Browsing by Author "King, Heather A"
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Item Open Access Baseline Antihypertensive Drug Count and Patient Response to Hypertension Medication Management.(Journal of clinical hypertension (Greenwich, Conn.), 2016-04) Crowley, Matthew J; Olsen, Maren K; Woolson, Sandra L; King, Heather A; Oddone, Eugene Z; Bosworth, Hayden BTelemedicine-based medication management improves hypertension control, but has been evaluated primarily in patients with low antihypertensive drug counts. Its impact on patients taking three or more antihypertensive agents is not well-established. To address this evidence gap, the authors conducted an exploratory analysis of an 18-month, 591-patient trial of telemedicine-based hypertension medication management. Using general linear models, the effect of medication management on blood pressure for patients taking two or fewer antihypertensive agents at study baseline vs those taking three or more was compared. While patients taking two or fewer antihypertensive agents had a significant reduction in systolic blood pressure with medication management, those taking three or more had no such response. The between-subgroup effect difference was statistically significant at 6 months (-6.4 mm Hg [95% confidence interval, -12.2 to -0.6]) and near significant at 18 months (-6.0 mm Hg [95% confidence interval, -12.2 to 0.2]). These findings suggest that baseline antihypertensive drug count may impact how patients respond to hypertension medication management and emphasize the need to study management strategies specifically in patients taking three or more antihypertensive medications.Item Open Access Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains.(Journal of health care chaplaincy, 2021-11-26) Wortmann, Jennifer H; Nieuwsma, Jason A; King, Heather A; Fernandez, Paola; Jackson, George L; Smigelsky, Melissa A; Cantrell, William; Meador, Keith GThe psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.Item Open Access Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration.(Frontiers in health services, 2023-01) Jackson, George L; Fix, Gemmae M; White, Brandolyn S; Cutrona, Sarah L; Reardon, Caitlin M; Damschroder, Laura J; Burns, Madison; DeLaughter, Kathryn; Opra Widerquist, Marilla A; Arasim, Maria; Lindquist, Jennifer; Gifford, Allen L; King, Heather A; Kaitz, Jenesse; Jasuja, Guneet K; Hogan, Timothy P; Lopez, Jaifred Christian F; Henderson, Blake; Fitzgerald, Blaine A; Goetschius, Amber; Hagan, Danielle; McCoy, Carl; Seelig, Alex; Nevedal, AndreaIntroduction
The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA.Methods
Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators.Results
In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank.Conclusion
DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.Item Open Access eConsults' Impact on Care Access and Wait Times in Rheumatology.(Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 2022-04) Malcolm, Elizabeth J; Brandon, Zachary; Wilson, Lauren E; Shoup, John Paul; King, Heather A; Lewinski, Allison; Greiner, Melissa A; Malone, Shauna; Miller, Julie; Keenan, Robert T; Tarrant, Teresa K; Phinney, Donna; Cho, Alex; Bosworth, Hayden B; Shah, KevinBackground/objective
A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits.Methods
In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program.Results
Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition.Conclusions
Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.Item Open Access Factors influencing support for the implementation of community-based out-of-hospital cardiac arrest interventions in high- and low-performing counties.(Resuscitation plus, 2024-03) Ezem, Natalie; Lewinski, Allison A; Miller, Julie; King, Heather A; Oakes, Megan; Monk, Lisa; Starks, Monique A; Granger, Christopher B; Bosworth, Hayden B; Blewer, Audrey LAim of the study
Survival to hospital discharge from out-of-hospital cardiac arrest (OHCA) after receiving treatment from emergency medical services (EMS) is less than 10% in the United States. Community-focused interventions improve survival rates, but there is limited information on how to gain support for new interventions or program activities within these populations. Using data from the RAndomized Cluster Evaluation of Cardiac ARrest Systems (RACE-CARS) trial, we aimed to identify the factors influencing emergency response agencies' support in implementing an OHCA intervention.Methods
North Carolina counties were stratified into high-performing or low-performing counties based on the county's cardiac arrest volume, percent of bystander-cardiopulmonary resuscitation (CPR) performed, patient survival to hospital discharge, cerebral performance in patients after cardiac arrest, and perceived engagement in the RACE-CARS project. We randomly selected 4 high-performing and 3 low-performing counties and conducted semi-structured qualitative interviews with emergency response stakeholders in each county.Results
From 10/2021 to 02/2022, we completed 29 interviews across the 7 counties (EMS (n = 9), telecommunications (n = 7), fire/first responders (n = 7), and hospital representatives (n = 6)). We identified three themes salient to community support for OHCA intervention: (1) initiating support at emergency response agencies; (2) obtaining support from emergency response agency staff (senior leadership and emergency response teams); and (3) and maintaining support. For each theme, we described similarities and differences by high- and low-performing county.Conclusions
