--- title: "Group-based DM prevention in healthcare delivery system. | Sutter Health" description: "Variation in the implementation of the DPP within a large multi-site healthcare system may affect effectiveness. Consider alternatives to anticipate barriers." url: "https://www.sutterhealth.org/research/publications/group-based-dm-prevention-in-healthcare-delivery-system-1055312659" --- 1. [Home](https://www.sutterhealth.org/) / 2. [Research](https://www.sutterhealth.org/research) / 3. [Research publications](https://www.sutterhealth.org/research/publications) / 4. Group-based DM prevention in healthcare delivery system. # Implementation of a group-based diabetes prevention program within a healthcare delivery system. Azar KMJ, Nasrallah C, Szwerinski NK, Petersen JJ, Halley MC, Greenwood D, & Romanelli RJ. _BMC Health Serv Res. 19(1):694. doi: 10.1186/s12913-019-4569-0._ 2019-10-15 ## Abstract BACKGROUND: Group-based Diabetes Prevention Programs (DPP), aligned with recommendations from the Centers for Disease Control and Prevention, promote clinically significant weight loss and reduce cardio-metabolic risks. Studies have examined implementation of the DPP in community settings, but less is known about its integration in healthcare systems. In 2010, a group-based DPP known as the Group Lifestyle Balance (GLB) was implemented within a large healthcare delivery system in Northern California, across three geographically distinct regional administration divisions of the organization within 12 state counties, with varying underlying socio-demographics. The regional divisions implemented the program independently, allowing for natural variation in its real-world integration. We leveraged this natural experiment to qualitatively assess the implementation of a DPP in this healthcare system and, especially, its fidelity to the original GLB curriculum and potential heterogeneity in implementation across clinics and regional divisions. METHODS: Using purposive sampling, we conducted semi-structured interviews with DPP lifestyle coaches. Data were analyzed using mixed-method techniques, guided by an implementation outcomes framework consisting of eight constructs: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. RESULTS: We conducted 33 interviews at 20 clinics across the three regional administrative divisions. Consistencies in implementation of the program were found across regions in terms of satisfaction with the evidence base (acceptability), referral methods (adoption), eligibility criteria (fidelity), and strategies to increase retention and effectiveness (sustainability). Heterogeneity in implementation across regions were found in all categories, including: the number and frequency of sessions (fidelity); program branding (adoption); lifestyle coach training (adoption), and patient-facing cost (cost). Lifestyle coaches expressed differing attitudes about curriculum content (acceptability) and suitability of educational level (appropriateness). While difficulties with recruitment were common across regions (feasibility), strategies used to address these challenges differed (sustainability). CONCLUSIONS: Variation exists in the implementation of the DPP within a large multi-site healthcare system, revealing a dynamic and important tension between retaining fidelity to the original program and tailoring the program to meet the local needs. Moreover, certain challenges across sites may represent opportunities for considering alternative implementation to anticipate these barriers. Further research is needed to explore how differences in implementation domains impact program effectiveness. [PubMed abstract](https://www.ncbi.nlm.nih.gov/pubmed/31615525) ![Kristen M J Azar, RN, MSN, MPH](https://dyn.mktgcdn.com/p/rFmyR1kiX8JzE5-XNwup0gVC1GRaVTlH7oSDlG0Tr5A/fit=crop,gravity=auto,dpr=2,width=188,height=250,quality=100) Kristen M J Azar, RN, MSN, MPH Principal investigator [View profile](https://www.sutterhealth.org/research/investigators/kristen-m-j-azar-rn-msn-mph-1049680985) ## Research topics - [Diabetes Type 2](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Diabetes+Type+2%5C%22%22) - [Diabetes, Insulin Resistance and Metabolic Syndrome](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Diabetes%2C+Insulin+Resistance+and+Metabolic+Syndrome%5C%22%22) - [Obesity](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Obesity%5C%22%22) ## Related publications [View all publications](https://www.sutterhealth.org/research-search-results?verticalKey=research_publication) - Publication ### [Examining paradoxical session attendance and weight loss relationships in a clinic based lifestyle modification intervention](https://www.sutterhealth.org/research/publications/paradoxical-session-attendance-weight-loss-relationships-1055312915) Kristen M. J. Azar, Sylvia Sudat, Qiwen Huang, Alice P. Pressman, Nina K. Szwerinski, Catherine Nasrallah, Elizabeth M. Venditti, Robert J. Romanelli Examining paradoxical session attendance and weight loss relationships in a clinic-based lifestyle modification intervention.Obes Sci Pract. 