Support Patient Self-management Research Articles

Abstract 104: Group Medical Visits versus Usual Care in Heart Failure: Clinical Trial Design & Rationale

Objective: The literature has demonstrated that patient self-care behaviors in heart failure (HF) and health system factors play an important role in patients’ health status and hospitalization risk. Utilizing the Chronic Care Model, shared medical appointments (SMA) are a type of care delivery redesign that provides patient self-management and peer support in addition to clinician-led disease management. In this model, the SMA team consists of a nutritionist, cardiology nurse, health psychologist, and a non-physician prescribing provider. The session begins with an assessment of patient needs followed by pre-assigned theme-based education and individualized medication management. Methods and Expected Results: At two VA medical centers, we will randomize 375 patients within 6 weeks of discharge from a HF hospitalization to receive either SMA intervention (4 sessions over 8 weeks) versus usual care (individual provider appointments) for HF. Inclusion criteria are: not enrolled in other programs for HF care, <2 hospitalizations last 6 months, left ventricular ejection fraction <40%. We will use stratified block randomization with block sizes of 4 at each site to ensure balance of the stratified variables. At 180 days, we will determine whether HF patients who participate in HF-SMA, as compared to patients who receive usual care: 1) Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D, secondary outcome); 2) Have fewer hospitalization or death and 3) Experience improvement in intermediate outcomes: a) increase in HF Self-Care Index, and b) decrease in plasma BNP levels. For patients who underwent HF-SMA, we will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to-face interviews with patients and (b) telephone interviews with physicians and administrators. Using VA cost data, we will perform a cost-effectiveness analysis to inform future VA resource allocation. Conclusions: This trial will generate critical knowledge regarding the clinical and cost-effectiveness of SMA in HF patients to provide patient-centered care, improve health status, and reduce readmission for patients with HF. Further, the results of the formative evaluation will support future implementation of this novel intervention into routine clinical practice.

Stakeholder Perspectives on Changes in Hypertension Care Under the Patient-Centered Medical Home.

IntroductionHypertension is a major modifiable risk factor for cardiovascular and kidney disease, yet the proportion of adults whose hypertension is controlled is low. The patient-centered medical home (PCMH) is a model for care delivery that emphasizes patient-centered and team-based care and focuses on quality and safety. Our goal was to investigate changes in hypertension care under PCMH implementation in a large multipayer PCMH demonstration project that may have led to improvements in hypertension control.MethodsThe PCMH transformation initiative conducted 118 semistructured interviews at 17 primary care practices in southeastern Pennsylvania between January 2011 and January 2012. Clinicians (n = 47), medical assistants (n = 26), office administrators (n = 12), care managers (n = 11), front office staff (n = 7), patient educators (n = 4), nurses (n = 4), social workers (n = 4), and other administrators (n = 3) participated in interviews. Study personnel used thematic analysis to identify themes related to hypertension care.ResultsClinicians described difficulties in expanding services under PCMH to meet the needs of the growing number of patients with hypertension as well as how perceptions of hypertension control differed from actual performance. Staff and office administrators discussed achieving patient-centered hypertension care through patient education and self-management support with personalized care plans. They indicated that patient report cards were helpful tools. Participants across all groups discussed a team- and systems-based approach to hypertension care.ConclusionPractices undergoing PCMH transformation may consider stakeholder perspectives about patient-centered, team-based, and systems-based approaches as they work to optimize hypertension care.

Digital interventions to promote self-management in adults with hypertension systematic review and meta-analysis.

Objective:To synthesize the evidence for using interactive digital interventions (IDIs) to support patient self-management of hypertension, and to determine their impact on control and reduction of blood pressure.Method:Systematic review with meta-analysis was undertaken with a search performed in MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Cochrane Library, DoPHER, TROPHI, Social Science Citation Index and Science Citation Index. The population was adults (>18 years) with hypertension, intervention was an IDI and the comparator was usual care. Primary outcomes were change in SBP and DBP. Only randomized controlled trials and studies published in journals and in English were eligible. Eligible IDIs included interventions accessed through a computer, smartphone or other hand-held device.Results:Four out of seven studies showed a significantly greater reduction for intervention compared to usual care for SBP, with no difference found for three. Overall, IDIs significantly reduced SBP, with the weighted mean difference being −3.74 mmHg [95% confidence interval (CI) −2.19 to −2.58] with no heterogeneity observed (I-squared = 0.0%, P = 0.990). For DBP, four out of six studies indicated a greater reduction for intervention compared to controls, with no difference found for two. For DBP, a significant reduction of −2.37 mmHg (95% CI −0.40 to −4.35) was found, but considerable heterogeneity was noted (I-squared = 80.1%, P = <0.001).Conclusion:IDIs lower both SBP and DBP compared to usual care. Results suggest these findings can be applied to a wide range of healthcare systems and populations. However, sustainability and long-term clinical effectiveness of these interventions remain uncertain.

