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Principal Investigator: Jamie Estock
Organization: VETERANS HEALTH ADMINISTRATION
Fiscal Year: 2024
Funding agency: Veterans Affairs
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.
Terms: <Access to Care><Accounting><Address><Adverse Experience><Adverse effects><Adverse event><Appointment><COVID crisis><COVID epidemic><COVID pandemic><COVID-19 crisis><COVID-19 epidemic><COVID-19 era><COVID-19 global health crisis><COVID-19 global pandemic><COVID-19 health crisis><COVID-19 pandemic><COVID-19 period><COVID-19 public health crisis><COVID-19 years><Caring><Clinic><Clinical><Data><Development and Research><Device Failures><Devices><Diabetes Mellitus><Education><Educational aspects><Endocrinology><Enrollment><Equipment Malfunction><Exclusion><Food and Drug Administration><Glycohemoglobin A><Glycosylated hemoglobin A><Goals><Hb A1><Hb A1a+b><Hb A1c><HbA1><HbA1c><Health Facilities><Health Services Accessibility><Health care facility><Healthcare Facility><Hemoglobin A(1)><Improve Access><Injury><Insulin Infusion Systems><Interview><Joints><Knowledge><Medical Device><Metabolism and Endocrinology><Methodology><Methods><Modeling><Outcome><Patients><Prevention><Process><Provider><QOC><Quality of Care><R & D><R&D><Recommendation><Recovery><Remote management><Reporting><Research><Research Priority><Risk><Rural Community><Rural Health><SARS-CoV-2 epidemic><SARS-CoV-2 global health crisis><SARS-CoV-2 global pandemic><SARS-CoV-2 pandemic><SARS-coronavirus-2 epidemic><SARS-coronavirus-2 pandemic><Sampling><Service delivery model><Service model><Severe Acute Respiratory Syndrome CoV 2 epidemic><Severe Acute Respiratory Syndrome CoV 2 pandemic><Severe acute respiratory syndrome coronavirus 2 epidemic><Severe acute respiratory syndrome coronavirus 2 pandemic><Specialty><Specific qualifier value><Specified><Structure><Technology><Time><USFDA><United States Food and Drug Administration><Veterans><access to health services><access to services><access to treatment><accessibility to health services><adverse event risk><availability of services><care access><care delivery><care delivery model><care facilities><clinical development><connected care><connected health care><connected healthcare><coronavirus disease 2019 crisis><coronavirus disease 2019 epidemic><coronavirus disease 2019 global health crisis><coronavirus disease 2019 global pandemic><coronavirus disease 2019 health crisis><coronavirus disease 2019 pandemic><coronavirus disease 2019 public health crisis><coronavirus disease crisis><coronavirus disease epidemic><coronavirus disease pandemic><coronavirus disease-19 global pandemic><coronavirus disease-19 pandemic><delivered remotely><design><designing><diabetes><enroll><evidence base><experience><health care delivery model><health service access><health services availability><healthcare delivery model><hemoglobin A1c><high risk><improved><injuries><insulin infusion device><insulin infusion pump><insulin pump><interest><medical complication><medical specialties><operation><operations><pandemic><pandemic caused disruption><pandemic containment><pandemic control><pandemic created disruption><pandemic disease><pandemic disruption><pandemic effect><pandemic impact><pandemic induced disruption><pandemic mitigation><pandemic outcome><pandemic related disruption><pandemic repercussions><pandemic response><post-pandemic><programs><remote care><remote delivery><remote health care><remote healthcare><research and development><satisfaction><service availability><severe acute respiratory syndrome coronavirus 2 global health crisis><severe acute respiratory syndrome coronavirus 2 global pandemic><telehealth><tool><treatment access><virtual care><virtual health care><virtual healthcare>