TBM
ORIGINAL RESEARCH
Telehealth delivery of the diabetes prevention program to rural communities Liane M. Vadheim, RD, LN, CDE,1 Katherine Patch, ATC, LAT, MS, NRP,1 Sarah M. Brokaw, MPH,2 Dorota Carpenedo, MPH,2 Marcene K. Butcher, RD, CDE,2 Steven D. Helgerson, MD, MPH,2 Todd S. Harwell, MPH2 1 Holy Rosary Healthcare, Miles City, MT, USA 2 Montana Department of Public Health and Human Services, Cogswell Building, B-201, PO Box 202951, Helena, MT 59620-2951, USA Correspondence to: T Harwell [email protected]
Cite this as: TBM 2017;7:364–370 doi: 10.1007/s13142-017-0496-y #Society of Behavioral Medicine 2017
Abstract The Centers for Disease Control and Prevention, State and Local Health Departments, and other organizations in the USA are working to increase population access to the Diabetes Prevention Program (DPP) lifestyle intervention. Delivering the DPP through telehealth videoconference may increase access to this intervention, particularly in rural communities. The purpose of this study was to compare participation, monitoring of diet and physical activity, and weight loss in participants receiving the intervention on-site and those participating virtually through telehealth. Beginning in 2008, Holy Rosary Healthcare collaborated with the Montana Department of Public Health and Human Services to provide the DPP to participants on-site in one community and simultaneously through telehealth to participants in multiple other communities. From 2008 through 2015, 894 participants were enrolled in the program (29% at telehealth sites). The mean age of participants was 51.7 years and 84% were female. Overall, participants attended 14.4, 3.9, and 15.0 weekly core, post-core, and total sessions, respectively. There were no statistically significant differences in number of intervention sessions attended by the telehealth or on-site participants. There were no statistically significant differences in the mean weight loss or reduction in BMI between the telehealth and the on-site groups. There also were no statistically significant differences in the percentage of telehealth or on-site participants who achieved ≥5% weight loss (56 vs. 57%) or the 7% weight loss goal (38 vs. 41%). Our findings suggest that participants receiving the DPP through telehealth have similar rates of participation and achieve similar weight loss as participants attending the program on-site. Keywords
Type 2 diabetes mellitus, Prediabetes, Prevention, Lifestyle intervention, Telehealth, Videoconferencing, Rural, DPP translation, Montana INTRODUCTION The prevalence of type 2 diabetes among adults in the USA has doubled from less than 4% in 1980 to over 8% in 2014 and more than 29 million US adults have diagnosed or undiagnosed diabetes [1]. The prevalence of page 286 of 291
Implications Policy: Delivery of the DPP lifestyle intervention through telehealth may allow a larger number of persons to participate, may increase geographic access to this service, and may reduce the per participant cost and thus improve the cost effectiveness of the intervention. Research: Additional research is necessary to confirm this study’s findings that virtual, synchronous participation in the DPP via telehealth is similarly effective to in-person participation with respect to different demographic groups. Utilizing telehealth can also reduce barriers to accessing the diabetes prevention program lifestyle intervention in remote rural communities, which often do not have the capacity to establish lifestyle intervention programs or the health professional workforce. Practice: Telehealth may also be utilized to deliver the lifestyle intervention to multiple sites simultaneously both in rural and non-rural areas.
