Diabetes Telemedicine Project

This study seeks to evaluate and document the processes of outreach consultation through joint-clinics via teleconferencing as an intervention for system improvement in care delivery and management of diabetes at CBOCs.

Background:

Diabetes is a national problem that has reached epidemic proportions, according to the U.S. Centers for Disease Control and Prevention. Diabetes has particular importance for the Department of Veterans Affairs (VA) because the prevalence among VA patients -- one in six, or 16 percent -- is substantially higher than in the general population.

Objectives:

The objective of this study was to evaluate and document the processes of outreach consultation through the use of joint-clinics via teleconferencing as an intervention for system improvement in care delivery and management of diabetes at CBOCs. The intervention consisted of a teleconferenced joint-clinic consultation session involving the patient, Diabetes Specialist Team, the PCP and other relevant care team members. The impact of the 16-month intervention was assessed based on patients who were involved in the telemedicine clinic and those who were referred to a specialist to be seen on-site at the Cleveland VAMC.

Methods:

Study settings include the CBOCs affiliated with the Cleveland VAMC and involve primary care referrals to see diabetes specialists at the Cleveland VAMC. Inclusion criteria patients(N=282) included: (i) current prescription of insulin or an oral hypoglycemic agent; (ii) A1c > 7.0%; or (iii) fasting glucose levels> 130 mg/dl; and (iv) referred to see a consultant (beginning three months prior to the active intervention phase and continuing through enrollment for the last month of the active intervention phase). Patients with either Type l or Type II diabetes will be included. Patients referred will be contacted and asked to participate.

Status:

Additional analyses are being conducted on health care costs and on impact beyond the patients directly involved in the study. Manuscripts are being prepared.

• Diabetes Mellitus Type 2
• Diabetes Mellitus, Type 1

• Behavioral: The Diabetes Treatment Satisfaction Questionnaire
  A six question likert scale questionnaire regarding the patients treatment satisfaction. The responses range from very dissatisfied to very satisfied.
• Behavioral: Diabetes Empowerment Scale
  A twenty-eight question likert scale questionnaire regarding the patients attitude towards diabetes. The responses range from strongly agree to strongly disagree.
• Behavioral: CBOC's undergo half-day joint-clinics via teleconference
  A patient has Diabetes/Endo clinic visit via teleconferencing. A patient is at a CBOC and the Diabetes/Endo physician is at Wade Park.

• Experimental: Arm 1
  Designated CBOC's were involved in the intervention phase where their DM patients were asked to participate in a telemedicine visit.
  Interventions:

  • Behavioral: The Diabetes Treatment Satisfaction Questionnaire
  • Behavioral: Diabetes Empowerment Scale
  • Behavioral: CBOC's undergo half-day joint-clinics via teleconference
• No Intervention: Arm 2
  The CBOC's not involved in the intervention phase had their patients not be involved in the telemedicine visit, but traditional education.

• Tomolo AM, Lawrence RH, Aron DC. A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum. Qual Saf Health Care. 2009 Jun;18(3):217-24.
• Pogach L, Aron D. Balancing hypoglycemia and glycemic control: a public health approach for insulin safety. JAMA. 2010 May 26;303(20):2076-7. No abstract available.
• F O Kern E, Beischel S, Stalnaker R, Aron DC, Kirsh SR, Watts SA. Building a diabetes registry from the Veterans Health Administration's computerized patient record system. J Diabetes Sci Technol. 2008 Jan;2(1):7-14.

Inclusion Criteria:

1) Current prescription of insulin or an oral hypoglycemic agent; 2) A1c > 7.0%; or 3) fasting glucose levels > 130 mg/dl; and 4) referred to see a consultant and are seen during the active intervention phase. Patients with either Type I or Type II DM will be included.

Exclusion Criteria:

1) primary care obtained at more than one site (based on stop codes with evidence of more than 1 CBOC involved in care during the last 6 months), and 2) documented dementia, aphasia, and psychosis.