Comparing Patient Satisfaction of Nurse Practitioner-Led Telemedicine and Usual Care Clinics

Approved May 2020 by the faculty of UMKC in partial fulfillment of the requirements for the degree of Doctor of Nursing PracticeThe rural veteran patient cohort is at high-risk for disparities in health care primarily due to geographic isolation and lack of primary care providers. As a result of these challenges, the rural patient is a population of interest to the Department of Veterans Affairs prompting the creation of primary care telemedicine clinics. This model of care was developed to close gaps in health care and has been utilized successfully for many years. Primary care providers are inserted into rural clinics virtually where the need is greatest reducing health care access delays. The primary purpose of this project was to measure Nurse Practitioner-led telemedicine clinic effects on patient satisfaction of care compared with usual face-to-face visits. This project used a quasi experimental design and convenience sampling. The population under study was rural veteran patients enrolling 34 in telemedicine and 68 in usual care patients. The project took place at a midwestern Veterans Integrated Service Network hub office and a rural outpatient clinic spoke site. Participants in both groups were provided the opportunity to complete a satisfaction of care questionnaire at the end of their visit. The primary outcome measurement was overall patient satisfaction of care, and the secondary outcome measurements included other aspects of patient satisfaction. Results found no statistically significant difference between the two groups for the primary or secondary outcomes and no association with the participant population demographics. The integration of telemedicine clinics maintains high patient satisfaction of care compared to usual care

The Use of Routinely Collected Data in Clinical Trial Research

RCTs are the gold standard for assessing the effects of medical interventions, but they also pose many challenges, including the often-high costs in conducting them and a potential lack of generalizability of their findings. The recent increase in the availability of so called routinely collected data (RCD) sources has led to great interest in their application to support RCTs in an effort to increase the efficiency of conducting clinical trials. We define all RCTs augmented by RCD in any form as RCD-RCTs. A major subset of RCD-RCTs are performed at the point of care using electronic health records (EHRs) and are referred to as point-of-care research (POC-R). RCD-RCTs offer several advantages over traditional trials regarding patient recruitment and data collection, and beyond. Using highly standardized EHR and registry data allows to assess patient characteristics for trial eligibility and to examine treatment effects through routinely collected endpoints or by linkage to other data sources like mortality registries. Thus, RCD can be used to augment traditional RCTs by providing a sampling framework for patient recruitment and by directly measuring patient relevant outcomes. The result of these efforts is the generation of real-world evidence (RWE). Nevertheless, the utilization of RCD in clinical research brings novel methodological challenges, and issues related to data quality are frequently discussed, which need to be considered for RCD-RCTs. Some of the limitations surrounding RCD use in RCTs relate to data quality, data availability, ethical and informed consent challenges, and lack of endpoint adjudication which may all lead to uncertainties in the validity of their results. The purpose of this thesis is to help fill the aforementioned research gaps in RCD-RCTs, encompassing tasks such as assessing their current application in clinical research and evaluating the methodological and technical challenges in performing them. Furthermore, it aims to assess the reporting quality of published reports on RCD-RCTs

Evaluating Acceptability, Feasibility and Efficacy of a Diabetes Care Support Program Facilitated by Cellular-Enabled Glucose Meters: A Dissertation

Background. Diabetes requires significant disease management, patient-provider communication, and interaction between patients, family members, caregivers, and care teams. Emerging patient-facing technologies, such as cellular-enabled glucose meters, can facilitate additional care support and improve diabetes self-management. This study evaluated patient acceptability, feasibility, and efficacy of a diabetes care support program facilitated by cellular-enabled glucose meters. Methods. A two-phase study approach was taken. Get In Touch – Phase 1 (GIT-1) was a 1-month pilot involving patients with type 1 and type 2 diabetes. Get In Touch – Phase 2 (GIT-2) was a 12-month randomized controlled crossover trial involving patients with poorly-controlled type 2 diabetes. Results from GIT-1 and preliminary results from GIT-2 are presented. Results. GIT-1 participants with type 1 (n=6) and type 2 (n=10) diabetes reported the intervention and cellular-enabled glucose meter were easy to use and useful while identifying potential areas of improvement. GIT-2 participants in both the intervention (n=60) and control (n=60) groups saw significant improvements in treatment satisfaction and A1c change, with intervention participants experiencing slightly greater improvements in each after 6 months (p=0.09 and p=0.16, respectively) compared to control participants. Conclusions. Patients reported favorable acceptability of the intervention. Preliminary results from a randomized trial demonstrated potential of intervention to improve patient-reported and physiological health outcomes. Future studies should evaluate feasibility and efficacy over a longer period of time, with a greater number of participants, and targeting different populations of patients with diabetes. Provider perspectives and changes in provider behavior, clinical work flow, and caregiver burden should also be assessed

