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CDA 13-267 – HSR&D Study

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CDA 13-267
Improving Veteran Engagement in Diabetes Prevention
Jeffrey T. Kullgren MD MPH MS
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: April 2015 - March 2020

BACKGROUND/RATIONALE:
Despite the availability of evidence-based strategies to prevent type 2 diabetes mellitus (T2DM), engagement in these strategies is low among at-risk Veterans. A key opportunity to engage at-risk Veterans in interventions to prevent T2DM is when they are informed they have prediabetes. It remains unclear how VHA communications to patients diagnosed with prediabetes could be optimized to improve their engagement in evidence-based preventive strategies.

OBJECTIVE(S):
Aim 1: To describe at-risk Veterans' current engagement in behaviors to prevent T2DM and the mediators of this engagement. Aim 2: To examine the effects of receipt of a prediabetes diagnosis on at-risk Veterans' weight and engagement in behaviors to prevent T2DM. Aim 3: To identify the effects of 5 strategies from behavioral economics and health psychology on weight, HbA1c, and engagement in behaviors to prevent T2DM among Veterans with prediabetes.

METHODS:
To accomplish Aim 1, we surveyed 369 non-diabetic Veterans with risk factors for T2DM about their engagement in behaviors to prevent T2DM and mediators of this engagement such as risk perception, motivation, and awareness of and preferences for preventive strategies. To accomplish Aim 2, we are conducting a pilot randomized trial among 315 non-diabetic Veterans from Project 1 in which 252 of these Veterans were randomly assigned to undergo screening for T2DM using a hemoglobin A1c (HbA1c) test. The 107 Veterans who were found to have HbA1c values in the prediabetes range received that diagnosis and preventive recommendations via brief standardized counseling. All 315 Veterans are having their weight tracked over the next year and are being surveyed immediately after the screening and brief counseling process, at 3 months, and at 1 year. In our analyses we will compare changes in weight, engagement in behaviors to prevent T2DM, and mediators of this engagement between the 107 Veterans found to have prediabetes and the 63 Veterans who were not screened. Among the 107 Veterans with prediabetes, we conducted 20 semi-structured interviews to gain insights into the effects of this diagnosis and brief counseling. To accomplish Aim 3, we are conducting a factorial design experiment to evaluate the effectiveness of 5 innovative strategies from behavioral economics and health psychology in promoting initial engagement in behaviors to prevent T2DM among 144 Veterans who at baseline had a recent HbA1c test result in the prediabetes range but were not engaged in an evidence-based strategy to prevent T2DM.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Prevention of T2DM is an important way to improve Veterans' health and limit the burden of T2DM on the VHA. In this CDA, we will identify new opportunities for improving Veteran engagement in evidence-based ways to prevent T2DM. Insights generated from this research will be exportable to other high-priority conditions in which Veteran engagement in preventive behaviors is essential and could be improved.

PUBLICATIONS:

