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BACKGROUND/RATIONALE:
The VHA is particularly interested in further development and implementation of Messaging and Monitoring Devices (MMD) for home tele-health. MMDs are tabletop devices that present text messages to patients in their homes for the purpose of patient monitoring and education. Patients enter information about their clinical condition using a touch screen, and the information is forwarded to clinicians at the VA medical center. The MMD system can also deliver patient questions and educational messages tailored to particular patient conditions. For example, a series of questions and educational messages have been developed for diabetes patients, focusing on glucose control, weight management, medication adherence, physical activity, and diabetes knowledge. Preliminary results indicate that participation in MMD/CM diabetes programs is associated with greater case management activity, such as follow-up phone calls and case management notes with A1c improvements that are comparable to patients using case management exclusively (CM), suggesting that there are added costs for MMD/CM.. However, these studies have not focused upon individuals for whom intensive glycemic treatment would be of greatest lifetime benefit.
Although the DCCT and UKPDS studies demonstrated the importance of glucose control in decreasing microvascular complications, the majority of patients did not achieve, and could not sustain, A1c <7%. Based upon a recent analysis of VHA administrative data from VANJHCS (oral abstract, 2006 VA HSRD) younger individuals (<65 years) with diabetes in 2000/2001 had a clinically significant increase in mean A1c levels [7.9 (1.92)] compared to individuals over 65 years of age [(7.31 (1.46)] even in patients without significant mental and medical illnesses.
OBJECTIVE(S):
1. To obtain perceptions from patients, primary care physicians and endocrinologists on potential barriers and facilitators to intensive glycemic control (primary outcome), including diet, exercise, weight management, and knowledge regarding insulin adjustment, in the veteran population at risk.
2. To obtain information from patients, primary care physicians and endocrinologists on the process by which the care coordination program influences intensive glycemic control (including data availability, use of spread sheets to analyze glycemic control patterns, impact upon reaction time to medication adjustment), and patient level factors mediating adherence (such as stress, medical nutrition therapy and exercise prescriptions).
3. To obtain quantitative information on the process and utilization of care for MMD patient, including microcosting.
METHODS:
This formative evaluation will utilize a mixed methods approach, including the use of both quantitative and qualitative approaches. The enrollment of patients into the Care Coordination Program is independent from the QUERI RRP, and is based upon referrals from primary care and Endocrine Section personnel. We will ask the Endocrinology Nurse Practitioners at VA New Jersey Health Care System to identify patients who have been enrolled in the Care Coordination Program for glycemic control, and whose target A1c is <7.5%. Patients will be on insulin treatment (either alone or with oral agents) . We will identify 6-8 veterans at each site who were entered into the program specifically for intensive management of glycemia. Patients who are identified will be contacted for informed consent for a) semi-structured interviews and b) review of glucose monitoring results and chart review. Following informed consent, primary care, specialists and tele-health personnel will be interviewed. We will work with the research staff at the QUERI-DM research coordinating center to design the questions for the interviews, as they are in the process of completing a study for their VISN, in which they examined the use of MMDs by older, more chronically ill patients with diabetes.
FINDINGS/RESULTS:
Expected products will include a white paper for VISN 3 tele-health leadership and PCS OCC summarizing our findings and presenting recommendations for the feasibility of MMD programs for intensive glycemic treatment. Another product will be a detailed flow chart describing the current process of intensive glycemic control for MMD patients, and a revised flow chart for the recommended process of care; and micro costing.
IMPACT:
To be assessed.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases
DRE:
Technology Development and Assessment
Keywords:
none
MeSH Terms:
none
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