Lessons learned: patient recruitment strategies for a type 2 diabetes intervention in a primary care setting [corrected]

Targeted recruitment of adults with type 2 diabetes for a physical activity intervention

Recruiting sufficient numbers of participants for physical activity trials for individuals with diabetes can be difficult because there are often many behavioral demands for participants, and inclusion and exclusion criteria can be extensive. This study examined the recruitment strategies used for a randomized, controlled trial designed to investigate the efficacy of an automated telephone intervention to promote physical activity in adults with type 2 diabetes in an urban Veterans Administration health care system. Traditional recruitment approaches of posting flyers and obtaining referrals from clinicians did not yield sufficient numbers of interested patients. Using the electronic medical record system to identify patients with uncontrolled diabetes allowed staff to send targeted mailings to participants, and 77% of participants were recruited using this method. The targeted mailing approach elicited a positive response rate of 12% (328 of 2,764 potential participants identified) and appeared to produce a more representative and appropriate sample than other recruitment methods used. Lessons learned in this study may be helpful to researchers in future trials who attempt to recruit participants with diabetes for physical activity protocols.

Goal setting: an integral component of effective diabetes care

Goal setting is a widely used behavior change tool in diabetes education and training. Prior research found specific relatively difficult but attainable goals set within a specific timeframe improved performance in sports and at the workplace. However, the impact of goal setting in diabetes self-care has not received extensive attention. This review examined the mechanisms underlying behavioral change according to goal setting theory and evaluated the impact of goal setting in diabetes intervention studies. Eight studies were identified, which incorporated goal setting as the primary strategy to promote behavioral change in individual, group-based, and primary care settings among patients with type 2 diabetes. Improvements in diabetes-related self-efficacy, dietary intake, physical activity, and A1c were observed in some but not all studies. More systematic research is needed to determine the conditions and behaviors for which goal setting is most effective. Initial recommendations for using goal setting in diabetes patient encounters are offered.

Protocol for the DREAM Project (Diabetes Research, Education, and Action for Minorities): a randomized trial of a community health worker intervention to improve diabetic management and control among Bangladeshi adults in NYC

Background

New York City (NYC) is currently home to the largest Bangladeshi population in the United States (US) at approximately 62,000 individuals. The high prevalence of Type 2 diabetes mellitus (T2DM) among Bangladeshis has been well documented in Bangladesh, as well as in Canada and the United Kingdom (UK). However, little is known about the diabetes prevalence and management practices of US Bangladeshis. This paper describes the protocol for a Community Health Worker (CHW) intervention to improve diabetic management and control among Bangladeshis with diabetes in NYC.

Methods/Design

For a two-arm, randomized controlled trial (RCT), investigators will recruit a sample of 256 participants, all of whom are 1) of Bangladeshi descent, 2) residing in NYC, 3) diagnosed with T2DM and a recent Hemoglobin A1c (HbA1c) of ≥ 6.5, and 4) between the ages of 21–85. The treatment group receives a six-month CHW-led intervention consisting of five monthly group educational sessions, two one-on-one visits, and follow-up phone calls as needed from a CHW. The control group receives an introductory educational session only. Primary and secondary outcomes include clinical and behavioral measures, such as HbA1c and weight change, access to and utilization of care (i.e. appointment keeping and use of specialty care), and knowledge and practice of physical activity and healthful eating. Additionally, information regarding CHW characteristics, the processes and mechanisms for influencing healthful behavior change, and fidelity of the intervention are collected. Outcomes are measured at Baseline, 3-Months, 6-Months for both groups, and at 12-Months for the treatment group.

Discussion

To our knowledge, this study represents the first attempt to document the efficacy of T2DM management strategies in the NYC Bangladeshi population. Thus, future qualitative and quantitative findings of the submitted protocol will fill an important gap in the health disparities literature.

Trial registration

NCT02041598

Strategies for in-person recruitment: lessons learned from a New Jersey primary care research network (NJPCRN) study

OBJECTIVE

To describe and evaluate participant recruitment for a research study conducted in primary care offices.

