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Principal Investigator: Stephanie Leah Shimada
Organization: EDITH NOURSE ROGERS MEMORIAL VETERANS HOSPITAL
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: Type 2 Diabetes, a common, complex condition with high comorbidity, affects 24% of Veterans.
Vulnerable Veterans (e.g., African-American, rural, comorbid mental health diagnosis, low-income) are less
likely to have controlled diabetes, and have higher mortality and morbidity compared to other Veterans.
Significance/Impact: Health Care Informatics interventions to support chronic disease self-management
through technology can improve access, health equity, and health outcomes for vulnerable Veterans.
Customizable, interactive self-management support through Annie addresses the VA's priority of improving
access, including via virtual modalities, and providing a tailored experience that incorporates Veteran needs and
preferences (VA Strategic Imperative 2). Research priority areas of access to care, women's health, mental
health, primary care practice, informatics, virtual care, health equity, and patient-centered care are all addressed.
Innovation: By incorporating the needs and preferences of vulnerable Veterans with diabetes in a self-
management texting intervention and testing its effectiveness against a more traditional education-only
intervention, lessons learned can improve the development of text-based support for other complex chronic
conditions. It can also improve future implementation of Annie-based self-management support throughout VA.
Specific Aims: AIM 1: Refine and beta test components of an interactive, tailored self-management texting
protocol (DD-TXT) using a participatory design process incorporating vulnerable Veterans' preferences, VA
clinician input, and evidence on effective texting-enabled self-management programs. The DD-TXT protocol will
consist of: Core Messaging: Customizable core modules on medication management, blood sugar and blood
pressure monitoring, preventive care, problem solving, appointment reminders, administrative messages; and
Optional Messaging: A library of patient-selected modules (e.g. nutrition, physical activity, weight management,
emotional coping, goal setting) designed to motivate and educate.
AIM 2: Conduct a randomized controlled comparative effectiveness trial with 400 Veterans whose diabetes
was uncontrolled (defined as HbA1c over 8.0% for at least 50% of the most recent 6 months) in 2018 in
Gainesville, FL or Chicago, IL. The primary aim will be to assess the comparative effectiveness of DD-TXT
compared to DSE, a diabetes skills education-only texting protocol based on a skills workbook that is currently
given to VA patients with diabetes. The primary outcome will be HbA1c percent time in control. Secondary
outcomes include self-reported adherence to diabetes self-care recommendations (SCI-R), diabetes self-
efficacy, diabetes distress, LDL, and blood pressure control. We hypothesize that DD-TXT will result in better
proximal health outcomes and diabetes self-management behaviors vs an education-only protocol (DSE).
AIM 3: Obtain information to guide future implementation of diabetes self-management support through texting
by (a) gathering and analyzing qualitative feedback from patients engaged in the comparative effectiveness
trial, overall and by subgroup (b) collecting qualitative feedback from providers and key stakeholders on the
barriers/facilitators of future RCT evaluation and implementation of DD-TXT vs DSE, (c) conducting a cost-
identification analysis and safety analysis to identify resources required for larger-scale implementation.
Methodology: We will refine the DD-TXT protocol through a participatory design process, conduct a
randomized controlled comparative effectiveness trial with 400 Veterans with uncontrolled diabetes, and collect
qualitative feedback from patients, providers, and other stakeholders and conduct a cost-identification analysis
to guide future implementation.
Next Steps/Implementation: This project will inform future processes for incorporating Veteran input into
Annie protocol development and lead to a future Type 2 hybrid implementation trial of DD-TXT or DSE (based
on our findings) to determine best implementation strategies for Annie-based self-management support.
Terms: <Access to Care><Address><Adherence><Adult-Onset Diabetes Mellitus><Affect><African American><Afro American><Afroamerican><Analgesic Management><Appointment><Area><BP control><BP management><Behavior><Blood Glucose><Blood Pressure Monitors><Blood Sugar><Cell Phone><Cellular Phone><Cellular Telephone><Chicago><Chronic Disease><Chronic Illness><Complex><Continuous Sphygmomanometers><Data><Development><Diabetes Mellitus><Diagnosis><Disease><Disorder><Disparities><Disparity><Drugs><Education><Educational aspects><Effectiveness><Emotional><Evaluation><Feedback><Female Health><Future><General Population><General Public><Glycohemoglobin A><Glycosylated hemoglobin A><Goals><Guidelines><Hb A1><Hb A1a+b><Hb A1c><HbA1><HbA1c><Health><Health Care Costs><Health Costs><Health Expenditures><Health Services Accessibility><Healthcare><Healthcare Costs><Heart><Hemoglobin A(1)><Heterogeneity><Hybrids><Improve Access><Informatics><Intervention><Intervention Strategies><Ketosis-Resistant Diabetes Mellitus><LDL><LDL Lipoproteins><Lead><Libraries><Logic><Low income><Low-Density Lipoproteins><Maturity-Onset Diabetes Mellitus><Medication><Medication Management><Medicine><Mental Health><Mental Hygiene><Methodology><Minority><Mobile Phones><Modality><Monitor><Morbidity><Morbidity - 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