Clinical trial NCT03590041: Comparative Effectiveness of Diabetes Shared Medical Appointment Models
Official title: Invested in Diabetes: Comparing Patient-Centered Outcomes of Standardized Versus Patient-Driven Diabetes Shared Medical Appointments (PCORI IHS-1609-36322)
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Diabetes Mellitus, Type 2
Keywords: Diabetes Mellitus Type 2, Comparative Effectiveness Trial
Lead sponsor: University of Colorado, Denver
Sponsor class: OTHER
Collaborators: name: Patient-Centered Outcomes Research Institute
First posted: 2018-07-18
Enrollment: 1085
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: The two interventions are based in the Chronic Care Model, which emphasizes whole person care, addressing physical, mental health and psychosocial needs. The conceptual model underlying patient-driven diabetes Shared Medical Appointments is based on self-determination theory (SDT) and principles of whole person care. According to SDT, human motivation and behavior are a function of the social environment and the extent to which that environment supports basic psychological needs shown to enhance "self-determined motivation."
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: In this study, the investigators will compare the effectiveness of patient-driven diabetes Shared Medical Appointments (SMAs) to standardized diabetes SMAs. The curriculum to be used is Targeted Training for Illness Management (TTIM), a 6-session modular group intervention for chronic illness self-management, and has been tested in diabetes. The standardized group visit model will consist of diabetes SMAs with the full TTIM 6-session curriculum, led by a health educator.

Detailed description: Type II Diabetes is a prevalent chronic disease with poor outcomes, and requires daily self-care, including blood glucose monitoring, following a diabetes-friendly diet, engaging in regular physical activity, and medication adherence. Patients with diabetes benefit from comprehensive diabetes self-management education (DSME) and self-management support (SMS) in primary care. Shared medical appointments (SMAs) are one way to efficiently and effectively provide DSME and SMS. SMAs can have a variety of different features, but it is not known which features are most effective for which types of patients. Patients and other stakeholders engaged in planning this study proposed a model with "diabetes' veterans" (i.e., diabetes peer mentors) who co-facilitating group visits with a variety of diabetes care professionals, and then working one-on-one with patients to help apply what they learned. The group visit curriculum should include topics on physical activity, healthy eating, taking medication, acceptance and coping, and social support, and each cohort of patients should get to select topics most relevant to them. The practice stakeholders want to do more comprehensive group visit models, but need to know the extent to which SMA participation and patient-centered outcomes are improved compared to the more common standardized approaches they tend to use now.

In this study, the investigators will compare the effectiveness of patient-driven diabetes SMAs to standardized diabetes SMAs. The curriculum to be used is Targeted Training for Illness Management (TTIM), a 6-session modular group intervention for chronic illness self-management, and has been tested in diabetes. The standardized group visit model will consist of diabetes SMAs with the full TTIM 6-session curriculum, led by a health educator. For the patient-driven SMAs, patients choose the topics and the order of sessions from the TTIM curriculum, which is delivered collaboratively by the multidisciplinary care team consisting of several professional providers (health educator, medical provider, and behavioral health provider) and a lay worker (diabetes peer mentor). The primary patient-centered outcome, selected by patient stakeholders, is diabetes distress. Secondary outcomes include autonomy support and diabetes self-management behaviors, clinical outcomes (hemoglobin A1c, blood pressure, and body mass index), patient reach and engagement, and practice-level value and sustainability. Patient, caregiver, practice, health plans, and research stakeholders will be engaged in all aspects of the research. Patients and other stakeholders will inform the process of implementation of patient-driven and standardized SMAs, help finalize the research protocol (including data collection and recruitment), and contribute to interpretation of findings and dissemination of findings, including messages that help other patients make decisions about whether or not to participate in SMAs.

Eligibility criteria: Inclusion Criteria:

* Patients must be:

  1. at least 18 years old,
  2. have Type II Diabetes, and
  3. receive care in a participating practice.
* For a practice to be eligible, they must be;

  1. a Federally Qualified Health Center,
  2. a private primary care practice, or
  3. Community Mental Health Center with primary care,
  4. They need to have

     1. a current panel of at least 150 adult patients with Type 2 Diabetes, and
     2. access to health educators, Behavioral Health Professionals, and diabetes peer mentors.

Exclusion Criteria:

* Are currently pregnant or plan to become pregnant in the next six months,
* Have limited cognitive ability due to dementia or a developmental disorder,
* Less than one year of life expectancy, or
* Plan to leave the area in the next year.

Primary outcomes:
measure: Diabetes Distress - Change in Patient Reported Outcomes (PROs)
timeFrame: At end of 6 group visits (time differs by practice, up to 6 months)
Secondary outcomes:
measure: Change in Patient HbA1c
timeFrame: At end of 6 group visits (time differs by practice, up to 6 months)
Other outcomes:
Locations:
city: Aurora
country: United States
facility: University of Colorado Anschutz Medical Campus
state: Colorado
Study officials:
affiliation: University of Colorado, Denver
name: Bethany Kwan, PHD, MSPH
role: PRINCIPAL_INVESTIGATOR
affiliation: University of Colorado, Denver
name: Jeanette Waxmonsky, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Holtrop JS, Gurfinkel D, Nederveld A, Phimphasone-Brady P, Hosokawa P, Rubinson C, Waxmonsky JA, Kwan BM. Methods for capturing and analyzing adaptations: implications for implementation research. Implement Sci. 2022 Jul 29;17(1):51. doi: 10.1186/s13012-022-01218-3.
citation: Glasgow RE, Gurfinkel D, Waxmonsky J, Rementer J, Ritchie ND, Dailey-Vail J, Hosokawa P, Dickinson LM, Kwan BM. Protocol refinement for a diabetes pragmatic trial using the PRECIS-2 framework. BMC Health Serv Res. 2021 Oct 2;21(1):1039. doi: 10.1186/s12913-021-07084-x.
citation: Dickinson LM, Hosokawa P, Waxmonsky JA, Kwan BM. The problem of imbalance in cluster randomized trials and the benefits of covariate constrained randomization. Fam Pract. 2021 Jun 17;38(3):368-371. doi: 10.1093/fampra/cmab007. No abstract available.
citation: Kwan BM, Dickinson LM, Glasgow RE, Sajatovic M, Gritz M, Holtrop JS, Nease DE Jr, Ritchie N, Nederveld A, Gurfinkel D, Waxmonsky JA. The Invested in Diabetes Study Protocol: a cluster randomized pragmatic trial comparing standardized and patient-driven diabetes shared medical appointments. Trials. 2020 Jan 10;21(1):65. doi: 10.1186/s13063-019-3938-7.