Significance of education and self-management support for patients with chronic heart failure in family physician practice

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Korzh O, Krasnokutskiy S. Significance of education and self-management support for patients with chronic heart failure in family physician practice. Family Medicine & Primary Care Review. 2016;18(4):432-436. doi:10.5114/fmpcr.2016.63697. APA Korzh, O., & Krasnokutskiy, S. (2016). Significance of education and self-management support for patients with chronic heart failure in family physician practice. Family Medicine & Primary Care Review, 18(4), 432-436. https://doi.org/10.5114/fmpcr.2016.63697 Chicago Korzh, Oleksii, and Sergiy Krasnokutskiy. 2016. "Significance of education and self-management support for patients with chronic heart failure in family physician practice". Family Medicine & Primary Care Review 18 (4): 432-436. doi:10.5114/fmpcr.2016.63697. Harvard Korzh, O., and Krasnokutskiy, S. (2016). Significance of education and self-management support for patients with chronic heart failure in family physician practice. Family Medicine & Primary Care Review, 18(4), pp.432-436. https://doi.org/10.5114/fmpcr.2016.63697 MLA Korzh, Oleksii et al. "Significance of education and self-management support for patients with chronic heart failure in family physician practice." Family Medicine & Primary Care Review, vol. 18, no. 4, 2016, pp. 432-436. doi:10.5114/fmpcr.2016.63697. Vancouver Korzh O, Krasnokutskiy S. Significance of education and self-management support for patients with chronic heart failure in family physician practice. Family Medicine & Primary Care Review. 2016;18(4):432-436. doi:10.5114/fmpcr.2016.63697.

Women in Control: Pioneering Diabetes Self-Management Medical Group Visits in the Virtual World

Background:The current state of diabetes self-management (DSM) education and support for diabetic patients is inadequate, especially for minority women who experience disproportionately high rates of diabetes mellitus (DM) in the US. While DSM education and support enables individuals with diabetes to make positive lifestyle choices and achieve clinical goals, this type of support is difficult to deliver in medical practice settings. Virtual reality can assist DM patients and their clinical teams by providing effective educational tools in an engaging, learner-centered environment that fosters self-efficacy and skill proficiency.Methods:Our prior research demonstrated that virtual worlds are suitable for supporting DSM education. Building upon this success, we are now investigating whether DSM virtual world medical group visits lead to similarly effective health and educational outcomes compared to face-to-face medical group visits. Currently in year one of a five year randomized controlled trial, we aim to compare the effectiveness of a virtual world DSM medical group visit format versus a face-to-face DSM medical group visit format to increase physical activity and improve glucose control (HbA1c) among Black/African American and Hispanic women with uncontrolled DM. We will also conduct a qualitative study of participant engagement with the virtual world platform to characterize learners’ interactions with the technology and assess its correlation with DSM behaviors and diabetes control.Discussion:Novel methods to promote diabetes self-management are critically needed, and the use of virtual world technology to conduct medical group visits offers a unique approach to such issue. If successful, our intervention will increase access to culturally-sensitive diabetes care and improve patient engagement in online DSM learning, leading to higher uptake of DSM behaviors and better diabetes control. Importantly, the program can be easily expanded to other chronic disease areas and scaled for widespread use.

HIV Care Providers' Attitudes regarding Mobile Phone Applications and Web-Based Dashboards to support Patient Self-Management and Care Coordination: Results from a Qualitative Feasibility Study.

In-depth qualitative interviews were conducted with healthcare providers (HCPs) from five HIV medical care coordination teams in a large Los Angeles County HIV clinic, including physicians, nurses, and psychosocial services providers. HCPs reported on the potential utility, acceptability, and barriers for patient self-monitoring and notifications via mobile phones, and web-based dashboards for HCPs. Potential benefits included: 1) enhancing patient engagement, motivation, adherence, and self-management; and 2) improving provider-patient relationships and HCP care coordination. Newly diagnosed and patients with co-morbidities were highest priorities for mobile application support. Facilitators included universal mobile phone ownership and use of smartphones or text messaging. Patient-level barriers included concerns about low motivation and financial instability for consistent use by some patients. Organizational barriers, cited primarily by physicians, included concerns about privacy protections, easy dashboard access, non-integrated electronic records, and competing burdens in limited appointment times. Psychosocial services providers were most supportive of the proposed mobile tools.

