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Diabetes Control With Reciprocal Peer Support Versus Nurse Care Management: A Randomized Trial

Michele Heisler, MD, MPA; Sandeep Vijan, MD, MS; Fatima Makki, MPH; and John D. Piette, PhD
[+] Article, Author, and Disclosure Information

From the University of Michigan and Ann Arbor Veterans Affairs Health Care System, Ann Arbor, Michigan.

Acknowledgment: The authors thank the very dedicated U.S. Department of Veterans Affairs (VA) nurse care managers Debra Beaulieu, Marion Cooper, Joanne Donovan, Kelly Johnston, Jacqueline Hurd, Wendy Morrish, Joe Pawelezyke, Carol Peterson, Ken Sizemore, Diane Sobecki-Ryniak, and other VA care managers, who participated in this intervention as part of their work assignments; VA clinical leaders Denise Ramsey, Jennifer Walch, Adam Tremblay, Thomas Gross, and Susan Meade; Barbara Stanislawski and Jennifer Burgess, who successfully conducted all patient recruitment and helped with facilitation and successful execution of the group sessions and with data collection; Martha Funnell and Mary Lou Gillard, who provided initial training to the VA nurse care managers in group facilitation, assisted in the creation of the peer partner workbooks, and documented intervention fidelity through periodic observation of group sessions; and Mary Rogers, PhD, for her technical assistance with study design and analysis.

Grant Support: By the U.S. Department of Veterans Affairs Health Services Research and Development Service (grant IIR 04-239), the Michigan Diabetes Research and Training Center (National Institutes of Health [NIH] grant 5P60-DK20572), the Robert Wood Johnson Foundation Clinical Scholars Program, and the Michigan Institute for Clinical and Health Research (NIH grant UL1RR024986).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1144.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Heisler (e-mail, mheisler@umich.edu). Data set will be deidentified.

Requests for Single Reprints: Michele Heisler, MD, MPA, University of Michigan Medical School/Veterans Affairs Ann Arbor Health System, Box 130170, MS 152, Ann Arbor, MI 48113-0170; e-mail, mheisler@umich.edu.

Current Author Addresses: Drs. Heisler, Vijan, and Piette and Ms. Makki: University of Michigan Medical School/Veterans Affairs Ann Arbor Health System, Box 130170, MS 152, Ann Arbor, MI 48113-0170.

Author Contributions: Conception and design: M. Heisler, S. Vijan, J.D. Piette.

Analysis and interpretation of the data: M. Heisler, S. Vijan, F. Makki, J.D. Piette.

Drafting of the article: M. Heisler, J.D. Piette.

Critical revision of the article for important intellectual content: M. Heisler, S. Vijan, J.D. Piette.

Final approval of the article: M. Heisler, S. Vijan, J.D. Piette.

Provision of study materials or patients: F. Makki.

Statistical expertise: S. Vijan, J.D. Piette.

Obtaining of funding: M. Heisler, J.D. Piette.

Administrative, technical, or logistic support: M. Heisler, F. Makki.

Collection and assembly of data: M. Heisler, F. Makki, J.D. Piette.

Ann Intern Med. 2010;153(8):507-515. doi:10.7326/0003-4819-153-8-201010190-00007
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Background: Resource barriers complicate diabetes care management. Support from peers may help patients manage their diabetes.

Objective: To compare a reciprocal peer-support (RPS) program with nurse care management (NCM).

Design: Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00320112)

Setting: 2 U.S. Department of Veterans Affairs health care facilities.

Patients: 244 men with hemoglobin A1c (HbA1c) levels greater than 7.5% during the previous 6 months.

Measurements: The primary outcome was 6-month change in HbA1c level. Secondary outcomes were changes in insulin therapy; blood pressure; and patient reports of medication adherence, diabetes-related support, and emotional distress.

Intervention: Patients in the RPS group attended an initial group session to set diabetes-related behavioral goals, receive peer communication skills training, and be paired with another age-matched peer patient. Peers were encouraged to talk weekly using a telephone platform that recorded call occurrence and provided reminders to promote peer contact. These patients could also participate in optional group sessions at 1, 3, and 6 months. Patients in the NCM group attended a 1.5-hour educational session and were assigned to a nurse care manager.

