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2023 HSR&D/QUERI National Conference Abstract

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1097 — Engaging Family Supporters of Veterans with Diabetes to Improve Patient Activation, Behavioral, and Clinical Outcomes: A Randomized Trial

Lead/Presenter: Ann-Marie Rosland,  COIN - Pittsburgh/Philadelphia
All Authors: Rosland AM (Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System; Department of Internal Medicine, University of Pittsburgh), Piette JD (Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI) Trivedi R (Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA; Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA) Lee A (Department of Psychology, University of Mississippi, University, MS) Stoll S (Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI) Youk A (Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA) Deverts DJ (Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA) Kerr EA (Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI) Heisler M (Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI; Department of Internal Medicine and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI)

Objectives:
Most adults with diabetes have family or friends who are involved in their medical and self-care (‘family supporters’). This support could be leveraged to improve Veterans’ engagement in care and health outcomes. However, health care teams lack structured and feasible approaches to effectively engage family supporters in Veterans’ care. We conducted an RCT of a dyadic family supporter-patient intervention, developed in partnership with the VA Offices of Primary Care and Social Work, aimed at improving patient activation, self-management and physiologic outcomes for adults with diabetes (AWD).

Methods:
239 AWD from 2 VA primary care (PC) sites were randomized with an adult family supporter to Caring Others Increasing EngageMent in PACT (CO-IMPACT) vs. usual care for 12 months. CO-IMPACT provided dyads one health coaching session, biweekly automated phone calls to prompt action plans related to diabetes health concerns, coaching calls to prepare for PC visits, and PC visit summaries. AWD were eligible with baseline HbA1c >8% or SBP >150mmHg. Pre-specified primary outcomes were 12-month changes in Patient Activation Measure (PAM, range 0-100); and 5-year UKPDS Diabetes-Specific Cardiac Event Risk. Pre-specified secondary outcomes were 12-month changes in HbA1c, SBP, self-management behaviors, supporter roles in care and supporter diabetes communication quality.

Results:
21% of Veterans with diabetes sent letters were recruited. Enrolled AWD were on average 60 (SD 9) years old with mean baseline HbA1c 8.5 (SD 1.60)% and SBP 140 (SD 18) mmHg. 70% lived with their enrolled supporter. 96% of patients had complete 12-month outcome data; In 75% of eligible weeks over 12 months, dyads completed automated calls (mean 18.6 calls per dyad). Based on ITT models, CO-IMPACT AWDs had greater 12-month improvements in PAM (adjusted intervention effect +2.60 points; 95%CI 0.02,5.18), healthy eating (+0.71 (0.20,1.22) days/week), diabetes self-efficacy (+0.40 (0.09,0.71) points), and satisfaction with VA health system support for family involvement in their care (+0.28 points, CI 0.07,0.49). Both arms had similar improvements in cardiac risk, HbA1c, and other behaviors. Positive impacts on supporter roles in care and supporter diabetes communication quality have been previously published.

Implications:
We successfully recruited, engaged, and retained Veteran-supporter dyads, which has been challenging in past studies. The CO-IMPACT intervention led to greater improvements in patient activation and confidence than the control group, outcomes that have been associated in other studies with improved long-term diabetes outcomes. Physiologic outcomes improved similarly in both arms, potentially reflecting the high quality of standard VA primary care for diabetes. Higher-intensity approaches with more direct supporter coaching, or targeting dyads in more need of training and support, may have greater impact on physiological outcomes.

Impacts:
To leverage CO-IMPACT’s high participant satisfaction, activation and self-management improvements, and previously reported improvements in supporter roles and communication, we developed two Toolkits to make program components accessible to professionals and patients/supporters. Guided tours of the Toolkits have been provided to national VA clinician, operations, and research networks, non-VA national diabetes educator networks, and directly to adults with diabetes via incorporation into virtual diabetes education classes.