Defining complexity in terms of the misalignment between patient needs and services offers new insights in how to research and develop solutions to patient care needs.

OBJECTIVEAlthough the benefits of in-person Diabetes Prevention Program (DPP) classes for diabetes prevention have been demonstrated in trials, effectiveness in clinical practice is limited by low participation rates. This study explores whether text message support enhances weight loss in patients offered DPP classes. RESEARCH DESIGN AND METHODSEnglish-and Spanish-speaking patients with prediabetes (n = 163) were randomized to the control group, which only received an invitation to DPP classes as defined by the Centers for Disease Control and Prevention, or to the text messageaugmented intervention group, which also received text messages adapted from the DPP curriculum for 12 months. RESULTSMean weight decreased 0.6 pounds (95% CI 22.7 to 1.6) in the control group and 2.6 pounds (95% CI 25.5 to 0.2) in the intervention group (P value 0.05). Three percent weight loss was achieved by 21.5% of participants in the control group (95% CI 12.5-30.6), compared with 38.5% in the intervention group (95% CI 27.7-49.3) (absolute difference 17.0%; P value 0.02). Mean glycated hemoglobin (HbA 1c ) increased by 0.19% or 2.1 mmol/mol (95% CI 20.1 to 0.5%) and decreased by 0.09% or 1.0 mmol/mol (95% CI 20.2 to 0.0%) in the control group and intervention participants, respectively (absolute difference 0.28%; P value 0.07). Stratification by language demonstrated a significant treatment effect in Spanish speakers but not in English speakers. CONCLUSIONSText message support can lead to clinically significant weight loss in patients with prediabetes. Further study assessing effect by primary language and in an operational setting is warranted.Approximately one-third of Americans have prediabetes, defined by a blood glucose level above the upper limit of normal but below the threshold for the diagnosis of diabetes. Patients with prediabetes are at elevated risk of developing type 2 diabetes, heart attack, and stroke (1), with low-income and Latino patients representing a disproportionate share of those who progress to diabetes (2,3). Moderate weight loss is effective in preventing progression from prediabetes to overt diabetes, with benefits that persist long-term even with partial weight regain (4-6). Intensive behavioral interventions are effective for diabetes prevention (5,7), with a 16% reduction in risk for every kilogram (2.2 pounds) of weight loss (8).

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Background To reach all 84.1 million US adults estimated to have prediabetes warrants need for low-cost and less burdensome alternatives to the National Diabetes Prevention Program (NDPP). In a previous randomized controlled trial, we demonstrated the efficacy of a 12-month short message service text message support program called SMS4PreDM amongst individuals with prediabetes. Objective The study aimed to evaluate the implementation and effectiveness of SMS4PreDM in a pragmatic study following dissemination in a safety net health care system. Methods English- and Spanish-speaking patients at risk for diabetes (eg, glycated hemoglobin 5.7-6.4) were referred by their providers and offered either NDPP classes, SMS4PreDM, or both. This analysis focuses on weight change among 285 SMS4PreDM-only participants who began the year-long intervention between October 2015 and April 2017 with accompanying pre- and postweights, as compared with 1233 usual-care control patients at risk for diabetes, who were identified from electronic health records during this time but not referred. Weight outcomes included time-related mean weight change and frequency of either ≥3% weight loss or gain. Mixed linear models adjusted for age, gender, race, ethnicity, preferred language, and baseline weight. A secondary analysis was stratified by language. We also assessed implementation factors, including retention and cost. Results SMS4PreDM participants had high retention (259 of 285 patients or 91.0% completion at 12-months, ) and a time-related mean weight loss of 1.3 pounds (SE 0.74), compared with the control group’s slight mean weight gain of 0.25 pounds (SE 0.59; P =.004). Spanish-speaking SMS4PreDM participants (n=130) had a time-related mean weight loss of 1.11 pounds (SE 1.22) compared with weight gain of 0.96 pounds (SE 1.14) in Spanish-speaking controls (n=382, P <.001). English-speaking intervention participants (n=155) had a comparable time-related mean weight change (–0.89 pounds; SE 0.93) as English-speaking controls (n=828; 0.31 pounds gained; SE 0.62, P =.14). Overall, frequency of achieving ≥3% weight loss was comparable between groups (54 of 285 or 19.0% of SMS4PreDM participants [95% CI 14.8-23.9] vs 266 of 1233 or 21.6% of controls [95% CI 19.3-24.0]; P =.33). Nonetheless, more controls had ≥3% weight gain compared with intervention participants (337 of 1233 or 27.3% of controls [95% CI 24.9-29.9] vs 57 of 285 or 20.0% of SMS4PreDM participants [95% CI 16.8-25.1]; P =.01). SMS4PreDM delivery costs were US $100.92 per participant. Conclusions Although SMS4PreDM was relatively low cost to deliver and demonstrated high retention, weight loss outcomes may not be sufficient to serve as a population health strategy.

