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2015 HSR&D/QUERI National Conference Abstract

1110 — Patient Perceptions of Effective, Scalable Telemedicine Care for Veterans with Persistent Poor Diabetes Control

Crowley MJ, Durham COIN; Sperber NR, Durham COIN; Gierisch JM, Durham COIN; Edelman D, Durham COIN; McAndrew AT, Durham VA Medical Center; Kistler S, Durham VA Medical Center; Danus S, Durham COIN; Jackson GL, Durham COIN; Bosworth HB, Durham COIN;

Uncontrolled diabetes generates complications and high costs. We developed Advanced Comprehensive Diabetes Care (ACDC) specifically for Veterans maintaining hemoglobin A1c (HbA1c) > 9.0% despite Veterans Affairs (VA) Primary Care and/or Endocrinology management. ACDC combines blood glucose telemonitoring with diabetes medication management, self-management behavioral support, and depression management, delivered via 12 phone encounters over 6 months. Notably, because it uses existing Care Coordination Home Telehealth (CCHT) infrastructure for delivery, ACDC is amenable to scaling throughout VA. We recently completed a randomized pilot trial in which ACDC lowered hemoglobin A1c (HbA1c) by 1.0% versus usual care (p = 0.05) and produced statistically significant improvements in diabetes self-care and blood pressure. The objective of the present study was to inform future implementation efforts by evaluating participant experiences with ACDC.

Following pilot study completion, we conducted phone-based, semi-structured interviews with 20 of the 25 individuals receiving ACDC. We sought patient impressions of ACDC's intervention components and CCHT-based implementation strategy. We analyzed qualitative interviews using conventional content analysis (blinded to HbA1c response), and subsequently sorted data by HbA1c improvement at 6 months ( < 1.0%, 1.0-2.0%, > 2.0%) and intervention participation level ( < or > = 6 phone encounters).

Our findings differed by HbA1c response and intervention participation. Participants whose HbA1c improved by < 1.0% (n = 4) reported that competing demands (e.g., employment, mental health, chronic pain) interfered with participation - within this group, the two patients completing > = 6 encounters did describe increased motivation for self-care. Participants with HbA1c improvement > 1.0% (n = 16) indicated that ACDC helped establish new 'routines' for glucose monitoring, diet, and medication-taking. Fourteen of these 16 patients completed > = 6 encounters. All those with HbA1c improvement > 2.0% (n = 7) completed > = 6 encounters, and additionally cited greater awareness of diabetes medications and blood glucose values. Regardless of HbA1c response, participants expressed frustration with the automated interface CCHT utilized for telemonitoring.

Most patients perceived that this effective intervention facilitated engagement with diabetes self-care. Although using CCHT to deliver intensive, telemedicine-based diabetes care appears feasible, dissatisfaction with the telemonitoring interface may threaten scaling unless addressed.

These findings will help us refine ACDC as an effective, scalable approach for Veterans maintaining persistently poor diabetes control despite current VA care.