Margaret A. Handley

Goal-setting for behavior change in primary care: An exploration and status report

OBJECTIVE This paper explores the behavior change method of goal-setting and reviews the literature on goal-setting in primary care for patients with chronic conditions. METHODS A literature search was conducted resulting in eight articles meeting the criteria of goal-setting interventions in primary care for adults or adolescents with chronic conditions. RESULTS Hypotheses are advanced that goal-setting is generally conducted by collaboratively working with patients to set short-term and specific goals, with follow-up to provide feedback to patients. The articles reviewed generally confirmed these hypotheses. This review did not focus on clinical outcomes, but on the processes of engaging patients in goal-setting discussions. CONCLUSION Evidence that goal-setting is superior to other behavior change methods has not been shown. Since goal-setting is being utilized as a behavior change technique in many primary care sites, primary care practices can benefit from information on how best to implement this innovation. PRACTICE IMPLICATIONS Generally, clinicians are minimally involved in goal-setting discussions with their patients. Engaging patients in goal-setting can be done with interactive computer programs and non-clinical members of the primary care team.

Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial.

OBJECTIVE Despite the importance of self-management support (SMS), few studies have compared SMS interventions, involved diverse populations, or entailed implementation in safety net settings. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model. RESEARCH DESIGN AND METHODS A total of 339 outpatients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial. Participants, more than half of whom spoke limited English, were uninsured, and/or had less than a high school education, were randomly assigned to usual care, interactive weekly automated telephone self-management support with nurse follow-up (ATSM), or monthly group medical visits with physician and health educator facilitation (GMV). We measured 1-year changes in structure (Patient Assessment of Chronic Illness Care [PACIC]), communication processes (Interpersonal Processes of Care [IPC]), and outcomes (behavioral, functional, and metabolic). RESULTS Compared with the usual care group, the ATSM and GMV groups showed improvements in PACIC, with effect sizes of 0.48 and 0.50, respectively (P < 0.01). Only the ATSM group showed improvements in IPC (effect sizes 0.40 vs. usual care and 0.25 vs. GMV, P < 0.05). Both SMS arms showed improvements in self-management behavior versus the usual care arm (P < 0.05), with gains being greater for the ATSM group than for the GMV group (effect size 0.27, P = 0.02). The ATSM group had fewer bed days per month than the usual care group (−1.7 days, P = 0.05) and the GMV group (−2.3 days, P < 0.01) and less interference with daily activities than the usual care group (odds ratio 0.37, P = 0.02). We observed no differences in A1C change. CONCLUSIONS Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life.

Cost-Effectiveness of Automated Telephone Self-Management Support With Nurse Care Management Among Patients With Diabetes

PURPOSE This study evaluated the cost-effectiveness of an automated telephone self-management support with nurse care management (ATSM) intervention for patients with type 2 diabetes, which was tested among patients receiving primary care in publicly funded (safety net) clinics, focusing on non-English speakers. METHODS We performed cost analyses in the context of a randomized trial among primary care patients comparing the effects of ATSM (n = 112) and usual care (n = 114) on diabetes-related outcomes in 4 San Francisco safety net clinics. ATSM uses interactive phone technology to provide surveillance, patient education, and one-on-one counseling, and was implemented in 3 languages for a 9-month period. Cost utility was examined using quality-adjusted life-years (QALYs) derived from changes in scores on the 12-Item Short Form Health Survey. We also examined cost-effectiveness for costs associated with a 10% increase in the proportion of patients meeting diabetes-specific public health goals for increasing exercise, as recommended by Healthy People 2010 and the American Diabetes Association. RESULTS The annual cost of the ATSM intervention per QALY gained, relative to usual care, was

Quasi-experimental designs in practice-based research settings: design and implementation considerations.

65,167 for start-up and ongoing implementation costs combined, and

Seeing in 3-D: Examining the Reach of Diabetes Self-Management Support Strategies in a Public Health Care System

32,333 for ongoing implementation costs alone. In sensitivity analyses, costs per QALY ranged from

A framework for training health professionals in implementation and dissemination science.

29,402 to

Practice-based Research is Community Engagement

72,407. The per-patient cost to achieve a 10% increase in the proportion of intervention patients meeting American Diabetes Association exercise guidelines was estimated to be

HIV infection among women in prison: an assessment of risk factors using a nonnominal methodology.

558 when all costs were considered and

Globalization, Binational Communities, and Imported Food Risks: Results of an Outbreak Investigation of Lead Poisoning in Monterey County, California

277 when only ongoing costs were considered. CONCLUSIONS The ATSM intervention for diverse patients with diabetes had a cost utility for functional outcomes similar to that of many other accepted interventions targeted at diabetes prevention and treatment, and achieved public health physical activity objectives at modest costs. Because a considerable proportion of costs were fixed, cost-utility and cost-effectiveness estimates would likely be substantially improved in a scaled-up ATSM program.

Use of an Interactive, Telephone-based Self-management Support Program to Identify Adverse Events Among Ambulatory Diabetes Patients

Background: Although randomized controlled trials are often a gold standard for determining intervention effects, in the area of practice-based research (PBR), there are many situations in which individual randomization is not possible. Alternative approaches to evaluating interventions have received increased attention, particularly those that can retain elements of randomization such that they can be considered “controlled” trials. Methods: Methodological design elements and practical implementation considerations for two quasi-experimental design approaches that have considerable promise in PBR settings – the stepped-wedge design, and a variant of this design, a wait-list cross-over design, are presented along with a case study from a recent PBR intervention for patients with diabetes. Results: PBR-relevant design features include: creation of a cohort over time that collects control data but allows all participants (clusters or patients) to receive the intervention; staggered introduction of clusters; multiple data collection points; and one-way cross-over into the intervention arm. Practical considerations include: randomization versus stratification, training run in phases; and extended time period for overall study completion. Conclusion: Several design features of practice based research studies can be adapted to local circumstances yet retain elements to improve methodological rigor. Studies that utilize these methods, such as the stepped-wedge design and the wait-list cross-over design, can increase the evidence base for controlled studies conducted within the complex environment of PBR.