Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes

Heisler, Michele; Simmons, David; Piatt, Gretchen

doi:10.1016/j.ecl.2021.07.010

Cited by 4 publications

(7 citation statements)

References 116 publications

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“…Using mobile health applications to improve T2D care outcomes has been explored extensively with promising results mainly in high-income settings [ 13 , 55 – 57 ]. The large majority of digitally supported T2D interventions have used tools directly addressed to patients providing educational content, behavioural interventions, or remote consultations by healthcare professionals [ 56 – 58 ].…”

Section: Discussionmentioning

confidence: 99%

Community-based type 2 diabetes care by lay village health workers in rural Lesotho: protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

Gerber,

Gupta,

Lejone

et al. 2023

Trials

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Background Type 2 diabetes (T2D) poses a growing public health burden, especially in low- and middle-income countries (LMICs). Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems (CDSS) are promising approaches to tackle the current T2D care gap in LMICs. However, evidence on the effectiveness of lay worker-led T2D care models, in which VHWs initiate and monitor drug treatment in addition to community-based screening and referral services, is lacking. Methods We are conducting a cluster-randomized trial nested within the Community-Based Chronic Disease Care Lesotho (ComBaCaL) cohort study (NCT05596773) using the trial within cohort (TwiC) design to assess the effectiveness of a VHW-led, CDSS-assisted T2D care model in rural Lesotho. Participants are non-pregnant members of the ComBaCaL cohort study with T2D. The ComBaCaL cohort study is conducted in approximately 100 villages in two rural districts in Lesotho and is managed by trained and supervised VHWs. In intervention villages, VHWs offer a community-based T2D care package including lifestyle counselling, first-line oral antidiabetic, lipid-lowering, and antiplatelet treatment guided by a tablet-based CDSS to participants who are clinically eligible, as well as treatment support to participants who prefer or clinically require facility-based T2D care. In control clusters, all participants will be referred to a health facility for T2D management. The primary endpoint is the mean glycosylated haemoglobin (HbA1c) 12 months after enrolment. Secondary endpoints include the 10-year risk for cardiovascular events estimated using the World Health Organization risk prediction tool. Discussion The trial was launched on May 13, 2023, and has enrolled 226 participants at the date of submission (October 6, 2023). To our knowledge, the trial is the first to assess task-shifting of T2D care to VHWs at the community level, including the prescription of first-line antidiabetic, lipid-lowering, and antiplatelet medication in sub-Saharan Africa, and will thus provide the missing evidence on the effectiveness of such a T2D care model in this setting. The study is operating within the established Lesotho VHW programme. Similar community health worker programmes which exist across sub-Saharan Africa may benefit from the findings. Trial registration ClinicalTrials.gov NCT05743387. Registered on February 24 2023.

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Section: Discussionmentioning

confidence: 99%

Community-based type 2 diabetes care by lay village health workers in rural Lesotho: protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

Gerber,

Gupta,

Lejone

et al. 2023

Trials

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“…Moreover, they provide more nonreimbursed team-based care, which is poorly represented in studies relying on payer data. [37][38][39] To our knowledge, no studies have assessed the impact of PHE-related telehealth implementation on the quantity of patient-health care team encounters overall. In this study, we evaluate rates of change in both visits and between-visit interactions among patients with diabetes with multiple health care team members in 2 health systems with different telehealth implementations.…”

Section: Introductionmentioning

confidence: 99%

“…Safety-net systems serve a disproportionate share of disadvantaged patients who face barriers to digital health uptake. Moreover, they provide more nonreimbursed team-based care, which is poorly represented in studies relying on payer data …”

Section: Introductionmentioning

confidence: 99%

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation

Nouri,

Lyles,

Sherwin

et al. 2023

JAMA Netw Open

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ImportanceTelehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient–clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions.ObjectiveTo evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics.Design, Setting, and ParticipantsThis retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed.ExposureTelehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021).Main Outcomes and MeasuresThe main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES).ResultsOf 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P &lt; .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03).Conclusions and RelevanceIn this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.

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“…Capacitating lay village health workers (VHWs) to deliver essential services at the community level is a promising approach to improve access to and outcomes of diabetes care in LMICs (11)(12)(13)(14)(15)(16), especially in sub-Saharan Africa, where most health systems face a substantial shortage of professional healthcare workforce (17). Screening, education and self-management support interventions by VHWs at the community level have been tested successfully, but it remains unclear whether such interventions are su ciently effective and scalable to close the existing treatment gap (10,13,15,18,19).…”

Section: Introductionmentioning

confidence: 99%

“…14,[55][56][57]. The large majority of digitally supported T2D interventions have used tools directly addressed to patients providing educational content, behavioural interventions or remote consultations by healthcare professionals (56-58).…”

mentioning

confidence: 99%

Community-based type 2 diabetes care by lay village health workers in rural Lesotho Protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

Gerber,

Gupta,

Lejone

et al. 2023

Preprint

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Background Type 2 diabetes (T2D) poses a growing public health burden, especially in low- and middle-income countries (LMICs). Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems (CDSS) are promising approaches to tackle the current T2D care gap in LMICs. However, evidence on the effectiveness of lay worker-led T2D care models, in which VHWs initiate and monitor drug treatment in addition to community-based screening and referral services, is lacking. Methods We are conducting a cluster-randomized trial nested within the ComBaCaL (Community-Based Chronic Disease Care Lesotho) cohort study (NCT05596773) using the trial within cohort (TwiC) design to assess the effectiveness of a VHW-led, CDSS-assisted T2D care model in rural Lesotho. Participants are non-pregnant members of the ComBaCaL cohort study with T2D. The ComBaCaL cohort study is conducted in approximately 100 villages in two rural districts in Lesotho and is managed by trained and supervised VHWs. In intervention villages, VHWs offer a community-based T2D care package including lifestyle counselling, first-line oral antidiabetic, lipid-lowering, and antiplatelet treatment guided by a tablet-based CDSS to participants who are clinically eligible, as well as treatment support to participants who prefer or clinically require facility-based T2D care. In control clusters, all participants will be referred to a health facility for T2D management. The primary endpoint is the mean glycosylated haemoglobin (HbA1c) 12 months after enrolment. Secondary endpoints include the 10-year risk for cardiovascular events estimated using the World Health Organisation risk prediction tool. Discussion The trial was launched on May 13, 2023, and has enrolled 194 participants at the date of submission (August 9, 2023). To our knowledge, the trial is the first to assess task-shifting of T2D care to VHWs at community level, including the prescription of first-line antidiabetic, lipid-lowering, and antiplatelet medication in sub-Saharan Africa, and will thus provide the missing evidence on the effectiveness of such a T2D care model in this setting. The study is operating within the established Lesotho VHW program. Similar community health worker programs which exist across sub-Saharan Africa may benefit from the findings. Trial registration The trial has been registered on clinicaltrials.gov (NCT05743387; February 24 2023).

show abstract

Update on Approaches to Improve Delivery and Quality of Care for People with Diabetes

Cited by 4 publications

References 116 publications

Community-based type 2 diabetes care by lay village health workers in rural Lesotho: protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

Community-based type 2 diabetes care by lay village health workers in rural Lesotho: protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation

Community-based type 2 diabetes care by lay village health workers in rural Lesotho Protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

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