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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 mellitus (DM) at a Community Based Outpatient Center (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 Primary Care Provider (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 Veterans Affairs Medical Center (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.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Telemedicine CBOC | Experimental | Designated CBOC's were involved in the intervention phase where their Diabetes Mellitus (DM) patients were asked to participate in a telemedicine visit. The Behavioral: The Diabetes Treatment Satisfaction Questionnaire given during this phase along with the Behavioral: Diabetes Empowerment Scale and the Behavioral: CBOC's undergo half-day joint-clinics via teleconference. |
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| Control CBOC | No Intervention | The CBOC's not involved in the intervention phase had their patients not be involved in the telemedicine visit, but traditional education. | |
| Provider Interviews | No Intervention | Qualitative interviews with providers |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| The Diabetes Treatment Satisfaction Questionnaire | Behavioral | A six question likert scale questionnaire regarding the patients treatment satisfaction. The responses range from very dissatisfied to very satisfied. |
| Measure | Description | Time Frame |
|---|---|---|
| A1c | Hemoglobin A1c is a measure of glycemic control | baseline and 18 months |
| Measure | Description | Time Frame |
|---|---|---|
| Patient Satisfaction | Diabetes Treatment Satisfaction Questionnaire (DTSQ) consists of 6 questions and ranges from 0-6. The following aspects of current treatment included were convenience, flexibility, understanding and continuing present form of treatment. The total range of the DTSQ is the sum of the 6 individual questions scores (i.e. 0-36) Higher scores represent greater satisfaction/convenience. |
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Inclusion Criteria:
A Primary Care Provider for a Cleveland CBOC
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| David C Aron, MD MS | Louis Stokes VA Medical Center | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| VA Ann Arbor Healthcare System | Ann Arbor | Michigan | 48113-0170 | United States | ||
| Louis Stokes VA Medical Center |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 19468006 | Result | 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. doi: 10.1136/qshc.2007.024729. | |
| 20501929 | Result |
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| ID | Title | Description |
|---|---|---|
| FG000 | Telemedicine CBOC | Designated CBOC's were involved in the intervention phase where their DM patients were asked to participate in a telemedicine visit. 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. 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. 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. |
| Title | Milestones | Reasons Not Completed | |||||
|---|---|---|---|---|---|---|---|
| Overall Study |
|
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| Diabetes Empowerment Scale | Behavioral | A twenty-eight question likert scale questionnaire regarding the patients attitude towards diabetes. The responses range from strongly agree to strongly disagree. |
|
| CBOC's undergo half-day joint-clinics via teleconference | Behavioral | A patient has Diabetes/Endo clinic visit via teleconferencing. A patient is at a CBOC and the Diabetes/Endo physician is at Wade Park. |
|
| Base line and at18 months. |
| Cleveland |
| Ohio |
| 44106-3800 |
| United States |
| Pogach L, Aron D. Balancing hypoglycemia and glycemic control: a public health approach for insulin safety. JAMA. 2010 May 26;303(20):2076-7. doi: 10.1001/jama.2010.655. No abstract available. |
| 19885172 | Result | 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. doi: 10.1177/193229680800200103. |
| FG001 | Control CBOC | The CBOC's not involved in the intervention phase had their patients not be involved in the telemedicine visit, but traditional education. |
| FG002 | Provider Interview | Qualitative interviews with providers |
| COMPLETED |
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| NOT COMPLETED |
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Cohort I will consist of high-risk patients referred to a specialist during the 9-month active intervention and enrollment phase.Cohort II will consist of all other patients with diabetes (i.e., all non-Cohort I patients). We didn't collect gender or the complete age data.
Qualitative interviews with providers
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| ID | Title | Description |
|---|---|---|
| BG000 | Telemedicine CBOC | Designated CBOC's were involved in the intervention phase where their DM patients were asked to participate in a telemedicine visit. 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. 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. 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. We did not collect gender and age related data. |
| BG001 | Control CBOC | The CBOC's not involved in the intervention phase had their patients not be involved in the telemedicine visit, but traditional education. |
| BG002 | Provider Interview | Qualitative interviews with providers |
| BG003 | Total | Total of all reporting groups |
| Units | Counts |
|---|---|
| Participants |
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| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Age, Customized | Number | participants |
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| Sex/Gender, Customized | Number | participants |
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| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Secondary | Patient Satisfaction | Diabetes Treatment Satisfaction Questionnaire (DTSQ) consists of 6 questions and ranges from 0-6. The following aspects of current treatment included were convenience, flexibility, understanding and continuing present form of treatment. The total range of the DTSQ is the sum of the 6 individual questions scores (i.e. 0-36) Higher scores represent greater satisfaction/convenience. | The number subjects was determined on the size of the CBOC. | Posted | Mean | Full Range | units on a scale | Base line and at18 months. |
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| Primary | A1c | Hemoglobin A1c is a measure of glycemic control | Posted | Mean | Full Range | percentage of Hb that is glycosylated | baseline and 18 months |
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Telemedicine CBOC | Designated CBOC's were involved in the intervention phase where their DM patients were asked to participate in a telemedicine visit. The Behavioral: The Diabetes Treatment Satisfaction Questionnaire given during this phase along with the Behavioral: Diabetes Empowerment Scale and the Behavioral: CBOC's undergo half-day joint-clinics via teleconference. 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. 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. 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. | 0 | 199 | 0 | 199 | ||
| EG001 | Control CBOC | The CBOC's not involved in the intervention phase had their patients not be involved in the telemedicine visit, but traditional education. | 0 | 83 | 0 | 83 | ||
| EG002 | Provider Interviews | Qualitative interviews with providers. | 0 | 22 | 0 | 22 |
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A potential factor jeopardizing both internal and external validity relates to fact that the consultation process may be very dependent on the particular individuals involved.
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| David C. Aron, MD, MS | Louis Stokes VA Medical Center | (216) 791-2300 | 5702 | david.aron@va.gov |
| ID | Term |
|---|---|
| D003924 | Diabetes Mellitus, Type 2 |
| D003922 | Diabetes Mellitus, Type 1 |
| D003920 | Diabetes Mellitus |
| ID | Term |
|---|---|
| D044882 | Glucose Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
| D004700 | Endocrine System Diseases |
| D001327 | Autoimmune Diseases |
| D007154 | Immune System Diseases |
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Comparisons were made between the intervention and control groups at 18 months
| t-test, 2 sided |
Threshold for statistical significance was p<0.025 using Bonferroni correction for 2 statistical tests. |
| >0.25 |
Threshold for statistical significance was p<0.025 using Bonferroni correction for 2 statistical tests. |
| 2-Sided |
| No |
| Superiority or Other |
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