DESCRIPTION (provided by applicant): There are over 24 million individuals affected by diabetes in the United States. The majority of these individuals are cared for by primary care providers (PCPs) rather than specialists. There has been significant improvement in our understanding and articulation of ideal patient and provider diabetes management practices. However, these optimal diabetes care behaviors are often not achieved in real world clinical experiences as a result of environmental and psychosocial barriers faced by providers and by patients. A significant barrier both to optimal provider practice and to optimal patient self-management and regimen adherence is "face time"-the amount of time available to the patient and provider to engage in any given clinical encounter. The short duration of typical primary care patient-provider interactions (PPIs), coupled with their relatively infrequency and erratic scheduling, presents a considerable barrier to achieving ideal diabetes management practices. In particular, extreme time pressures placed upon PCP and the common lack of support structures, often cause the focus of the diabetic PPI to shift away from important but time-intensive elements of self- management, such as lifestyle change and behavioral modification support, toward a more narrow emphasis on "fixing the numbers," with, perhaps as a result, the vast majority of patients not being treated to target. Additionally, infrequent diabetic PPIs equate to fewer opportunities to gather patient outcomes data points: providers receive less, and less frequent, data regarding their patients status and, as a result, are both less informed regarding health status progression and less able to modify the regimen for optimal management. For patients, infrequent and erratic contact with the health care system may lead to suboptimal diabetes self- management as a result of relatively inconsistent opportunities for feedback regarding and reinforcement of their medication regimen, and their lifestyle change and behavioral modification efforts. Ideally, this situation would be remedied by providing PCPs with more time for diabetic PPIs; however, for a variety of sociotechnical reasons this is unlikely to occur within the structure and pressures of the US healthcare system. Therefore, other approaches to achieving more optimal outcomes, without increasing provider and patient burden, must be explored. One innovative approach to increasing the frequency and duration of the PPI is to extend such "face time" with web-based, interactive technologies, including social virtual reality environments (SVRE). Through SVRE, aspects of ideal patient and provider diabetes management practices which are either omitted or which occur with suboptimal frequency can be conducted virtually before, after, and between face-to-face PPI. Such an extension of the clinical encounter would represent a valuable augmentation of usual care, increasing opportunities for patient outcome tracking, feedback, and reinforcement, and thereby potentially improving adherence, reducing mismanagement and sequalae, and improving patient outcomes and quality of life. Drawing on AEI's media, educational and performance support experience with a wide range of behavioral change and PCP support efforts and IUSOM's Diabetes Translational Research Center's expertise in diabetes care, access to diabetes PCP providers and patients, and well-known electronic records systems, the proposed effort will examine the impact of using SVRE to augment usual care. The effort will translate aspects of ideal PCP diabetes management care to a SVRE by carefully creating a PCP diabetes care SVRE through an established iterative user-centered development methodology. The acceptability, utility, and impact of the resulting SVRE will be examined in a controlled, mixed methods, multivariate, repeated measures field trial with follow-up conducted among diabetes patients and providers within the IUSOM medical care system. A significant barrier both to optimal provider practice and to optimal diabetes management is "face time"- the amount of time available to the patient and provider to engage in any given clinical encounter. One possible approach to increasing the frequency and duration of the PPI is to extend such "face time" with web-based, interactive technologies, including social virtual reality environments (SVRE). Such an extension of the clinical encounter would represent a valuable augmentation of usual care, increasing opportunities for patient outcome tracking, feedback, and reinforcement, and thereby potentially improving adherence, reducing mismanagement and sequalae, and improving patient outcomes and quality of life. Very little is known regarding the acceptability and impact of SVRE among diabetes patients and even less regarding the utility of patients interacting with live and simulated provider avatars. By developing a PCP diabetes care SVRE, examining patient satisfaction with the environment, and comparing patient outcomes of those in SVRE- augmented usual care with those in usual care, the proposed effort will fill this gap in our understanding, provide generalizable findings related to best practices in this arena, and potentially lead to a disseminable tool for improving diabetes patient care, outcomes and quality of life.

PROJECT NARRATIVE A significant barrier both to optimal provider practice and to optimal diabetes management is "face time"- the amount of time available to the patient and provider to engage in any given clinical encounter. One possible approach to increasing the frequency and duration of the PPI is to extend such "face time" with web-based, interactive technologies, including social virtual reality environments (SVRE). Such an extension of the clinical encounter would represent a valuable augmentation of usual care, increasing opportunities for patient outcome tracking, feedback, and reinforcement, and thereby potentially improving adherence, reducing mismanagement and sequalae, and improving patient outcomes and quality of life. Very little is known regarding the acceptability and impact of SVRE among diabetes patients and even less regarding the utility of patients interacting with live and simulated provider avatars. By developing a PCP diabetes care SVRE, examining patient satisfaction with the environment, and comparing patient outcomes of those in SVRE- augmented usual care with those in usual care, the proposed effort will fill this gap in our understanding, provide generalizable findings related to best practices in this arena, and potentially lead to a disseminable tool for improving diabetes patient care, outcomes and quality of life.