprocal peer support program-the Peer to Peer Program (P2P)-in maintaining gains from diabetes SMAs. In a prior VA efficacy randomized controlled trial, P2P improved VA patients' diabetes-specific social support, insulin starts, and glycemic control compared to usual nurse care management. PROJECT METHODS: P2P program components include at-least weekly telephone calls between paired Veterans with poor diabetes control who are participating in the same SMA group and periodic Veteran-directed group sessions. Participants are matched with another patient of similar age and facing similar self-management challenges. These "peer buddies" are encouraged to talk by phone at least weekly to provide mutual support and share their progress setting and meeting their self-management goals. The goal is to enhance and help maintain improvements achieved through short-term diabetes self-management training and clinical programs such as diabetes SMAs. Based on the success of separate efficacy trials of diabetes SMAs and of the P2P program, this project will examine the comparative effectiveness of SMAs alone, SMAs + P2P, and usual care without either of these programs and study the implementation process at seven sites in five diverse VA facilities. Outcomes measured at 6- and 12-months post-enrollment include: 1) changes in participants' glycemic and blood pressure control and statin use; 2) service utilization; 3) satisfaction with VA care; 4) diabetes-specific distress; 5) diabetes socia support; and 5) diabetes self- management behaviors. Constructs from the Consolidated Framework for Implementation (CFIR) have already been used in a completed pre-implementation formative evaluation at the study sites that was used to refine the implementation plan at each site. CFIR constructs will also be used during the post- implementation evaluation process to identify recommendations for facilitating widespread dissemination efforts and to contribute to the implementation science literature. Data will be gathered throughout implementation on staff effort required in order to calculate costs of the program.