Results: Of the 244 patients enrolled, 216 (89%) completed the HbA1c assessments and 231 (95%) completed the survey assessments at 6 months. Mean HbA1c level decreased from 8.02% to 7.73% (change, −0.29%) in the RPS group and increased from 7.93% to 8.22% (change, 0.29%) in the NCM group. The difference in HbA1c change between groups was 0.58% (P = 0.004). Among patients with a baseline HbA1c level greater than 8.0%, those in the RPS group had a mean decrease of 0.88%, compared with a 0.07% decrease among those in the NCM group (between-group difference, 0.81%; P < 0.001). Eight patients in the RPS group started insulin therapy, compared with 1 patient in the NCM group (P = 0.020). Groups did not differ in blood pressure, self-reported medication adherence, or diabetes-specific distress, but the RPS group reported improvement in diabetes social support.

Limitation: The study included only male veterans and lasted only 6 months.

Conclusion: Reciprocal peer support holds promise as a method for diabetes care management.

Primary Funding Source: U.S. Department of Veterans Affairs Health Services Research and Development Service.


Grahic Jump Location
Figure 1.
Study flow diagram.

HbA1c = hemoglobin A1c.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Distribution of interactive voice-response telephone call data.
Grahic Jump Location




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Observed Clinical Evidence for Findings in Diabetes Control with Reciprocal Peer Support Versus Nurse Care Management Study
Posted on November 22, 2010
Katie E. Savin
ACT1 Diabetes: Adults Coping with Type 1 Diabetes
Conflict of Interest: None Declared

I am writing in response to this article to share my practice experience as observed evidence in support of the findings in the randomized control trial. I am the founding director of ACT1 Diabetes (www.act1diabetes.org): Adults Coping with Type 1 Diabetes, a start-up organization providing diabetes-related social services that evolved out of a single peer-led support group for women with type 1 diabetes. As the facilitator of support group meetings for the past couple years, I have acquired significant anecdotal evidence of the power of peers to impact each other's disease management. I have watched women go from testing their blood sugar once per day due to shame from testing in public, to testing six times per day, whether at home or out at work. In one woman's instance, her increased blood glucose monitoring which resulted from reduced shame and exposure to peer role-modeling, brought her hemoglobin A1c down to the point that she was able to complete a successful pregnancy. In just two years I observed her behaviors change -- changes which now have produced meaningful changes in her A1c, reduced likelihood of diabetes-related complications, increased sense of self-efficacy, and a beautiful, healthy, six-month old baby girl.

She is just one of many similar stories of challenges and triumphs in the 200-plus people in ACT1's support groups. When new members join, I invite them to share what prompted them their attendance. The usual response is that they learned about the group and wanted to come because it would be a space to meet diabetics without anticipatory guilt and shame expected when health care professionals are present. The first question members ask me when I announce my role as facilitator is, "Do you have diabetes?" When I respond affirmatively, I see shoulders relax, members take their seats, and open up to the group about their diabetes-related distress. The findings in the article that A1c reductions were higher in peer over nurse directed support systems did not surprise me. Not because of any expected incompetency on the part of nurses, but because of the culture of a chronic patient, one which often leads to yearning for a peer-only space. I am delighted to see this research published in your journal. I hope to collaborate with the article authors to further this field of powerful peer-led interventions as it becomes increasingly important for its fiscal and public health implications.

Sincerely, Katie Savin

Conflict of Interest:

None declared

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Summary for Patients

Can Patients With Diabetes Help Each Other Get Better?

The summary below is from the full report titled “Diabetes Control With Reciprocal Peer Support Versus Nurse Care Management. A Randomized Trial.” It is in the 19 October 2010 issue of Annals of Internal Medicine (volume 153, pages 507-515). The authors are M. Heisler, S. Vijan, F. Makki, and J.D. Piette.


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