1. Monika M. Safford, MD University of Alabama at Birmingham

2.  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. Reach  Participation rates  Representativeness among the sampling frame of patients with diabetes Strengths:  Telephonic delivery Challenges:  Community realities - “bring a neighbor”  Denominators

4. Reach  HIGH

5. 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. Effectiveness  MED-HIGH

7. Adoption  More speculative (!)  Cost  Requires new resources? Strengths:  Low-cost Challenges:  No infrastructure to sustain program (Healthcare Reform?)

8. Adoption  LOW (MED?)

9. 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. Implementation  LOW (MED?)

11. 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. 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. Maintenance  MED

14. REAIMAudience(s)Clinical Area(s) In Person CHW Outreach Acad. Detailing Med Low Med Patient Provider Diabetes Group CER Training School Group Therapy Med High Low Med Low Med Low Med Policy Patient Multiple Heart Disease Diabetes eHealth Clinic Kiosk Web Patient Portal Med Low Med High Med High Patient Patient & Provider Diabetes Print/Media Targeted VideoMed PatientHeart Disease

15. REAIMAudience(s)Clinical Area(s) In Person CHW Outreach Acad. Detailing Med Low Med Patient Provider Diabetes Group CER Training School Group Therapy Med High Low Med Low Med Low Med Policy Patient Multiple Heart Disease Diabetes eHealth Clinic Kiosk Web Patient Portal Med Low Med High Med High Patient Patient & Provider Diabetes Print/Media Targeted VideoMed PatientHeart Disease

16. REAIM In Person CHW Outreach CHW Telephonic Outreach Med High Med (High?) Low (Med?) Low Low (Med?) Low Med

17.  CER’s  “Arm chair quarterbacking”  Comparison framework  e-VALUE-ation  QALYs?