prediabetes among adults in the USA, a group at highrisk for developing type 2 diabetes, has increased from 29.2% in 1999–2002 to 38.0% in 2011–2012 [2]. Randomized controlled clinical trials including the Da Qing Diabetes Prevention Study, Finnish Diabetes Prevention Study, and the National Institutes of Health’s (NIH) Diabetes Prevention Program (DPP) demonstrated that the incidence of type 2 diabetes mellitus among adults at high risk can be significantly reduced through an intensive lifestyle intervention [3, 4]. The lifestyle interventions in these studies were delivered one-on-one to participants [3, 4]. It was demonstrated by the DPP that participants in the lifestyle intervention group reduced their risk for developing type 2 diabetes by 58 and 34% when compared to the placebo group at 3 and 10 years, respectively [4, 5]. In addition to these randomized clinical trials, multiple translation studies with group-based TBM
ORIGINAL RESEARCH
interventions have demonstrated clinically meaningful weight and cardiometabolic health improvements among participants [6]. Currently in the USA, the Centers for Disease Control and Prevention (CDC), State and Local Health Departments, and other organizations are working to increase access to this evidence-based lifestyle intervention through the establishment of a trained workforce and intervention sites to provide this prevention service [7, 8]. Delivering the DPP lifestyle intervention through telehealth video conferencing can increase the number of persons receiving this intervention, reduce the overall cost per participant, and reach remote rural communities where residents might not otherwise be able to access these services. In 2009, we implemented a small pilot study (N = 27) to test the feasibility to deliver the DPP via telehealth to rural communities. We found that participation rates and weight loss were similar between telehealth and on-site participants [9]. Since 2009, Holy Rosary Healthcare in collaboration with the Montana Department of Public Health and Human Services (DPHHS) has continued to enroll adults at high-risk for type 2 diabetes in the DPP both on-site in Miles City and in seven surrounding frontier communities through telehealth. The objective of this study was to evaluate participation adherence, self-monitoring behaviors, and weight loss among a larger cohort of participants receiving the lifestyle intervention on-site compared to those receiving the intervention via telehealth.
METHODS Setting Holy Rosary Healthcare in Miles City, Montana, in collaboration with the Montana DPHHS began providing the DPP lifestyle intervention on-site beginning in 2008 and to surrounding remote frontier communities through telehealth in 2009. Holy Rosary Healthcare is located in Custer County in southeastern Montana. Custer County is designated as a frontier county (less than six people per square mile), with a 2010 census population of 11,699 [10]. Between 2009 and 2015, telehealth delivery sites were established in the towns of Ashland, Baker, Broadus, Colstrip, Ekalaka, Forsyth, and Wibaux. These towns are all located in frontier counties with 2010 census populations ranging from 1160 to 12,865 [10]. The mean distance between these towns and Miles City is 83 miles (range 46 to 115). Lifestyle intervention and delivery through telehealth A description of this intervention has been published previously [8, 9, 11]. Briefly, the Montana DPHHS began implementing the DPP in a group setting through multiple intervention sites in 2008. The lifestyle coaches at Holy Rosary Healthcare provided the 16 core sessions followed by six monthly post core sessions. Initially, these sessions were delivered using the original DPP’s 10month Lifestyle Balance curriculum, and in 2012, the Holy Rosary began implementing an updated version TBM
using the CDC’s National DPP curriculum [12, 13]. To maintain fidelity to the original NIH DPP, each of the of the lifestyle coaches at Holy Rosary received training on the curriculum, and the intervention sessions were provided in the same order as the NIH DPP and recommended by the CDC. Additionally, the lead lifestyle coach is a certified master DPP trainer by the Diabetes Training and Technical Assistance Center at Emory University. This coach has delivered over 20 different lifestyle coach trainings across the USA, which includes how to maintain intervention fidelity and engage participants. The participant lifestyle change goals for this intervention are the same as those in the NIH DPP [12]. These goals include (1) daily self-monitoring of dietary fat