Patient perceptions of a comprehensive telemedicine intervention to address persistent poorly controlled diabetes

Figures & data

Table 1 ACDC patient interview guide

Opening questions:

• How do you think your general health has changed since beginning the ACDC program? How has your ability to manage your diabetes changed?

• How was the program for you?

○ In what ways was it helpful?

○ In what ways was it not helpful?

ACDC home telehealth nurse interaction:

The telehealth nurse called you at least once every other week to discuss your blood sugars, which we asked you to check at home and send into the VA by telephone.

• What did you think about these calls? Were they helpful or not?

• How did you feel about the frequency of these calls? Were they too often? Not often enough?

• How did you feel about how long these calls took? Were they too long? Too short?

Blood glucose self-monitoring:

Now let us talk a bit about home blood sugar monitoring.

• What was it like for you to measure your blood sugar at home?

• Was there anything difficult about measuring your blood sugars? If so, what?

• Tell me about any changes you have made as the result of measuring your blood sugar at home.

○ How did it affect your diet?

○ How did it affect your exercise habits?

○ How did it affect the way you take your medications?

○ What other ways did checking your blood sugar levels at home influence your life?

• In the future, how likely would you be to continue monitoring and transmitting blood sugar readings from home if you had the chance? Tell me more about that.

• What would make it easier for you to check and transmit your home blood sugar readings?

• How does at-home blood sugar reading fit with your regular VA care?

○ Do you feel that transmitting your home blood sugar readings replaced some of your clinic visits or do you feel that this is an additional piece of your VA care? Tell me more about that.

ACDC diabetes medication management intervention:

The telehealth nurse also called you to give you information about changes to your diabetes medications recommended by our study doctor.

• How did you feel about having your insulin or other medication adjusted by phone?

• How did this affect the way you take your insulin and other medications?

• What did you do with the recommendations? Did you accept them or not? Tell me more.

• How has this affected your relationship with your primary provider?

ACDC self-care behavior support intervention:

The telehealth nurse also reviewed with you lots of information about how to best take care of your diabetes.

• What do you think about the information the nurse shared with you? Did you find it helpful or not? In what ways?

• How did this information affect the way you monitor your sugar, take your insulin, and follow recommendations about diet and exercise?

• What did you do with the recommendations? Did you accept them or not? Tell me more.

• How has this affected your relationship with your primary provider?

Closing questions:

• If we could do anything to change the program we offered you to make it better meet your needs, what would that be?

• Is there anything that you would like to mention that I did not ask about?

Abbreviations: ACDC, Advanced Comprehensive Diabetes Care; VA, Veterans Affairs.

Table 2 ACDC home telehealth nurse interview guide

Opening questions:

• In your opinion, what was the most useful part of the program?

• What was challenging?

Patient interaction:

At least once every other week, you spoke with intervention patients by phone to discuss their blood sugars and evaluate medication adherence.

• How receptive were patients to the idea of monitoring their blood sugars and reporting them by phone? Can you tell me more about this?

• How did you feel about the frequency of these calls? Were they too often? Not often enough?

• How did you feel about how long these calls took? Were they too long? Too short?

• What worked well about your interactions with patients with respect to blood sugar monitoring? What did not work well?

• How did patients respond to the recommended blood sugar monitoring? Were they generally adherent or not? Tell me more.

• What do you think are the biggest barriers to adherence to the recommended blood sugar monitoring in this study?

• How was it to assess patients’ adherence to their medications during these calls? Do you think that you were able to do this accurately? Tell me more.

• What would you change or improve about the ACDC intervention with respect to blood sugar monitoring and medication adherence evaluation?

ACDC diabetes medication management:

At times, you were asked to relay recommendations regarding diabetes medication adjustments from the study physician to patients.

• How receptive were patients to having their diabetes medications adjusted by phone? Did patients accept the recommendations?

• How long did the process of relaying medication adjustment recommendations take? How could this process be improved?

• What kinds of questions did patients have? How was it for you to answer these?

• How did patients feel about how phone-based medication adjustment might affect their relationship with their primary provider?

• What would you change or improve about the ACDC intervention with respect to the process of diabetes medication adjustment?

ACDC self-care behavior support:

You also reviewed information with patients regarding diabetes self-care support.

• How receptive were patients to information regarding diabetes self-care by phone? Did patients accept the recommendations?

• How long did the process of relaying information regarding diabetes self-care take? Was this too long?

• What kinds of questions did patients have? How was it for you to answer these?

• What conversations did you have with patients about how this part of the intervention might affect their relationship with their primary provider?

Did they seem concerned? Tell me more.

• What would you change or improve about the ACDC intervention with respect to the process of diabetes self-care support?

Provider interaction:

• In general, what was it like to interact with the study physician and study psychiatrist?

○ How did the process whereby you conveyed data to the study providers and received recommendations for medication changes work?

○ How available were the study providers for dialog with you when necessary?

○ Did you have questions about the rationale behind providers’ recommendations? Or did you understand the rationale? Tell me more.

○ Did you generally agree with the recommendations? Tell me more.

• How did these interactions generally take place?

○ Was there one modality (phone, email, etc) that you used most commonly?

○ Was there one that worked the best?

• What would you change or improve about the ACDC intervention with respect to the process of interacting with study providers?

Closing questions:

• If we could do anything else to change the ACDC intervention to make it work better, what would that be?

• Is there anything that you would like to mention that I did not ask about?

Abbreviation: ACDC, Advanced Comprehensive Diabetes Care.

Table 3 Derivation of codes applied to ACDC patient interviews

Code grouping	Code	Code origin
Patient characteristics	• Attitude toward provider	Data derived (all)
	• Balancing multiple chronic conditions
	• Being motivated to change
	• Claiming baseline knowledge
	• Dealing with depression
	• Dealing with stress
	• Handling competing demands
	• Has consulted with a dietitian
	• Having memory issues
	• Recognizing disease severity
	• Wanting more information
	• Willingness to accept recommendations
Program structure	• Automated telemonitoring interface	A priori (all)
	• Integrating with current care
	• Medication management
	• Self-monitoring and recording blood glucose
	• HT nurse encounters
	○ Call duration
	○ Call frequency
Program value	• Acquiring new knowledge	Data derived (except “likelihood of continuing to check and transmit blood glucose,” which was a priori)
	• Applying prior knowledge
	• Becoming more mindful
	• Changing diet/exercise
	• Desiring alternate platform for SMBG
	• Establishing a routine
	• Frustrated with interface
	• Getting support from intervention
	• Having accountability
	• Having increased access to diabetes care/supplies
	• Improving medication adherence
	• Likelihood of continuing to check and transmit blood glucose
	• Monitoring more frequently
	• Seeing results

Note: A priori represents deductive codes based on program structure.

Abbreviations: ACDC, Advanced Comprehensive Diabetes Care; HT, home telehealth; SMBG, self-monitored blood glucose.