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 由于护理的复杂性和不良事件的风险而被排除在退伍军人管理局远程医疗计划之外 (Aes)。退伍军人远程保健计划中缺乏VIP注册导致了对最佳医疗保健知识的差距 远程胰岛素泵管理的做法，使与大流行有关的护理中断特别困难 对这些退伍军人来说风险也更大。将所有退伍军人切换到远程医疗以进行非紧急护理的紧迫性 大流行导致VIP和提供者需要适应新的护理流程，并迅速“ 共同“数据共享技术，以克服障碍并维持安全和有效的护理。目标是 这项研究的目的是解决远程胰岛素泵管理最佳实践的知识差距，以 减轻持续大流行对高危贵宾的不利影响。这项研究的长期目标是 为安全有效的远程胰岛素泵管理建立循证远程保健计划 改善贵宾获得远程护理的机会，满足日益增长的胰岛素泵治疗需求。 意义：这项研究将为远程胰岛素的远程医疗过程和工具的发展提供信息 水泵管理将：(1)使生活在农村社区的弱势退伍军人和其他退伍军人受益 面临准入挑战，(2)扩大糖尿病退伍军人的护理选择，他们可能是 胰岛素泵治疗，但无法获得VA专科护理，以及(3)增强VIP连接能力 他们的关怀团队负责对意外设备故障进行关键实时故障排除并预防AE。 扩大退伍军人获得远程胰岛素泵管理的机会可确保持续的高质量护理和 为贵宾建立联系，并支持退伍军人管理局改善退伍军人获得医疗服务的临床和立法目标。 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。使用纵向观察性设计，我们将检查VIP的护理过程和临床 从大流行爆发前1.5年开始的3年期间的结果。我们将使用混合 比较大流行前和大流行期间结果的效应和COX回归模型 对于可能影响感兴趣的结果的实践、提供者和患者水平的协变量。 2.检查贵宾和供应商对胰岛素泵管理的经验和满意度 以及在新冠肺炎大流行期间，找出安全有效的障碍和促进者 远程护理。我们将对VIP和供应商进行结构化访谈，并应用快速定性 胰岛素泵实施前、中管理经验及满意度分析 新冠肺炎大流行，并找出安全有效远程护理的障碍和促进者。 3.制定建议，以改进远程医疗流程和工具，实现安全有效的远程医疗 胰岛素泵管理。我们将通过联合展示整合AIMS 1和AIMS 2的调查结果 与退伍军人管理局专家咨询小组和VIP代表一起审查它们，以生成以下建议 立即改进远程胰岛素泵管理并用于未来的研究。 方法：我们选择了一种混合方法设计，通过获得一个 通过我们的量化分析和对大流行进程的感觉来说明与大流行有关的结果 通过我们的定性分析将VIP过渡到远程医疗。我们将使用我们的综合调查结果来生成 改进退伍军人管理局如何向未来的VIP提供远程护理的建议。 下一步/实施：我们在弗吉尼亚州国家内分泌学/糖尿病项目办公室的合作伙伴 农村卫生办公室和退伍军人事务部互联医疗办公室将在我们的 研究并促进我们的研究成果在退伍军人事务部迅速传播。

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.