Fidelity Observations of Diabetes Shared Medical Appointments for the Invested in Diabetes Pragmatic Trial

DENNIS GURFINKEL, MPH
University of Colorado

The Invested in Diabetes study is a comparative-effectiveness pragmatic trial comparing two diabetes shared medical appointment (SMA) delivery models (standardized [STD] vs patient-driven [PTD]). PTD SMAs use the same skills-building curriculum as the STD SMAs but include peer mentors and behavioral health providers (BHPs) as part of a multidisciplinary team, and allow patients to select topic order and emphasis. We hypothesized these features would yield increased patient engagement, evidenced by better attendance, and psychological needs support (autonomy, competence, and relatedness) as defined by self-determination theory (SDT) in the PTD arm. We also explored if greater demands of the PTD practices would result in lower fidelity to protocol.

21 primary care practices in CO and MO.

Trained observers observed approximately 8% of randomly selected SMAs using a structured template. SMA facilitators’ overall skill and style (didactic vs discussion) and fidelity to SDT core constructs (autonomy, competence, relatedness support) were graded on 5-point bipolar scales (low to high on skill, discussion, and support). Observers also reported on elements of protocol fidelity (time spent, personnel included, and use of curriculum). Practice attendance sheets were reviewed for patient attendance and personnel scheduled. We report results of 67 observed SMAs (37 STD, 30 PTD) and 147 cohorts (72 STD, 75 PTD). Descriptive statistics and t-tests assessed differences overall and between conditions.

Facilitators across both conditions demonstrated high support for autonomy (M=4.34), competence (M=4.55), and relatedness (M=4.60) overall. Facilitation skills were generally very good (M=3.86) and style was a balance of didactic and discussion (M=2.73). Results were not significantly different between study conditions. Both PTD and STD spent less time than expected on sessions (94min PTD vs. 88min STD out of 120min, p=.274), and covered a similar amount of the curriculum (86.7% PTD vs. 83.3% STD, p=.712). Attendance did not differ between PTD and STD (4.90 PTD vs. 4.96 STD of 6 sessions attended, p=.589). PTD classes had a BHP assigned in 81% of cohorts and a peer mentor assigned at 93% of cohorts (vs. 0 for both for STD). However, peer mentors were present at 53.3% of PTD sessions and 2% of STD sessions observed. BHPs were not required to be at each session so similar comparison could not be made.

Existing primary care personnel trained to deliver diabetes SMAs using a skills-building curriculum demonstrated excellent support for SDT-related psychological needs – with little observed difference in facilitation style or needs support between SMA delivery models and personnel types involved. Increased patient-focused features in the PTD protocol did not increase psychological needs support observed or patient attendance, but some issues with fidelity to protocol regarding personnel was show