Monika M. Safford, MD University of Alabama at Birmingham

1. Monika M. Safford, MD University of Alabama at Birmingham Using RE-AIM to Evaluate Encourage-2: A cluster-randomized trial in rural Alabama funded under the iADAPTopportunitySeptember 19, 2011AHRQ Annual Conference, 2011iADAPT Grantee Session

2. Community Health Workers 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 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 • CERs: OA, diabetes; integrated into education/training program content • Outcomes: risk factors (A1c, BP, chol), functional status

3. RE-AIM for iADAPT in Rural AlabamaReach – 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

4. RE-AIM for iADAPT in Rural AlabamaReach – Effectiveness – Adoption – Implementation - Maintenance Reach • HIGH

5. RE-AIM for iADAPT in Rural AlabamaReach – 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

6. RE-AIM for iADAPT in Rural AlabamaReach – Effectiveness – Adoption – Implementation - Maintenance Effectiveness • MED-HIGH

7. RE-AIM for iADAPT in Rural AlabamaReach – Effectiveness – Adoption – Implementation - Maintenance Adoption • More speculative (!) • Cost • Requires new resources? Strengths: • Low-cost Challenges: • No infrastructure to sustain program (Healthcare Reform?)

8. RE-AIM for iADAPT in Rural AlabamaReach – Effectiveness – Adoption – Implementation - Maintenance Adoption • LOW (MED?)

9. RE-AIM for iADAPT in Rural AlabamaReach – 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?)

10. RE-AIM for iADAPT in Rural AlabamaReach – Effectiveness – Adoption – Implementation - Maintenance Implementation • LOW (MED?)

11. RE-AIM for iADAPT in Rural AlabamaReach – 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?)

12. RE-AIM for iADAPT in Rural AlabamaReach – 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

13. RE-AIM for iADAPT in Rural AlabamaReach – Effectiveness – Adoption – Implementation - Maintenance Maintenance • MED

14. RE-AIM for iADAPT?

15. RE-AIM for iADAPT?

16. RE-AIM for iADAPT?Reach – Effectiveness – Adoption – Implementation - Maintenance

17. RE-AIM for iADAPT? • CER’s • “Arm chair quarterbacking” • Comparison framework • e-VALUE-ation • QALYs?