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2015 HSR&D/QUERI National Conference Abstract

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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;

Objectives:
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.

Methods:
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).

Results:
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.

Implications:
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.

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