BackgroundMost studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback.Methods5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews.ResultsMany providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources.ConclusionsPatient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts.Trial RegistrationClinicalTrials.gov: NCT00827710

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Background The evidence-based National Diabetes Prevention Program (NDPP) is now widely disseminated, yet strategies to increase its effectiveness are needed, especially for underserved populations. The yearlong program promotes lifestyle changes for weight loss and can be offered in-person, online, via distance learning, or a combination of modalities. Less is known about which delivery features are optimal and may help address disparities in outcomes for subgroups. We previously demonstrated the efficacy of a stand-alone text messaging intervention based on the NDPP (SMS4PreDM) in a randomized controlled trial in a safety net health care system. Upon broader dissemination, we then showed that SMS4PreDM demonstrated high retention and modest weight loss at a relatively low cost, suggesting the potential to improve in-person NDPP delivery. Objective In this study, we aim to compare the effectiveness of in-person NDPP classes with and without supplementary SMS4PreDM on attendance and weight loss outcomes to determine whether text messaging can enhance in-person NDPP delivery for a safety net patient population. Methods From 2015 to 2017, patients with diabetes risks were identified primarily from provider referrals and enrolled in NDPP classes, SMS4PreDM, or both per their preference and availability. Participants naturally formed three groups: in-person NDPP with SMS4PreDM (n=236), in-person NDPP alone (n=252), and SMS4PreDM alone (n=285). This analysis compares the first two groups to evaluate whether supplemental text messaging may improve in-person NDPP outcomes. Outcomes for SMS4PreDM-only participants were previously reported. NDPP classes followed standard delivery guidelines, including weekly-to-monthly classes over a year. SMS4PreDM delivery included messages promoting lifestyle change and modest weight loss, sent 6 days per week for 12 months. Differences in characteristics between intervention groups were assessed using chi-square and t tests. Differences in NDPP attendance and weight loss outcomes were analyzed with multivariable linear and logistic regressions. Results The mean age was 50.4 years (SD 13.9). Out of a total of 488 participants, 76.2% (n=372) were female and 59.0% (n=288) were Hispanic. An additional 17.2% (n=84) were non-Hispanic white and 12.9% (n=63) were non-Hispanic black. A total of 48.4% (n=236) of participants elected to receive supplemental text message support in addition to NDPP classes. Participants who chose supplemental text message support were on average 5.7 (SD 1.2) years younger (P<.001) than the 252 participants who preferred in-person classes alone. Relatively more women and Hispanic individuals enrolled in the NDPP with supplemental text messages than in NDPP classes alone, 83.9% (n=198) vs 69.0% (n=174, P<.001) and 68.6% (n=162) vs 50.0% (n=126, P=.001), respectively. Attendance and weight loss outcomes were comparable between groups. Conclusions Despite its appeal among priority populations, supplemental text messaging did not significantly increase attendance and weight loss for the in-person NDPP. Further research is needed to identify optimal strategies to improve the effectiveness of the NDPP.