Experiences of Self-Management Support Following a Stroke: A Meta-Review of Qualitative Systematic Reviews.

BackgroundSupporting self-management in stroke patients improves psychological and functional outcomes but evidence on how to achieve this is sparse. We aimed to synthesise evidence from systematic reviews of qualitative studies in an overarching meta-review to inform the delivery and development of self-management support interventions.MethodsWe systematically searched eight electronic databases including MEDLINE, EMBASE and CINAHL for qualitative systematic reviews (published January 1993 to June 2012). We included studies exploring patients’, carers’ or health care professionals’ experiences relevant to self-management support following a stroke, including studies describing the lived experience of surviving a stroke. We meta-synthesised the included review findings using a meta-ethnographic framework.ResultsSeven reviews, reporting 130 unique studies, were included. Themes emerging from the reviews were pertinent, consistent and showed data saturation; though explicit mention of self-management support was rare. Our meta-review highlighted the devastating impact of stroke on patients’ self-image; the varying needs for self-management support across the trajectory of recovery; the need for psychological and emotional support throughout recovery particularly when physical recovery plateaus; the considerable information needs of patients and carers which also vary across the trajectory of recovery; the importance of good patient-professional communication; the potential benefits of goal-setting and action-planning; and the need for social support which might be met by groups for stroke survivors.ConclusionsThe observed data saturation suggests that, currently, no further qualitative research simply describing the lived experience of stroke is needed; we propose that it would be more useful to focus on qualitative research informing self-management support interventions and their implementation. Our findings demonstrate both the on-going importance of self-management support and the evolving priorities throughout the stages of recovery following a stroke. The challenge now is to ensure these findings inform routine practice and the development of interventions to support self-management amongst stroke survivors.

Digital Interventions to Promote Self-Management in Adults With Hypertension: Protocol for Systematic Review and Meta-Analysis.

BackgroundDigital interventions, defined as any intervention accessed and taking input from patients in the form of a computer/Web-based program or mobile phoned-based app, can potentially help empower patients to self-manage long-term conditions such as hypertension. Importantly, digital interventions have the potential to provide patients with personalized information and support for active involvement in treatment as well as cost saving.ObjectiveThe purpose of this systematic review is to synthesize the evidence for using digital interventions to support patient self-management of hypertension, and determine their impact on control and reduction of blood pressure, other clinical outcomes, quality of life, medication adherence, health service utilization, and economic benefits.MethodsA systematic search of bibliographic databases including Medline, Embase, CINAHL, and PsycINFO will be undertaken. s and citations will be independently screened by 2 researchers against predetermined inclusion criteria. Any disagreements will be resolved by discussion and further consideration of the inclusion criteria. Only randomized controlled trials which have been published in peer peer-reviewed journals with a diagnosis of hypertension will be considered. Inclusion criteria will be (1) adults (age ≥ 18 years) with hypertension (as defined by the primary authors); (2) an interactive digital intervention compared with usual care; and (3) outcomes of objectively measured change in blood pressure. Data extraction from identified articles will be undertaken by 2 independent reviewers using a uniform template. The main outcomes are systolic blood pressure (SBP) and diastolic blood pressure (DBP), and quality of life indicators. Secondary outcomes include cost- effectiveness, medication adherence, emotional well-being, and physical activity. Risk of bias of included studies will be assessed using the Cochrane tool.ResultsOur research is currently ongoing. Data will be summarized narratively, and if possible, meta-analyses will be performed to assess the impact of the interventions on outcomes.ConclusionsBy summarizing and synthesizing available data, this review will help inform policy on the use of digital interventions for self-management of hypertension and will clarify areas for further research.Trial RegistrationProspero 2014: CRD42014010268; http://www.crd.york.ac.uk/PROSPERO/display_record.asp? ID=CRD42014010268 (Archived by WebCite at http://www.webcitation.org/6c5alQQJL)

A systems-based approach to managing blood pressure in children following kidney transplantation.

