Diabetes Disparities: Texting to Extend Treatment (DD-TXT)

背景：2型糖尿病是一种常见的复杂疾病，具有很高的共患率，24%的退伍军人受到影响。 易受伤害的退伍军人(例如，非裔美国人、农村人、患有精神疾病的诊断、低收入)较少 可能已经控制了糖尿病，与其他退伍军人相比，他们的死亡率和发病率更高。 意义/影响：支持慢性病自我管理的保健信息学干预 通过技术可以改善弱势退伍军人的机会、健康公平和健康结果。 通过Annie提供的可定制、交互式的自我管理支持解决了退伍军人管理局的优先事项 访问，包括通过虚拟医疗设备，并提供结合了退伍军人需求和 偏好(退伍军人事务部战略要务2)。研究优先领域：获得护理、妇女健康、心理健康 健康、初级保健实践、信息学、虚拟保健、健康公平和以患者为中心的保健都在讨论中。 创新：通过将易受伤害的糖尿病退伍军人的需求和偏好纳入自我 管理层短信干预并测试其与更传统的纯教育的有效性 干预，吸取经验教训可以改善发展，以文本为基础的支持其他复杂的慢性疾病 条件。它还可以改进整个退伍军人管理局未来基于安妮的自我管理支持的实施情况。 具体目标：目标1：完善和测试交互式、量身定制的自我管理短信组件 协议(DD-TXT)使用参与式设计过程，纳入易受伤害退伍军人的偏好，弗吉尼亚州 临床医生的输入，以及有效的短信自我管理计划的证据。DD-TXT协议将 包括：核心消息：关于药物管理、血糖和血液的可定制核心模块 压力监测、预防性护理、解决问题、预约提醒、行政信息；以及 可选消息：患者选择模块的库(例如营养、体力活动、体重管理、 情感应对、目标设定)旨在激励和教育。 目的2：对400名患有糖尿病的退伍军人进行随机对照比较有效性试验 2018年不受控制(定义为HbA1c在最近6个月中至少有50%超过8.0%) 佛罗里达州盖恩斯维尔或伊利诺伊州芝加哥。主要目的是评估DD-TXT的相对有效性 与DSE相比，一种仅针对糖尿病技能教育的短信协议，基于目前 给退伍军人管理局的糖尿病患者服用。主要结果将是HbA1c控制时间百分比。次要的 结果包括自我报告遵守糖尿病自我护理建议(SCI-R)，糖尿病自我护理 疗效、糖尿病痛苦、低密度脂蛋白和血压控制。我们假设DD-TXT将导致更好的 近期健康结局和糖尿病自我管理行为与仅教育方案(DSE)的比较。 目标3：通过短信获取信息以指导未来糖尿病自我管理支持的实施 通过(A)收集和分析参与比较有效性的患者的定性反馈 试验，总体和分组(B)收集提供者和主要利益攸关方关于 DD-TXT与DSE的未来RCT评估和实施的障碍/促进者，(C)进行成本- 识别分析和安全分析，以确定大规模实施所需的资源。 方法：我们将通过参与式设计过程来完善DD-TXT协议，进行 400名未控制糖尿病退伍军人的随机对照比较疗效试验，收集 来自患者、提供者和其他利益相关者的定性反馈，并进行成本识别分析 指导今后的实施。 下一步/实施：该项目将告知未来将经验丰富的意见纳入 Annie协议开发并导致未来DD-TXT或DSE(基于)的类型2混合实施试验 根据我们的调查结果)，以确定安妮为基础的自我管理支持的最佳实施战略。

Background: Type 2 Diabetes, a common, complex condition with high comorbidity, affects 24% of Veterans. Vulnerable Veterans (e.g., African-American, rural, comorbid mental health diagnosis, low-income) are less likely to have controlled diabetes, and have higher mortality and morbidity compared to other Veterans. Significance/Impact: Health Care Informatics interventions to support chronic disease self-management through technology can improve access, health equity, and health outcomes for vulnerable Veterans. Customizable, interactive self-management support through Annie addresses the VA's priority of improving access, including via virtual modalities, and providing a tailored experience that incorporates Veteran needs and preferences (VA Strategic Imperative 2). Research priority areas of access to care, women's health, mental health, primary care practice, informatics, virtual care, health equity, and patient-centered care are all addressed. Innovation: By incorporating the needs and preferences of vulnerable Veterans with diabetes in a self- management texting intervention and testing its effectiveness against a more traditional education-only intervention, lessons learned can improve the development of text-based support for other complex chronic conditions. It can also improve future implementation of Annie-based self-management support throughout VA. Specific Aims: AIM 1: Refine and beta test components of an interactive, tailored self-management texting protocol (DD-TXT) using a participatory design process incorporating vulnerable Veterans' preferences, VA clinician input, and evidence on effective texting-enabled self-management programs. The DD-TXT protocol will consist of: Core Messaging: Customizable core modules on medication management, blood sugar and blood pressure monitoring, preventive care, problem solving, appointment reminders, administrative messages; and Optional Messaging: A library of patient-selected modules (e.g. nutrition, physical activity, weight management, emotional coping, goal setting) designed to motivate and educate. AIM 2: Conduct a randomized controlled comparative effectiveness trial with 400 Veterans whose diabetes was uncontrolled (defined as HbA1c over 8.0% for at least 50% of the most recent 6 months) in 2018 in Gainesville, FL or Chicago, IL. The primary aim will be to assess the comparative effectiveness of DD-TXT compared to DSE, a diabetes skills education-only texting protocol based on a skills workbook that is currently given to VA patients with diabetes. The primary outcome will be HbA1c percent time in control. Secondary outcomes include self-reported adherence to diabetes self-care recommendations (SCI-R), diabetes self- efficacy, diabetes distress, LDL, and blood pressure control. We hypothesize that DD-TXT will result in better proximal health outcomes and diabetes self-management behaviors vs an education-only protocol (DSE). AIM 3: Obtain information to guide future implementation of diabetes self-management support through texting by (a) gathering and analyzing qualitative feedback from patients engaged in the comparative effectiveness trial, overall and by subgroup (b) collecting qualitative feedback from providers and key stakeholders on the barriers/facilitators of future RCT evaluation and implementation of DD-TXT vs DSE, (c) conducting a cost- identification analysis and safety analysis to identify resources required for larger-scale implementation. Methodology: We will refine the DD-TXT protocol through a participatory design process, conduct a randomized controlled comparative effectiveness trial with 400 Veterans with uncontrolled diabetes, and collect qualitative feedback from patients, providers, and other stakeholders and conduct a cost-identification analysis to guide future implementation. Next Steps/Implementation: This project will inform future processes for incorporating Veteran input into Annie protocol development and lead to a future Type 2 hybrid implementation trial of DD-TXT or DSE (based on our findings) to determine best implementation strategies for Annie-based self-management support.