Despite data showing success of Share Medical Appointments (SMAs) in the VA in improving diabetes care, the spread and access of these services is limited in rural areas due to lack of healthcare specialists of different disciplines and skill sets to conduct SMA's, which limits the scope of care available to Veterans who reside in remote settings. This geographic barrier can be overcome by another VHA telehealth initiative, through video-clinical encounters. Thus, SMA's can be provided through the VHA supported tools, henceforth, called video-SMA's.
The overall objective is to improve diabetes care in VA sites without local expertise through novel care delivery methods such as video-SMA's and conduct a quasi-experimental trial to evaluate the efficacy and processes of delivery of this intervention.
We hypothesize that a non-physician multi-disciplinary SMA care model delivered to a remote rural setting via video-conferencing would improve diabetes outcomes.
A team consisting of a clinical pharmacist and a nurse practitioner from the VA Medical Center in Hawaii delivered video-SMA to a remote clinic on the island of Guam. Veterans with diabetes with hemoglobin A1c >7% or referred by provider were enrolled into the study.
The participants attended 4 weekly group sessions followed by 2 bi-monthly booster SMA visits for a total of 5 months. Each session consisted of self-management education and medication management. Patients with diabetes and A1c >7% that had primary care visits at the same time but no vSMA intervention were selected from electronic patient records as controls.
We compared changes from baseline in A1c, blood pressure, and lipid levels using mixed effect modeling within and between the vSMA and control groups. We also analyzed differences in phone visits, unscheduled visits, emergency room visits and hospitalizations between the vSMA and the control groups.
Over the period of 9 months, 31 patients received video-SMA and charts of 69 controls were abstracted for a total of 100 patients in the study. Mean age was 61 8.4, and 93% were males. Sixty one percent of patients had 6-15 years duration of diabetes and 13% of patients had diabetes for greater than 15 years.
Over the 5 month period, the intervention video-SMA group showed a significant decline in A1c vs. the control group (9.1 1.9 to 8.3 1.8 vs. 8.6 1.4 to 8.7 1.6, respectively, p = 0.03).
No significant changes over time in blood pressure or lipid levels were found between the vSMA versus the control group.
Although changes were not statistically significant, the video-SMA group had a trend towards fewer unscheduled outpatient visits (0.28 vs. 0.26 visits), ER visits (0.06 vs. 0.03 visits), and hospitalizations (0.04 vs. 0.03) compared to controls.
In conclusion, the SMA model appeared to improve diabetes outcomes with potential to reduce healthcare utilization in a rural setting.
The challenges of health-care delivery in rural areas are social and geographic isolation, and limited access to multi-disciplinary expertise for patients, and lack of decision support and interprofessional exchange for the local health providers.
This proposed quality initiative attempts to target the above obstacles using advanced video-conferencing system in the CBOC's with telemedicine capabilities.
Thus, aside from improvement in access to SMA's in diabetes and its potential benefits, multi-disciplinary care; local providers and participants of the video-SMA will also have increased interaction with off-site experts in diabetes care and decision support in the co-management of these patients.
- Tokuda L, Lorenzo L, Theriault A, Taveira TH, Marquis L, Head H, Edelman D, Kirsh SR, Aron DC, Wu WC. The utilization of video-conference shared medical appointments in rural diabetes care. International journal of medical informatics. 2016 Sep 1; 93:34-41.