BACKGROUND/RATIONALE:
The purpose of this study is to improve the quality of VA diabetes care using an automated telephone disease management (ATDM) system that administers patient assessments and targeted self-care education between clinic visits.

OBJECTIVE(S):
In this ongoing study, we are determining: 1) the reliability and validity of Automated Telephone Disease Management (ATDM) assessments of patients' glycemic control, health-related quality of life (HRQL), self-care, and satisfaction with care; 2) the extent to which these assessments identify patients at risk for poor outcomes; and 3) the cost-effectiveness of an intervention in which ATDM assessment reports are provided regularly to patients' primary care providers.

METHODS:
We are refining and expanding previously-developed ATDM assessment instruments by incorporating measures of patient-centered outcomes. We are enrolling 450 patients from VISN 12 and VISN 21. Patients receive weekly ATDM assessments for six months. Other data on their health status and service use are being collected from medical records, laboratory tests, telephone surveys, and Austin Automation Center files. After determining the concurrent reliability, validity, and prognostic significance of the ATDM assessments, we will examine variation in ATDM-reported outcomes across Networks, facilities, and patient groups. In the second phase of the study, we will conduct an effectiveness trial with a one year follow up period. We will use the findings from our process evaluation to modify the ATDM assessments and design provider feedback reports. We will enroll 240 patients from the two Networks (i.e., 480 patients overall). Patients will be assigned to experimental or usual care control groups using a combination of randomization and cutoff-based assignment. We will measure the intervention's impact on patients' glycemic control, symptoms, self-care, and patient-centered outcomes. We will use VA costing database and Medicare claims files to evaluate cost-effectiveness.

FINDINGS/RESULTS:
Data from patients' baseline surveys have identified a variety of doctor-patient communication styles associated with better adherence to self-care regimens and improved health outcomes. VA patients’ were much less likely to forego medication due to cost pressures than patients with any other insurance type. Participants have completed roughly 5,000 automated telephone assessments out of about 20,000 individual calling attempts. ATDM reports of functioning and treatment satisfaction are reliable and valid.

IMPACT:
The model of automated telephone assessments developed and evaluated in this study could be a cost-effective means of improving clinical decision-making and diabetes treatment outcomes. The study is identifying clinic and provider factors that facilitate effective implementation in VA. Large-scale implementation of this intervention could save treatment costs, improve patients' access to care, and improve providers' adherence to treatment guidelines.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Heisler M, Piette JD. "I help you, and you help me": facilitated telephone peer support among patients with diabetes. The Diabetes educator. 2005 Nov 1; 31(6):869-79. [view]
2. Piette JD, Richardson C, Valenstein M. Addressing the needs of patients with multiple chronic illnesses: the case of diabetes and depression. The American journal of managed care. 2004 Feb 1; 10(2 Pt 2):152-62. [view]
3. Heisler M, Wagner TH, Piette JD. Clinician identification of chronically ill patients who have problems paying for prescription medications. The American journal of medicine. 2004 Jun 1; 116(11):753-8. [view]
4. Schillinger D, Piette J, Grumbach K, Wang F, Wilson C, Daher C, Leong-Grotz K, Castro C, Bindman AB. Closing the loop: physician communication with diabetic patients who have low health literacy. Archives of internal medicine. 2003 Jan 13; 163(1):83-90. [view]
5. Piette JD, Heisler M, Wagner TH. Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. American journal of public health. 2004 Oct 1; 94(10):1782-7. [view]
6. Piette JD, Heisler M, Wagner TH. Cost-related medication underuse: do patients with chronic illnesses tell their doctors? Archives of internal medicine. 2004 Sep 13; 164(16):1749-55. [view]
7. McKellar JD, Humphreys K, Piette JD. Depression increases diabetes symptoms by complicating patients' self-care adherence. The Diabetes educator. 2004 May 1; 30(3):485-92. [view]
8. Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. Journal of general internal medicine. 2003 Aug 1; 18(8):624-33. [view]
9. Piette JD. Enhancing support via interactive technologies. Current Diabetes Reports. 2002 Apr 1; 2(2):160-5. [view]
10. Piette JD, Wagner TH, Potter MB, Schillinger D. Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care. Medical care. 2004 Feb 1; 42(2):102-9. [view]
11. Piette JD, Heisler M, Wagner TH. Problems paying out-of-pocket medication costs among older adults with diabetes. Diabetes Care. 2004 Feb 1; 27(2):384-91. [view]

Conference Presentations

1. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C. Association of functional health literacy with glycemic control among diabetes patients. Paper presented at: Society of General Internal Medicine Annual Meeting; 2002 May 2; Atlanta, GA. [view]

DRA: Health Systems
DRE: Diagnosis
Keywords: Diabetes, Education (patient), Telemedicine
MeSH Terms: none