• The outcomes for this study are patient satisfaction and self-efficacy. Both outcomes will be measured at baseline and then after the intervention at 18 months. [ Time Frame: 18 months ] [ Designated as safety issue: No ]
  

• Patient A1c [ Time Frame: Will be measured at baseline and then after the active intervention phase ] [ Designated as safety issue: No ]
  

Background:

Diabetes is a national problem that has reached epidemic proportions, according to the U.S. Centers for Disease Control and Prevention. Diabetes has particular importance for the Department of Veterans Affairs (VA) because the prevalence among VA patients -- one in six, or 16 percent -- is substantially higher than in the general population.

Objectives:

The immediate objective is to evaluate and document the processes of outreach consultation through using joint-clinics via teleconferencing as an intervention for system improvement in care delivery and management of diabetes at CBOCs. The intervention consists of a teleconferenced joint-clinic consultation session involving the patient, Diabetes Specialist Team, the PCP and other relevant care team members. The impact of the intervention will be assessed using both high-risk patients who are referred to a diabetes specialist for consultation during the 18-month active intervention phase (Cohort I) and other patients with diabetes who are not referred during the intervention phase (Cohort II). The specific aims are:

1. compare the impact of diabetes specialist joint-clinic consultations via teleconferencing conducted at CBOCs to the usual consultation process on referred high-risk Cohort I patients and providers;
2. compare the impact of diabetes joint-clinic consultations via teleconferencing to usual consultation process on outcomes related to providers' care of other patients (non-Cohort I patients);
3. compare processes and change in processes associated with diabetes specialist joint-clinic consultations to usual outpatient consultation process for patients with diabetes using qualitative and quantitative methods (microsystem factors);
4. evaluate short-term medical care utilization and costs associated with the intervention.

The long-term objectives are to improve the quality of care delivered and decrease diabetes-related complications.

Methods:

Study settings include the CBOCs and involves primary care referrals to see diabetes specialists at the Cleveland VAMC. Inclusion criteria for Cohort I patients are: (i) current prescription of insulin or an oral hypoglycemic agent; (ii) A1c > 7.0%; or (iii) fasting glucose levels > 130 mg/dl; and (iv) referred to see a consultant (beginning three months prior to the active intervention phase and continuing through enrollment for the last month of the active intervention phase). Patients with either Type I or Type II diabetes will be included. Patients referred will be contacted and asked to participate (N=710 anticipated to complete the study).

Cohort II patients will be determined by the above criteria minus referral (N=10,270). All PCP/PC CBOC team members (N=90) and CBOC staff involved in the care of patients will be asked to participate.

Status:

Provider and patient enrollment began in August, 2005. Subsequently, joint-clinic consultations began in September, 2005. Active patient enrollment ended June of 2007. Data is being analyzed for the patients and providers. Also the final provider interview will be complete shortly.