Hypertension is one of the most common and well-known complications following kidney transplantation in children. Yet, despite numerous available therapies many pediatric kidney transplant recipients continue to have poorly controlled blood pressure, suggesting that traditional approaches to blood pressure management in this population might be inadequate. Over the last two decades, the Chronic Care Model has been developed to improve chronic illness outcomes through delivery system design and clinical information systems that support patient self-management and provider decision-making. In this educational review we discuss key elements of managing blood pressure following pediatric kidney transplantation and suggest ways that they may be reliably implemented into clinical practice using principles from the Chronic Care Model.

Development of a Novel Mobile Application to Support Self-Management in Patients With Chronic Obstructive Pulmonary Disease (COPD)

Development of a Novel Mobile Application to Support Self-Management in Patients With Chronic Obstructive Pulmonary Disease (COPD)

A user-centred home monitoring and self-management system for patients with heart failure: a multicentre cohort study.

Previous generations of home monitoring systems have had limited usability. We aimed to develop and evaluate a user-centred and adaptive system for health monitoring and self-management support in patients with heart failure. Patients with heart failure were recruited from three UK centres and provided with Internet-enabled tablet computers that were wirelessly linked with sensor devices for blood pressure, heart rate, and weight monitoring. Patient observations, interviews, and concurrent analyses of the automatically collected data from their monitoring devices were used to increase the usability of the system. Of the 52 participants (median age 77 years, median follow-up 6 months [interquartile range, IQR, 3.6-9.2]), 24 (46%) had no, or very limited prior, experience with digital technologies. It took participants about 1.5 min to complete the daily monitoring tasks, and the rate of failed attempts in completing tasks was <5%. After 45 weeks of observation, participants still used the system on 4.5 days per week (confidence interval 3.2-5.7 days). Of the 46 patients who could complete the final survey, 93% considered the monitoring system as easy to use and 38% asked to keep the system for self-management support after the study was completed. We developed a user-centred home monitoring system that enabled a wide range of heart failure patients, with differing degrees of IT literacy, to monitor their health status regularly. Despite no active medical intervention, patients felt that they benefited from the reassurance and sense of connectivity that the monitoring system provided.

Improving care for patients on antiretroviral therapy through a gap analysis framework.

To improve quality of care through decreasing existing gaps in the areas of coverage, retention, and wellness of patients receiving HIV care and treatment. The antiretroviral therapy (ART) Framework utilizes improvement methods and the Chronic Care Model to address the coverage, retention, and wellness gaps in HIV care and treatment. This is a time-series study. The ART Framework was applied in five health centers in Buikwe District, Uganda. Quality improvement teams, consisting of healthcare workers and expert patients, were established in each of the five healthcare facilities. The intervention period was October 2010 to September 2012. It consisted of quality improvement teams analyzing their facility and systems of care from the perspective of the Chronic Care Model to identify areas of improvement. They implemented the ART Framework, collected data and assessed outcomes, focused on self-management support for patients, to improve coverage, retention, and wellness gaps in HIV care and treatment. Coverage was defined as every patient who needs ART in the catchment area, receives it. Retention was defined as every patient who receives ART stays on ART, and wellness defined as having a positive clinical, immunological, and/or virological response to treatment without intolerable or unmanageable side-effects. Results from Buikwe show the gaps in coverage, retention, and wellness greatly decreased a gap in coverage of 44-19%, gap in retention of 49-24%, and gap in wellness of 53-14% during a 2-year intervention period. The ART Framework is an innovative and practical tool for HIV program managers to improve HIV care and treatment.

Disclosure of complementary health approaches among low income and racially diverse safety net patients with diabetes

ObjectivePatient–provider communication about complementary health approaches can support diabetes self-management by minimizing risk and optimizing care. We sought to identify sociodemographic and communication factors associated with disclosure of complementary health approaches to providers by low-income patients with diabetes. MethodsWe used data from San Francisco Health Plan's SMARTSteps Program, a trial of diabetes self-management support for low-income patients (n=278) through multilingual automated telephone support. Interviews collected use and disclosure of complementary health approaches in the prior month, patient–physician language concordance, and quality of communication. ResultsAmong racially, linguistically diverse participants, half (47.8%) reported using complementary health practices (n=133), of whom 55.3% disclosed use to providers. Age, sex, race/ethnicity, nativity, education, income, and health literacy were not associated with disclosure. In adjusted analyses, disclosure was associated with language concordance (AOR=2.21, 95% CI: 1.05, 4.67), physicians’ interpersonal communication scores (AOR=1.50, 95% CI: 1.03, 2.19), shared decision making (AOR=1.74, 95% CI: 1.33, 2.29), and explanatory-type communication (AOR=1.46, 95% CI: 1.03, 2.09). ConclusionSafety net patients with diabetes commonly use complementary health approaches and disclose to providers with higher patient-rated quality of communication. Practice implicationsPatient–provider language concordance and patient-centered communication can facilitate disclosure of complementary health approaches.