intake and achieving a dietary fat intake goal tailored to their baseline weight, (2) achieving ≥150 min weekly of moderately vigorous physical activity, and (3) achieving weight loss of ≥7% of participant’s baseline weight at completion of the core. We also assessed participant achievement of ≥5% weight loss. Participants collect information regarding their weekly physical activity minutes beginning in week 5, and selfmonitor their daily fat intake beginning in week 2. The technology used to deliver the DPP via telehealth was based upon the local health facility’s capability. We primarily used established teleconferencing networks with cross-system bridging, which utilized equipment that was often obtained through rural health grants. In facilities where these networks were unavailable and in areas with local area network access and sufficient bandwidth, the Web-based applications Adobe Connect (San Jose, CA) and Vidyo (Hackensack, NJ) were used to broadcast the sessions. The criteria used to select the telehealth sites included the site having access appropriate technology, meeting space, support of the local site administration and medical providers, and the ability to identify a local site coordinator. The facilities hosting the telehealth sites included local hospitals, outpatient clinics, and schools. We experienced a number of challenges delivering the lifestyle intervention through telehealth (e.g., technology, room arrangements) and have described potential solutions to these challenges [14]. Holy Rosary Healthcare delivered the lifestyle intervention via telehealth to one individual community at a time and rotated the schedule to allow all seven towns to have access to these services multiple times between 2008 and 2015. The lifestyle intervention was delivered simultaneously to both the on-site and telehealth participants. Telehealth participants were able to see and communicate with the lifestyle coaches and the on-site participants in real time during each session. The group size of the on-site and telehealth sites ranged from 3 to 25 with 8 to 12 being the most common number of participants. Participants were charged a fee of US$150 to participate in the program. Scholarships were provided to participants who could not afford the participation fee and no one was prohibited from participating based on the inability to pay for the program. page 287 of 291
ORIGINAL RESEARCH
Participant eligibility criteria and recruitment Overweight (BMI ≥25.0 kg/m2 from 2008 to 2014 and BMI ≥24.0 kg/m2 starting 2015) adults aged ≥18 years with medical clearance from their referring provider and one or more of the following risk factors for CVD and/or type 2 diabetes were eligible for the program: a current diagnosis of prediabetes, impaired glucose tolerance, or impaired fasting glucose; hemoglobin A1C between 5.7 and 6.4%; high blood pressure (≥130/85 mmHg or treatment); dyslipidemia (triglycerides >150 mg/dl, LDL-cholesterol >130 mg/dl or treatment, or HDLcholesterol
ORIGINAL RESEARCH
Telehealth delivery of the diabetes prevention program to rural communities Liane M. Vadheim, RD, LN, CDE,1 Katherine Patch, ATC, LAT, MS, NRP,1 Sarah M. Brokaw, MPH,2 Dorota Carpenedo, MPH,2 Marcene K. Butcher, RD, CDE,2 Steven D. Helgerson, MD, MPH,2 Todd S. Harwell, MPH2 1 Holy Rosary Healthcare, Miles City, MT, USA 2 Montana Department of Public Health and Human Services, Cogswell Building, B-201, PO Box 202951, Helena, MT 59620-2951, USA Correspondence to: T Harwell [email protected]
Cite this as: TBM 2017;7:364–370 doi: 10.1007/s13142-017-0496-y #Society of Behavioral Medicine 2017
Abstract The Centers for Disease Control and Prevention, State and Local Health Departments, and other organizations in the USA are working to increase population access to the Diabetes Prevention Program (DPP) lifestyle intervention. Delivering the DPP through telehealth videoconference may increase access to this intervention, particularly in rural communities. The purpose of this study was to compare participation, monitoring of diet and physical activity, and weight loss in participants receiving the intervention on-site and those participating virtually through telehealth. Beginning in 2008, Holy Rosary Healthcare collaborated with the Montana Department of Public Health and Human Services to provide the DPP to participants on-site in one community and simultaneously through telehealth to participants in multiple other communities. From 2008 through 2015, 894 participants were enrolled in the program (29% at telehealth sites). The mean age of participants was 51.7 years