ADVANCING INTERPROFESSIONAL PRIMARY HEALTH CARE SERVICES IN RURAL SETTINGS FOR PEOPLE WITH CHRONIC LOW BACK DISORDERS: A TEAM AND TECHNOLOGY APPROACH

Background Rural Canadians are more likely to have chronic back disorders than their urban counterparts. Their barriers to accessing providers with expertise in chronic back disorder management include: reduced availability of local practitioners and lengthy travel requirements. Joining an urban Physical Therapist (PT) with expertise in chronic back disorders with a rural primary team and patient using telehealth may be an option for this disparity in access. Methods This dissertation includes three studies presented in the following manuscripts: 1) A systematic review examining the use of videoconferencing by PTs for the management of musculoskeletal conditions; 2) A comparison of three different intervention groups: PTalone, Nurse Practitioner alone (NPalone), and NP/PTteam to determine the agreement of the models of care on diagnosis and management decisions; and 3) an examination of the experiences of patients and practitioners involved in a teamand technology model of care for chronic back disorders. Results Gaps in the literature included: few large RCTs and comparative studies, an absence of studies examining interprofessional models of care, no examination of combined telehealth and in-person types of care, and the need for more rigorous study designs to facilitate meta-analysis. The NP/PTteam made similar decisions regarding diagnosis and management for chronic back disorders compared to an in-person PT. This demonstrated that the contribution of PT to the team resulted in the same findings as a PT who examined a patient independently. It is a feasible method of managing chronic back disorders in rural areas, and is met with satisfaction by patients and practitioners. Analysis of semi-structured interviews of patients and practitioners who experienced the team and technology model of care identified the following themes: access to care for chronic back disorders, effective interprofessional practice (team), enhanced clinical care for CBD, and technology. Conclusions A team and technology approach to care is comparable to in-person PT for diagnosis and management decisions in chronic back disorders. This approach can enhance access to care for chronic back disorders in rural areas and result in improved clinical care for rural residents with chronic back disorders

Effectiveness of Telepsychiatry Among Geriatric Participants with Age-Related Hearing Loss

Presbycusis (hearing loss that occurs with age) affects 30% of adults aged 65 to 74, yet hearing loss is rarely considered when developing novel treatment deliveries. For example, research shows that telepsychiatry improves depression symptoms among geriatric patients similarly to traditional forms of therapy, however, there is no literature on effectiveness of telepsychiatry in geriatrics with presbycusis. The objective of this study is to assess whether, compared to face-to-face psychotherapy, telepsychiatry produces superior outcomes assessed by the Beck Depression Inventory II, among depressed geriatric patients suffering from presbycusis. We will conduct a randomized controlled trial among elderly individuals with depressive disorders and presbycusis who will be randomly allocated to 8 weekly, 60-minute manual sessions of Behavioral Activation Therapy for Depression either in the clinic or in the participants’ home, using telepsychiatry. This study will help guide future therapies directed towards the growing geriatric population, many of whom suffer from presbycusis

Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.Fil: Beratarrechea, Andrea Gabriela. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Diez Canseco, Francisco. Universidad Peruana Cayetano Heredia; PerúFil: Irazola, Vilma. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Miranda, Jaime. Universidad Peruana Cayetano Heredia; PerúFil: Ramirez Zea, Manuel. Institute of Nutrition of Central America and Panama; GuatemalaFil: Rubinstein, Adolfo Luis. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Telehealth and Type 2 Diabetes Management

The use of telehealth in healthcare has grown in recent years; however, little is known about the effectiveness of this delivery method in the management of Type 2 diabetes mellitus (T2DM). Guided by the chronic care model and telehealth in chronic disease model, the purpose of this systematic literature review was to explore evidence related to lowering hemoglobin A1c levels and managing T2DM using telehealth in the outpatient setting. The practice-focused questions explored telehealth interventions used in T2DM management and their effectiveness. The Joanna Briggs Institute (JBI) method for conducting systematic literature reviews was the process, and data were compiled using the PRISMA evidence-based minimum set for reporting. Eighteen studies met the inclusion criteria for this project. Data were extracted, analyzed, and synthesized using JBI tools for data extraction and critical appraisal. Article appraisals revealed numerous telehealth interventions for management of T2DM including telephone, Internet-based, clinical video, remote monitoring, and smart phones/applications. Overall, telehealth interventions showed statistically significant improvement in the hemoglobin A1c levels of participants compared to traditional outpatient care. Success of the interventions is associated with components of evidenced-based diabetes management such as education, self-management, support, and feedback loop. The implications of this project for positive social change include the integration of telehealth interventions in the outpatient setting to manage T2DM with enhanced access to care, reduction in health disparities, and improved health outcomes for society

