DENNIS GURFINKEL, MPH
University of Colorado

Pragmatic trials examine effectiveness of health interventions in real-world settings. To enhance relevance and scalability, interventions can be delivered by existing healthcare practice personnel, necessitating implementation strategies such as staff training. Invested in Diabetes is a pragmatic trial of two models of diabetes shared medical appointments (SMA) delivered in primary care settings. SMAs are delivered by care teams including health educators, behavioral health specialists, peer mentors, and providers with prescribing privileges. This abstract describes SMA care team training content, resources, evaluations, and adaptations.

Practice staff and peer mentors recruited to deliver SMAs at 21 primary care sites.

Health educators and behavioral health specialists participated in a 6-hour SMA facilitator training to learn about the project protocols, assigned SMA model, group facilitation skills, and SMA curriculum. Peer mentors participated in a 4-hour training adapted from materials from Peers for Progress; some participated in the general SMA facilitator training. Providers participated in one-hour “lunch & learns.” Training events were summarized via agendas and notes. Adaptations, including number of trainings, content, and style, were documented. Satisfaction surveys were collected after facilitator trainings.

There were 26 facilitator, 9 peer mentor and 13 provider trainings delivered to a total of 166 individuals across 22 practices from 2018-2021. Initially, trainings were held in-person; virtual and hybrid trainings were introduced for those with travel barriers and/or pandemic restrictions. Trainee satisfaction was high in both in-person and virtual delivery, while virtual delivery was easier to schedule and reduced travel time/expenses. Based on satisfaction surveys, trainings began incorporating facilitation techniques and role play rather than just intervention protocol and curriculum. The role of the main trainer changed from investigators to research assistants; the number of research staff present at trainings varied between 4 in earlier iterations to 1-2 later iterations. A total of ~412 hours of research staff time was used for trainings.

Pragmatic trialists should plan for adequate effort and resources to train practice personnel in delivery of an intervention. Notably, plan to offer trainings throughout the course of the study as new staff are identified. Approaches that decrease personnel and time burden, such as virtual and pre-recorded trainings, may optimize use of available resources.

JEANETTE WAXMONSKY, PhD
University of Colorado

Shared medical appointments (SMAs) for patients with diabetes are an evidence-based and potentially efficient approach to provide self-management education and support in a group setting. For sustainability planning, we evaluated personnel time and other costs for delivering diabetes SMAs in primary care.

Twenty two practices were randomized and trained to deliver standardized or patient-driven models of diabetes SMAs in a comparative effectiveness study. Both models included six two-hour sessions using the Targeted Training in Illness Management curriculum for groups of approximately 5-15 patients. Standardized SMAs were delivered by a health educator with accompanying prescribing provider visits. Patient-driven SMAs further incorporated behavioral health providers, peer mentors, and patient-led topic prioritization (expected to yield better value albeit with higher costs).

Practices were surveyed regarding personnel time for SMA delivery and support and additional resources needed (e.g., travel, materials, overhead) for start-up (prior to first cohort), and initial delivery phases (after completing first cohort).

Starting-up standardized and patient-driven SMA models required similar amount of personnel time on average (46 vs. 45 hrs.). Delivering patient-driven SMAs on average required more personnel hours (75 hours) than standardized SMAs (50 hours). Other costs for patient-driven SMAs on average were higher for both start-up ($957 vs. $1,717) and initial delivery ($137 vs. $177). Overall, hours and other costs varied greatly by practice, as indicated by wide ranges reported in both hours spent (min = 12 hrs., max = 135 hrs.) and other costs (min = $0, max = $802).

Reported costs of delivering diabetes SMAs varied considerably among practices, both in personnel time and other expenditures. As expected, delivering a model with a larger team involved more hours during implementation than an approach with fewer personnel, plus modest increases in other costs. Practices seeking to implement diabetes SMAs should consider what elements of SMAs are most important to their patients and the resources required relative to reimbursement for each model.

SHARON LANG, BA
Brown University School of Public Health

Promotion of evidence-based practices (EBPs) often hinges upon training workshops designed to help counselors deliver EBPs with fidelity. The COVID-19 pandemic necessitated a rapid shift from in-person to virtual workshop training, yet the relative effectiveness and cost-effectiveness of these modalities is unknown. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) is an ongoing cluster-randomized hybrid type 3 trial examining strategies to implement contingency management (CM), a behavioral EBP, across opioid treatment programs. Counselors from the first cohort received in-person workshop training, whereas counselors from the second cohort received virtual workshop training. The shift to virtual training as a response to federal guidelines of social distancing presented a rare opportunity to compare the modalities. This study compared the effectiveness and cost-effectiveness of in-person and virtual training workshops for equipping opioid treatment program staff to implement contingency management.

The first cohort consisted of 26 counselors from eight opioid treatment programs, and the second cohort consisted of 31 counselors from 10 opioid treatment programs. All opioid treatment programs were located throughout the New England area, and the research study was based at Brown University in Rhode Island.

Counselors submitted post-training role-plays that were rated by independent coders for both readiness and proficiency to deliver CM. Per-clinician costs were estimated for the two modalities. Adjusted differences between cohorts were estimated using ordinary least squares, and an incremental cost effectiveness ratio was calculated to specify cost differences across cohorts.

Attainment rates of the readiness and proficiency benchmarks were higher in the virtual than in-person condition, though these differences were not statistically significant. Aggregated costs showed a $399 difference in per-clinician cost favoring virtual workshop training. Due to its lower cost and comparable effectiveness, the virtual modality was the dominant strategy.

Our findings support the utility and effectiveness of virtual workshop training and may inform the delivery of workshop training for other EBPs post-pandemic.