and 84% were female. Overall, participants attended 14.4, 3.9, and 15.0 weekly core, post-core, and total sessions, respectively. There were no statistically significant differences in number of intervention sessions attended by the telehealth or on-site participants. There were no statistically significant differences in the mean weight loss or reduction in BMI between the telehealth and the on-site groups. There also were no statistically significant differences in the percentage of telehealth or on-site participants who achieved ≥5% weight loss (56 vs. 57%) or the 7% weight loss goal (38 vs. 41%). Our findings suggest that participants receiving the DPP through telehealth have similar rates of participation and achieve similar weight loss as participants attending the program on-site. Keywords
Type 2 diabetes mellitus, Prediabetes, Prevention, Lifestyle intervention, Telehealth, Videoconferencing, Rural, DPP translation, Montana INTRODUCTION The prevalence of type 2 diabetes among adults in the USA has doubled from less than 4% in 1980 to over 8% in 2014 and more than 29 million US adults have diagnosed or undiagnosed diabetes [1]. The prevalence of page 286 of 291
Implications Policy: Delivery of the DPP lifestyle intervention through telehealth may allow a larger number of persons to participate, may increase geographic access to this service, and may reduce the per participant cost and thus improve the cost effectiveness of the intervention. Research: Additional research is necessary to confirm this study’s findings that virtual, synchronous participation in the DPP via telehealth is similarly effective to in-person participation with respect to different demographic groups. Utilizing telehealth can also reduce barriers to accessing the diabetes prevention program lifestyle intervention in remote rural communities, which often do not have the capacity to establish lifestyle intervention programs or the health professional workforce. Practice: Telehealth may also be utilized to deliver the lifestyle intervention to multiple sites simultaneously both in rural and non-rural areas.
prediabetes among adults in the USA, a group at highrisk for developing type 2 diabetes, has increased from 29.2% in 1999–2002 to 38.0% in 2011–2012 [2]. Randomized controlled clinical trials including the Da Qing Diabetes Prevention Study, Finnish Diabetes Prevention Study, and the National Institutes of Health’s (NIH) Diabetes Prevention Program (DPP) demonstrated that the incidence of type 2 diabetes mellitus among adults at high risk can be significantly reduced through an intensive lifestyle intervention [3, 4]. The lifestyle interventions in these studies were delivered one-on-one to participants [3, 4]. It was demonstrated by the DPP that participants in the lifestyle intervention group reduced their risk for developing type 2 diabetes by 58 and 34% when compared to the placebo group at 3 and 10 years, respectively [4, 5]. In addition to these randomized clinical trials, multiple translation studies with group-based TBM
ORIGINAL RESEARCH
interventions have demonstrated clinically meaningful weight and cardiometabolic health improvements among participants [6]. Currently in the USA, the Centers for Disease Control and Prevention (CDC), State and Local Health Departments, and other organizations are working to increase access to this evidence-based lifestyle intervention through the establishment of a trained workforce and intervention sites to provide this prevention service [7, 8]. Delivering the DPP lifestyle intervention through telehealth video conferencing can increase the number of persons receiving this intervention, reduce the overall cost per participant, and reach remote rural communities where residents might not otherwise be able to access these services. In 2009, we implemented a small pilot study (N = 27) to test the feasibility to deliver the DPP via telehealth to rural communities. We found that participation rates and weight loss were similar between telehealth and on-site participants [9]. Since 2009, Holy Rosary Healthcare in collaboration with the Montana Department of Public Health and Human Services (DPHHS) has continued to enroll adults at high-risk for type 2 diabetes in the DPP both on-site in Miles City and in seven surrounding frontier communities through telehealth. The objective of this study was to evaluate participation adherence, self-monitoring behaviors, and weight loss among a larger cohort of participants receiving the lifestyle intervention on-site compared to those receiving the intervention via telehealth.
