Expanding Technology-Enabled, Nurse-Delivered Chronic Disease Care : A Pragmatic, Randomized, Effectiveness-Implementation Trial.

BACKGROUND: Comprehensive telehealth is used effectively for treatment-resistant chronic diseases in certain integrated health systems but has seldom been implemented in systems that provide mainly fee-for-service (FFS) care. OBJECTIVE: To examine the effectiveness and implementation of comprehensive telehealth delivered in an FFS environment for patients with uncontrolled type 2 diabetes (T2D) and comorbid hypertension. DESIGN: Pragmatic, randomized, effectiveness-implementation trial. (ClinicalTrials.gov: NCT05120544). SETTING: 6 academic primary care or endocrinology clinics. PARTICIPANTS: Participants had both T2D with hemoglobin A1c (HbA1c) persistently at 8.0% or higher for at least 6 months and hypertension with at least 1 systolic blood pressure (BP) above 140 mm Hg or diastolic BP above 90 mm Hg in the past year. INTERVENTION: Two 12-month, mobile monitoring-enabled interventions: a self-monitoring control program and a nurse-delivered, comprehensive telehealth program incorporating self-management support and medication management. MEASUREMENTS: Primary (HbA1c) and secondary outcomes were evaluated at 12 months. Implementation analyses evaluated fidelity and barriers to intervention delivery. RESULTS: Participants were 64% female and 68% Black. The mean age was 54.5 years, mean HbA1c 9.8%, and mean BP 135/81 mm Hg. The estimated mean change in HbA1c from 0 to 12 months was -0.7 percentage points with self-monitoring and -1.1 percentage points with comprehensive telehealth; the estimated mean between-group difference in HbA1c change at 12 months was -0.4 percentage points (95% CI, -1.0 to 0.3 percentage points). Between-group differences in change in secondary outcomes did not reach statistical significance, except for diabetes self-care (0.4 [CI, 0.0 to 0.9], favoring comprehensive telehealth). The comprehensive program was delivered with suboptimal fidelity (median encounters per participant, 9; fidelity threshold, ≥12); analyses identified barriers to program delivery. LIMITATION: Generalizability to dissimilar populations and systems lacking telehealth infrastructure may be limited. CONCLUSION: Comprehensive telehealth did not substantially lower HbA1c relative to control in this study. Population factors, intervention and control program design, and barriers to FFS implementation of comprehensive telehealth may have contributed to these findings. PRIMARY FUNDING SOURCE: National Institute of Nursing Research and Duke Clinical & Translational Science Institute.

Duke Scholars

Author Ranee Chatterjee Medicine, General Internal Medicine

Author Matthew Janik Crowley Medicine, Endocrinology, Metabolism, and Nutrition

Author Allison A. Lewinski School of Nursing

Author Qing Yang School of Nursing

Author Anushka Palipana  

Author Jashalynn German Medicine, Endocrinology, Metabolism, and Nutrition

Author Hayden Barry Bosworth Population Health Sciences

Author Brystana G. Kaufman Population Health Sciences

Author Ryan Shaw School of Nursing