EFFECTS OF SELF-MANAGEMENT SUPPORT ON STRUCTURE, PROCESS AND OUTCOMES AMONG VULNERABLE PATIENTS WITH DIABETES: A 3-ARM PRACTICAL CLINICAL TRIAL

Abstract

Objective: Despite the importance of self-management support (SMS), few studies compare SMS interventions, involve diverse populations, or entail implementation in safety net settings. We examined effects of 2 SMS strategies across outcomes corresponding to the Chronic Care Model.

Research design and methods: 339 outpatients with poorly-controlled diabetes from county-run clinics were enrolled in a 3-arm trial. Participants, > half of whom spoke limited English, were uninsured, and/or < high school education, were randomized to usual care (UC), 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, metabolic).

Results: Compared to UC, ATSM and GMV reported improvements in PACIC, with effect sizes (ES) of 0.48 and 0.50, respectively (P<.01). Only ATSM reported improvements in IPC (ES 0.40 vs. UC; 0.25 vs. GMV, P<.05). Both SMS arms reported improvements in self-management behavior vs. UC (P<.05), with gains greater for ATSM vs. GMV (ES 0.27, P=.02). ATSM reported fewer bed days/month vs. UC (−1.7 days, P=.05) and vs. GMV (−2.3 days, P<.01), and less interference with daily activities than UC (OR 0.37, P=.02). We observed no differences in HbA1c change.

Conclusions: Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM appears to be a more effective communication vehicle than GMV in improving behavior and quality of life.