Effect of Personalized Feedback Report and Peer Support on Diabetes
Condition: Diabetes
MeSH terms: Diabetes Mellitus
Study type: Interventional

Summary: 
      In this project, the investigators hypothesize that in an integrated, multifaceted,
      team-based program incorporating comprehensive assessment with risk stratification, diabetic
      patients with high risk of negative emotions and hospitalization will benefit from additional
      peer support which will improve their psychological health, cardio-metabolic control,
      self-management, quality of life and reduce hospitalization. The investigators further
      hypothesize that peer support will interact with regular personalized feedback reporting to
      improve clinical outcomes.
    

Detailed description: 
      Diabetes self-management is often emotionally and physically taxing, demanding lifelong
      commitment to medication adherence and lifestyle modification. People with diabetes have to
      be well-educated and supported to make clinical decisions in their daily living. However,
      most diabetes self-management education (DSME) interventions are short-term and have little
      external support. In order to empower patients to self-manage over a lifetime after the
      initial DSME, ongoing multidisciplinary programs which coordinates individual components of
      care into a structured system and further supported by reinforcement through multiple
      contacts are necessary to provide practical tips as well as social and psychological support
      to diabetic patients, so as to sustain behavioral changes and improve metabolic control.

      Based on these principles, the Joint Asia Diabetes Evaluation (JADE) Program was developed in
      2007 as a quality improvement initiative to deliver technologically integrated and
      multidisciplinary team-based care. It is enabled by a web-based portal containing templates
      which guide care providers in providing standardized comprehensive assessments, the results
      of which are then used for personalized risk stratification and feedback reports. The
      personalized feedback report contains the patient's risk category according to the JADE
      definition, with visual displays of important trends including those of glycated haemoglobin
      (HbA1c), blood pressure (BP), low-density-lipoprotein-cholesterol (LDL-C), and body mass
      index (BMI), and practical suggestions to help the individual to reach multiple treatment
      targets based on the latest values.

      On the other hand, according to a recent WHO consultation report, peer support intervention
      is considered to have enormous potential to improve self-management in patients with chronic
      disease. Programs using peer supporters to teach and support their peers with diabetes have
      shown significant reductions in HbA1c, enhanced self-efficacy, improved health status and
      better self-management behaviors. In our previous study, we found that a combined program
      which integrates structured care, peer support and clinical decision support by regular
      follow up report significantly improved psychological health and medication adherence of
      diabetic patients, and reduced hospitalization of patients with negative emotions like
      depression, distress, and anxiety, who were most likely to suffer from chronic kidney disease
      or poor glycemic control. In this program, we hypothesize that using a multifaceted program
      which incorporates structured care, personalized feedback reporting, and peer support to
      influence and motivate diabetic patients with high risk of hospitalization and negative
      emotions on diabetes self-management, will further improve their self-management,
      psychological health and metabolic control, and reduce hospitalization. We further
      hypothesize that receiving personalized feedback report with decision support will improve
      glycemic control and reduce hospitalization in patients with diabetes.

      Around 286 patients with high risk of negative emotion and hospitalization will be invited to
      join the peer support program. We anticipate that half of the patients will agree (n=143) and
      be assigned 24 peer supporters on a 5~6:1 ratio. Peer supporters are patients who have good
      glycemic control and self-care and trained to provide both informational and emotional
      support to the peer group. For patients who decline to participate, they will be identified
      as refused peer group and their reasons for declining will be documented. Half of the
      patients in each group will be randomized to receive 2 personalized feedback reports through
      the mail.

      1200 adult patients consecutively enrolled in JADE program will be recruited and half of them
      (n=600) will be randomized to receive a personalized feedback report twice a year. All
      patients will be followed up at their usual clinics and will be observed for at least 1 year
      when we shall evaluate the effects of providing regular personalized report on clinical
      outcomes including metabolic control and hospitalization.

      To evaluate the independent effects of peer support , we further used a case-control design
      to. Within the 1200 patients who were not offered peer support, a group of patients who met
      the criteria of "high risk" were matched to those agreed to receive peer support on a 3:1
      basis by age, gender, diabetes duration, and baseline HbA1c as a control group. Data of
      metabolic control and hospitalization of the control group were retrieved from the CMS and
      compared to that of the peer group after 1 year.

      The study objectives are:

        1. To study the effect of regular personalized feedback reports to patients with diabetes
           managed within an integrated care program on hospitalization and metabolic control,
           irrespective of their risk levels.

        2. To study the feasibility of using trained diabetes patients (peer supporters) to assist
           diabetes educators in diabetes management.

        3. To study the acceptability of peer support in a real life setting and the effects of
           non-participation in peer support program on clinical outcomes including hospitalization
           and glycemic control in high risk patients for negative emotions and multiple risk
           factors.

        4. To study the independent and interactive effects of peer support and regular
           personalized feedback report on cardio-metabolic risk factor control, psychological
           health, self-efficacy, self-management, quality of life and hospitalization rates in
           patients with diabetes at high risk for negative emotions and multiple risk factors.
    

Intervention name(s): Peer support; Personalized feedback report
Intervention type(s): Behavioral; Behavioral
Intervention description(s): 15 patients who have good glycemic control and self-care will be trained as peer supporters to deliver peer support under supervision by a program manager. Peer supporters will call their peers at least 12 times a year to provide both informational and emotional support.; Patients will receive a personalized feedback report displaying trends of metabolic control of A1c, BP, LDL-C, and body weight, with automated decision support based on their own attained values every 4 months through mails.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Keywords: diabetes; peer support; personalized feedback report