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.
The objective of this study was to evaluate and document the processes of outreach consultation through the use of joint-clinics via teleconferencing as an intervention for system improvement in care delivery and management of diabetes at CBOCs. The intervention consisted 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 16-month intervention was assessed based on patients who were involved in the telemedicine clinic and those who were referred to a specialist to be seen on-site at the Cleveland VAMC.
Study settings include the CBOCs affiliated with the Cleveland VAMC and involve primary care referrals to see diabetes specialists at the Cleveland VAMC. Inclusion criteria patients(N=282) included: (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 l or Type II diabetes will be included. Patients referred will be contacted and asked to participate.
Patients in the intervention (Teleconsultation) group had a greater decrease in A1c values than those in the control (usual consultation) group (-1.14 and -.64, respectively). The difference showed a trend with p=0.098. There was a significant difference in the change in systolic blood pressure: -4.5 and +3.9mmHg for intervention and control groups respectively (p<0.005). There were no significant changes in LDL-cholesterol or serum creatinine. Results from patient questionnaires Telemedicine Consultation was as good or better than usual consultation from a patient's perspective. Usual care patients were more likely to disagree or strongly disagree with the statement that they benefited from the specialist visit (14.1% vs 2.4%, usual care vs teleconsultation, respectively). In the teleconsultation group, 99.3% agree that telemedicine made it easier to get medical care and <2% would have preferred to see the specialist in person. Several themes emerged from the staff interviews. These include, Changes in Referral Process, Communication, Alignment of Role and Training, Patient Focused Care, Patient Care / Compliance with Care Plan, and Patient Satisfaction with Diabetes Care. Comments were almost uniformly positive.
The project can be summarized in the words of one primary care provider: "From my personal experience, this has been an excellent change. It's a win-win situation for providers and for patients." As a direct consequence of this project, a weekly telemedicine clinic has been established to serve all affiliated CBOCs and their patients referred for an appointment with a specialist related to their diabetes.
External Links for this Project
- Tomolo AM, Lawrence RH, Aron DC. A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum. Quality & Safety in Health Care. 2009 Jun 1; 18(3):217-24. [view]
- F O Kern E, Beischel S, Stalnaker R, Aron DC, Kirsh SR, Watts SA. Building a diabetes registry from the Veterans Health Administration's computerized patient record system. Journal of Diabetes Science and Technology. 2008 Jan 1; 2(1):7-14. [view]
- Pogach L, Aron D. Balancing hypoglycemia and glycemic control: a public health approach for insulin safety. JAMA : the journal of the American Medical Association. 2010 May 26; 303(20):2076-7. [view]