Chronic disease management programmes for adults with asthma.

The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education. To evaluate the effectiveness of chronic disease management programmes for adults with asthma. Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews. We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months. After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs). A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes. There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

Does Compensating Primary Care Providers to Produce Higher Quality Make Them More or Less Patient Centric?

Both payment reform and patient engagement are key elements of health care reform. Yet the question of how incentivizing primary care providers (PCPs) on quality outcomes affects the degree to which PCPs are supportive of patient activation and patient self-management has received little attention. In this mixed-methods study, we use in-depth interviews and survey data from PCPs working in a Pioneer Accountable Care Organization that implemented a compensation model in which a large percentage of PCP salary is based on quality performance. We assess how much PCPs report focusing their efforts on supporting patient activation and self-management, and whether or not they become frustrated with patients who do not change their behaviors. The findings suggest that most PCPs do not see the value in investing their own efforts in supporting patient self-management and activation. Most PCPs saw patient behavior as a major obstacle to improving quality and many were frustrated that patient behaviors affected their compensation.

Primary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study: A Randomized Clinical Trial.

Heart failure (HF) has a major effect on patients' health status, including their symptom burden, functional status, and health-related quality of life. To determine the effectiveness of a collaborative care patient-centered disease management (PCDM) intervention to improve the health status of patients with HF. The Patient-Centered Disease Management (PCDM) trial was a multisite randomized clinical trial comparing a collaborative care PCDM intervention with usual care in patients with HF. A population-based sample of 392 patients with an HF diagnosis from 4 Veterans Affairs centers who had a Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score of less than 60 (heavy symptom burden and impaired functional status and quality of life) were enrolled between May 2009 and June 2011. The PCDM intervention included collaborative care by a multidisciplinary care team consisting of a nurse coordinator, cardiologist, psychiatrist, and primary care physician; home telemonitoring and patient self-management support; and screening and treatment for comorbid depression. The primary outcome was change in the KCCQ overall summary score at 1 year (a 5-point change is clinically significant). Mortality, hospitalization, and depressive symptoms (Patient Health Questionnaire 9) were secondary outcomes. There were no significant differences in baseline characteristics between patients randomized to the PCDM intervention (n=187) vs usual care (n=197); baseline mean KCCQ overall summary scores were 37.9 vs 36.9 (P=.48). There was significant improvement in the KCCQ overall summary scores in both groups after 1 year (mean change, 13.5 points in each group), with no significant difference between groups (P=.97). The intervention was not associated with greater improvement in the KCCQ overall summary scores when the effect over time was estimated using 3-month, 6-month, and 12-month data (P=.74). Among secondary outcomes, there were significantly fewer deaths at 1 year in the intervention arm (8 of 187 [4.3%]) than in the usual care arm (19 of 197 [9.6%]) (P = .04). Among those who screened positive for depression, there was a greater improvement in the Patient Health Questionnaire 9 scores after 1 year in the intervention arm than in the usual care arm (2.1 points lower, P=.01). There was no significant difference in 1-year hospitalization rates between the intervention arm and the usual care arm (29.4% vs 29.9%, P=.87). This multisite randomized trial of a multifaceted HF PCDM intervention did not demonstrate improved patient health status compared with usual care. clinicaltrials.gov Identifier: NCT00461513.

Structuring and coding in health care records: a qualitative analysis using diabetes as a case study

BackgroundGlobally, diabetes mellitus presents a substantial and increasing burden to individuals, health care systems and society. Structuring and coding of information in the electronic health record underpin attempts to improve...

Measuring the Implementation and Effects of a Coordinated Care Model Featuring Diabetes Self-management Education Within Four Patient-Centered Medical Homes.

