Tailored, eHealth-based Management for Persistent Poorly-Controlled Diabetes

描述（由申请人提供）： 这项职业发展奖（CDA）提案旨在改善对患有持续性控制不良糖尿病（PPDM）的退伍军人的管理。糖尿病是退伍军人肾衰竭、截肢和失明的主要原因，也是心脏病发作和中风的主要危险因素。糖尿病也与退伍军人死亡率的两倍增加有关，并且是VA最昂贵的疾病之一。由于糖尿病并发症和费用随着血红蛋白A1 c（HbA 1c）的增加呈指数级上升，HbA 1c>9%的维持是一个风险因素，可以通过改善血糖控制来改变。因此，患有PPDM的退伍军人（定义为尽管进行了VA初级护理或内分泌管理，但HbA 1c持续>9%>1年）可能是VA中风险最高的糖尿病患者。 鉴于他们对糖尿病并发症和成本的不成比例的贡献，迫切需要新的方法来管理PPDM的退伍军人。然而，目前有两个证据差距阻碍了针对这些退伍军人的干预措施的开发：1）解决退伍军人PPDM潜在因素的最佳糖尿病管理内容尚不清楚; 2）针对患有PPDM的退伍军人的理想干预实施策略尚不清楚。拟议的CDA将解决这些差距，并产生一种新的干预措施，专门用于改善PPDM退伍军人的糖尿病控制。该CDA的中心假设是，如果它：1）提供针对患有PPDM的退伍军人中改善的特定障碍的内容; 2）利用以患者为中心的交付策略，以符合该组偏好的方式促进频繁的患者-提供者联系，则该干预将是有效的。 拟议的CDA包括三个互补的具体目标，和基于健康信念模型的理论框架将指导这项研究计划。对于目标1，将分析现有数据，以确定与退伍军人PPDM相关的患者因素。根据CDA的理论模型，这些因素将指向PPDM改善的障碍，这反过来又将指导有针对性的干预内容的选择。目标2将利用定性方法询问利益相关者关于PPDM中糖尿病控制的感知障碍和促进因素，这将进一步细化干预内容。额外的定性工作将定义患有PPDM的退伍军人首选的干预实施策略，以促进频繁的患者-提供者联系;评估的策略将包括目前在整个VA中广泛使用的策略（例如，MyHealtheVet、家庭远程医疗、团体医疗诊所）。目标3将利用目标1和2的数据，设计和试点测试一种专门针对PPDM退伍军人的新干预措施。最终，通过将以患者为中心的干预应用于高风险人群中的昂贵状况，该CDA与相关VA组织的战略目标（例如，VA HSR&D，Diabetes QUERI），对VA具有重要意义。 本CDA的PI为Matthew Crowley，MD，达勒姆VA创新中心（COIN）的核心研究者。克劳利博士在达勒姆硬币组织了一个专家指导小组。他的主要导师是大卫埃德尔曼，高级卫生服务研究（HSR）调查员谁进行了多次试验的护理提供重新设计糖尿病。Crowley博士的共同导师Hayden Bosworth在HSR方面拥有广泛的专业知识，包括使用理论模型来指导干预设计。Karen Steinhauser是主要合作者，擅长使用定性方法来开发和评估HSR干预措施。Crowley博士和他的导师设计了一个CDA培训计划，通过全面的教学和指导培训，系统地解决核心HSR能力，填补了他目前专业知识（包括行为/社会理论，定性研究，实施研究）的关键空白。Crowley实现他的长期目标：跟随他的导师成为独立的VA健康服务研究员，并成为难治性糖尿病管理的国家思想领袖。

DESCRIPTION (provided by applicant): This career development award (CDA) proposal seeks to improve management of Veterans with persistent poorly-controlled diabetes mellitus (PPDM). Diabetes is the leading cause of kidney failure, limb amputation, and blindness among Veterans, and is a major risk factor for heart attack and stroke. Diabetes is also associated with a two-fold increase in mortality among Veterans, and is among the most costly diseases to VA. Because diabetes complications and costs rise exponentially as hemoglobin A1c (HbA1c) increases, maintenance of an HbA1c >9% represents a risk factor that can be modified with improved glycemic control. For this reason, Veterans with PPDM (defined as having HbA1c continuously >9% for >1 year despite VA Primary Care or Endocrinology management), are likely the highest-risk diabetes patients within VA. Given their disproportionate contribution to diabetes complications and costs, novel approaches to managing Veterans with PPDM are urgently needed. However, two evidence gaps currently hinder the development of interventions targeting these Veterans: 1) the optimal diabetes management content to address factors underlying PPDM in Veterans is unclear; and 2) the ideal intervention delivery strategy for Veterans with PPDM is not known. The proposed CDA will address these gaps and generate a novel intervention specifically designed to improve diabetes control among Veterans with PPDM. The central hypothesis for this CDA is that this intervention will be effective if it: 1) delivers content targeting specific barriers to improvemen among Veterans with PPDM; and 2) utilizes a patient-centered delivery strategy that facilitates frequent patient-provider contact in a manner consistent with this group's preferences. The proposed CDA comprises three complementary Specific Aims, and a theoretical framework based on the Health Belief Model will guide this program of research. For Aim 1, existing data will be analyzed to identify patient factors associated with PPDM in Veterans. Per this CDA's theoretical model, these factors will point toward barriers to improvement in PPDM, which in turn will guide the selection of targeted intervention content. Aim 2 will utilize qualitative methodoloy to query stakeholders regarding perceived barriers and facilitators of diabetes control in PPDM, which will further refine intervention content. Additional qualitative work will define the intervention delivery strategy/strategies preferred by Veterans with PPDM for facilitating frequent patient-provider contact; strategies evaluated will include those currently in wide use throughout VA (e.g., MyHealtheVet, Home Telehealth, Group Medical Clinics). Aim 3 will utilize data from Aims 1 and 2 to design and pilot test a novel intervention specifically targeting Veterans with PPDM. Ultimately, by applying a patient- centered intervention to a costly condition in a high-risk population, this CDA aligns with strategic goals for relevant VA organizations (e.g., VA HSR&D, Diabetes QUERI) and has great significance for VA. The PI for this CDA is for Matthew Crowley, MD, a Core Investigator at the Durham VA Center of Innovation (COIN). Dr. Crowley has assembled an expert mentorship team based at the Durham COIN. His primary mentor is David Edelman, a senior Health Services Research (HSR) investigator who has conducted multiple trials of care delivery redesign in diabetes. Dr. Crowley's co-mentor, Hayden Bosworth, has broad expertise in HSR, including using theoretical models to guide intervention design. Karen Steinhauser, a key collaborator, is expert in using qualitative methods to develop and evaluate HSR interventions. Dr. Crowley and his mentors have designed a CDA training plan that will fill key gaps in his current expertise (including behavioral/social theory, qualitative research, implementation research) by systematically addressing core HSR competencies through comprehensive didactic and mentored training. This CDA will enable Dr. Crowley to meet his long-term objectives: following his mentors as an independent VA Health Services Researcher and emerging as a national thought-leader in the management of refractory diabetes.