METHODS

Nine recruiters administered a written survey to 1485 primary care patients (from 25 practices) during baseline and 1-year follow-up of a quality improvement study aimed at increasing colorectal cancer screening. Before recruitment, recruiters attended training sessions, during which they received tools and information designed to facilitate successful recruitment. Quantitative and qualitative recruitment data were analyzed to assess and describe recruitment efforts.

RESULTS

The overall practice-level recruitment rate was 72.7% (range, 56.3% to 91.4%). Practice characteristics did not affect the recruitment rate. Recruitment rate differed significantly between recruiters (P = .0007) as did nonparticipants' reasons for refusal (P < .0001). Anticipated barriers to recruitment (older age of sampled population, lack of incentives, and discomfort discussing colorectal cancer) did not occur. Two key strategies facilitated recruitment: ((1)) recruiter flexibility and ((2)) building rapport with participants.

CONCLUSION

Recruiters may be more effective if they are able to adapt to participants' needs and successfully build rapport with potential participants. The likelihood of recruitment success may be increased by anticipating potential recruitment barriers and providing training that minimizes the inherent variation that exists among recruiters.

Computerized dietary assessments compare well with interviewer administered diet histories for patients with type 2 diabetes mellitus in the primary healthcare setting

OBJECTIVE

To test repeatability and relative validity of a computerized and interviewer administered assessment.

METHODS

Using a context-based case-control trial, 41 adults with type 2 diabetes mellitus were randomized into four groups to complete dietary assessments (computerized or interviewer administered) at 0, 2 and 8 weeks and food records at 0 and 2 weeks. Repeatability of reported energy, total fat, saturated, polyunsaturated and monounsaturated fatty acids between the computerized and interviewer administered methods were assessed using repeated measures ANOVA. Paired t-tests and Pearson's correlations determined relative validity of the assessments.

RESULTS

Thirty-one patients completed all visits. Statistically significant differences were found between computerized and interviewer administered data for total fat (p=0.048) and saturated fatty acids (p=0.019) between 0 and 2 weeks. Computerized assessments correlated better with food records (r=0.16-0.52) compared with interviewer administered assessments (r=-0.02 to 0.51).

CONCLUSION

Computerized assessments saw a learning effect with repeated use indicating that users were becoming more familiar with the website with repeated use. Relative validity suggests that the website may capture more foods though this requires further investigation.

PRACTICE IMPLICATIONS

By allowing patients to self-report their intakes on a computer, dietitians will have the ability to spend increased time with their patients counseling them toward change.

Value of recruitment strategies used in a primary care practice-based trial

PURPOSE

"Physicians-recruiting-physicians" is the preferred recruitment approach for practice-based research. However, yields are variable; and the approach can be costly and lead to biased, unrepresentative samples. We sought to explore the potential efficiency of alternative methods.

METHODS

We conducted a retrospective analysis of the yield and cost of 10 recruitment strategies used to recruit primary care practices to a randomized trial to improve cardiovascular disease risk factor management. We measured response and recruitment yields and the resources used to estimate the value of each strategy. Providers at recruited practices were surveyed about motivation for participation.

RESULTS

Response to 6 opt-in marketing strategies was 0.40% (53/13290), ranging from 0% to 2.86% by strategy; 33.96% (18/53) of responders were recruited to the study. Of those recruited from opt-out strategies, 8.68% joined the study, ranging from 5.35% to 41.67% per strategy. A strategy that combined both opt-in and opt-out approaches resulted in a 51.14% (90/176) response and a 10.80% (19/90) recruitment rate. Cost of recruitment was $613 per recruited practice. Recruitment approaches based on in-person meetings (41.67%), previous relationships (33.33%), and borrowing an Area Health Education Center's established networks (10.80%), yielded the most recruited practices per effort and were most cost efficient. Individual providers who chose to participate were motivated by interest in improving their clinical practice (80.5%); contributing to CVD primary prevention (54.4%); and invigorating their practice with new ideas (42.1%).

