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

背景：在大流行之前，大约10，000名使用胰岛素泵（VIP）的退伍军人 由于其护理的复杂性和不良事件的风险， （不良事件）。在VA远程医疗计划中缺乏VIP的登记导致了对最佳治疗的知识差距。 远程胰岛素泵管理的实践，使得与流行病相关的护理中断特别困难 对这些退伍军人来说风险更大。紧急切换所有退伍军人远程医疗非紧急护理期间 大流行导致VIP和提供者需要适应新的护理流程， “一起”数据共享技术，以克服障碍，保持安全和有效的护理。客观 本研究的目的是解决远程胰岛素泵管理最佳实践知识方面的差距， 减轻当前流行病对高风险贵宾的不利影响。这项研究的长期目标是 建立一个以证据为基础的远程医疗计划，以实现安全有效的远程胰岛素泵管理， 改善VIP的远程护理，满足对胰岛素泵治疗日益增长的需求。 意义：这项研究将为远程胰岛素的远程医疗过程和工具的进步提供信息。 泵管理将：（1）有利于生活在农村社区的弱势退伍军人和其他退伍军人 谁面临访问的挑战，（2）扩大护理选择的退伍军人与糖尿病谁可能是候选人， 胰岛素泵治疗，但无法访问VA专业护理，和（3）增强VIP与 他们的护理团队对非预期器械故障进行关键的实时故障排除并预防不良事件。 扩大退伍军人对远程胰岛素泵管理的访问，确保持续的优质护理， 连接的VIP和支持VA的临床和立法目标，改善退伍军人获得护理。 具体目标： 1.描述大流行对VIP结果的影响，包括护理过程和临床 结果。采用纵向观察设计，我们将研究VIP的护理过程和临床 从大流行病爆发前1.5年开始的3年期间的结果。我们将使用混合 影响和考克斯回归模型，以比较大流行之前和期间的结果， 对于可能影响感兴趣结果的实践、提供者和患者水平的协变量。 2.检查VIP和供应商对胰岛素泵管理的经验和满意度， 以及在COVID-19大流行期间，并确定安全和有效 远程护理我们将与VIP和供应商进行结构化访谈，并应用快速定性 分析检查之前和期间胰岛素泵管理的经验和满意度 COVID-19大流行，并确定安全有效的远程护理的障碍和促进因素。 3.提出建议，以推进远程保健进程和工具， 胰岛素泵管理。我们将利用联合展示， 与VA专家咨询小组和VIP代表一起审查它们，以生成建议， 立即改进远程胰岛素泵管理和用于未来研究。 方法：我们选择了一种混合方法设计，通过获得一个 通过我们的定量分析和对大流行过程的认识， 通过我们的定性分析将VIP转变为远程医疗。我们将利用我们的综合调查结果， 建议，以改善VA如何提供远程护理的VIP向前迈进。 下一步/实施：我们在弗吉尼亚州国家内分泌/糖尿病计划办公室的合作伙伴，弗吉尼亚州 农村卫生办公室和VA互联护理办公室将在我们的整个过程中提供指导和支持。 研究并促进我们的研究结果在VA的快速传播。

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.