2023; 2023 Jul 04 - Publication ### [Longitudinal weight outcomes from a behavioral lifestyle intervention in clinical practice.](https://www.sutterhealth.org/research/publications/weight-outcomes-from-behavioral-lifestyle-intervention-1055312674) Romanelli RJ, Huang HC, Chopra V, Ma J, Venditti EM, Sudat S, Greenwood DA, Pressman AR, Azar KMJ. Diabetes Educ. 145721719872553. doi: 10.1177/0145721719872553. \[Epub ahead of print\] 2019 Sep 03 - Publication ### [Early weight loss and treatment response: data from a lifestyle change program in clinical practice.](https://www.sutterhealth.org/research/publications/early-wt-loss-and-tx-response-in-lifestyle-change-program-1055312721) Romanelli RJ, Sudat S, Huang Q, Pressman AR, Azar K. Am J Prev Med. pii: S0749-3797(19)30421-0. doi: 10.1016/j.amepre.2019.09.014. \[Epub ahead of print\] 2019 Dec 20 - Publication ### [Short-term weight trajectories and long-term weight outcomes from a lifestyle intervention in real-world clinical practice.](https://www.sutterhealth.org/research/publications/short-term-weight-trajectories-and-long-term-weight-outcomes-1055312769) Romanelli RJ, Sudat S, Huang Q, Ma J, Venditti EM, Greenwood DA, Pressman AR, Azar KMJ. Transl Behav Med. pii: ibz118. doi: 10.1093/tbm/ibz118. \[Epub ahead of print\] 2019 Aug 01 - Publication ### [Baseline obesity status modifies effectiveness of adapted diabetes prevention program lifestyle interventions for weight management in primary care.](https://www.sutterhealth.org/research/publications/obesity-status-modifies-dpp-program-for-wt-mgmt-1055312603) Azar KM, Xiao L, Ma J. Biomed Res Int. 2013:191209. doi: 10.1155/2013/191209. Epub 2013 Dec 4. 2013 Dec 04 [View all publications](https://www.sutterhealth.org/research-search-results?verticalKey=research_publication) ```json {"@context":"https://schema.org","@type":"MedicalOrganization","name":"Sutter Health","@id":"https://www.sutterhealth.org/#medicalorganization","url":"https://www.sutterhealth.org","logo":"https://www.sutterhealth.org/static/images/sutter-health-logo.svg","address":{"@type":"PostalAddress","streetAddress":"2200 River Plaza Drive","addressLocality":"Sacramento","addressRegion":"CA","postalCode":"95833","addressCountry":"US"},"areaServed":{"@type":"AdministrativeArea","name":"California"},"sameAs":["https://www.facebook.com/SutterHealth","https://www.instagram.com/sutterhealth/","https://x.com/SutterHealth","https://www.youtube.com/sutterhealth","https://www.linkedin.com/company/sutter-health","https://en.wikipedia.org/wiki/Sutter_Health"]} ``` ```json {"@context":"https://schema.org","@type":"BreadcrumbList","@id":"https://www.sutterhealth.org/research/publications/group-based-dm-prevention-in-healthcare-delivery-system-1055312659#breadcrumblist","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https://www.sutterhealth.org/"},{"@type":"ListItem","position":2,"name":"Research","item":"https://www.sutterhealth.org/research"},{"@type":"ListItem","position":3,"name":"Research publications","item":"https://www.sutterhealth.org/research/publications"},{"@type":"ListItem","position":4,"name":"Group-based DM prevention in healthcare delivery system."}]} ``` ```json {"@context":"https://schema.org","@type":"MedicalScholarlyArticle","@id":"https://www.sutterhealth.org/research/publications/group-based-dm-prevention-in-healthcare-delivery-system-1055312659#medicalscholarlyarticle","name":"Implementation of a group-based diabetes prevention program within a healthcare delivery system.","headline":"Group-based DM prevention in healthcare delivery system.","abstract":"BACKGROUND: Group-based Diabetes Prevention Programs (DPP), aligned with recommendations from the Centers for Disease Control and Prevention, promote clinically significant weight loss and reduce cardio-metabolic risks. Studies have examined implementation of the DPP in community settings, but less is known about its integration in healthcare systems. In 2010, a group-based DPP known as the Group Lifestyle Balance (GLB) was implemented within a large healthcare delivery system in Northern California, across three geographically distinct regional administration divisions of the organization within 12 state counties, with varying underlying socio-demographics. The regional divisions implemented the program independently, allowing for natural variation in its real-world integration. We leveraged this natural experiment to qualitatively assess the implementation of a DPP in this healthcare system and, especially, its fidelity to the original GLB curriculum and potential heterogeneity in implementation across clinics and regional divisions. METHODS: Using purposive sampling, we conducted semi-structured interviews with DPP lifestyle coaches. Data were analyzed using mixed-method techniques, guided by an implementation outcomes framework consisting of eight constructs: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. RESULTS: We conducted 33 interviews at 20 clinics across the three regional administrative divisions. Consistencies in implementation of the program were found across regions in terms of satisfaction with the evidence base (acceptability), referral methods (adoption), eligibility criteria (fidelity), and strategies to increase retention and effectiveness (sustainability). Heterogeneity in implementation across regions were found in all categories, including: the number and frequency of sessions (fidelity); program branding (adoption); lifestyle coach training (adoption), and patient-facing cost (cost). Lifestyle coaches expressed differing attitudes about curriculum content (acceptability) and suitability of educational level (appropriateness). While difficulties with recruitment were common across regions (feasibility), strategies used to address these challenges differed (sustainability). CONCLUSIONS: Variation exists in the implementation of the DPP within a large multi-site healthcare system, revealing a dynamic and important tension between retaining fidelity to the original program and tailoring the program to meet the local needs. Moreover, certain challenges across sites may represent opportunities for considering alternative implementation to anticipate these barriers. Further research is needed to explore how differences in implementation domains impact program effectiveness.","description":"Variation in the implementation of the DPP within a large multi-site healthcare system may affect effectiveness. 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