The purpose of this study is to measure the implementation and effects of a multisite coordinated care approach that delivered diabetes self-management education (DSME) and diabetes self-management support (DSMS) for disadvantaged patients within 4 patient-centered medical homes (PCMH). A total of 173 patients (69.9% African American, 26.0% Caucasian, and 4.1% other) experienced elements of the intervention, which featured DSME and coordinated care. Key informant interviews with PCMH site staff were used to capture, code, and characterize activities related to implementation and sustainability of the intervention. Outcome measures collected at baseline and at 6 months included clinical health indicators, A1C, body mass index (BMI), blood pressure, and lipids, as well as the AADE7 Behaviors. A statistically significant decrease occurred in A1C and BMI within 6 months for participants within 1 PCMH. This improvement among clinical health outcomes was associated with the frequency of services provided (eg, DSME, patient support). Integrating and delivering DSME and DSMS within coordinated care settings have the potential to improve PCMH practice and associated clinical health outcomes for populations experiencing health disparities.

Telehealth program for type 2 diabetes: usability, satisfaction, and clinical usefulness in an urban community health center.

We examined the usability, satisfaction, and clinical impact of a 3-month diabetes telehealth intervention for poorly controlled type 2 diabetes (T2D) patients. The urban community health center sample (n=30) was 56.7% female, mean age of 60.6 years, 56.7% high school education or higher, and 73% African American and 26% Latino. We integrated an electronic pillbox into an existing diabetes remote home monitoring (RHM) device suite comprising a Bluetooth(®) (Bluetooth SIG, Kirkland, WA)-enabled blood glucose meter and an automatic blood pressure monitor connected to a cellular hub for data upload to our clinical application. This telehealth program involved minimal clinician training and functioned as a nonurgent patient self-management support service to increase the scope of clinic services. Telehealth nurse interventionists received regular RHM data alerts and called patients by phone at scheduled intervals. A graphical report summarizing patient RHM data was sent to providers to inform clinical decision making during a scheduled clinic visit at the 3-month follow-up. The results showed consistently high levels of RHM device use during the intervention period, high ratings of usability and program satisfaction from patients, and high ratings of provider satisfaction with the program. There was a clinically and statistically significant improvement in blood glucose control at 3 months, such that hemoglobin A1c improved 0.6% from a baseline level of 8.3% (p<0.05). These findings provide encouraging empirical support for the usability and clinical value of a diabetes telehealth program integrating a user-friendly cellular pillbox and clinical decision support tools that was delivered to an urban poor T2D clinic population.

A participatory approach to designing and enhancing integrated health information technology systems for veterans: protocol.

BackgroundThe Department of Veterans Affairs (VA) has developed health information technologies (HIT) and resources to improve veteran access to health care programs and services, and to support a patient-centered approach to health care delivery. To improve VA HIT access and meaningful use by veterans, it is necessary to understand their preferences for interacting with various HIT resources to accomplish health management related tasks and to exchange information.ObjectiveThe objective of this paper was to describe a novel protocol for: (1) developing a HIT Digital Health Matrix Model; (2) conducting an Analytic Hierarchy Process called pairwise comparison to understand how and why veterans want to use electronic health resources to complete tasks related to health management; and (3) developing visual modeling simulations that depict veterans’ preferences for using VA HIT to manage their health conditions and exchange health information.MethodsThe study uses participatory research methods to understand how veterans prefer to use VA HIT to accomplish health management tasks within a given context, and how they would like to interact with HIT interfaces (eg, look, feel, and function) in the future. This study includes two rounds of veteran focus groups with self-administered surveys and visual modeling simulation techniques. This study will also convene an expert panel to assist in the development of a VA HIT Digital Health Matrix Model, so that both expert panel members and veteran participants can complete an Analytic Hierarchy Process, pairwise comparisons to evaluate and rank the applicability of electronic health resources for a series of health management tasks.ResultsThis protocol describes the iterative, participatory, and patient-centered process for: (1) developing a VA HIT Digital Health Matrix Model that outlines current VA patient-facing platforms available to veterans, describing their features and relevant contexts for use; and (2) developing visual model simulations based on direct veteran feedback that depict patient preferences for enhancing the synchronization, integration, and standardization of VA patient-facing platforms. Focus group topics include current uses, preferences, facilitators, and barriers to using electronic health resources; recommendations for synchronizing, integrating, and standardizing VA HIT; and preferences on data sharing and delegation within the VA system.ConclusionsThis work highlights the practical, technological, and personal factors that facilitate and inhibit use of current VA HIT, and informs an integrated system redesign. The Digital Health Matrix Model and visual modeling simulations use knowledge of veteran preferences and experiences to directly inform enhancements to VA HIT and provide a more holistic and integrated user experience. These efforts are designed to support the adoption and sustained use of VA HIT to support patient self-management and clinical care coordination in ways that are directly aligned with veteran preferences.