Using RE-AIM to Evaluate Encourage-2: A Cluster-randomized Trial in Rural Alabama Funded under the iADAPT Opportunity

Slide Presentation from the AHRQ 2011 Annual Conference

Slide 1

Monika M. Safford, MD
Universiry of Alabama at Birmingham

Using RE-AIM to Evaluate Encourage-2:
A cluster-randomized trial in rural Alabama funded under the iADAPT opportunity

September 19, 2011
AHRQ Annual Conference, 2011
iADAPT Grantee Session

Slide 2

Community Health Workers (CHW) to improve functioning in diabetes + chronic pain

Community Health Workers (CHW) to improve functioning in diabetes + chronic pain

Pain is common in diabetes:
- 60-80% persons with diabetes report chronic pain.
- Osteoarthritis (OA) most common cause.
Pain is a barrier to self-care.
Cluster-randomized controlled trial (RCT), rural Alabama:
- Participants: adults w. diabetes + chronic pain.
- Intervention:
  - CHW-delivered telephone + DVD.
  - Cognitive behavior training to maximize functioning despite pain.
  - Diabetes self �care.
  - Comparative Effectiveness Reviews (CERs): OA, diabetes; integrated into education/training program content.
- Outcomes: risk factors (A1c, BP, chol), functional status.

Slide 3

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Reach

Participation rates.
Representativeness among the sampling frame of patients with diabetes.

Strengths:

Telephonic delivery.

Challenges:

Community realities—"bring a neighbor".
Denominators.

Slide 4

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Reach

HIGH.

Slide 5

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Efficacy/Effectiveness:

Design: RCT.
Outcomes:
- Primary:
  Metabolic control (A1c, BP, chol).
  Functional status.
- Secondary:
  Self-care behaviors.
  Cost.

Strengths:

Community setting—representativeness/effectiveness.
One-on-one, potent intervention.
DVD component.

Challenges:

Community-member delivered—intervention fidelity.

Slide 6

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Effectiveness

MED-HIGH.

Slide 7

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Adoption:

More speculative (!).
Cost.
Requires new resources?

Strengths:

Low-cost.

Challenges:

No infrastructure to sustain program (Healthcare Reform?).

Slide 8

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Adoption

LOW (MED?).

Slide 9

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Implementation:

Low complexity: high.
Sustainable intervention fidelity: high.

Strengths:

Cultural concordance lowers complexity.
Telephone.

Challenges:

Community interventionists increase complexity.
Training needs.
Reliance on tenuous infrastructure (Healthcare Reform?).

Slide 10

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Implementation

LOW (MED?).

Slide 11

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Maintenance:

Individual:
- What is f/u?
- Do social networks form?
- Is tailoring required?
System:
- Does motivation for intervention reside in community-based organization?
- Outreach via telephone: low cost, flexible (reimbursement?).

Slide 12

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Maintenance:

Strengths:
- Social networks?
- Telephone delivery.
Challenges:
- No structure for sustained f/u (Healthcare Reform?).
- Motivation for intervention does not reside in community-based organization.

Slide 13

RE-AIM for iADAPT in Rural Alabama

RE-AIM for iADAPT in Rural Alabama
Reach—Effectiveness—Adoption—Implementation—Maintenance

Maintenance

MED.

Slide 14

RE-AIM for iADAPT?

RE-AIM for iADAPT?

	R	E	A	I	M	Audience(s)	Clinical Area(s)
In Person CHW Outreach Acad. Detailing	Med Med	Med Med	Low Low	Low Low	Low Med	Patient Provider	Diabetes Diabetes
Group CER Training School Group Therapy	Med High Low	Low Low Med	Med Med Med	Med Low Low	Med Low Med	Policy Patient Patient	Multiple Heart Disease Diabetes
eHealth Clinic Kiosk Web Patient Portal	Med Med	Med Med	Low Med	High High	Med High	Patient Patient & Provider	Diabetes Diabetes
Print/Media Targeted Video	Med	Med	Med	Med	Med	Patient	Heart Disease

Slide 15

RE-AIM for iADAPT?

RE-AIM for iADAPT?

	R	E	A	I	M	Audience(s)	Clinical Area(s)
In Person CHW Outreach Acad. Detailing	Med Med	Med Med	Low Low	Low Low	Low Med	Patient Provider	Diabetes Diabetes
Group CER Training School Group Therapy	Med High Low	Low Low Med	Med Med Med	Med Low Low	Med Low Med	Policy Patient Patient	Multiple Heart Disease Diabetes
eHealth Clinic Kiosk Web Patient Portal	Med Med	Med Med	Low Med	High High	Med High	Patient Patient & Provider	Diabetes Diabetes
Print/Media Targeted Video	Med	Med	Med	Med	Med	Patient	Heart Disease

Note: The row beginning "CHW Outreach" is circled.

Slide 16

RE-AIM for iADAPT?

RE-AIM for iADAPT?

	R	E	A	I	M
In Person *CHW Outreach*	Med	Med	Low	Low	Low
CHW Telephonic Outreach	High	Med (High?)	Low (Med?)	Low (Med?)	Med

Slide 17

RE-AIM for iADAPT?

RE-AIM for iADAPT?

CER's.
"Arm chair quarterbacking".
Comparison framework:
- e-VALUE-ation.
QALYs?

Current as of March 2012

Internet Citation: Using RE-AIM to Evaluate Encourage-2: A Cluster-randomized Trial in Rural Alabama Funded under the iADAPT Opportunity. March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/safford/index.html