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

背景：2型糖尿病是一种常见的、复杂的疾病，并发症高，影响24%的退伍军人。 易受伤害的退伍军人（例如，非裔美国人、农村、共病精神健康诊断、低收入）较少 可能已经控制糖尿病，并有较高的死亡率和发病率相比，其他退伍军人。 意义/影响：支持慢性病自我管理的医疗保健信息学干预措施 通过技术可以改善弱势退伍军人的可及性、健康公平性和健康结果。 通过Annie提供的可定制的交互式自我管理支持解决了VA的优先事项， 访问，包括通过虚拟模式，并提供量身定制的体验， 战略优先（VA Strategic Imperative 2）获得保健、妇女健康、心理健康、 健康、初级保健实践、信息学、虚拟保健、健康公平和以病人为中心的保健都得到了解决。 创新：通过将糖尿病脆弱退伍军人的需求和偏好纳入自我- 管理短信干预和测试其有效性对一个更传统的教育只 干预，吸取的教训可以改善其他复杂的慢性发展的文本为基础的支持 条件它还可以改善整个VA基于Annie的自我管理支持的未来实施。 具体目标：目标1：完善和beta测试组件的互动，量身定制的自我管理短信 协议（DD-TXT）使用参与式设计过程，纳入弱势退伍军人的喜好，VA 临床医生输入，以及有效的文本使能自我管理程序的证据。DD-TXT协议将 包括：核心信息：关于药物管理、血糖和血液的可定制核心模块 压力监测、预防护理、解决问题、预约提醒、行政信息;以及 可选信息：患者选择的模块库（例如营养、体力活动、体重管理， 情绪应对，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年未得到控制（定义为最近6个月至少50%的HbA 1c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的比较有效性 与DSE相比，DSE是一种基于技能手册的糖尿病技能教育短信协议， 给患有糖尿病的退伍军人管理局的病人。主要结局将是HbA 1c控制时间百分比。二次 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， 疗效、糖尿病痛苦、LDL和血压控制。我们假设DD-TXT将导致更好的 近端健康结果和糖尿病自我管理行为与仅教育方案（DSE）。 目的3：通过短信获取信息，以指导未来实施糖尿病自我管理支持 通过（a）收集和分析来自参与比较有效性的患者的定性反馈， 试验，总体和亚组（B）收集供应商和关键利益相关者对 DD-TXT与DSE的未来RCT评价和实施的障碍/促进因素，（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完善DD-TXT协议， 随机对照比较有效性试验，400名退伍军人与控制糖尿病，并收集 从患者、提供者和其他利益相关者那里获得定性反馈，并进行成本识别分析 以指导今后的实施。 后续步骤/实施：该项目将告知未来将退伍军人投入纳入 Annie协议开发，并导致DD-TXT或DSE（基于 根据我们的调查结果），以确定基于Annie的自我管理支持的最佳实施策略。

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.