CONCLUSIONS

This analysis provides suggestions for future recruitment efforts and research. Translational studies with limited funds could consider multi-modal recruitment approaches including in-person presentations to practice groups and exploitation of previous relationships, which require the providers to opt-out, and interactive opt-in approaches which rely on borrowed networks. These approaches can be supplemented with non-relationship-based opt-out strategies such as cold calls strategically targeted to underrepresented provider groups.

Subject Recruitment for Cancer Control Studies in an Adverse Environment

Subject recruitment in an adverse environment prompted researchers to identify a novel method to gain a different perspective on the problem. Lewin's Model of Change was used in a post hoc examination of recruitment strategies from 5 cancer control studies of breast or prostate cancer. Based on this evaluation, driving and restraining forces in recruitment were identified. Lessons learned and recommendations are discussed based on this evaluation. Five categories of restrainers were identified from this evaluation and include sociocultural, institutional, individuals, budget, and study design. Conversely, only 3 categories of drivers were elucidated by the examination: sociocultural, institutional, and individuals. Lessons and recommendations ranged from addressing institutional barriers to capitalizing on public relations. Researchers entering a new environment for recruitment would benefit from using Lewin's force field analysis before writing a proposal or implementing a project. This approach better directs energy and resources and enhances the ability of the investigator to maintain a broad, less biased perspective.

The role of rapport: lessons learned from conducting research in a primary care setting

Conducting research in a primary care setting is difficult because of the competing demands primary care offices have to manage in the current medical environment. Every primary care office has its own relationship and reporting structures, norms, and ways of conducting day-to-day affairs. Regardless of the setting, when carrying out qualitative and/or mixed-methods research, researchers must have rapport with the individuals or group of individuals they will be working with to carry out the research. In this article, the authors describe the different approaches that research staff have used to create rapport with practice staff that were not only participants in the study but were also responsible for the delivery and implementation of this effectiveness study.

The frequency and behavioral outcomes of goal choices in the self-management of diabetes

PURPOSE

The purpose of this study was to determine the frequency and effectiveness of behavioral goal choices in the self-management of diabetes and to test goal-setting theory hypotheses that self-selection and behavioral specificity of goals are key to enhancing persistence.

METHODS

Participants with type 2 diabetes in a randomized controlled trial (n = 422) completed baseline behavioral assessments using a clinic-based, interactive, self-management CD-ROM that allowed them to select a behavioral goal and receive mail and telephone support for the initial 6 months of the trial followed by additional behavioral assessments. Frequency of behavioral goal selection and 6-month behavioral data were collected.

RESULTS

Approximately 49%, 27%, and 24% of the participants, respectively, set goals to increase physical activity (PA), reduce fat intake, or increase fruits and vegetables (F&V) consumed. At baseline, participants who selected PA, reduced fat consumption, or F&V were significantly, and respectively, less active, consumed more dietary fat, and ate fewer F&V regardless of demographic characteristics. Participants who selected a reduced-fat goal showed a significantly larger decrease than did those that selected PA or F&V goals. Participants who selected an F&V goal showed significant changes in F&V consumption. Participants who selected a PA goal demonstrated significant changes in days of moderate and vigorous physical activity.

CONCLUSIONS

When participants are provided with information on health behavior status and an option of behavioral goals for managing type 2 diabetes, they will select personally appropriate goals, resulting in significant behavioral changes over a 6-month period.

Variation in perceived competence, glycemic control, and patient satisfaction: relationship to autonomy support from physicians

There is considerable variation in care provided to patients with diabetes related to metabolic control, preventive services, and degree of patient-centered support. This study evaluates the relation of self-determination theory (SDT) constructs of clinician autonomy support, and patient competence to glycemic control, depressive symptoms, and patient satisfaction from baseline surveys of 634 patients of 31 Colorado primary care physicians participating in a program to improve diabetes care. Spearman correlations of autonomy support from one's clinician with patient competence, HbA1c, depressive symptoms and satisfaction were significant (R = -0.11 to 0.55, P < 0.005). Structural equation modeling demonstrated that autonomy support was significantly related to perceived competence, depressive symptoms, patient satisfaction, and indirectly to glycemic control. Perceived competence was significantly related to depressive symptoms, patient satisfaction and glycemic control. Further, the motivation constructs from SDT accounted for 5% of the variance in glycemic control, 8% of the variance in depression, and 42% of the variance in patient satisfaction. Quality improvement efforts need to pay greater attention to patient competence, satisfaction, and depression, in addition to glycemic control. Clinician autonomy support was found to be reliably measured and moderately correlated with psychosocial and biologic outcomes related to diabetes self-management. These results suggest training clinicians to increase their support of patient autonomy may be one important avenue to improve diabetes outcomes.

Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort: Kaiser Permanente of Colorado GDM Screening Program

OBJECTIVE

The prevalence of gestational diabetes mellitus (GDM) varies in direct proportion with the prevalence of type 2 diabetes in a given population or ethnic group. Given that the number of people with diabetes worldwide is expected to increase at record levels through 2030, we examined temporal trends in GDM among diverse ethnic groups.

RESEARCH DESIGN AND METHODS

Kaiser Permanente of Colorado (KPCO) has used a standard protocol to universally screen for GDM since 1994. This report is based on 36,403 KPCO singleton pregnancies occurring between 1994 and 2002 and examines trends in GDM prevalence among women with diverse ethnic backgrounds.

RESULTS

The prevalence of GDM among KPCO members doubled from 1994 to 2002 (2.1-4.1%, P < 0.001), with significant increases in all racial/ethnic groups. In logistic regression, year of diagnosis (odds ratio [OR] and 95% CI per 1 year = 1.12 [1.09-1.14]), mother's age (OR per 5 years = 1.7 [1.6-1.8]) and ethnicity other than non-Hispanic white (OR = 2.1 [1.9-2.4]) were all significantly associated with GDM. Birth year remained significant (OR = 1.06, P = 0.006), even after adjusting for prior GDM history.

CONCLUSIONS

This study shows that the prevalence of GDM is increasing in a universally screened multiethnic population. The increasing GDM prevalence suggests that the vicious cycle of diabetes in pregnancy initially described among Pima Indians may also be occurring among other U.S. ethnic groups.

Randomized effectiveness trial of a computer-assisted intervention to improve diabetes care

OBJECTIVE

There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care settings. This report presents 12-month follow-up results from a computer-assisted, patient-centered intervention to improve the level of recommended services patients received from a variety of primary care settings.

RESEARCH DESIGN AND METHODS

A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on two primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program (PRP). Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale, lipid and HbA1c levels, and the Patient Health Questionnaire-9 depression scale.

RESULTS

The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition. There was overall improvement on secondary outcomes of lipids, HbA1c, quality of life, and depression scores; between-condition differences were not significant.

CONCLUSIONS

Staff in small, mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care. Alternative explanations for why these process improvements did not lead to improved outcomes, and suggested directions for future research are discussed.

A practical randomized trial to improve diabetes care

OBJECTIVE

There is a well-documented gap between diabetes care guidelines and the services received by patients in almost all health care settings. This project reports initial results from a computer-assisted, patient-centered intervention to improve the level of recommended services received by patients from a wide variety of primary care providers.

DESIGN AND SETTINGS

Eight hundred eighty-six patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on 2 primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed. Secondary outcomes were evaluated using the Problem Areas in Diabetes scale and the Patient Health Questionnaire (PHQ)-9 depression scale, and the RE-AIM framework was used to evaluate potential for dissemination.

RESULTS

The program was well-implemented and significantly improved both number of recommended laboratory assays (3.4 vs 3.1; P <.001) and patient-centered aspects of diabetes care patients received (3.6 vs 3.2; P <.001) compared to those in randomized control practices. Activities that were increased most were foot exams (follow-up rates of 80% vs 52%; P <.003) and nutrition counseling (76% vs 52%; P <.001).

CONCLUSIONS

Patients are very willing to participate in a brief computer-assisted intervention that is effective in enhancing quality of diabetes care. Staff in primary care offices can consistently deliver an intervention of this nature, but most physicians were unwilling to participate in this translation research study.