Objective
Recent studies have documented the powerful impact of how the emotional side of diabetes, called “diabetes distress,” (DD) affects diabetes management and quality of life among adults with type 1 diabetes. Although the development and use of structured patient reported outcome (PRO) DD assessment and intervention to reduce DD among adults with type 1 diabetes has been highly encouraged by the ADA, NCQA and other professional organizations, little effort has been devoted to helping clinicians make good clinical use of the DD PRO data collected in time-efficient and effective ways. Our study directly determines the added benefit of a more intensive clinical training and implementation program to support DD intervention, compared to a more basic, less time consuming and less costly training program. This is information will be crucial as DD assessment and intervention is expanded into real-world diabetes care.
Background Rationale
Diabetes distress (DD) refers to the often hidden emotional burdens, stresses, and worries that are part of managing a demanding, progressive, chronic disease like type 1 diabetes. Elevated DD is common (as high as 42% of adults with type 1 diabetes in community settings) and is linked with challenges in diabetes management (including HbA1c and time in range) and quality of life among adults with type 1 diabetes. Without intervention, DD remains relatively constant over time with its effects, becoming chronic. Conversely, a growing literature not only suggests that DD decreases with intervention, but that reductions in DD have led to improvements in glycemic-management and medication use. Thus, efforts to systematically identify, address and reduce DD in clinical care can improve diabetes outcomes.
The American Diabetes Association published guidelines promoting screening for and addressing DD as a critical part of clinical care. Multiple studies from our lab and others have tested standardized screening/assessment instruments for DD and controlled intervention studies in research settings have demonstrated dramatic reductions in DD. However, in real world clinical settings less than one-quarter of adults with diabetes report their health care team asked them how diabetes affected their lives and far fewer currently receive DD screening and assistance or follow-up. Thus, although DD is an important problem to be addressed in clinical care, and although there are well-validated clinical tools for its assessment, there is a significant knowledge gap in how to make use of these tools in care settings and then, how to use the assessment data to intervene clinically to reduce DD.
Clinics often require assistance integrating new programs into clinical operations, however at present it is not clear what kinds of systematic programs are necessary to introduce and maintain DD assessment and intervention as part of clinical care over time. In this application we seek to build upon our existing evidence-based interventions by implementing them in diabetes specialty clinic real world settings and compare two pragmatic interventions to each other: (1) DD-ASSIST, a “low-touch” virtual program to train diabetes health professionals to assess for DD with guideline-based screening/assessment to train diabetes health care professionals and intervention methods through a time-limited, training program and (2) DD-ASSIST+, which adds personalized clinical skill building and program implementation support through practice coaching to integrate DD assessment and intervention into staff roles and clinical workflows.
Description of Project
Recent studies have documented the powerful impact of how the emotional side of diabetes, called “diabetes distress,” (DD) affects diabetes management and quality of life among adults with type 1 diabetes. Although the development and use of structured patient reported outcome (PRO) DD assessment and intervention to reduce DD among adults with type 1 diabetes has been highly encouraged by the ADA, NCQA and other professional organizations, little effort has been devoted to helping clinicians make good clinical use of the DD PRO data collected in time-efficient and effective ways. Clinics often require assistance integrating new programs into clinical operations, however at present it is not clear what kinds of systematic programs are necessary to introduce and maintain DD assessment and intervention as part of clinical care over time. The proposed research evaluates the impact of two systematic strategies for training and implementing DD screening and treatment interventions into real-world diabetes specialty clinic settings: (1) DD-ASSIST, to train diabetes health care professionals to assess for DD with guideline-based screening/assessment tools and intervention methods through a time-limited, virtual training program and (2) DD-ASSIST+, which adds clinician-focused clinical skill building and practice implementation support to enhance DD assessment and intervention skills, and to integrate DD assessment and assistance into clinical roles and clinic workflows. Given the need to include DD assessment and intervention into routine clinical care, our study design allows us to directly determine the added benefit of a more intensive clinical training and implementation program to support DD intervention, compared to a more basic, less time consuming and less costly training program. This is information will be crucial as DD assessment and intervention is expanded into real-world diabetes care. To maximize the generalizability of our findings, we will compare program effectiveness of DD-ASSIST to DD-ASSIST+ while at the same time gathering information on program reach, adoption, implementation and maintenance for each intervention arm. The results will provide much needed information to help incorporate DD assessment and intervention programs into clinical care for adults with type 1 diabetes.
Anticipated Outcome
Anticipated Outcomes of the proposed study:
1. To understand the added benefit (if any) of a high intensity clinical training and implementation support program (DD-ASSIST+) compared to a lower intensity DD clinician training program (DD-ASSIST); providing timely evidence to inform future DD program spread and maintenance where there is great need.
2. Provides insights into real world T1D specialty care DD assessment and intervention implementation and workflows to inform dissemination and sustainability work.
3. Estimates of the cost for both clinic interventions (DD-ASSIST and DD-ASSIST+) and costs relative to the patient and implementation outcomes to inform dissemination and sustainability work.
Relevance to T1D
We know that diabetes distress (DD) interventions are effective in improving outcomes for patients with type 1 diabetes. We also know that many specialty care practices are increasingly interested in assessing for and addressing DD. What we now need are effective strategies for implementing DD assessment and interventions in these practices. We propose to evaluate the impact of a time- and potentially cost-efficient virtual DD training program (DD-ASSIST) compared to the impact of a higher touch DD clinical skills training with practice coaching to enhance the program implementation (DD-ASSIST+). The proposed research is the first study to test a DD intervention in the real world of diabetes specialty care and uses a comprehensive evaluation framework to examine both intervention effectiveness and implementation. Study findings will provide us with an understanding of how to proceed in program spread, dissemination and sustainability to bring DD assessment and assistance to specialty care and bring the emotional side of diabetes into diabetes care.