Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial.

BACKGROUND: Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems. In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus (PPDM) despite clinic-based care, we evaluated a comprehensive telemedicine intervention that we specifically designed for delivery using existing Veterans Health Administration (VHA) clinical staffing and equipment. MATERIALS AND METHODS: We conducted a 6-month randomized trial among 50 veterans with PPDM; all maintained hemoglobin A1c (HbA1c) levels continuously >9.0% for >1 year despite clinic-based management. Participants received usual care or a telemedicine intervention combining telemonitoring, medication management, self-management support, and depression management; existing VHA clinical staff delivered the intervention. Using linear mixed models, we examined HbA1c, diabetes self-care (measured by the Self-Care Inventory-Revised questionnaire), depression, and blood pressure. RESULTS: At baseline, the model-estimated common HbA1c intercept was 10.5%. By 6 months, estimated HbA1c had improved by 1.3% for intervention participants and 0.3% for usual care (estimated difference, -1.0%, 95% confidence interval [CI], -2.0%, 0.0%; p = 0.050). Intervention participants' diabetes self-care (estimated difference, 7.0; 95% CI, 0.1, 14.0; p = 0.047), systolic blood pressure (-7.7 mm Hg; 95% CI, -14.8, -0.6; p = 0.035), and diastolic blood pressure (-5.6 mm Hg; 95% CI, -9.9, -1.2; p = 0.013) were improved versus usual care by 6 months. Depressive symptoms were similar between groups. CONCLUSIONS: A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care. Because we specifically designed this intervention with scalability in mind, it may represent a practical, real-world strategy to reduce the burden of poor diabetes control among veterans.

Training psychiatry residents in quality improvement: an integrated, year-long curriculum.

OBJECTIVE The authors describe a curriculum for psychiatry residents in Quality Improvement (QI) methodology. METHODS All PGY3 residents (N=12) participated in a QI curriculum that included a year-long group project. Knowledge and attitudes were assessed before and after the curriculum, using a modified Quality Improvement Knowledge Assessment Tool (QIKAT) and a QI Self-Assessment survey. RESULTS QIKAT scores were significantly higher for residents after participating in the curriculum when compared with pretest scores. Self-efficacy ratings in QI improved after the course for each item. Residents demonstrated gains in QI skills through participation in the group projects in which they increased rates of depression-screening and monitoring in an outpatient clinic. CONCLUSIONS Combining didactic and experiential learning can be an effective means for training psychiatry residents in QI.

A curriculum in measurement-based care: screening and monitoring of depression in a psychiatric resident clinic.

OBJECTIVE: The goal of this curriculum was to train residents in measurement-based care (MBC). METHOD: Third-year psychiatry residents were educated in MBC through didactic seminars and a quality-improvement (QI) initiative with the goal of implementing the Patient Health Questionnaire Depression Scale (PHQ-9) to screen and monitor patients for symptoms of depression. RESULTS: Residents suggested strategies for integrating the PHQ-9 into the clinic. Over the first 6 months, residents showed an increase in rate of depression screening from 4% to 92% of patients. Also, they increased monthly monitoring of outpatients with a diagnosis of depression from 1% to 76%. Residents who used the PHQ-9 to monitor patients with depression were significantly more likely to use additional standardized assessments. CONCLUSIONS: Combining an educational intervention with QI strategies can significantly affect residents' use of standardized assessments in an outpatient setting. Using standardized measures allows residents to assess their own clinical effectiveness, an emerging priority in training.