Research ArticleOriginal Research

Peer Coaches to Improve Diabetes Outcomes in Rural Alabama: A Cluster Randomized Trial

Monika M. Safford, Susan Andreae, Andrea L. Cherrington, Michelle Y. Martin, Jewell Halanych, Marquita Lewis, Ashruta Patel, Ethel Johnson, Debra Clark, Christopher Gamboa and Joshua S. Richman
The Annals of Family Medicine August 2015, 13 (Suppl 1) S18-S26; DOI: https://doi.org/10.1370/afm.1798

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Consort diagram.

    Note: For purposes of analysis, the terms “practices” and “communities” are used interchangeably. As detailed in Andreae, et al,17 we initially recruited at the participating practices but had to expand into the surrounding communities to meet recruitment targets. Each community in the study corresponded to a single recruited practice, but participants living in that community could have a doctor in any primary care practice, not just the practices recruited for the study. As can be seen in the figure, not all primary care practices we approached agreed to participate.

    a1 practice had 0 participants enrolled.

  • Figure 2
    Figure 2
    Figure 2
    Figure 2
    Figure 2
    Figure 2

    A–E. Control-intervention arm differences in change in primary outcome measures for all study participants, showing raw change scores (top of each panel) and change scores from generalized additive models adjusting for differences in time from baseline to follow-up, season, baseline value, clustering, education, and race.

    Note: In each panel, the top graph presents the raw change scores for each participant, with circles and solid lines signifying control arm and triangles and dotted lines signifying intervention arm. The x axis shows the time in days between baseline and follow-up. Vertical lines show the 12 and 15-month follow-up points. The bottom graph in each panel presents the differences between intervention and control change scores from generalized additive mixed models with p-values from tests of statistical significance of the difference between control and intervention arms. See the article text as well.

    BMI = body mass index; BP = blood pressure; EDF = estimated degrees of freedom; GAMM = generalized additive mixed models; LDL-C = low density lipoprotein cholesterol.

  • Figure 3
    Figure 3
    Figure 3

    A and B. Control-intervention arm differences in change in secondary outcome measures for all study participants by study arm showing raw change scores (top of each panel) and change scores from generalized additive models adjusting for differences in time from baseline to follow-up, season, baseline value, clustering, education, and race.

    EDF= estimated degrees of freedom; GAMM = generalized additive mixed models.

    In each panel, the top graph presents the raw change scores for each participant with circles and solid lines signifying control arm and triangles and dotted lines signifying intervention arm. The x axis shows the time in days between baseline and follow-up. Vertical lines show the 12 and 15-month follow-up points. The bottom graph in each panel presents the differences between intervention and control change scores from generalized additive models with p-values from tests of statistical significance between control and intervention arms. See the article text as well.

Tables

  • Table 1

    Characteristics of Participants in the Cluster Randomized Trial

    All (N = 360)aControl (n = 192)Intervention (n = 168)P valueb
    Age, mean (SD), y60.2 (12.1)61.1 (12.4)59.2 (11.8).14
    Female, No. (%)271 (75.3)140 (72.9)131 (78.0).32
    Blacks, No. (%)313 (87.4)155 (81.2)158 (94.6)<.001
    Education, No. (%)
     ≤High school111 (31.2)58 (30.5)53 (31.9).05
     High school graduate151 (42.4)72 (37.9)79 (47.6)
     Some college, college graduate94 (26.4)60 (31.6)34 (20.5)
    Annual household income, No. (%)
     ≥$40,00032 (8.9)22 (11.5)10 (6.0).10
     <$40,000293 (81.4)155 (80.7)138 (82.1)
     Declined to report35 (9.7)15 (7.8)20 (11.9)
    Number of medications, mean (SD)7.7 (4.07.9 (4.07.5 (4.0.26
    Adherent to medications, No. (%)c189 (52.5)106 (55.2)83 (49.4).33
    Treated with insulin, No. (%)142 (39.4)75 (39.1)67 (39.9).99
    Baseline hemoglobin A1c, mean (SD), %7.9 (2.0)7.9 (1.9)8.0 (2.1).56
    Baseline body mass index, mean (SD), kg/m236.3 (8.5)36.0 (9.1)36.5 (7.7).57
    Baseline systolic blood pressure, mean (SD), mm Hg135.2 (21.4)135.8 (21.2)134.6 (21.7).61
    Baseline LDL-C, mean (SD), mg/dL110.6 (38.2)111.6 (38.8)109.4 (37.6).59
    Baseline quality of life score, mean (SD)d0.76 (0.2)0.78 (0.2)0.74 (0.2).03
    Baseline diabetes distress score,* mean (SD)e2.1 (1.2)2.1 (1.2)2.1 (1.2).92
    Baseline activation score,* mean (SD)f27.8 (6.1)28.0 (6.7)27.5 (5.3).51

    • LDL-C = low density lipoprotein cholesterol; SD = standard deviation.

    • ↵a Includes all participants who provided both baseline and follow-up data.

    • ↵b P-values were derived from χ2 tests for categorical variables and t-tests for continuous variables.

    • ↵c We assessed medication adherence using the 4-item Morisky scale (dichotomized as adherent or not).

    • ↵d We assessed quality of life using the EuroQol 5D (range 0–1.0).

    • ↵e We assessed diabetes distress using the Diabetes Distress Scale (range 1–6, with scores ≥3 indicative of moderate or greater distress).

    • ↵f We assessed activation using the Patient Activation Measure (range 13–57).

  • Table 2

    Mean Changes in Primary Study Outcomes from Baseline to Follow-up for Participants Followed Up Within 15 Months, by Treatment Arm

    OutcomeIntervention (n = 138)Control (n = 130)P valuea
    Hemoglobin A1c, mean (SD), %−0.004 (1.5)0.070 (1.3).68
    Body mass index, mean (SD), kg/m2−0.23 (2.4)−0.49 (2.8).44
    Systolic blood pressure, mean (SD), mm Hg−0.41 (21.3)−1.88 (22.8).59
    LDL-C, mean (SD), mg/dL3.40 (31.5)−0.18 (31.3).35
    Quality of life score, mean (SD)b−0.006 (0.2)−0.017 (0.2).63
    Diabetes distress score, mean (SD)c−0.13 (1.2)−0.29 (1.1).26
    Activation score, mean (SD)d2.64 (7.4)0.69 (7.0).04

    • LDL-C = low density lipoprotein cholesterol; SD = standard deviation.

    • ↵a P values are for intervention compared with control group mean values, adjusted for clustering and for education, which was imbalanced at baseline across treatment arms. P-values were derived from χ2 tests for categorical variables and t-tests for continuous variables.

    • ↵b We assessed quality of life using the EuroQol 5D (range 0–1.0).

    • ↵c We assessed diabetes distress using the Diabetes Distress Scale (range 1–6 with scores ≥3 indicative of moderate or greater distress).

    • ↵d We assessed activation using the Patient Activation Measure (range 13–57).

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