June 2023

In This Issue: HSR&D Research on Telehealth

Diabetes Disparities: Texting to Extend Treatment

Feature Article

Takeaway: Type 2 diabetes, a complex condition with high comorbidity, is common among Veterans and disproportionately affects African American, low income, and other vulnerable populations. Technological interventions such as VA's Annie text messaging app support chronic disease self-management while improving access, health equity, and health outcomes for vulnerable Veterans. This study will compare the effectiveness of an interactive, tailored self-management texting intervention to a diabetes skills education-only texting intervention.

Type 2 diabetes, a complex condition with high comorbidity, affects 24% of Veterans. Vulnerable Veterans (e.g., African Americans, Veterans in rural areas or living with comorbid mental health diagnosis or low income) are less likely to have controlled diabetes, and have higher mortality and morbidity compared to other Veterans.

Technological interventions such as VA’s Annie text messaging app to support chronic disease self-management can improve access, health equity, and health outcomes for vulnerable Veterans and provide customizable, interactive support. Incorporating the needs and preferences of vulnerable Veterans with diabetes in a self-management texting intervention and testing its effectiveness against a more traditional education-only intervention can improve future implementation of Annie-based self-management support as well as development of text-based support for other complex chronic conditions.

This ongoing study (May 2020–October 2024) aims to:

• Refine and beta test an interactive, customizable self-management texting intervention (DD-TXT) that combines diabetes self-management education with optional (patient-selected) messaging to support medication management, blood sugar and blood pressure monitoring, physical activity, weight management, and additional factors.
• Conduct a comparative effectiveness trial to assess the effectiveness of DD-TXT compared to a diabetes skills education-only texting intervention (DSE).
• Guide future implementation of diabetes self-management support through texting by:
  • Gathering and analyzing qualitative feedback from Veterans engaged in the comparative effectiveness trial.
  • Collecting qualitative feedback from providers and key stakeholders on the barriers/facilitators of future evaluation and implementation of DD-TXT vs. DSE.
  • Conducting a cost-identification analysis and safety analysis to identify resources required for larger-scale implementation.

Methods

To develop DD-TXT, the research team generated diabetes self-management education text messages based on content such as the VA/DoD Self-Care Skills for Patients with Diabetes and other trusted diabetes self-management education materials. Researchers incorporated input from Veterans living with diabetes by seeking input via survey from Veterans around the country (N=90), conducting one-on-one interviews with a subset of respondents about their needs and preferences for a text-based intervention (N=23), and working throughout the study with two Veteran co-investigators living with diabetes. Text messages were reviewed by a clinical expert panel for appropriateness and were programmed into the Annie SMS text messaging system and beta tested.

Participants are being enrolled in the comparative effectiveness trial, with Veterans randomized to receive DD-TXT or DSE Annie texting support for six months. The primary outcome will be HbA1c percent time in control. Secondary outcomes will include self-reported adherence to diabetes self-care recommendations, diabetes self-efficacy, diabetes distress, LDL cholesterol, and blood pressure control.

Findings are not yet available.

Anticipated Impact

This project will inform future processes for incorporating Veteran input into Annie intervention development and will lead to a future Type 2 hybrid implementation trial of DD-TXT or DSE (based on the study’s findings) to determine the best implementation strategies for Annie-based self-management support.

Principal Investigator

Stephanie Shimada, PhD, is part of HSR&D’s Center for Healthcare Organization and Implementation Research in Bedford, MA.

Related research by this investigator

Robinson SA, Netherton D, Shimada SL, et al. Differences in secure messaging, self-management, and glycemic control between rural and urban patients: Secondary data analysis. JMIR Diabetes. November 19, 2021;6(4):e32320.

View study abstract.