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IIR 12-412 – HSR&D Study

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IIR 12-412
Technologically Enhanced Coaching (TEC):A Program for Improving Diabetes Outcomes
Mary Ellen Michele Heisler MD MPA
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: February 2014 - September 2018

BACKGROUND/RATIONALE:
Peer support among patients with diabetes has been found to be an effective intervention to address barriers to diabetes self-management, however, one potential limitation of peer support programs is that peer supporters by definition lack substantial medical and other content knowledge. To increase the potential impact of peer support programs, a key next step is to test whether providing peer supporters with evidence-based educational tools enhances the effectiveness of such programs. We thus developed a personally tailored, interactive diabetes medication and self-management e-health decision aid (iDecide). In a prior study, we found that low-income, urban Latino and African American adults with diabetes who worked with Community Health Workers (CHWs) using iDecide had greater improvements with satisfaction and decreased diabetes distress. Since many health care systems in low-resource settings do not have trained CHWs or other outreach workers, it is important to investigate whether programs such as iDecide are helpful in assisting peer coaches. Accordingly, in the current study we conducted a trial in a low-resource health care system (Detroit VA Medical Center) testing the effectiveness of a peer coach-delivered iDecide intervention for patients with poor glycemic control.

OBJECTIVE(S):
The three main objectives of this randomized controlled trial were to: 1) Test the effectiveness of a technology-enhanced peer coaching program (iDecide arm) in improving glucose control relative to peer coaching without technology enhancement (Peer Support-Alone arm); 2) Assess the impact of the intervention on key patient-centered outcomes, including patients' satisfaction and involvement with care, perceived social support, diabetes-specific quality of life, and medication adherence; and 3) Identify patient characteristics associated with engagement in the intervention and mediators and moderators of the intervention's impact on patient outcomes.

METHODS:
From September 2014 to September 2016, Veterans with A1c>8.0% were enrolled in a 6-month peer coaching intervention. Participants were randomized to either the iDecide arm or Peer Support-Alone arm, both consisting of an initial face-to-face coaching session followed by weekly phone calls to discuss behavioral goals. Veterans who had poor glycemic control in the past (A1c>8.0%) but whose most recent A1c in the prior 6 months was <8.0% were recruited as peer coaches. For peer coaches in both arms, we held a 2-hour initial training session that focused on key Motivational Interviewing-based communication skills and helping participants define a longer-term behavioral goal and specific short-term steps to reach that goal ('action planning'). Peer coaches in the iDecide arm participated in an additional 1-hour training session on how to navigate the iDecide tool that was delivered on iPads.

The iDecide program consisted of four main sections: 1) information and illustrative animations on how diabetes affects how glucose is processed in the body and how different medication classes, foods, and physical activity act to affect blood sugar; 2) participants viewed their own risk of diabetes complications (tailored based upon their baseline A1c) and could interactively change their A1c levels and see in pictographs how this changed their risk of different complications; 3) participants reviewed their current diabetes medications and barriers to taking medications that they had identified on the baseline survey and engaged with an interactive "issue card" to help elicit their preferences and priorities in terms of different medication characteristics; and 4) participants were prompted to set goals, develop a specific action plan to address identified barriers or other concerns, and generate specific questions and concerns to discuss with their doctor. Participants were given the link to the iDecide program with their personal information for them to access at their convenience throughout the intervention period and encouraged to continue to access the program as needed.

FINDINGS/RESULTS:
Of the 260 Veterans enrolled, 255 participants (88%) completed 6-month assessments and 237 (82%) completed 12-month assessments. 98% were men, and 63% were African American. In the Peer Support-Alone group, mean baseline A1cs of 9.07% improved to 8.39% (-0.68%, p<0.001) at 6 months and remained 8.55% (-0.54, p=0.004) at 12 months. Mean baseline A1c in the iDecide group was 9.08% at baseline and improved to 8.38% (-0.70, p<0.001) at 6 months and remained 8.52% (-0.55, p=0.002) at 12 months. There were no significant between-group differences at 6-month or 12-month follow-up. There were no significant changes in systolic blood pressure at any time point in either group. Significant within-group improvements were observed in self-reported diabetes-specific social support in both groups between baseline and 6 months and between baseline and 12 months.

Conclusion: Clinical gains achieved through a volunteer peer coach program were not increased by the addition of a tailored e-Health educational tool.

IMPACT:
This study is among the first efforts to respond to the call for the testing of e-health consumer health applications for use by nontraditional caregivers such as volunteer peer coaches with racial and ethnic minority and low-literate populations. Our study found that both peer support models were effective in improving A1c levels right after the interventions, and importantly, these gains were sustained 6 months after the programs' conclusion. The A1c improvements of >0.5% achieved at both 6- and 12-months in both intervention arms in this study are both statistically and clinically significant. A mean difference in A1c level of 0.5% translates into an absolute 2.8% risk reduction in diabetes events over 10 years.

Of note, these clinically significant and sustained gains were not further improved through use of an e-health educational tool in the initial face-to-face visit and its availability to participants throughout the intervention period. This suggests that the ongoing supportive relationships between peer coaches and their assigned patients in both peer support arms were the most important active ingredient in the intervention's success. This is good news for resource-constrained health systems that may lack the capacity to develop, continually update, and manage tailored e-health programs. Volunteer peer support programs can be important complements to over-burdened formal health care providers to improve the frequency and intensity of ongoing support between face-to-face clinic visits. Unlike most other tested diabetes management support programs, gains achieved over the 6-month intervention period were sustained 6 months after the end of the program. Moreover, such programs that mobilize patients to help other patients could realistically be provided over sustained periods of time.

PUBLICATIONS:

Conference Presentations

  1. Heisler MM. Uniting m-Health and Peer Support to Improve Chronic Disease Self-management and Outcomes. Paper presented at: Kaiser Permanente Interregional Geriatrics Annual Symposium; 2014 Oct 21; Oakland, CA.


DRA: Health Systems, Diabetes and Related Disorders
DRE: Technology Development and Assessment, Treatment - Comparative Effectiveness
Keywords: Adherence, Care Management Tools, Comparative Effectiveness, Decision Support, Diabetes, Ethnicity/Race, Outcomes - Patient, Telemedicine/Telehealth
MeSH Terms: none