BRInging the Diabetes prevention program to GEriatric populations (BRIDGE): a feasibility study

Consolidated guidance for behavioral intervention pilot and feasibility studies

BACKGROUND

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

METHODS

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of a well-known PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

RESULTS

A total of 496 authors were invited to take part in the three-round Delphi survey (round 1, N = 46; round 2, N = 24; round 3, N = 22). A set of twenty considerations, broadly categorized into six themes (intervention design, study design, conduct of trial, implementation of intervention, statistical analysis, and reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

CONCLUSION

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Development and Feasibility of an eHealth Diabetes Prevention Program Adapted for Older Adults-Results from a Randomized Control Pilot Study

Lifestyle programs that reduce health risks and support weight loss (WL) in older adults face adherence and attendance challenges due to reduced energy requirements, impaired mobility, lack of transportation, and low social support. Tailored lifestyle and weight management programs are needed to better support healthy aging for older adults. Here, we developed and piloted an age-adapted, remotely delivered modification of the Diabetes Prevention Program (DPP). The modification includes age-appropriate goals, visuals, and examples; flexible dietary composition; remote classroom and fitness-monitoring technology; and standardized online classroom materials employing pedagogical and behavior change theory. The modifications were designed to safeguard fidelity and to boost adherence, engagement, and knowledge integration, with the convenience of a fully remote WL program for diverse older adults. Six-month pilot data are presented from older adults (55-85 years, body mass index (BMI) 27-39.9 kg/m2, N = 20) randomly allocated to an online DPP intervention with weight, diet, and activity monitored remotely, or into a waitlisted control. The intervention achieved 100% attendance and adherence to self-monitoring. The intervention group mean (±SD) body weight change was -9.5% (±4.1); 90% lost ≥ 5%. By contrast, the control group gained 2.4% (±1.8). Once thought incompatible with older adults, remote interventions are feasible for older adults and can support fidelity, adherence, engagement, and clinically significant WL. Standardized materials are provided for future implementation.

Factors influencing older adults' participation in telehealth interventions for primary prevention and health promotion: A rapid review

OBJECTIVE

To identify facilitators and barriers to older adults' participation in telehealth interventions for primary prevention and health promotion.

METHODS

Relevant articles were searched using keywords in Embase and MEDLINE. Study characteristics, type of telehealth interventions and technology involved, as well as facilitators and barriers to their use, were extracted from selected articles. The Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) model was used to organise data.

RESULTS

A total of 24 articles (pertaining to 20 studies) were included. Nine facilitators and 11 barriers influencing the participation in telehealth interventions for primary prevention and health promotion among older adults were identified. The most recurrent facilitators were related to the individual's performance expectancy and effort expectancy, as well as the presence of a social dimension associated with the intervention (i.e. having a good relationship with the other participants in the program). The two most prevalent barriers were also related to effort expectancy and performance expectancy, followed by barriers related to the inherent characteristics of the technology and older adults' health condition. Experience, age and gender were also found to moderate technology use and acceptance.

CONCLUSIONS

This rapid review highlights the importance of adopting a holistic perspective when designing telehealth interventions aimed at preventive and health promotion purposes among older adults.

Group-based patient education via videoconference: A scoping review

OBJECTIVES

To summarize recent evidence on the feasibility, acceptability, and effectiveness of videoconference (VC) group-based patient and caregiver education.

METHODS

Systematic searches of the literature were conducted. Data was extracted on the characteristics of the studies and interventions and on the feasibility, acceptability, and effectiveness of the interventions.

RESULTS

From 12,570 hits, 65 studies were eligible for inclusion. Their results confirmed previously identified tendencies of high feasibility and acceptability of VC group patient education, and improved health outcomes. However, evidence of effectiveness is limited, and the quality of studies is varied. Several patient and caregiver groups also remain under-researched. Only four studies stated that facilitators were trained in using VC-technology.

CONCLUSION

VC group-based patient and caregiver education is feasible and acceptable and may improve health outcomes for participant patients and caregivers. However future research should increase the number of high-quality randomized controlled trials to establish the effectiveness of VC group-based education for several groups of patients and caregivers. Studies of the training of facilitators is also warranted.

PRACTICE IMPLICATIONS

The results suggest that interventions should be more accessible. An overview of the recent evidence may also stimulate the development and evaluation of VC group-based patient and caregiver education.

