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IIR 04-239 – HSR&D Study

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IIR 04-239
Improving Insulin Therapy with Enhanced Care Management and Peer Support
John D. Piette PhD
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: April 2006 - March 2010

BACKGROUND/RATIONALE:
Many VA facilities face barriers to implementing resource-intensive care management programs for patients with poorly controlled diabetes. Mobilizing patients to provide reciprocal peer support may enhance care management and improve clinical outcomes.

OBJECTIVE(S):
To compare the effectiveness of a reciprocal diabetes peer support program (RPS) with nurse care management (NCM) in improving glycemic control in real-world clinical settings.

METHODS:
Six-month parallel randomized controlled effectiveness study from 2007-2010 (Trial Registration NCT00320112) conducted in two U.S. Veterans'Affairs (VA) health care facilities among 244 male diabetes patients with a hemoglobin A1c (HbA1c) in the prior 6 months of 7.5% or more. The primary outcome was change in HbA1c between baseline and six months. Secondary outcomes were new insulin starts and intensification, blood pressure, diabetes-specific social support, emotional distress, and medication adherence.
Participants in both arms attended an initial session led by a nurse care manager to review and discuss their point-of-service HbA1c and blood pressure values, and most recent medical record cholesterol values. RPS patients then participated in a group session to set diabetes-related behavioral goals, receive brief training in peer communication skills, and be paired with another age-matched participant. Paired peer partners were encouraged to talk weekly using a telephone platform that recorded call frequency and duration and provided automated reminders promoting peer contact. Intervention participants were also offered three optional 1.5 hour patient-driven group sessions at months 1, 3, and 6 to share concerns, questions, strategies, and progress on goals. Patients in the NCM arm attended a 1.5 hour session to receive education on care manager services and diabetes educational materials and be assigned to a nurse care manager with whom they were encouraged to follow up regularly.

FINDINGS/RESULTS:
Of the 244 patients enrolled, at six months 216 (89%) completed the HbA1c and 231 (95%) the survey assessments. RPS participants had a mean HbA1c of 8.02% at baseline, which improved to 7.73% at six months (-0.29%) compared with an average increase in HbA1c among NCM participants (7.93 to 8.22 [SD 0.29]). The difference between groups was 0.58% (p=0.004).
Among patients with a baseline HbA1c >8.0%, RPS participants had a mean decrease of 0.88% compared with a 0.07% decrease among NCM participants (p<0.001). Eight RPS patients started insulin compared to one NCM patient (p=0.02), and RPS participants reported greater increases in diabetes social support than NCM participants (+11.4 vs. +4.5, p=0.01). There were no differences between groups at follow-up in blood pressure, self-reported medication adherence, or diabetes-specific distress.

IMPACT:
Periodic nurse-facilitated, patient-driven group sessions supplemented with one-on-one peer-support telephone calls between age-matched partners improved glycemic control and other key outcomes more than provision of nurse care management services alone among VA diabetes patients. Because many chronically-ill patients need more support for self-care than the VA and other healthcare systems can provide, models such as this that increase the quality and intensity of assistance through peer support are an promising approach for VA. Reciprocal peer models can be an effective and efficient approach for helping patients help each other and themselves.

PUBLICATIONS:

Journal Articles

  1. Heisler M, Vijan S, Makki F, Piette JD. Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Annals of internal medicine. 2010 Oct 19; 153(8):507-15.
Conference Presentations

  1. Vijan S. Using healthcare data to develop models of sequential decision making. Paper presented at: Neural Information Processing Systems Annual Conference; 2010 Dec 9; Vancouver, Canada.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Comparative Effectiveness, Diabetes, Management and Human Factors, Outcomes - Patient, Patient outcomes, Quality assessment
MeSH Terms: none