Journal Articles

  1. Cliff BQ, Krenz C, West BT, Levy H, Fendrick AM, Winkelman TNA, So J, Fagerlin A, Kullgren JT. Attitudes About Consumer Strategies Among Americans in High-deductible Health Plans. Medical care. 2019 Mar 1; 57(3):187-193.
  2. Kullgren JT, Cliff BQ, Krenz CD, Levy H, West B, Fendrick AM, So J, Fagerlin A. A Survey Of Americans With High-Deductible Health Plans Identifies Opportunities To Enhance Consumer Behaviors. Health affairs (Project Hope). 2019 Mar 1; 38(3):416-424.
  3. Tipirneni R, Politi MC, Kullgren JT, Kieffer EC, Goold SD, Scherer AM. Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost. JAMA Network Open. 2018 Nov 2; 1(7):e184796.
  4. Scherer LD, Kullgren JT, Caverly T, Scherer AM, Shaffer VA, Fagerlin A, Zikmund-Fisher BJ. Medical Maximizing-Minimizing Preferences Predict Responses to Information about Prostate-Specific Antigen Screening. Medical decision making : an international journal of the Society for Medical Decision Making. 2018 Aug 1; 38(6):708-718.
  5. Hafez D, Heisler M, Choi H, Ankuda CK, Winkelman T, Kullgren JT. Association Between Purpose in Life and Glucose Control Among Older Adults. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2018 Mar 15; 52(4):309-318.
  6. Kullgren JT, Cliff EQ, Krenz C, West BT, Levy H, Fendrick AM, Fagerlin A. Consumer Behaviors Among Individuals Enrolled in High-Deductible Health Plans in the United States. JAMA internal medicine. 2018 Mar 1; 178(3):424-426.
  7. Griauzde DH, Kullgren JT, Liestenfeltz B, Richardson C, Heisler M. A mobile phone-based program to promote healthy behaviors among adults with prediabetes: study protocol for a pilot randomized controlled trial. Pilot and feasibility studies. 2018 Feb 13; 4:48.
  8. Kerr EA, Kullgren JT, Saini SD. Choosing Wisely: How To Fulfill The Promise In The Next 5 Years. Health affairs (Project Hope). 2017 Nov 1; 36(11):2012-2018.
  9. Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Acharya Y, Alford J, Duffy R, Adler-Milstein J. Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial. BMJ quality & safety. 2018 May 1; 27(5):355-364.
  10. Kullgren JT, Hafez D, Fedewa A, Heisler M. A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus. Current Diabetes Reports. 2017 Sep 1; 17(9):73.
  11. Scherer LD, Shaffer VA, Caverly T, Scherer AM, Zikmund-Fisher BJ, Kullgren JT, Fagerlin A. The role of the affect heuristic and cancer anxiety in responding to negative information about medical tests. Psychology & Health. 2018 Feb 1; 33(2):292-312.
  12. Harkins KA, Kullgren JT, Bellamy SL, Karlawish J, Glanz K. A Trial of Financial and Social Incentives to Increase Older Adults' Walking. American journal of preventive medicine. 2017 May 1; 52(5):e123-e130.
  13. Kullgren JT, Youles B, Shetty S, Richardson C, Fagerlin A, Heisler M. ForgIng New paths in DIabetes PrevenTion (FINDIT): Study Protocol for a Randomized Controlled Trial. Trials. 2017 Apr 8; 18(1):167.
  14. Hafez D, Nelson DB, Martin EG, Cohen AJ, Northway R, Kullgren JT. Understanding type 2 diabetes mellitus screening practices among primary care physicians: a qualitative chart-stimulated recall study. BMC family practice. 2017 Apr 4; 18(1):50.
  15. Segel JE, Kullgren JT. Health Insurance Deductibles and Their Associations With Out-of-Pocket Spending and Affordability Barriers Among US Adults With Chronic Conditions. JAMA internal medicine. 2017 Mar 1; 177(3):433-436.
  16. Hafez D, Fedewa A, Moran M, O'Brien M, Ackermann R, Kullgren JT. Workplace Interventions to Prevent Type 2 Diabetes Mellitus: a Narrative Review. Current Diabetes Reports. 2017 Feb 1; 17(2):9.
  17. Zikmund-Fisher BJ, Kullgren JT, Fagerlin A, Klamerus ML, Bernstein SJ, Kerr EA. Perceived Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of Primary Care Providers. Journal of general internal medicine. 2017 Feb 1; 32(2):210-217.
  18. Sears ED, Caverly TJ, Kullgren JT, Fagerlin A, Zikmund-Fisher BJ, Prenovost K, Kerr EA. Clinicians' Perceptions of Barriers to Avoiding Inappropriate Imaging for Low Back Pain-Knowing Is Not Enough. JAMA internal medicine. 2016 Dec 1; 176(12):1866-1868.
  19. Scherer LD, Caverly TJ, Burke J, Zikmund-Fisher BJ, Kullgren JT, Steinley D, McCarthy DM, Roney M, Fagerlin A. Development of the Medical Maximizer-Minimizer Scale. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2016 Nov 1; 35(11):1276-1287.
  20. Kullgren JT, Troxel AB, Loewenstein G, Norton LA, Gatto D, Tao Y, Zhu J, Schofield H, Shea JA, Asch DA, Pellathy T, Driggers J, Volpp KG. A Randomized Controlled Trial of Employer Matching of Employees' Monetary Contributions to Deposit Contracts to Promote Weight Loss. American Journal of Health Promotion : AJHP. 2016 Jul 1; 30(6):441-52.
  21. Becker NV, Asch DA, Kullgren JT, Bellamy SL, Sen AP, Volpp KG. Stages of change and patient activation measure scores in the context of incentive-based health interventions. American Journal of Health Promotion : AJHP. 2015 Nov 1; 30(2):133-5.
  22. Kullgren JT, Dicks TN, Fu X, Richardson D, Tzanis GL, Tobi M, Marcus SC. Financial incentives for completion of fecal occult blood tests among veterans: a 2-stage, pragmatic, cluster, randomized, controlled trial. Annals of internal medicine. 2014 Nov 18; 161(10 Suppl):S35-43.
  23. Kullgren JT, Harkins KA, Bellamy SL, Gonzales A, Tao Y, Zhu J, Volpp KG, Asch DA, Heisler M, Karlawish J. A mixed-methods randomized controlled trial of financial incentives and peer networks to promote walking among older adults. Health education & behavior : the official publication of the Society for Public Health Education. 2014 Oct 1; 41(1 Suppl):43S-50S.
Journal Other