Impact of web-based cognitive behavioral therapy for insomnia on stress, health, mood, cognitive, inflammatory, and neurodegenerative outcomes in rural dementia caregivers: Protocol for the NiteCAPP CARES and NiteCAPP SHARES randomized controlled trial

BACKGROUND: Chronic insomnia affects up to 63% of family dementia caregivers. Research suggests that chronic insomnia prompts changes in central stress processing that have downstream negative effects on health and mood, as well as on cognitive, inflammatory, and neurodegenerative functioning. We hypothesize that cognitive behavioral therapy for insomnia (CBT-I) will reverse those downstream effects by improving insomnia and restoring healthy central stress processing. Rural caregivers are particularly vulnerable, but they have limited access to CBT-I; therefore, we developed an accessible digital version using community input (NiteCAPP CARES). OBJECTIVE: This trial will evaluate the acceptability, feasibility, and short-term and long-term effects of NiteCAPP CARES on the sleep and stress mechanisms underlying poor caregiver health and functioning. METHODS: Dyads (n=100) consisting of caregivers with chronic insomnia and their coresiding persons with dementia will be recruited from Columbia and surrounding areas in Missouri, United States. Participant dyads will be randomized to 4 weeks (plus 4 bimonthly booster sessions) of NiteCAPP CARES or a web-based sleep hygiene control (NiteCAPP SHARES). Participants will be assessed at baseline, after treatment, and 6- and 12-month follow-ups. The following assessments will be completed by caregivers: 1 week of actigraphy and daily diaries measuring sleep, Insomnia Severity Index, arousal (heart rate variability), inflammation (blood-derived biomarkers: interleukin-6 and C-reactive protein), neurodegeneration (blood-derived biomarkers: plasma amyloid beta [Aβ40 and Aβ42], total tau, and phosphorylated tau [p-tau181 and p-tau217]), cognition (Joggle battery, NIH Toolbox for Assessment of Neurological and Behavioral Function, and Cognitive Failures Questionnaire), stress and burden, health, and mood (depression and anxiety). Persons with dementia will complete 1 week of actigraphy at each time point. RESULTS: Recruitment procedures started in February 2022. All data are expected to be collected by 2026. Full trial results are planned to be published by 2027. Secondary analyses of baseline data will be subsequently published. CONCLUSIONS: This randomized controlled trial tests NiteCAPP CARES, a web-based CBT-I for rural caregivers. The knowledge obtained will address not only what outcomes improve but also how and why they improve and for how long, which will help us to modify NiteCAPP CARES to optimize treatment potency and support future pragmatic testing and dissemination. TRIAL REGISTRATION: ClinicalTrials.gov NCT04896775; https://clinicaltrials.gov/ct2/show/NCT04896775. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37874

Investigating the behavioural effects of a mobile-phone based home telehealth intervention in people with insulin-requiring diabetes: Results of a randomized controlled trial with patient interviews

INTRODUCTION: Evidence supporting home telehealth effects on clinical outcomes in diabetes is available, yet mechanisms of action for these improvements remain poorly understood. Behavioural change is one plausible explanation. This study investigated the behavioural effects of a mobile-phone based home telehealth (MTH) intervention in people with diabetes. It was hypothesized that MTH would improve self-efficacy, illness beliefs, and diabetes self-care. METHODS: A randomized controlled trial compared standard care to standard care supplemented with MTH (self-monitoring, data transmission, graphical and nurse-initiated feedback, educational calls). Self-report measures of self-efficacy, illness beliefs, and self-care were repeated at baseline, three months, and nine months. MTH effects were based on the group by time interactions in hierarchical linear models and effect sizes with 95% confidence intervals (CIs). Interviews with MTH participants explored the perceived effects of MTH on diabetes self-management. RESULTS: Eighty-one participants were randomized to the intervention (n = 45) and standard care (n = 36). Significant group by time effects were observed for five out of seven self-efficacy subscales. Effect sizes were large, particularly at nine months. Interaction effects for illness beliefs and self-care were non-significant, but effect sizes and confidence intervals suggested MTH may positively affect diet and exercise. In interviews, MTH was associated with increased awareness, motivation, and a greater sense of security. Improved self-monitoring and diet were reported by some participants. DISCUSSION: MTH empowers people with diabetes to manage their condition and may influence self-care. Future MTH research would benefit from investigating behavioural mechanisms and determining patient profiles predictive of greater behavioural effectiveness