Comparative Effectiveness of Two Approaches to Diabetes Management in the Uninsured

Comparative Effectiveness of Two Community Based Diabetes Management Approaches

The results of the pre-pilot and pilot studies will be used to determine the feasibility of a fully powered trial that will test the effectiveness of two different approaches to diabetes management in an uninsured diabetic population who receives their care from a community based free clinic, namely nurse-directed interdisciplinary care management compared to peer-led self management. Effective programs for the uninsured diabetic will benefit both the individual and society by preventing serious illness, decreasing mortality and disability, decreasing medical debt, stimulating economic growth, improving business productivity, reducing job lock, decreasing health disparities, improving quality of life, and reducing cost shifting by decreasing uncompensated care. Findings will be generalizable to uninsured and insured patients across a wide spectrum of chronic conditions.

Study Overview

• Status: Completed
• Conditions: Diabetes
• Intervention / Treatment: Other: nurse-led care management or peer-led self management

Detailed Description

The randomized pre-pilot and pilot studies will inform the design of a fully powered trial that will test the effectiveness of a nurse-led interdisciplinary care management intervention (CM) for improving hemoglobin A1c in uninsured diabetic patients who receive their primary medical care from a community-based free clinic compared to similar patients who undergo peer-led self management (SM). The comparative effectiveness of these approaches has not been tested in a randomized trial.

To ensure the success of the pilot study the investigators will perform a 6 month pre-pilot study using 10 patients per group. This pre-pilot will be used to establish protocols covering enrollment, HIPAA, consent, interventions and outcome measurement. The subsequent 1 year pilot will be used to demonstrate feasibility, estimate recruitment, attendance and follow up, refine inclusion criteria, provide power analysis, optimize the interventions and determine appropriate secondary outcomes for a fully powered trial. For the pilot, thirty patients will be randomized to the CM intervention for the first 6 months. Major components of the nurse-led CM model include: 1) assessment and goal setting for self-management; 2) education for self efficacy and productive clinical encounters; 3) access to specialist care via an interdisciplinary team; 4) evidence-based treatment recommendations responsive to patients' goals; and 5) care coordination by a nurse care manager. From 6-12 months patients will return to usual clinic care.

The 30 patients randomized to the SM group will be invited to attend weekly peer-led SM training broadly based on the Stanford University Diabetes Self-management Program's Train the Trainer Model. The training will occur over 6 weeks and will cover topics common to most chronic disease SM programs including: goal setting, self-management of chronic conditions, making action plans, feedback and problem solving, handling emotions, symptom management techniques, communication with health care providers, medications and making treatment decisions. The peer advisors and a nurse will then lead 1 hour monthly group sessions for the remainder of the first 6 months for review/revision of action plans, review of self management techniques and ongoing social persuasion and modeling. From 6-12 months patients will return to usual clinic care.

For the pilot, outcome measures will be obtained at 6 and 12 months. For this pilot, the investigators will not test any hypotheses. Instead, effect sizes and confidence intervals will be calculated for each outcome. These results will be used for power analysis. The results will also allow us to see which interventions are most effective on which outcomes and allow us to optimize the interventions to have the greatest impact on the primary outcome, hemoglobin A1c. Cost effectiveness will be determined in a fully powered trial.

• Study Type: Interventional
• Enrollment (Actual): 64
• Phase: Not Applicable

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 25 years to 75 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• patients will be eligible if they are between the ages of 25 and 75,
• have a diagnosis of diabetes (type II) with a hemoglobin A1c >[7.0] There will be no exclusions based on gender, race or ethnicity.

Exclusion Criteria:

• have no other illness that would dominate their care (e.g., terminal cancer, numerous exacerbations of CHF), and
• are not pregnant.
• patients must have no cognitive impairment.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Nurse-led care management; Nurse-led care management involves a nurse care manager who performs a comprehensive assessment of the patient then presents those assessment findings to an interdisciplinary team. The team makes care recommendations that are implemented by the care manager in collaboration with the patient's PCP.	Other: nurse-led care management or peer-led self management
Experimental: peer-led self managment; Peer-led self management follows the chronic disease self management model where peer counselors lead self management classes for 6 weeks, then conduct monthly support groups	Other: nurse-led care management or peer-led self management

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
hemoglobin A1c	change from baseline at 6 months for pre-pilot and change from baseline at 6 months and change from baseline at 12 months for pilot

Collaborators and Investigators

• Sponsor: Summa Health System
• Collaborators: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); Ohio State University
• Investigators: Principal Investigator: Edward D Scott, MD, Summa Health System

Study record dates

Study Major Dates

• Study Start: August 1, 2011
• Primary Completion (Actual): April 1, 2015
• Study Completion (Actual): April 1, 2015

Study Registration Dates

• First Submitted: July 20, 2012
• First Submitted That Met QC Criteria: July 27, 2012
• First Posted (Estimate): July 31, 2012

Study Record Updates

• Last Update Posted (Estimate): July 20, 2015
• Last Update Submitted That Met QC Criteria: July 16, 2015
• Last Verified: July 1, 2015

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Endocrine System Diseases; Diabetes Mellitus
• Other Study ID Numbers: shs250014; 1R03DK090351-01 (U.S. NIH Grant/Contract)