Education for Equity (E4E)intervention intends to improve care delivery through a well designed educational program that address not only the issues of diabetes care delivery to Aboriginal patients with diabetes, but also the issues of effective cross-cultural and culturally safe communication between healthcare providers and Aboriginal patients, and the issues related to effective implementation of appropriate chronic disease management programs for Aboriginal patients in a range of practice settings. The purpose of this study is to evaluate the effectiveness of the E4E education program through measuring patient clinical outcomes, patient experience with their doctors, and the changes in physicians' approaches to care perceived by Aboriginal diabetic patients.

Two waves of the E4E intervention will be delivered to family physicians who have Aboriginal patients with type 2 diabetes on and off reserves. A mix-method approach will be employed in this evaluation study. Evaluation instruments include: (1) chart reviews and (2) patient experience surveys.

1. Chart review: A randomized, controlled, pre- and post intervention study design will be used to evaluate the effect of the E4E intervention on type 2 diabetes clinical outcomes of the Aboriginal patients. A retrospective chart audit will be used to gather the clinical data from 12 months prior to and 12 month after the intervention, not including the time during intervention.

   Sample Size for chart review: The primary outcome measure of HbA1C value will be used to identify the impact of E4E intervention on the clinical outcome of Aboriginal patients with type 2 diabetes. It is hypothesized that the A1C value would be reduced in the E4E Intervention Group's patients whose A1C values are at or above 8.0% prior to the E4E intervention (baseline) compared to the patients in E4E Late Intervention Control Group. A 0.5% difference of patients' A1C values between these two groups will be a clinically significant difference. The sample size needed to detect such a difference is estimated to be 98 eligible patients charts with A1C at or above 8.0% from E4E Intervention Group and 98 eligible patient charts from E4E Late Intervention Control Group, with an a=0.05 and ß=0.15. Given the proportion of 61.1% of Aboriginal patients with type 2 diabetes having A1C at or above 8.0%, we need to review 163 patient charts to obtain 98 eligible charts from each group. When 10 charts extractions per physician are performed, we need 17 physicians from each group. Considering a possible 20% loss to follow up, we need to recruit 20 physicians from E4E Intervention Group and 20 physicians from E4E Late Intervention Control Group, a total of 40 physicians to be invited to participate in chart reviews.

   Recruitment of physicians: After obtaining ethics approval from Queen's University Research Office, we will recruit 8-10 physicians to participate in the project at each potential site. Once recruitment is completed on each site, physicians will be randomized into E4E Intervention Group and E4E Late Intervention Control Group (sham comparator) who will participate in the second wave of E4E intervention 12 month later. Letters of information and consent form will be sent to the physicians to obtain their signed consent to participating in E4E chart review, patient survey and patient interview.

   Data collection regarding chart reviews for diabetes: The evaluation team will require the consenting physicians to create a list of all of their Aboriginal patients with type 2 diabetes using billing code 250, removing non-Aboriginal patients. This process can either be managed by the practice (with staff being reimbursed for time required) or can be conducted by the research staff at time of the chart audit. Each physician will then be asked to review the list for accuracy. Random number generation will be used to select charts at random from the list until the required number of eligible patient charts has been identified. Chart reviewers will be trained staff from the evaluation team and travel to each selected location to conduct chart audits.

2. Patient experience survey: Two (2) patient experience surveys will be conducted to evaluate the experience of Aboriginal patient with type 2 diabetes with his/her physician, respectively at the point of 3-month after the E4E intervention and at the point of 12-month after the intervention.

Sample size for patient experience surveys: An effective sample size needed for patient experience survey, with an a=0.05 and power 85% (ß=0.15), is estimated to be 102 eligible Aboriginal type 2 diabetic patients from E4E Intervention Group and the same number of eligible Aboriginal patients from E4E Late Intervention Control Group. We will recruit 10 eligible Aboriginal patients from each of the physicians in E4E Group A and 10 eligible Aboriginal patients from each of the physicians in E4E Group B. A total of 400 patients will be recruited to participate in Patient Experience surveys. This sample size (200 from each group) is more than sufficient to achieve 85% power even after allowing for drop out of physicians and any unanticipated difficulties in patient recruitment.

Data collection regarding patient experience surveys: The Patient Experience Surveys will take approximately 15-20 minutes to complete and will be completed on the day of patient visit. Patient Experience Survey is designed in two sections: pre-visit section and post visit section. Consent needs to be obtained from patients in pre-visit section.

• The receptionist of the selected practice will notify eligible patients about the study, and ask if they are willing to discuss with support/research staff about participating in a Patient Experience Survey. If the patient is interested, the receptionist will refer her/him to the onsite support/research staff, or provide access to a private phone with toll free number to contact support/research staff.
• Support/Research staff will review the information letter with the patient and obtain informed consent.
• The patient completes the pre-visit section and sign on the consent before seeing the doctor.
• After seeing the doctor, the patient will be asked to complete the post-visit survey and return it to the support/research staff before leaving the clinic. For patients who are not able to do so, they will be offered a choice to complete the survey by toll free telephone or fill in a hard copy of questionnaire and mail it out by pre-paid mail.
• Regular updates will be performed during data collection process to keep tack of patients participation in the survey.

1. Family physicians Inclusion criteria

   • Fluent in English
   • Participate in the early or late E4E MAINPRO-C workshop
   • minimum 6 months in practice working with Aboriginal population
   • Minimum of 20 Aboriginal type 2 diabetic patients in patient roster
   • Intend to remain in practice location for 12 months post early intervention.

   Exclusion criteria:

   • Locum physician or plan to relocate before the study is completed

2. Patient chart inclusion criteria:

   Inclusion criteria

   • minimum 18 years of age
   • See the same physician for care over the course of study
   • minimum 5 years diagnosed with type 2 diabetes
   • Self identified as Aboriginal
   • A1C ≥ 8.0% at baseline (one year prior to the start of early E4E intervention)

   Exclusion criteria:

   • <18 years of age
   • Living in a nursing home
   • Physicians did not consent to audit
   • Type 1 diabetes or gestational diabetes diagnosis or impaired glucose
   • Not self-identified as Aboriginal population
   • A1C < 8.0% at baseline one year prior to intervention

3. Patients participating in Patient Experience Survey

Inclusion criteria:

• minimum 18 years of age
• See the same physician for care over the course of study
• minimum 5 years diagnosed with type 2 diabetes
• Self identified as Aboriginal
• Patients participating in interviews.

Exclusion criteria:

• <18 years of age
• Living in a nursing home
• Type 1 diabetes or gestational diabetes diagnosis or impaired glucose
• Not self-identified as Aboriginal population