December 2018

In This Issue: Advances in Telehealth
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Telemedicine to Improve Treatment for Veterans with Difficult to Treat Diabetes

Feature Article

Although efforts by clinicians and researchers have improved diabetes control across the VA healthcare system, many Veterans still have persistently poor control. Study investigators define persistent poorly-controlled diabetes mellitus (PPDM) as maintenance of a hemoglobin A1c (HbA1c) >8.5% for >1 year, despite receiving clinic-based diabetes care during this period. Approximately 12% of all Veterans with type 2 diabetes meet this definition, and thus experience increased complications and costs of care. While clinic-based care is insufficiently effective to treat PPDM, telemedicine-based management that comprehensively addresses factors underlying poor diabetes control could improve outcomes for these high-risk Veterans. However, telemedicine interventions must be developed with an emphasis on feasible delivery through the existing workforce, infrastructure, and technical resources.

The main objective of this ongoing (2018–2021) HSR&D study is to evaluate a comprehensive telemedicine intervention for Veterans with PPDM. The trial will evaluate 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. Investigators are recruiting 200 Veterans with PPDM from two sites (Durham, NC and Richmond, VA), who will be randomized to one of two home-telehealth interventions:

• PRACTICE-DM that combines telemonitoring, self-management support, diet/activity support, medication management, and depression support; or
• Standard home-telehealth care coordination and telemonitoring (active control).

Both interventions will be delivered over a 12-month period, and all participating Veterans will continue to receive usual VA care.

The primary study outcome will be change in HbA1c from study baseline to 12 months. The secondary outcomes will include diabetes self-care, diabetes burden, self-efficacy, and depressive symptoms. Interviews will be conducted with 20 intervention-group Veterans, the home-telehealth nurses delivering the intervention, as well as administrators at each site. In addition, intervention costs will be assessed and compared to standard home-telehealth care coordination and telemonitoring.

Findings: To be determined.

Impact: Although VA is a leader in telemedicine, its telemedicine capabilities are currently under-used for Veterans with PPDM. 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 patient population. Because the proposed intervention is designed for delivery using existing home-telehealth services, it may represent an effective, practical approach to reducing the burden of poor diabetes control across VHA.

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

Publications: None to date.

View project abstract.