Original Research
A Randomized Trial
Michele Heisler, MD, MPA; Sandeep Vijan, MD, MS; Fatima Makki, MPH; and John D. Piette, PhD
+ Author Affiliations
From the University of Michigan and Ann Arbor Veterans Affairs Health Care System, Ann Arbor, Michigan.
Abstract
Background: Resource barriers complicate diabetes care management. Support from peers may help patients manage their diabetes.
Objective: To compare a reciprocal peer-support (RPS) program with nurse care management (NCM).
Design: Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00320112)
Setting: 2 U.S. Department of Veterans Affairs health care facilities.
Patients: 244 men with hemoglobin A1c (HbA1c) levels greater than 7.5% during the previous 6 months.
Measurements: The primary outcome was 6-month change in HbA1c level. Secondary outcomes were changes in insulin therapy; blood pressure; and patient reports of medication adherence, diabetes-related support, and emotional distress.
Intervention: Patients in the RPS group attended an initial group session to set diabetes-related behavioral goals, receive peer communication skills training, and be paired with another age-matched peer patient. Peers were encouraged to talk weekly using a telephone platform that recorded call occurrence and provided reminders to promote peer contact. These patients could also participate in optional group sessions at 1, 3, and 6 months. Patients in the NCM group attended a 1.5-hour educational session and were assigned to a nurse care manager.
Results: Of the 244 patients enrolled, 216 (89%) completed the HbA1c assessments and 231 (95%) completed the survey assessments at 6 months. Mean HbA1c level decreased from 8.02% to 7.73% (change, −0.29%) in the RPS group and increased from 7.93% to 8.22% (change, 0.29%) in the NCM group. The difference in HbA1c change between groups was 0.58% (P = 0.004). Among patients with a baseline HbA1c level greater than 8.0%, those in the RPS group had a mean decrease of 0.88%, compared with a 0.07% decrease among those in the NCM group (between-group difference, 0.81%; P < 0.001). Eight patients in the RPS group started insulin therapy, compared with 1 patient in the NCM group (P = 0.020). Groups did not differ in blood pressure, self-reported medication adherence, or diabetes-specific distress, but the RPS group reported improvement in diabetes social support. Limitation: The study included only male veterans and lasted only 6 months. Conclusion: Reciprocal peer support holds promise as a method for diabetes care management. Primary Funding Source: U.S. Department of Veterans Affairs Health Services Research and Development Service. Article and Author Information Acknowledgment: The authors thank the very dedicated U.S. Department of Veterans Affairs (VA) nurse care managers Debra Beaulieu, Marion Cooper, Joanne Donovan, Kelly Johnston, Jacqueline Hurd, Wendy Morrish, Joe Pawelezyke, Carol Peterson, Ken Sizemore, Diane Sobecki-Ryniak, and other VA care managers, who participated in this intervention as part of their work assignments; VA clinical leaders Denise Ramsey, Jennifer Walch, Adam Tremblay, Thomas Gross, and Susan Meade; Barbara Stanislawski and Jennifer Burgess, who successfully conducted all patient recruitment and helped with facilitation and successful execution of the group sessions and with data collection; Martha Funnell and Mary Lou Gillard, who provided initial training to the VA nurse care managers in group facilitation, assisted in the creation of the peer partner workbooks, and documented intervention fidelity through periodic observation of group sessions; and Mary Rogers, PhD, for her technical assistance with study design and analysis. Grant Support: By the U.S. Department of Veterans Affairs Health Services Research and Development Service (grant IIR 04-239), the Michigan Diabetes Research and Training Center (National Institutes of Health [NIH] grant 5P60-DK20572), the Robert Wood Johnson Foundation Clinical Scholars Program, and the Michigan Institute for Clinical and Health Research (NIH grant UL1RR024986). Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1144. Reproducible Research Statement: Study protocol, statistical code, and data set: Available from Dr. Heisler (e-mail, mheisler@umich.edu). Data set will be deidentified. Requests for Single Reprints: Michele Heisler, MD, MPA, University of Michigan Medical School/Veterans Affairs Ann Arbor Health System, Box 130170, MS 152, Ann Arbor, MI 48113-0170; e-mail, mheisler@umich.edu. Current Author Addresses: Drs. Heisler, Vijan, and Piette and Ms. Makki: University of Michigan Medical School/Veterans Affairs Ann Arbor Health System, Box 130170, MS 152, Ann Arbor, MI 48113-0170. Author Contributions: Conception and design: M. Heisler, S. Vijan, J.D. Piette. Analysis and interpretation of the data: M. Heisler, S. Vijan, F. Makki, J.D. Piette. Drafting of the article: M. Heisler, J.D. Piette. Critical revision of the article for important intellectual content: M. Heisler, S. Vijan, J.D. Piette. Final approval of the article: M. Heisler, S. Vijan, J.D. Piette. Provision of study materials or patients: F. Makki. Statistical expertise: S. Vijan, J.D. Piette. Obtaining of funding: M. Heisler, J.D. Piette. Administrative, technical, or logistic support: M. Heisler, F. Makki. Collection and assembly of data: M. Heisler, F. Makki, J.D. Piette.
