Jim Bailey, MD, MPH, professor of Internal Medicine and Preventive Medicine in the College of Medicine and director of the Center for Health System Improvement at the University of Tennessee Health Sciences Center, has been approved for a $5.2 million funding award from the Patient-Centered Outcomes Research Institute (PCORI). The funds, which will be distributed over four years and four months, will be used to study the effectiveness of patient-driven resources to improve health care for African-Americans who have uncontrolled diabetes and live in underserved areas.
Dr. Bailey and his co-principal investigator, James Robinson, PsyD, CEO of Methodist South Hospital, have brought together a coalition of primary care providers across the Mid-South, including Methodist Primary Care Group, Christ Community Health Services, University of Tennessee Family Medicine, and University Clinical Health (formerly UT Medical Group), to test two innovative approaches to strengthen primary care and its ability to help the most vulnerable patients improve their self-care decisions and their health.
The project is the first study to compare the effectiveness of text messaging and health coaching in a vulnerable population. The project will study how text messaging and health coaching — both of which rely on patient involvement — can empower patients to better care for themselves by improving their healthy eating, physical activity, and medication taking habits.
Nationwide, only half of all patients with hypertension, 43 percent of patients with diabetes and 80 percent of patients with high cholesterol have reached their goals for blood pressure, blood sugar control or cholesterol. In medically underserved African-American communities, rates of control are even lower, contributing to high rates of hospitalization, complications and death.
More than 61 million adults in the United States had multiple chronic conditions in 2010. The number with two or more chronic conditions is projected to rise to 81 million by 2020.
“Limited access to primary care, poor primary care infrastructure, and poor patient engagement in both primary care and self-care serve to compound the disproportionate suffering experienced by individuals in these underserved communities,” Dr. Bailey said.
Participants in the health coaching arm of the study will meet with their diabetes wellness coach at scheduled times. The coaches will provide information and support regarding health habits — diet/weight loss, physical activity and taking medication correctly — with a focus on areas related to patient-identified health goals, needs and barriers to change.
The participants in the text messaging arm will discuss the health behaviors they’re most interested in working to improve with members of their primary care team. The patient will choose the subjects and the frequency of messages, and can change their message preferences over time.
“We expect that certain patients will need a personal approach with coaching, and others will do better with motivational text messaging,” Dr. Bailey said.
Researchers believe that both methods will provide significant improvement in primary and secondary outcomes. “We anticipate that health coaching will be best for the most medically and socially complex patients,” Dr. Bailey said. “But text messages tailored to patients’ interests will work just as well for most patients, and both coaching and texting will improve patient self-care more than distribution of standard educational materials.”
The study will compare how well the two methods work to improve diabetes self-care related to diet, exercise and medication. It also aims to determine the role of urban versus rural residence, health literacy, medical complexity, social complexity, smart phone ownership and age in the effectiveness of the two methods. Finally, the project expects to determine whether text messaging and health coaching improve secondary outcomes including average blood sugar, quality of life, and relationship with the primary care provider.
The project, titled “Improving Self-Care Decisions of Medically Underserved African-Americans with Uncontrolled Diabetes: Effectiveness of Patient-Driven Text Messaging versus Health Coaching,” was developed in close collaboration with patients and their doctors. Dr. Bailey’s research team met dozens of times with patients, community members and providers to identify the most pressing health needs and the solutions most likely to make a difference.
“From the beginning, we were thinking about how we could strengthen primary care and support people’s ability to understand and help them take control of their diabetes,” Dr. Bailey said. “People are in a doctor’s office for a few minutes, but this is a condition that affects the patient every minute of every day.”
In underserved communities with limited access to primary care, patients typically don’t get reminders such as phone calls and don’t have easy access to diabetes education. Additionally, patients who are working may not be able to get to a primary care office when it’s open, or they may have limited transportation options. Without regular contact with a primary care provider, patients are more likely to go to the emergency room for treatment.
“We’re enrolling 1,000 patients in the study and following them for a year,” Dr. Bailey said. “Some will drop out, and that will be important for us to understand what works and what doesn’t.”
He said health coaching and text messaging show a lot of promise and should be widely adopted. “Every primary care practice should have health coaches, nutritionists, diabetes educators, as well as automated reminder systems and other ways of using technology to help patients.”
PCORI Executive Director Joe Selby, MD, MPH, said, “this project was selected for PCORI funding not only for its scientific merit and commitment to engaging patients and other stakeholders, but also for its potential to fill an important gap in our health knowledge and give people information to help them weigh the effectiveness of their care options. We look forward to following the study’s progress and working with the University of Tennessee Health Science Center to share the results.”
The study was selected for funding through a highly competitive review process in which patients, clinicians and other stakeholders joined clinical scientists to evaluate the proposals. Applications were assessed for scientific merit, how well they will engage patients and other stakeholders, and their methodological rigor among other criteria.
The award has been approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract.
PCORI is an independent, nonprofit organization authorized by Congress in 2010. Its mission is to fund research that will provide patients, their caregivers, and clinicians with the evidence-based information needed to make better-informed health care decisions. For more information about PCORI’s funding, visit www.pcori.org.