title: Increasing efficacy of primary care-based counseling for diabetes prevention: rationale and design of the ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial.
abstract: BACKGROUND
  Studies have shown that lifestyle behavior changes are most effective to prevent onset of diabetes in high-risk patients. Primary care providers are charged with encouraging behavior change among their patients at risk for diabetes, yet the practice environment and training in primary care often do not support effective provider counseling. The goal of this study is to develop an electronic health record-embedded tool to facilitate shared patient-provider goal setting to promote behavioral change and prevent diabetes.
  
  
  METHODS
  The ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial leverages an innovative system that integrates evidence-based interventions for behavioral change with already-existing technology to enhance primary care providers' effectiveness to counsel about lifestyle behavior changes. Using principles of behavior change theory, the multidisciplinary design team utilized in-depth interviews and in vivo usability testing to produce a prototype diabetes prevention counseling system embedded in the electronic health record.
  
  
  RESULTS
  The core element of the tool is a streamlined, shared goal-setting module within the electronic health record system. The team then conducted a series of innovative, "near-live" usability testing simulations to refine the tool and enhance workflow integration. The system also incorporates a pre-encounter survey to elicit patients' behavior-change goals to help tailor patient-provider goal setting during the clinical encounter and to encourage shared decision making. Lastly, the patients interact with a website that collects their longitudinal behavior data and allows them to visualize their progress over time and compare their progress with other study members. The finalized ADAPT system is now being piloted in a small randomized control trial of providers using the system with prediabetes patients over a six-month period.
  
  
  CONCLUSIONS
  The ADAPT system combines the influential powers of shared goal setting and feedback, tailoring, modeling, contracting, reminders, and social comparisons to integrate evidence-based behavior-change principles into the electronic health record to maximize provider counseling efficacy during routine primary care clinical encounters. If successful, the ADAPT system may represent an adaptable and scalable technology-enabled behavior-change tool for all primary care providers.
  
  
  BACKGROUND
  ClinicalTrials.gov Identifier NCT01473654.
authors.affiliation: Department of Medicine, Section of Preventive Medicine and Epidemiology, Boston University School of Medicine, Boston, MA, USA. dmann@bu.edu
authors.forename: Devin M
authors.initials: DM
authors.lastname: Mann
authors.forename: Jenny J
authors.initials: JJ
authors.lastname: Lin
mesh_terms: D003376:Counseling / Q000592:standards*; D003920:Diabetes Mellitus / Q000517:prevention & control*; D057286:Electronic Health Records; D015438:Health Behavior; D006293:Health Promotion; D006801:Humans; D008019:Life Style; D009765:Obesity / Q000517:prevention & control; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D016032:Randomized Controlled Trials as Topic; D012107:Research Design; D040242:Risk Reduction Behavior; D016896:Treatment Outcome