April 2019

In This Issue: Improving Care for Veterans with Diabetes
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Telemedicine to Improve Outcomes for Veterans with Clinic-Refractory Diabetes

Feature Article

Although efforts by clinicians and researchers have improved diabetes control across the VA healthcare system, Veterans with persistent poorly-controlled diabetes mellitus (PPDM) have not benefitted from these advances. Investigators define PPDM as maintenance of a hemoglobin A1c (HbA1c) of (?) 8.5% for >1 year, despite receiving clinic-based diabetes care during this period. Veterans meeting this definition – approximately 12% of all Veterans with type 2 diabetes – contribute disproportionately to VA's burden of diabetes complications and costs. While clinic-based care is insufficiently effective in PPDM, telemedicine-based management that comprehensively addresses factors underlying poor diabetes control could improve outcomes for these high-risk Veterans. But for telemedicine to reduce the burden of PPDM, interventions must be developed with an emphasis on feasible delivery through existing workforce, infrastructure, and technical resources, such that effective implementation is eventually achievable. Thus, this ongoing (2018–2021) HSR&D trial is evaluating Practical Telemedicine to Improve Control and Engagement for Veterans with Clinic-Refractory Diabetes Mellitus (PRACTICE-DM)—a novel, comprehensive telemedicine intervention for PPDM that is designed for practical delivery within VA. Study investigators are working to:

• Determine PRACTICE-DM's effectiveness;
• Evaluate PRACTICE-DM's acceptability and mechanisms of effect using a mixed method process evaluation; and
• Understand costs associated with PRACTICE-DM.

Two hundred Veterans with PPDM from two sites (Durham, NC and Richmond, VA) will be randomized to receive one of two home telehealth-delivered interventions: PRACTICE-DM or an active control, standard home telehealth (HT) care coordination and telemonitoring. Both interventions will be delivered over a 12-month period and all participants will continue to receive usual VA care. The primary study outcome will be change in HbA1c from study baseline to 12 months. Secondary outcomes include diabetes self-care, diabetes burden, self-efficacy, and depressive symptoms. Qualitative interviews will be conducted with 20 intervention-group Veterans, the HT nurses delivering the intervention, and administrators at each site. Intervention costs will be comprehensively assessed and compared to standard HT care coordination and telemonitoring.

Findings: No findings to report at this time.

Impact: This study will leverage VA's unique telemedicine infrastructure to deliver comprehensive management designed for PPDM, with the goal of improving outcomes in this high-risk, high-cost population. Moreover, because the proposed intervention is designed for delivery using existing HT services, it may represent an effective, practical approach to reducing the burden of poor diabetes control across the VA healthcare system.

Principal Investigator: Matthew Crowley, MD, is part of HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) in Durham, NC.

View project abstract.