Social virtual reality and diabetes management: Extending the clinical encounter

描述（由申请人提供）：在美国有超过2400万人患有糖尿病。这些人中的大多数是由初级保健提供者（pcp）而不是专家照顾的。我们对理想的患者和提供者糖尿病管理实践的理解和表达有了显著的提高。然而，由于提供者和患者面临的环境和社会心理障碍，这些最佳的糖尿病护理行为往往无法在现实世界的临床经验中实现。对于最佳的医生实践和最佳的病人自我管理和方案依从性来说，一个重要的障碍是“面对面时间”——病人和医生在任何给定的临床接触中可用的时间。典型的初级保健患者-提供者互动（PPIs）持续时间短，加上其相对较少和不稳定的安排，对实现理想的糖尿病管理实践构成了相当大的障碍。特别是，施加在PCP上的极端时间压力和支持结构的普遍缺乏，经常导致糖尿病患者PPI的重点从重要但需要时间的自我管理元素转移，如生活方式改变和行为矫正支持，转向更狭隘地强调“固定数字”，可能导致绝大多数患者没有得到目标治疗。此外，不频繁的糖尿病PPIs等同于收集患者结局数据点的机会更少：提供者收到的关于患者状态的数据更少、更少，因此，他们对健康状况进展的了解更少，也更无法修改方案以获得最佳管理。对于患者来说，与卫生保健系统的不频繁和不稳定的接触可能导致糖尿病自我管理不理想，因为他们的药物治疗方案、生活方式改变和行为改变的反馈机会相对不一致。理想情况下，这种情况可以通过为pcp提供更多的时间用于糖尿病PPIs来补救；然而，由于各种社会技术原因，这在美国医疗保健系统的结构和压力下不太可能发生。因此，必须探索在不增加提供者和患者负担的情况下实现更理想结果的其他方法。增加PPI频率和持续时间的一种创新方法是使用基于网络的交互式技术，包括社交虚拟现实环境（SVRE）来延长这种“面对面时间”。通过SVRE，可以在面对面PPI之前、之后和之间进行理想的患者和提供者糖尿病管理实践，这些实践要么被忽略，要么以次优频率出现。这种临床接触的延伸将代表着常规护理的有价值的增强，增加了患者结果跟踪、反馈和强化的机会，从而有可能提高依从性，减少管理不善和后遗症，并改善患者的结果和生活质量。利用AEI在广泛的行为改变和PCP支持工作方面的媒体、教育和表现支持经验，以及IUSOM糖尿病转化研究中心在糖尿病护理方面的专业知识，获得糖尿病PCP提供者和患者，以及知名的电子记录系统，拟议的工作将检查使用SVRE增强常规护理的影响。通过建立以用户为中心的迭代开发方法，精心创建PCP糖尿病护理SVRE，将理想的PCP糖尿病管理护理的各个方面转化为SVRE。将在IUSOM医疗保健系统内的糖尿病患者和医疗服务提供者中进行一项对照、混合方法、多变量、重复测量的现场试验，以检验所得SVRE的可接受性、效用和影响。最佳医疗服务提供者实践和最佳糖尿病管理的一个重要障碍是“面对面时间”——患者和医疗服务提供者在任何给定的临床接触中可用的时间量。增加PPI频率和持续时间的一种可能方法是使用基于网络的交互式技术，包括社交虚拟现实环境（SVRE）来延长这种“面对面时间”。这种临床接触的延伸将代表着常规护理的有价值的增强，增加了患者结果跟踪、反馈和强化的机会，从而有可能提高依从性，减少管理不善和后遗症，并改善患者的结果和生活质量。关于SVRE在糖尿病患者中的可接受性和影响，我们所知甚少，关于患者与实时和模拟提供者虚拟形象互动的效用就更少了。通过开发PCP糖尿病护理SVRE，检查患者对环境的满意度，并比较SVRE增强常规护理与常规护理的患者结果，所提出的努力将填补我们理解中的空白，提供与该领域最佳实践相关的可推广的发现，并有可能成为改善糖尿病患者护理，结果和生活质量的可推广工具。

DESCRIPTION (provided by applicant): There are over 24 million individuals affected by diabetes in the United States. The majority of these individuals are cared for by primary care providers (PCPs) rather than specialists. There has been significant improvement in our understanding and articulation of ideal patient and provider diabetes management practices. However, these optimal diabetes care behaviors are often not achieved in real world clinical experiences as a result of environmental and psychosocial barriers faced by providers and by patients. A significant barrier both to optimal provider practice and to optimal patient self-management and regimen adherence is "face time"-the amount of time available to the patient and provider to engage in any given clinical encounter. The short duration of typical primary care patient-provider interactions (PPIs), coupled with their relatively infrequency and erratic scheduling, presents a considerable barrier to achieving ideal diabetes management practices. In particular, extreme time pressures placed upon PCP and the common lack of support structures, often cause the focus of the diabetic PPI to shift away from important but time-intensive elements of self- management, such as lifestyle change and behavioral modification support, toward a more narrow emphasis on "fixing the numbers," with, perhaps as a result, the vast majority of patients not being treated to target. Additionally, infrequent diabetic PPIs equate to fewer opportunities to gather patient outcomes data points: providers receive less, and less frequent, data regarding their patients status and, as a result, are both less informed regarding health status progression and less able to modify the regimen for optimal management. For patients, infrequent and erratic contact with the health care system may lead to suboptimal diabetes self- management