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Income Patients With Diabetes: A Randomized Controlled Trial

Time:2019-01-06 04:03Turbochargers information Click:

with Income Patients Diabetes

This randomized controlled trial of clinic-based peer coaching for low-income, underserved patients with poorly controlled type 2 diabetes found a clinically important and statistically significant greater reduction in HbA1c levels in patients who received peer coaching compared with those in the usual care arm. Our results are consistent with the results from 2 prior studies of peer coaching, in veterans, who were almost entirely male. In the one negative randomized controlled trial of peer coaching, the coaches’ role was limited to reinforcing goals set by the patients’ physician, in contrast to the 2 positive studies and our study, which used patient-defined goals.

The results of the current study add to the growing body of support for the effectiveness of peer coaching in improving glycemic control for patients with type 2 diabetes. Peer coaching was accepted by a large proportion of patients in this safety-net population, as well as by clinicians and clinic staff. Whether peer coaching would be as acceptable outside a veterans’ or a public clinic population remains to be shown, but there does not appear to be any reason it would not. The generalizability of peer coaching to other chronic diseases is not known. Most studies of peer support have focused on patients with diabetes. Given that issues typically addressed in action plans for patients with diabetes are relevant to most chronic conditions, it seems likely that peer coaching could be effective for patients with such chronic conditions as hypertension, asthma or congestive heart failure. Many important aspects of peer coaching remain to be studied, including patients’ experience with and preferences for peer coaching and how peer coaches can be more integrated into the health care team.

Perhaps the single most important question is how peer coaching can be supported outside research studies. Although peers coaches are generally volunteers, they need training and some level of supervision. Most peers receive reimbursement for costs and some financial incentive. Reducing these costs would likely increase coach turnover and impair the effectiveness of the program. Moreover, successful coaching to improve patient self-management may not decrease costs in the short run, as patients are encouraged to take their medication as prescribed, get appropriate tests and preventive services, and have regular follow-up with their clinician.

Some potential benefits, such as reducing time needed by clinic staff to support patient self-management, are difficult to quantify. Other benefits, such as fewer emergency department visits, a lower no-show rate for appointments, or fewer complications from poorly controlled diabetes, may not outweigh the costs of increased medications. Long-term benefits from improved glycemic control can be calculated, but are most relevant to payers and providers who pay for costs for the same patients over a long period. Nonetheless, peer coaching appears to improve glycemic control and can take the pressure off the primary care clinicians and staff to provide support for patient self-management.

The findings from the current study should be considered in the context of study’s limitations. We chose to conduct the study with a diverse group of underserved patients who had poorly controlled diabetes because they represent a population at higher risk for diabetic complications and may have difficulty accessing medical care. We do not know to what extent our results will generalize to other populations, such as middle-class white patients or patients with better diabetes control. Baseline HbA1c was measured, on average 1 month and up to 6 months before enrollment for some patients. Timing did not differ between study arms, however, and would be unlikely to bias the results. Because patients receiving peer coaching and those receiving usual care were seen at the same clinics, and often by the same clinicians, it is possible that the presence of peer coaching influenced (contaminated) the usual care group. Such an effect would be expected to make the groups more alike and make it more difficult to show a difference between groups. Our follow-up ended at 6 months; thus, we do not know whether the impact of coaching on diabetes control will diminish with time.

Patients are generally not considered as potential resources available to increase primary care capacity. The peer-coaching model creates a structure whereby volunteer peer coaches contribute to the work of primary care teams by providing one-on-one self-management support to patients. Our study shows that clinic-based peer coaches can take on this role in low-income communities and that peer coaching, when compared with usual care conducted in the same clinics, is associated with a significant improvement in patients’ glycemic control.

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