Expert Perspectives on Pilot and Feasibility Studies: A Delphi Study and Consolidation of Considerations for Behavioral Interventions

Background

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

Methods

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of well-know PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

Results

A total of 496 authors were invited to take part in the Delphi survey, 50 (10.1%) of which completed all three rounds, representing 60 (37.3%) of the 161 identified PFS-related guidelines, checklists, frameworks, and recommendations. A set of twenty considerations, broadly categorized into six themes (Intervention Design, Study Design, Conduct of Trial, Implementation of Intervention, Statistical Analysis and Reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

Conclusion

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Enhancing access and impact of the Medicare Diabetes Prevention Program using telehealth: a narrative review

Background and Objective

Over 26 million older adults in the United States (US) have prediabetes, which is often a precursor to type 2 diabetes. The Medicare Diabetes Prevention Program (MDPP) is an evidence-based, lifestyle program for older-adult Medicare beneficiaries to prevent progression to diabetes. However, the MDPP has been drastically underutilized. Telehealth delivery may be a promising strategy to increase the reach and impact of the MDPP, including for underserved populations. The objective of this narrative review is to explore the role of telehealth on the accessibility and effectiveness of diabetes prevention programs (DPPs) for older adults.

Methods

We searched the online databases of MEDLINE, APA PsycInfo, CINAHL, and Academic Search Elite for studies that used telehealth to deliver DPPs to older adults through distance learning, i.e., live program delivery where participants join via phone- or video-conferencing. Relevant information from policy documents and related publications was also included.

Key Content and Findings

Three themes emerged from the literature on telehealth delivery of DPPs for older adults (I) clinical effectiveness for weight loss, (II) feasibility and acceptability of this format; and (III) policy considerations to support greater public health impact. There is a growing body of recent evidence to suggest that older adults achieve a clinically meaningful amount of weight loss from participation in telehealth DPPs. The literature suggests that telehealth program delivery is feasible, and older adults find it acceptable, with some specific accommodations. Effectiveness and acceptability of telehealth interventions were also noted for older adults from rural, ethnically-diverse, and low-income groups. Policy considerations include adjustments in rulemaking by the Centers for Medicare and Medicaid Services (CMS) to allow MDPP delivery via telehealth using distance learning, along with sufficient reimbursement rates.

Conclusions

The evidence indicates that delivery of the MDPP via telehealth is beneficial for increasing program reach and impact, including among underserved groups, as well as providing social support for older participants. Scalable delivery of the MDPP via telehealth is essential to make a national, population-level impact for older adults with prediabetes who receive Medicare benefits.

A Scoping Review of Nutrition Health for Older Adults: Does Technology Help?

The technological developments in healthcare may help facilitate older adult nutritional care. This scoping review includes research in technology and nutrition to (1) explain how technology is used to manage nutrition needs and (2) describe the forms of technology used to manage nutrition. Five major databases were the foundation for papers published from January 2000 to December 2020. The most common type of technology used is software to (1) "track, plan, and execute" nutrition management and for (2) "assessing" technology use. "Track, plan, and execute" includes tracking food intake, planning for changes, and executing a plan. "Assessing" technology use is collecting nutrition data from a provider's or an older adult's self-use of technology to understand dietary intake. Hardware is the second most type of technology used, with tablet computers for software and internet access. The findings reveal that software for older adults lacks standardization, the Internet of Things is a promising area, the current device emphasis is the tablet computer, and broadband internet access is essential for nutrition care. Only 38 studies were published in the last five years, indicating that nutrition management for older adults with hardware or software has not reached a significant research mass.

Adapting the Diabetes Prevention Program for Older Adults: Descriptive Study

BACKGROUND

Prediabetes affects 26.4 million people aged 65 years or older (48.8%) in the United States. Although older adults respond well to the evidence-based Diabetes Prevention Program, they are a heterogeneous group with differing physiological, biomedical, and psychosocial needs who can benefit from additional support to accommodate age-related changes in sensory and motor function.

OBJECTIVE

The purpose of this paper is to describe adaptations of the Centers for Disease Control and Prevention's Diabetes Prevention Program aimed at preventing diabetes among older adults (ages ≥65 years) and findings from a pilot of 2 virtual sessions of the adapted program that evaluated the acceptability of the content.

METHODS

The research team adapted the program by incorporating additional resources necessary for older adults. A certified lifestyle coach delivered 2 sessions of the adapted content via videoconference to 189 older adults.

RESULTS

The first session had a 34.9% (38/109) response rate to the survey, and the second had a 34% (30/88) response rate. Over three-quarters (50/59, 85%) of respondents agreed that they liked the virtual program, with 82% (45/55) agreeing that they would recommend it to a family member or a friend.