as a result of relatively inconsistent opportunities for feedback regarding and reinforcement of their medication regimen, and their lifestyle change and behavioral modification efforts. Ideally, this situation would be remedied by providing PCPs with more time for diabetic PPIs; however, for a variety of sociotechnical reasons this is unlikely to occur within the structure and pressures of the US healthcare system. Therefore, other approaches to achieving more optimal outcomes, without increasing provider and patient burden, must be explored. One innovative approach to increasing the frequency and duration of the PPI is to extend such "face time" with web-based, interactive technologies, including social virtual reality environments (SVRE). Through SVRE, aspects of ideal patient and provider diabetes management practices which are either omitted or which occur with suboptimal frequency can be conducted virtually before, after, and between face-to-face PPI. Such an extension of the clinical encounter would represent a valuable augmentation of usual care, increasing opportunities for patient outcome tracking, feedback, and reinforcement, and thereby potentially improving adherence, reducing mismanagement and sequalae, and improving patient outcomes and quality of life. Drawing on AEI's media, educational and performance support experience with a wide range of behavioral change and PCP support efforts and IUSOM's Diabetes Translational Research Center's expertise in diabetes care, access to diabetes PCP providers and patients, and well-known electronic records systems, the proposed effort will examine the impact of using SVRE to augment usual care. The effort will translate aspects of ideal PCP diabetes management care to a SVRE by carefully creating a PCP diabetes care SVRE through an established iterative user-centered development methodology. The acceptability, utility, and impact of the resulting SVRE will be examined in a controlled, mixed methods, multivariate, repeated measures field trial with follow-up conducted among diabetes patients and providers within the IUSOM medical care system. A significant barrier both to optimal provider practice and to optimal diabetes management is "face time"- the amount of time available to the patient and provider to engage in any given clinical encounter. One possible approach to increasing the frequency and duration of the PPI is to extend such "face time" with web-based, interactive technologies, including social virtual reality environments (SVRE). Such an extension of the clinical encounter would represent a valuable augmentation of usual care, increasing opportunities for patient outcome tracking, feedback, and reinforcement, and thereby potentially improving adherence, reducing mismanagement and sequalae, and improving patient outcomes and quality of life. Very little is known regarding the acceptability and impact of SVRE among diabetes patients and even less regarding the utility of patients interacting with live and simulated provider avatars. By developing a PCP diabetes care SVRE, examining patient satisfaction with the environment, and comparing patient outcomes of those in SVRE- augmented usual care with those in usual care, the proposed effort will fill this gap in our understanding, provide generalizable findings related to best practices in this arena, and potentially lead to a disseminable tool for improving diabetes patient care, outcomes and quality of life.