Pandemic-Related Disruptions in care for Veterans on Insulin Pumps (PD-VIP): A Mixed Methods Analysis

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Background: Prior to the pandemic, the approximately 10,000 Veterans on insulin pumps (VIPs) were excluded from VA telehealth programs due to the complexity of their care and their risk of adverse events (AEs). The lack of enrollment of VIPs in VA telehealth programs resulted in a gap in knowledge of best practices for remote insulin pump management, making pandemic-related disruptions in care especially difficult and riskier for these Veterans. The urgency to switch all Veterans to telehealth for non-emergent care during the pandemic resulted in the need for VIPs and providers to adapt to new care processes and quickly “piece together” data-sharing technologies to overcome barriers and maintain safe and effective care. The objective of this study is to address the gap in knowledge of best practices for remote insulin pump management to mitigate adverse effects the ongoing pandemic has on high-risk VIPs. The long-term goal of this research is to establish an evidence-based telehealth program for safe and effective remote insulin pump management to improve access to remote care for VIPs and meet the growing demand for insulin pump therapy. Significance: This study will inform the advancement of telehealth processes and tools for remote insulin pump management that will: (1) benefit vulnerable Veterans living in rural communities and other Veterans who face access challenges, (2) expand care options for Veterans with diabetes who may be candidates for insulin pump therapy but are unable to access VA specialty care, and (3) enhance VIPs ability to connect with their care team for critical real-time troubleshooting of unexpected device failures and prevention of AEs. Expanding Veteran access to remote insulin pump management assures continued quality care and connection for VIPs and supports VA's clinical and legislative goals of improving Veteran access to care. Specific Aims: 1. Characterize the pandemic's impact on VIP outcomes, including process of care and clinical outcomes. Using a longitudinal observational design, we will examine VIP process of care and clinical outcomes over a 3-year period beginning 1.5 years prior to onset of the pandemic. We will use mixed effects and Cox regression models to compare outcomes before and during the pandemic while accounting for practice, provider, and patient-level covariates that are likely to influence the outcomes of interest. 2. Examine VIPs' and providers' experiences and satisfaction with insulin pump management before and during the COVID-19 pandemic and identify barriers to and facilitators of safe and effective remote care. We will conduct structured interviews with a VIPs and providers and apply rapid qualitative analysis to examine experiences and satisfaction with insulin pump management before and during the COVID-19 pandemic and identify barriers to and facilitators of safe and effective remote care. 3. Develop recommendations to advance telehealth processes and tools for safe and effective remote insulin pump management. We will integrate our findings from Aims 1 and 2 using joint displays and review them with a VA Expert Advisory Panel and VIP representatives to generate recommendations for immediate improvement to remote insulin pump management and for future research. Methodology: We selected a mixed-methods design to expand the breadth of our inquiry by obtaining an account of pandemic-related outcomes through our quantitative analysis and a sense of the process of transitioning VIPs to telehealth through our qualitative analysis. We will use our integrated findings to generate recommendations to improve how VA delivers remote care to VIPs moving forward. Next Steps/Implementation: Our partners at the VA National Endocrinology/Diabetes Program Office, VA Office of Rural Health, and VA Office of Connected Care will provide guidance and support throughout our study and facilitate the rapid dissemination of our findings across VA.