What’s the clinical and cost data behind social engagement health interventions like mutual peer support?
Shared medical appointments have a long body of research showing improved clinical outcomes, says Michele Heisler. And if you see 10 patients within 2 hours, that certainly is cost effective.
The clinical data on different peer support models varies, however — for some populations the evidence is strong, but not for others. Heisler describes a randomized, controlled trial for a mutual peer support intervention where two people with poor glycemic control were matched with each other and trained in action planning. When compared with nurse care management — because “we know nurse care management is effective” — in two clinical settings, the mutual peer support intervention showed 1% lower A1Cs than the nurse care management arm.
That 1% difference in A1C is huge, adds David Asch. “It’s an effect much larger than one sees typically from the introduction of a new drug.”
But randomized, controlled trials with people with severe heart failure and intractable diabetes did not work. “They were not engaged enough; a mutual peer support model was not the right model for those populations,” says Heisler, suggesting more intensive interventions for this population.
The clinical evidence for peer coach models is also strong, according to Heisler. She describes models where patients with diabetes are trained and then reach out to support their peers. The trials completed in diabetes showed significant improvement in A1C, diabetes support, diabetes distress, and other key outcomes compared to usual care, and equivalent outcomes to interventions by well-trained behavioral counselors.
Formal cost effectiveness analyses for social interventions are underway, says Heisler, in large-scale implementation studies. But costs in general are low — many models use volunteers, with peer coaches in some cases receiving a small stiped to reimburse them for their costs. “You are very much trying to tap into that sense of altruism,” Heisler says.
What about impact on utilization outcomes? Namita Seth Mohta asks if peer support interactions help decrease hospital readmissions and emergency room visits.
Heisler says there is evidence for shared medical appointments and solid data for community health workers, who are a form of peer, in reducing hospital admissions and inappropriate ED utilization. Peer coach data also shows some declines in ED utilization.
Heisler stresses the importance of looking at a hybrid of models when increasing the rigor of research. “It’s a spectrum,” she says. “You may have a nurse who supervises a community health worker who is trained to lead an intensive self-management training program,” for example, “and then you might have a patient who had participated in the education program to serve as a peer coach, to help sustain gains.” Similarly, participants in shared medical appointments may be matched to support each other in between appointments.
“We subject a new drug that might enter into the market to an enormous number of tests to generate evidence about its effectiveness — sometimes about its cost, but typically about its effectiveness,” adds Asch. “I don’t see why we should be using any different standard for testing the effectiveness of these social interactions.”
But first, hospitals and health systems need to recognize that creating a platform for these trials is part of their role. “We should start becoming more comfortable with doing this in the first place so that we can generate even more evidence,” says Asch.
From the NEJM Catalyst event Hardwiring Patient Engagement to Deliver Better Health at Kaiser Permanente Southern California, April 13, 2017.