  1. Bowen ME, Schmittdiel JA, Kullgren JT, Ackermann RT, O'Brien MJ. Building Toward a Population-Based Approach to Diabetes Screening and Prevention for US Adults. Current Diabetes Reports. 2018 Sep 19; 18(11):104.
  2. Kullgren JT. Helping Consumers Make High-Value Health Care Choices: The Devil Is in the Details. [Editorial]. Health services research. 2018 Aug 1; 53 Suppl 1:2655-2661.
  3. Kullgren JT. Injecting Facts Into the Heated Debates Over Medicaid Expansion. [Editorial]. Annals of internal medicine. 2016 Jun 21; 164(12):848-9.
  4. Kullgren JT, Hwang A, Kozhimannil KB. Innovations to more effectively engage patients and caregivers across the health care spectrum. [Editorial]. Healthcare (Amsterdam, Netherlands). 2016 Mar 1; 4(1):1-2.
  5. Caverly TJ, Fagerlin A, Zikmund-Fisher BJ, Kirsh S, Kullgren JT, Prenovost K, Kerr EA. Appropriate Prescribing for Patients With Diabetes at High Risk for Hypoglycemia: National Survey of Veterans Affairs Health Care Professionals. [Letter to the Editor]. JAMA internal medicine. 2015 Dec 1; 175(12):1994-6.
Online News Media Articles

  1. Kullgren JT. Medicaid expansions improve insurance and outcomes for poor. Medscape [Internet]. 2016 Apr 19. Available from: http://search.medscape.com/search/?q=Medicaid expansion improves insurance.
  2. Kullgren JT. Medicaid expansion encourages more poor adults to seek health care. Washington Post [Internet]. 2016 Apr 18.
Conference Presentations

  1. Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Alford J, Duffy R, Adler-Milstein J. Commitment to Choosing Wisely® is a low cost, scalable strategy that can decrease clinician ordering of services that can lead to over diagnosis. Paper presented at: Preventing Overdiagnosis Annual Conference; 2016 Sep 20; Barcelona, Spain.
  2. Kieffer E, Scherer A, Kullgren JT, Clark S, Rowe Z, Beathard E, Olorode T, Zamora MV, Solway E, Ayanian J, Goold S. Early Experiences of Michigan’s Medicaid Expansion Beneficiaries with Cost-Sharing and Financial Incentives for Healthy Behaviors. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
  3. Kullgren JT, Cliff EQ, So J, Saksewski S, Peterson T, Singh S. Exploring Early Small Business Decisions under the Affordable Care Act. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
  4. Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Alford J, Adler-Milstein J. A Randomized Trial of a Behavioral Economic Intervention to Decrease Overuse of Low-Value Health Services. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
  5. Segel JE, Kullgren JT. Effects of high-deductible health plan enrollment on out-of-pocket spending and high medical cost burdens among Americans with chronic conditions. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 26; Boston, MA.
  6. Kieffer E, Scherer A, Kullgren JT, Clark S, Rowe Z, Beathard E, Olorode T, Szymecko L, Zamora MV, Solway E, Ayanian J, Goold S. Early Experiences of Michigan’s Medicaid Expansion Beneficiaries with Cost-Sharing and Financial Incentives for Healthy Behaviors. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
  7. Kullgren JT, Knaus M, Rahrig Jenkins K, Heisler MM. A Mixed Methods Study of Initial Engagement in Behaviors to Prevent Diabetes among Employees with Prediabetes. Paper presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
  8. Kullgren JT, Krupka E, Schachter A, Linden A, Miller J, Alford J, Adler-Milstein J. A Randomized Trial of a Behavioral Economic Intervention to Decrease Overuse of Low-Value Health Services. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2016 May 11; Hollywood, FL.
  9. Scherer LD, Burke J, Caverly T, Kullgren JT, Zikmund-Fisher BJ, Roney M, Fagerlin A. Influence of information about risks, lack of benefits, and expert recommendations on uptake of cancer screening tests. Paper presented at: Preventing Overdiagnosis Annual Conference; 2015 Sep 1; Bethesda, MD.
  10. Caverly T, Fagerlin A, Zikmund-Fisher BJ, Kirsh SR, Kullgren JT, Bernstein SJ, Prenovost K, Kerr EA. Appropriate Prescribing for Diabetic Patients at High-Risk for Hypoglycemic: National Survey of VA Primary Care Providers. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.


DRA: Aging, Older Veterans' Health and Care, Diabetes and Related Disorders
DRE: Prevention
Keywords: QUERI Implementation
MeSH Terms: none