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.
Diabetes generates significant morbidity, mortality, and costs within VA. Veterans with persistent poor diabetes control despite standard care are the highest-risk diabetes patients in the VA system, and likely contribute disproportionately to complications and costs. An intervention targeting these refractory Veterans is needed, but the optimal diabetes management content and preferred delivery strategy for such an intervention are unknown. The proposed career development award program of research will address these knowledge gaps and generate a novel, patient-centered intervention to improve the management of Veterans with persistent poor diabetes control. This intervention will effectively lower hemoglobin A1c among Veterans with persistent poorly-controlled diabetes, thereby reducing their likelihood of developing complications and costs. Further, as it will be based on rigorous quantitative and qualitative research, this intervention will be amenable to eventual implementation and dissemination throughout the VA system, so will reduce the wider burden of diabetes.