METHODS Setting Holy Rosary Healthcare in Miles City, Montana, in collaboration with the Montana DPHHS began providing the DPP lifestyle intervention on-site beginning in 2008 and to surrounding remote frontier communities through telehealth in 2009. Holy Rosary Healthcare is located in Custer County in southeastern Montana. Custer County is designated as a frontier county (less than six people per square mile), with a 2010 census population of 11,699 [10]. Between 2009 and 2015, telehealth delivery sites were established in the towns of Ashland, Baker, Broadus, Colstrip, Ekalaka, Forsyth, and Wibaux. These towns are all located in frontier counties with 2010 census populations ranging from 1160 to 12,865 [10]. The mean distance between these towns and Miles City is 83 miles (range 46 to 115). Lifestyle intervention and delivery through telehealth A description of this intervention has been published previously [8, 9, 11]. Briefly, the Montana DPHHS began implementing the DPP in a group setting through multiple intervention sites in 2008. The lifestyle coaches at Holy Rosary Healthcare provided the 16 core sessions followed by six monthly post core sessions. Initially, these sessions were delivered using the original DPP’s 10month Lifestyle Balance curriculum, and in 2012, the Holy Rosary began implementing an updated version TBM
using the CDC’s National DPP curriculum [12, 13]. To maintain fidelity to the original NIH DPP, each of the of the lifestyle coaches at Holy Rosary received training on the curriculum, and the intervention sessions were provided in the same order as the NIH DPP and recommended by the CDC. Additionally, the lead lifestyle coach is a certified master DPP trainer by the Diabetes Training and Technical Assistance Center at Emory University. This coach has delivered over 20 different lifestyle coach trainings across the USA, which includes how to maintain intervention fidelity and engage participants. The participant lifestyle change goals for this intervention are the same as those in the NIH DPP [12]. These goals include (1) daily self-monitoring of dietary fat intake and achieving a dietary fat intake goal tailored to their baseline weight, (2) achieving ≥150 min weekly of moderately vigorous physical activity, and (3) achieving weight loss of ≥7% of participant’s baseline weight at completion of the core. We also assessed participant achievement of ≥5% weight loss. Participants collect information regarding their weekly physical activity minutes beginning in week 5, and selfmonitor their daily fat intake beginning in week 2. The technology used to deliver the DPP via telehealth was based upon the local health facility’s capability. We primarily used established teleconferencing networks with cross-system bridging, which utilized equipment that was often obtained through rural health grants. In facilities where these networks were unavailable and in areas with local area network access and sufficient bandwidth, the Web-based applications Adobe Connect (San Jose, CA) and Vidyo (Hackensack, NJ) were used to broadcast the sessions. The criteria used to select the telehealth sites included the site having access appropriate technology, meeting space, support of the local site administration and medical providers, and the ability to identify a local site coordinator. The facilities hosting the telehealth sites included local hospitals, outpatient clinics, and schools. We experienced a number of challenges delivering the lifestyle intervention through telehealth (e.g., technology, room arrangements) and have described potential solutions to these challenges [14]. Holy Rosary Healthcare delivered the lifestyle intervention via telehealth to one individual community at a time and rotated the schedule to allow all seven towns to have access to these services multiple times between 2008 and 2015. The lifestyle intervention was delivered simultaneously to both the on-site and telehealth participants. Telehealth participants were able to see and communicate with the lifestyle coaches and the on-site participants in real time during each session. The group size of the on-site and telehealth sites ranged from 3 to 25 with 8 to 12 being the most common number of participants. Participants were charged a fee of US$150 to participate in the program. Scholarships were provided to participants who could not afford the participation fee and no one was prohibited from participating based on the inability to pay for the program. page 287 of 291
ORIGINAL RESEARCH
Participant eligibility criteria and recruitment Overweight (BMI ≥25.0 kg/m2 from 2008 to 2014 and BMI ≥24.0 kg/m2 starting 2015) adults aged ≥18 years with medical clearance from their referring provider and one or more of the following risk factors for CVD and/or type 2 diabetes were eligible for the program: a current diagnosis of prediabetes, impaired glucose tolerance, or impaired fasting glucose; hemoglobin A1C between 5.7 and 6.4%; high blood pressure (≥130/85 mmHg or treatment); dyslipidemia (triglycerides >150 mg/dl, LDL-cholesterol >130 mg/dl or treatment, or HDLcholesterol
