Judith Long, MD, of the University of Pennsylvania, and colleagues reported in the March 20 issue of Annals of Internal Medicine that in a sixth-month intervention among black veterans, those in a peer mentoring program lowered their HbA1c levels more than either those on usual care or those given a financial incentive.
They wrote, "On average, patients in the peer mentor group decreased their HbA1c levels by close to 1% compared with the control group, whereas patients in the financial incentive group decreased their levels by just 0.5% compared with the control group."
Diabetes is more common and more severe in African Americans, which makes them an important target for specific glucose control programs, the researchers said.
While the lifestyle and dietary changes that are required for successful HbA1c lowering are challenging, prior studies have shown that both peer support and financial incentives can help motivate patients.
So Long and colleagues conducted a six-month study among 118 patients at the Philadelphia Veterans Affairs Medical Center who hadn't been successful at lowering their HbA1c. Patients were assigned to one of three groups: usual care, peer mentoring, or a financial incentive.
The usual care group was solely given specific goals for HbA1c control, while those in the peer mentoring group were connected with another diabetes patient who once had poor glucose control but had brought it to a target level (mean 6.7% at baseline). Mentors and mentees were told to speak at least once per week, and mentors were paid $20 for the trial.
Those in the financial incentive group could earn $100 by dropping their HbA1c levels by 1%, or $200 if they lowered them by 2% or hit 6.5% or lower.
Long and colleagues found that patients who spoke with a peer mentor on a weekly basis achieved the greatest declines in blood sugar. HbA1c fell from 9.9% to 9.8% among controls, from 9.8% to 8.7% among those with peer mentors, and from 9.5% to 9.1% in the financial incentive group.
Compared with the usual care group, the mean change in HbA1c from baseline to six months was -1.07% for those in the peer mentoring group and -0.45% for those in the financial incentive group.
The decline in HbA1c achieved in the financial incentive group wasn't clinically significant, but confidence intervals were wide so it's not conclusive that the intervention was ineffective, the researchers said. They also found that mentors and mentees spoke most frequently in the first month, with a mean of four calls per month, dropping off to a mean of two per month by the end of the trial. It's not clear whether fewer calls reflect reduced motivation or a perceived decrease in need, they noted.
Patients in the mentoring group likely benefitted from a culture of camaraderie, specifically because all patients were veterans, the researchers said -- so a similar culture may not be cultivated among other diabetic groups.
The intervention was also likely a success because the "long history of mistreatment and distrust in the healthcare system may make peer support particularly effective for African Americans," they wrote.
"Perhaps the most obvious attraction of this type of peer mentoring is that it is virtually free, almost certainly enhancing its cost-effectiveness relative to more expensive interventions, such as nurse care management, telemedicine, and group medical appointments," they added.
Long and colleagues called for future studies to determine whether the effects are sustainable, noting that one possible approach to maintaining its effects would be to transition patients who achieve good control from mentee to mentor roles.
- Note that the decline in A1c achieved in the financial incentive group wasn't clinically significant, but confidence intervals were wide so it's not conclusive that the intervention was ineffective.
- Note that mentoring by diabetic peers who were successful in controlling their blood sugar helped other African-American diabetes patients bring down their own level.
Long JA, et al "Peer mentoring and financial incentives to improve glucose control in African American veterans" Ann Intern Med 2012; 156: 416-424.