Glucose control is necessary to avoid the immediate and long-term adverse effects associated with type 1 diabetes (T1D), and frequent self-monitoring of blood glucose (SMBG) is the first important step to achieving glucose control. Data suggest that large proportions of adolescents and young adults fail to adhere to standard guidelines of SMBG testing and have hemoglobin A1c levels >7.5%. A finite period of poor metabolic control can lead to increased risk of medical complications over an individual's lifespan, necessitating novel interventions to improve SMBG testing and metabolic control in emerging adults with T1D. We have extensive experience designing, adapting and testing interventions based on behavioral economic principles to improve adherence and outcomes in a variety of clinical populations. Our treatment approach, which provides direct tangible reinforcement for objective evidence of behavior change, is efficacious in decreasing substance use, reducing weight, and improving medication adherence. The purpose of this project is to develop, pilot test, and refine an intervention based on behavioral economic principles for improving SMBG in young persons with T1D. Using well-established behavioral economic principles, the intervention will provide escalating financial reinforcement for SMBG. Initially, w will conduct a feasibility/pilot test of the intervention with 10 patients for 6 months. Patients wll send a text, via cell phones, each time they SMBG, and a return text will inform them of reinforcers earned. We will collect data on SMBG frequency and A1c levels preceding treatment initiation and throughout a 6 month treatment period. Based on experiences with the pilot, procedures may be adjusted before randomizing patients (N = 60) to one of two conditions for 6 months: standard care with diabetes self management education alone or with reinforcers. Primary outcomes will include SMBG frequencies and A1c levels. A 6- month follow-up will assess enduring effects. Data from this study will provide valuable information about the feasibility, safety, and acceptability of reinforcement-based interventions for improving adherence to SMBG and reducing A1c levels. If promising, this study will lead to larger scale evaluations of reinforcement interventions alone, or in combination with multimodal treatment approaches, and it may be applied to other clinical issues such as adherence to continuous glucose monitoring. Importantly, this intervention can be administered remotely and in an automated fashion, allowing for widespread adoption if efficacious.
Patients with type 1 diabetes in the 15-26 year age range have the highest mean A1c levels, necessitating novel interventions to improve outcomes in this group. Blood glucose monitoring is the diabetes self care activity with which patients report the lowest level of adherence, and the activity upon which all other diabetes management decisions rest. This study will test the efficacy of a new intervention integrating behavioral economic principles to increase glucose monitoring in these patients and reduce A1c.
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