CONCLUSIONS

This data will be used to inform intervention delivery in a randomized controlled trial comparing in-person versus virtual delivery of the adapted program.

Evaluation of feasibility and acceptability of a web-based diabetes prevention program (DPP) for diabetes risk reduction in Chinese Americans in New York City

Introduction

Intensive lifestyle intervention remains an effective modality to reduce diabetes incidence and delay the progression to type 2 diabetes. The primary aim of this study was to pilot-test the feasibility and acceptability of a culturally and linguistically tailored web-based DPP intervention among Chinese Americans with prediabetes living in New York City.

Methods

Thirteen Chinese American participants with prediabetes were recruited to complete a 1-year web-based Diabetes Prevention Program (DPP) lifestyle intervention. Quantitative and qualitative measures such as retention rate and data collected from web-based questionnaires and focus groups were collected and analyzed to assess study feasibility and acceptability.

Results and Discussion

Participants were receptive to the program through high engagement, retention and satisfaction. Retention rate was 85%. 92% of participants completed at least 16 sessions out of 22 sessions. Post-trial surveys indicated high satisfaction of 27.2/32 based on Client Satisfaction Questionnaire (CSQ-8) score. Participants expressed the program increased their knowledge and methods to prevent onset of type 2 diabetes such as incorporating healthy eating habits and increasing physical activities. Although not a primary outcome, there was a significant weight reduction of 2.3% at the end of month 8 of the program (p < 0.05). The culturally and linguistically adapted DPP via online platform successfully demonstrated feasibility and acceptability among Chinese Americans with prediabetes. Further evaluation of the web-based Chinese Diabetes Prevention Program in a larger trial is warranted.

Study protocol: BRInging the Diabetes prevention program to GEriatric Populations

In the Diabetes Prevention Program (DPP) randomized, controlled clinical trial, participants who were  ≥ 60 years of age in the intensive lifestyle (diet and physical activity) intervention had a 71% reduction in incident diabetes over the 3-year trial. However, few of the 26.4 million American adults age ≥65 years with prediabetes are participating in the National DPP. The BRInging the Diabetes prevention program to GEriatric Populations (BRIDGE) randomized trial compares an in-person DPP program Tailored for Older AdulTs (DPP-TOAT) to a DPP-TOAT delivered via group virtual sessions (V-DPP-TOAT) in a randomized, controlled trial design (N = 230). Eligible patients are recruited through electronic health records (EHRs) and randomized to the DPP-TOAT or V-DPP-TOAT arm. The primary effectiveness outcome is 6-month weight loss and the primary implementation outcome is intervention session attendance with a non-inferiority design. Findings will inform best practices in the delivery of an evidence-based intervention.

Group-based nutrition interventions to promote healthy eating and mobility in community-dwelling older adults: a systematic review

OBJECTIVE

To identify the efficacy of group-based nutrition interventions to increase healthy eating, reduce nutrition risk, improve nutritional status and improve physical mobility among community-dwelling older adults.

DESIGN

Systematic review. Electronic databases MEDLINE, CINAHL, EMBASE, PsycINFO and Sociological Abstracts were searched on July 15, 2020 for studies published in English since January 2010. Study selection, critical appraisal (using the Joanna Briggs Institute's tools) and data extraction were performed in duplicate by two independent reviewers.

SETTING

Nutrition interventions delivered to groups in community-based settings were eligible. Studies delivered in acute or long-term care settings were excluded.

PARTICIPANTS

Community-dwelling older adults aged 55+ years. Studies targeting specific disease populations or promoting weight loss were excluded.

RESULTS

Thirty-one experimental and quasi-experimental studies with generally unclear to high risk of bias were included. Interventions included nutrition education with behaviour change techniques (BCT) (e.g. goal setting, interactive cooking demonstrations) (n 21), didactic nutrition education (n 4), interactive nutrition education (n 2), food access (n 2) and nutrition education with BCT and food access (n 2). Group-based nutrition education with BCT demonstrated the most promise in improving food and fluid intake, nutritional status and healthy eating knowledge compared with baseline or control. The impact on mobility outcomes was unclear.

CONCLUSIONS

Group-based nutrition education with BCT demonstrated the most promise for improving healthy eating among community-dwelling older adults. Our findings should be interpreted with caution related to generally low certainty, unclear to high risk of bias and high heterogeneity across interventions and outcomes. Higher quality research in group-based nutrition education for older adults is needed.

Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Background

Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated.

Objective

This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings.

Methods

A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted.

Results

The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low.

Conclusions

Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.