title: Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial.
abstract: Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems. In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus (PPDM) despite clinic-based care, we evaluated a comprehensive telemedicine intervention that we specifically designed for delivery using existing Veterans Health Administration (VHA) clinical staffing and equipment.
  
  
  
  We conducted a 6-month randomized trial among 50 veterans with PPDM; all maintained hemoglobin A1c (HbA1c) levels continuously >9.0% for >1 year despite clinic-based management. Participants received usual care or a telemedicine intervention combining telemonitoring, medication management, self-management support, and depression management; existing VHA clinical staff delivered the intervention. Using linear mixed models, we examined HbA1c, diabetes self-care (measured by the Self-Care Inventory-Revised questionnaire), depression, and blood pressure.
  
  
  
  At baseline, the model-estimated common HbA1c intercept was 10.5%. By 6 months, estimated HbA1c had improved by 1.3% for intervention participants and 0.3% for usual care (estimated difference, -1.0%, 95% confidence interval [CI], -2.0%, 0.0%; p = 0.050). Intervention participants' diabetes self-care (estimated difference, 7.0; 95% CI, 0.1, 14.0; p = 0.047), systolic blood pressure (-7.7 mm Hg; 95% CI, -14.8, -0.6; p = 0.035), and diastolic blood pressure (-5.6 mm Hg; 95% CI, -9.9, -1.2; p = 0.013) were improved versus usual care by 6 months. Depressive symptoms were similar between groups.
  
  
  
  A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care. Because we specifically designed this intervention with scalability in mind, it may represent a practical, real-world strategy to reduce the burden of poor diabetes control among veterans.
authors.affiliation: 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.|2 Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Duke University , Durham, North Carolina.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Crowley
authors.affiliation: 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.|3 Division of General Internal Medicine, Department of Medicine, Duke University , Durham, North Carolina.
authors.forename: David
authors.initials: D
authors.lastname: Edelman
authors.affiliation: 4 Home Telehealth Program, Durham Veterans Affairs Medical Center , Durham, North Carolina.
authors.forename: Ann T
authors.initials: AT
authors.lastname: McAndrew
authors.affiliation: 4 Home Telehealth Program, Durham Veterans Affairs Medical Center , Durham, North Carolina.
authors.forename: Susan
authors.initials: S
authors.lastname: Kistler
authors.affiliation: 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.
authors.forename: Susanne
authors.initials: S
authors.lastname: Danus
authors.affiliation: 3 Division of General Internal Medicine, Department of Medicine, Duke University , Durham, North Carolina.|5 Department of Psychiatry and Behavioral Medicine, Duke University , Durham, North Carolina.|6 Mental Health Service, Durham Veterans Affairs Medical Center , Durham, North Carolina.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Webb
authors.affiliation: 3 Division of General Internal Medicine, Department of Medicine, Duke University , Durham, North Carolina.|5 Department of Psychiatry and Behavioral Medicine, Duke University , Durham, North Carolina.|6 Mental Health Service, Durham Veterans Affairs Medical Center , Durham, North Carolina.
authors.forename: Joseph
authors.initials: J
authors.lastname: Zanga
authors.affiliation: 3 Division of General Internal Medicine, Department of Medicine, Duke University , Durham, North Carolina.
authors.forename: Linda L
authors.initials: LL
authors.lastname: Sanders
authors.affiliation: 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.|7 Department of Biostatistics and Bioinformatics, Duke University Medical Center , Durham, North Carolina.
authors.forename: Cynthia J
authors.initials: CJ
authors.lastname: Coffman
authors.affiliation: 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.|3 Division of General Internal Medicine, Department of Medicine, Duke University , Durham, North Carolina.
authors.forename: George L
authors.initials: GL
authors.lastname: Jackson
authors.affiliation: 1 Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center , Durham, North Carolina.|3 Division of General Internal Medicine, Department of Medicine, Duke University , Durham, North Carolina.
authors.forename: Hayden B
authors.initials: HB
authors.lastname: Bosworth
mesh_terms: D000368:Aged; D015190:Blood Glucose Self-Monitoring; D001794:Blood Pressure; D003863:Depression / Q000453:epidemiology / Q000628:therapy; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology / Q000628:therapy*; D019468:Disease Management; D005260:Female; D006442:Glycated Hemoglobin; D006801:Humans; D008297:Male; D054539:Medication Therapy Management / Q000458:organization & administration; D008875:Middle Aged; D064872:Patient Care Bundles / Q000379:methods; D010865:Pilot Projects; D012648:Self Care / Q000379:methods*; D017216:Telemedicine / Q000379:methods*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans
chemical_list: D006442:Glycated Hemoglobin
keywords: e-health; home health monitoring; telehealth; telemedicine