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PPO 13-153 – HSR&D Study

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PPO 13-153
Personal Health Record-Facilitated Diabetes Self-Management Among Rural Veterans
Cheryl Lynch MD MPH BS
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: April 2014 - June 2015

BACKGROUND/RATIONALE:
Veterans bear a disproportionate burden of diagnosed diabetes at a 24% prevalence compared to 8.3% nationally. Patient-level factors account for >95% of patient care and health management. Poor patient knowledge/information and participation are two key factors responsible for the most prevalent disparities in the VA healthcare system for which patient activation and adherence interventions may help to reduce disparities in care, but patients have a low rate of engagement in self-care behaviors. Healthcare systems have established personal health records (PHRs), such as My HealtheVet (MHV), that enable patients to access their own health records, obtain health information, and communicate with providers about their disease conditions. This study proposes to activate patients and improve patient diabetes-related behaviors through development of an adapted brief MHV-driven patient activation and self-care intervention that enhances DSM skills (e.g., physical activity, diet, medication adherence, and self-monitoring) in high-risk, rural Veterans.

OBJECTIVE(S):
The objectives of this study are to: (a) Adapt a brief My HealtheVet (MHV) intervention to enhance its appropriateness for Veterans with diabetes increase patient activation and DSM skills; (b) test feasibility and preliminary effectiveness of the adapted brief MHV intervention on DSM skills in rural Veterans; and (c) evaluate Veterans' experience with the adapted brief MHV intervention and identify perceived barriers, facilitators, and enablers of its use, and assess the potential for wider dissemination.

METHODS:
To achieve these objectives, we will develop an adapted brief MHV intervention that targets DSM skills. Training for features of My HealtheVet (setting goals, entering/tracking data, researching health-related information, secure messaging) will first be developed. We will obtain a nonrandomized sample of at least 20 rural Veterans, age 45+ years, with diabetes and either hypertension or hyperlipidemia from community-based outpatient clinics in the Charleston VA catchment area. The intervention will involve an initial in-person session with the rest of intervention sessions delivered remotely. In addition, weekly reminders (or booster messages) will be sent to each participant through the MHV secure messaging. All participants will undergo assessments at baseline and at 6 weeks follow-up. For those who agree, semi-structured telephone interviews will be conducted with study participants to evaluate Veterans' experience with learning and navigating MHV through the intervention and to assess feasibility, ease of use, and refinement for potential dissemination to a broader audience. The primary outcome, frequency of and satisfaction with MHV use, and secondary outcomes, change in DSM skills and clinical indicators, will be assessed in all participants at 6 weeks follow-up. The primary analysis will involve mixed effects models.

FINDINGS/RESULTS:
The study enrolled 14 male Veterans with 50% African American, 42.9% non-Hispanic white, and 7.1% Hispanic. The mean age was 62 years (range 39-88 years) and 71.4% were married; 71.4% were retired. The average intervention session lasted 45 minutes. Results showed that 60% of participants reported the 'Research Health' feature of the My HealtheVet (MHV) personal health record was most helpful and thought this feature was what they needed to learn how to manage their diabetes. Most (80%) planned to continue using MHV. All rated inter-session assignments as 5 (very helpful) on a 5-point scale in learning how to use MHV. One Veteran reported creative design features like certain aspects of the PHR "should talk to you" and podcasts should be developed on the use of different MHV features. Another stated what was most helpful to him was the educator "walking me through [MHV]".

IMPACT:
The proposed project offers a potential solution to strengthening Veterans' self-management of chronic disease conditions through intervention to an easily accessible, self-management tool, the VA's PHR - My HealtheVet that fosters the knowledge and skill-building aspects of diabetes self-management. The proposed approach creates flexible and accessible strategies for increasing knowledge, developing self-monitoring skills, building self-efficacy and enhancing patient empowerment. Thus, active orientation to the use of MHV as a skill-building tool will foster adoption of proper self-monitoring behaviors. The proposed project serves to yield a more patient-oriented process in access to and quality of care, and disease management. Furthermore, this project will provide early evidence to increase adoption and use of MHV in disadvantaged Veteran groups.

These findings demonstrate good feasibility of using MHV, a tethered PHR, to implement a diabetes-focused intervention among Veterans who also reported high usability. In addition, the experience of devising creative solutions to logistical issues and meeting training needs was invaluable. This pilot study accomplished its aims and the findings serve as preliminary data to assess the effectiveness of a behavioral intervention on improving DSM behaviors and reducing CVD risk among Veterans. Regardless, important challenges need to be addressed in order to improve the practicality of the intervention, improve Veterans' experience, and potentially enhance the impact on diabetes-related outcomes as presented in the approach of this proposed study.

PUBLICATIONS:

Journal Articles

  1. Bunnell BE, Davidson TM, Hamblen JL, Cook DL, Grubaugh AL, Lozano BE, Tuerk PW, Ruggiero KJ. Protocol for the evaluation of a digital storytelling approach to address stigma and improve readiness to seek services among veterans. Pilot and feasibility studies. 2017 Feb 17; 3(7):7.
  2. Lynch CP, Strom Williams J, Voronca D, Walker RJ, Egede LE. Meaning of Illness and Cardiovascular Risk Factors in Patients With Type 2 Diabetes. The Diabetes educator. 2016 Apr 1; 42(2):220-7.
  3. Lynch CP, Williams JS, J Ruggiero K, G Knapp R, Egede LE. Tablet-Aided BehavioraL intervention EffecT on Self-management skills (TABLETS) for Diabetes. Trials. 2016 Mar 22; 17:157.
Conference Presentations

  1. Lynch C, Williams JS, Walker R, Voronca D, Egede LE. Meaning of Illness and Cardiovascular Risk Factors in Patients with Diabetes. Paper presented at: Society of General Internal Medicine Southern Regional Annual Meeting; 2015 Feb 26; New Orleans, LA.
  2. Lynch C. Does Low Literacy and Low Income Equate to Low Nutritional Health? Paper presented at: American Diabetes Association Annual Consensus; 2014 Jun 16; San Diego, CA.
  3. Lynch C. Tablet-Aided BehavioraL intervention EffecT on Self-management skills (TABLETS). Paper presented at: VA Charleston Center for Health Disparities Research Noon Conference; 2014 Apr 14; Charleston, SC.


DRA: Diabetes and Related Disorders
DRE: Prevention
Keywords: Diabetes, Health Promotion and Education, Personal Health Record, Rural
MeSH Terms: none