Learnings in Diabetes Prevention from an Integrated Delivery System

描述(由申请人提供)：项目摘要/摘要北加州凯撒永久医院(KPNC)及其研究部(DOR)对KPNC系统层面预防高危成员发展糖尿病的努力提出了一套三项评估。这些研究中的一项或多项非常适合与该研究网络中其他系统关于类似干预措施的数据合并。申请者研究团队在与KPNC临床和运营负责人合作评估糖尿病护理方面的自然实验方面经验丰富，包括最近作为CDC/NIDDK赞助的三合会研究的一部分进行的评估。我们认为，现在是检查对糖尿病患者有效的人群方法是否可以调整以支持糖尿病前期高危患者改变生活方式和防止发展为糖尿病的时机。初步评估是对KP-Employer合作伙伴关系的评估，该合作伙伴关系调整了其工作场所健康计划，以使用电子健康记录(EHR)数据对所有员工进行风险分层，并使用密集的外展、激励和培训(网络、电话或面对面)来支持高危员工改变生活方式。干预和控制雇主地点的选择将与CalPERS协商，CalPERS是一个代表多个雇主的大型福利管理组织。我们预计在每个地点确定大约750名高风险员工。将使用EHR和患者调查(通过邮件、电话或互联网在基线和12个月时)来评估影响，以衡量身体质量指数(BMI)、体力活动、血压和血脂水平的变化。第一项辅助研究评估了2010年1月建立的电话健康指导计划。它旨在成为教练支持组合的一部分，该组合还包括在线和面对面服务。它由KPNC的地区卫生教育部(RHE)运营，全面实施后，每年将针对多达10,000名高危人群。我们将与RHE合作，评估从EHR或健康风险评估数据或组合中确定的高风险成员的计划影响。基线和12个月的调查将再次测量BMI、体力活动、血压和血脂的变化。我们还将评估对改变的准备情况、对教练类型的偏好以及这些偏好之间的相关性。第二项辅助研究检查了2006年实施的一项地区性计划，该计划旨在确保在所有患有妊娠期糖尿病(GDM)的妇女中，使用75克口服葡萄糖耐量测试进行产后糖尿病筛查。该计划向那些在测试中被证明患有糖尿病前期的人进行推广。该计划将通过检查2001-05与2006-2010(每个队列中n=12,000)所有妊娠期糖尿病妇女队列中人口发病率(产后5年以上)的变化来进行评估。发病率将分为不太严重的(通常是筛查发现的)和较严重的(A1C和GT；8%或需要两种药物)。我们假设，该计划将导致较严重糖尿病的减少，但较轻微疾病的增加。我们还列出了一些我们将能够评估的糖尿病护理的自然实验。

DESCRIPTION (provided by applicant): Project Summary / Abstract Kaiser Permanente Northern California (KPNC) and its Division of Research (DOR) propose a set of three evaluations of KPNC system-level efforts to prevent development of diabetes in high-risk members. One or more of these studies would be well-suited for pooling with data from other systems in this research network on similar interventions. The applicant research team is highly experienced in working with KPNC clinical and operational leaders to evaluate natural experiments in diabetes care, including recent evaluations as part of the CDC/NIDDK-sponsored TRIAD study. We believe this is an is an opportune moment to examine whether the population approaches that have been effective for patients with diabetes can be adapted to support high-risk pre-diabetic patients to modify lifestyles and prevent progression to diabetes. The primary evaluation is of a KP - employer partnership that has adapted its worksite wellness program to risk stratify all employees using electronic health record (EHR) data and to use intensive outreach, incentives, and coaching (web, telephone, or in-person) to support lifestyle change in high-risk employees. Intervention and control employer sites will be selected in consultation with CalPERS, a large benefits management group representing multiple employers. We expect to identify approximately 750 high-risk employees at each site. Impact will be assessed using both EHR and patient surveys (via mail, phone, or internet at baseline and 12 months) to measure changes in body mass index (BMI), physical activity, blood pressure and lipid levels. The first ancillary study evaluates a telephonic wellness coaching program established in January 2010. It is intended to be part of a portfolio of coaching support that also includes online and in-person services. It is operated by KPNC's Regional Health Education Department (RHE), and will target as many as 10,000 high risk persons per year when fully implemented. We will work with RHE to evaluate program impact among high risk members identified either from EHR or health risk appraisal data, or from a combination. Surveys at baseline and 12 months will again measure changes in BMI, physical activity, blood pressure and lipids. We will also assess readiness to change, preferences for type of coaching, and correlates of these preferences. A second ancillary study examines a regionwide program implemented in 2006 that aims to ensure postpartum screening for diabetes, using a 75-gram oral glucose tolerance test, in all women with gestational diabetes mellitus (GDM). The program conducts outreach to those who prove to have pre-diabetes at testing. The program will be evaluated by examining changes in population incidence (over 5 years postpartum) in cohorts of all women with GDM from 2001-05 vs 2006-2010 (n=12,000 in each cohort). Incidence will be divided into less severe (often screen-detected) and more severe (with A1c >8% or requiring two medications). We hypothesize that the program will lead to decreases in more severe diabetes but to increases in milder disease. We also list a number of natural experiments in diabetes care that we would be able to evaluate.