Peer Coaching Improves Glucose Control in Diabetes

Miriam E. Tucker

March 18, 2013

Clinic-based peer health coaching significantly improved type 2 diabetes control among low-income primary-care patients, a 6-month randomized study found.

The findings were published in the March/April issue of the Annals of Family Medicine by David H. Thom, MD, PhD, from the University of California, San Francisco, and colleagues.

Peer health coaches are laypeople with the same disease as those they assist, who are trained to provide ongoing support for self-management to small groups of clients. Typically volunteers but sometimes salaried employees, they are increasingly viewed as being able to fill in the gaps left by shortages of primary-care providers, particularly in underserved areas.

"Because they experience similar challenges of living with the same chronic condition as the patients they assist, peer supporters are uniquely poised to engage and motivate other patients in self-management," Dr. Thom and colleagues write. For diabetes patients in particular, peer coaches can teach time-consuming self-management skills, they add.

"The most important message is that supporting patients in better managing their diabetes can lead to a major improvement in diabetes control and that peer coaches are an effective way to provide this support," Dr. Thom told Medscape Medical News.

Athena Philis-Tsimikas, MD, an endocrinologist from Scripps Whittier Diabetes Institute, La Jolla, California, who has worked with peer coaches for more than a decade, told Medscape Medical News that this new study is important because it provides outcome data. "This helps crystalize that we can get improvements using this approach as well. It's not just the feel-good part of it, but it actually translates into real improvements in their clinical outcomes.

"There's not a lot of really well-done work around peer education, and I thought this [study] was very nicely done," added Dr. Philis-Tsimikas.

Ruth Lipman, PhD, Chief Science and Practice Officer, American Association of Diabetes Educators (AADE) said her organization's policies include peer coaches among the types of personnel who can serve as "level-1 educators" as part of a diabetes care team.

"In the study by Thom et al, peer health coaches were added to usual care, which included access to a nutritionist and diabetes educator through primary-care referral. This is wholly consistent with the multilevel diabetes education team approach advocated by AADE," Dr. Lipman told Medscape Medical News.

Half of Coached Group Dropped HbA1c by 1 Percentage Point

In the study, both the peer coaches and the patients were seen at 1 of 6 public-health clinics that were part of a San Francisco research network. Potential coaches had to have glycated hemoglobin (HbA1c) levels less than 8.5% and be recommended as suitable by their primary-care physicians. Patients, also screened by their doctors, all had HbA1c levels of 8.0% or higher.

The 24 coach trainees (mean age, 58 years) received 36 hours of training over 8 weeks, based on a curriculum developed by the authors that includes instruction in active listening and nonjudgmental communication, helping with diabetes self-management skills, providing emotional and social support, assisting with lifestyle change and medication understanding/adherence, and accessing community resources.

Trainees were required to pass both written and oral exams to become peer coaches. They were paid $150 for the training and $25/month per patient coached. They met one-on-one with a median of 7 patients each, with a median of 5 telephone or in-person interactions (range, 0–29) over the 6 months. The coaches helped patients design their own action plans based on self-chosen goals.

A total of 299 patients (mean age, 55 years) were randomly assigned to receive either coaching or usual care. Patients in both groups were paid $10 and were assessed via questionnaires and clinical evaluation at baseline and at 6 months.

At baseline, the coaches' mean HbA1c was 6.9%, vs 10.1% for the 148 patients in the coaching group and 9.8% for the 151 assigned usual care. Two thirds of the coaches were female, while about half of the patients were male.

At 6 months, HbA1c levels had fallen by 1.1 percentage points in the coached group, a significantly greater drop than the 0.3 percentage points seen with usual care (P = .01). Half of the coached group (49.6%) experienced a drop of 1.0 percentage points or more, compared with less than a third (31.5%) of the usual-care group (P = .001, adjusted for baseline variables). Also, more of the coached patients achieved HbA1c levels below 7.5% than did the usual-care group (22% vs 7.5%; P = .04, adjusted).

After adjustment, the 2 groups didn't differ with regard to changes in LDL cholesterol, systolic blood pressure, or body mass index.

Patient Caring for Patient: A New Care Model?

Dr. Thom told Medscape Medical News that the extent to which peer support is currently being employed in patients with chronic conditions such as type 2 diabetes is not clear. "It is likely that peer support is being used in a variety of ways in different settings, though most of these programs are not formally evaluated or published."

Regardless of the type of program, appropriate training and supervision are essential, the experts agree.

Dr. Lipman said: "In this study, the peer health coaches were trained and presumably supervised by [someone with an MPH or MD degree]. In the AADE multilevel model for diabetes education, they would have been supervised by a credentialed diabetes educator."

At Dr. Philis-Tsimikas's institution, peer educators are salaried employees who undergo extensive training via a structured program that includes protocols for emergency situations. (The term "peer educators" generally refers to those who lead classes or support groups, as opposed to "coaches," who deliver one-on-one counseling.)

She noted that issues surrounding both training and reimbursement affect the extent to which peer support models can be used in various clinical settings.

In a fixed-payment care-delivery model, peer coaches could potentially provide self-management education, thereby freeing up nurses for other, more sophisticated tasks such as care coordination and chronic disease management, she said.

Dr. Thom said that it is not yet clear whether the initial costs of training, supervision, and program management of peer coaching programs would eventually be recouped. However, he said that studies have found cost per quality-adjusted life-years ranging from $10,000 to $30,000, "which is well within the range considered cost-effective."

Both Dr. Thom and Dr. Philis-Tsimikas are looking into the possibility of extending peer support models to other chronic medical conditions as well, including  hypertension, hyperlipidemia, and chronic obstructive pulmonary disease.

Dr. Philis-Tsimikas said that when she first encountered the idea of patients themselves delivering care to fellow patients, she thought it was "radical and kind of crazy."

"Yet, after we started working with these folks with a very structured training and curriculum, they actually do it in an incredibly passionate [manner], with an understanding and a perspective from the community that I as a provider could never do… It's an incredibly powerful tool that I actually think should be utilized more broadly…if done in the right way. And I think this paper helps demonstrate how some of it can be done in the right way."

A program called "Peers for Progress," sponsored by the American Academy of Family Physicians, aims to facilitate best practices in peer support.

Dr. Thom and Dr. Lipman have disclosed no relevant financial relationships. Dr. Philis-Tsimikas serves on the advisory boards for Sanofi and Novo-Nordisk and receives grants from Merck, Bristol-Myers Squibb, Janssen, Genentech, and others but has no disclosures relevant to peer coaching.

Ann Fam Med 2013;11:137-144.

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