We identified techniques for supporting effective engagement of emergency response agencies in community-based interventions for OHCA improving survival rates. This work may inform future programs and initiatives around implementation of community-based interventions for OHCA.Item Open Access Partner engagement for planning and development of non-pharmacological care pathways in the AIM-Back trial.(Clinical trials (London, England), 2023-06) Ballengee, Lindsay A; King, Heather A; Simon, Corey; Lentz, Trevor A; Allen, Kelli D; Stanwyck, Catherine; Gladney, Micaela; George, Steven Z; Hastings, S NicoleBackground/aims
Embedded pragmatic clinical trials are increasingly recommended for non-pharmacological pain care research due to their focus on examining intervention effectiveness within real-world settings. Engagement with patients, health care providers, and other partners is essential, yet there is limited guidance for how to use engagement to meaningfully inform the design of interventions to be tested in pain-related pragmatic clinical trials. This manuscript aims to describe the process and impacts of partner input on the design of two interventions (care pathways) for low back pain currently being tested in an embedded pragmatic trial in the Veterans Affairs health care system.Methods
Sequential cohort design for intervention development was followed. Engagement activities were conducted with 25 participants between November 2017 and June 2018. Participants included representatives from multiple groups: clinicians, administrative leadership, patients, and caregivers.Results
Partner feedback led to several changes in each of the care pathways to improve patient experience and usability. Major changes to the sequenced care pathway included transitioning from telephone-based delivery to a flexible telehealth model, increased specificity about pain modulation activities, and reduction of physical therapy visits. Major changes to the pain navigator pathway included transitioning from a traditional stepped care model to one that offers care in a feedback loop, increased flexibility regarding pain navigator provider type, and increased specificity for patient discharge criteria. Centering patient experience emerged as a key consideration from all partner groups.Conclusion
Diverse input is important to consider before implementing new interventions in embedded pragmatic trials. Partner engagement can increase acceptability of new care pathways to patients and providers and enhance uptake of effective interventions by health systems.Trial registration
NCT#04411420. Registered on 2 June 2020.Item Open Access Patient beliefs and behaviors about genomic risk for type 2 diabetes: Implications for prevention(Journal of Health Communication, 2015-01-01) Gallagher, Patrick; King, Heather A; Haga, Susanne B; Orlando, Lori A; Joy, Scott V; Trujillo, Gloria M; Scott, William Michael; Bembe, Marylou; Creighton, Dana L; Cho, Alex H; Ginsburg, Geoffrey S; Vorderstrasse, AllisonCopyright © Taylor & Francis Group, LLC 2015.Type 2 diabetes is a major health burden in the United States, and population trends suggest this burden will increase. High interest in, and increased availability of, testing for genetic risk of type 2 diabetes presents a new opportunity for reducing type 2 diabetes risk for many patients; however, to date, there is little evidence that genetic testing positively affects type 2 diabetes prevention. Genetic information may not fit patients illness representations, which may reduce the chances of risk-reducing behavior changes. The present study aimed to examine illness representations in a clinical sample who are at risk for type 2 diabetes and interested in genetic testing. The authors used the Common Sense Model to analyze survey responses of 409 patients with type 2 diabetes risk factors. Patients were interested in genetic testing for type 2 diabetes risk and believed in its importance. Most patients believed that genetic factors are important to developing type 2 diabetes (67%), that diet and exercise are effective in preventing type 2 diabetes (95%), and that lifestyle changes are more effective than drugs (86%). Belief in genetic causality was not related to poorer self-reported health behaviors. These results suggest that patients interest in genetic testing for type 2 diabetes might produce a teachable moment that clinicians can use to counsel behavior change.Item Open Access Patients' Experiences With Staphylococcus aureus and Gram-Negative Bacterial Bloodstream Infections: Results From Cognitive Interviews to Inform Assessment of Health-Related Quality of Life.(Open forum infectious diseases, 2022-02) King, Heather A; Doernberg, Sarah B; Grover, Kiran; Miller, Julie; Oakes, Megan; Wang, Tsai-Wei; McFatrich, Molly; Ruffin, Felicia; Staman, Karen; Lane, Hannah G; Rader, Abigail; Sund, Zoë; Bosworth, Hayden B; Reeve, Bryce B; Fowler, Vance G; Holland, Thomas LBackground
We previously conducted a concept elicitation study on the impact of Staphylococcus aureus and gram-negative bacterial bloodstream infections (SAB/GNB) on health-related quality of life (HRQoL) from the patient's perspective and found significant impacts on HRQoL, particularly in the physical and functional domains. Using this information and following guidance on the development of patient-reported outcome (PRO) measures, we determined which combination of measures and items (ie, specific questions) would be most appropriate in a survey assessing HRQoL in bloodstream infections.Methods
We selected a variety of measures/items from the Patient-Reported Outcomes Measurement Information System (PROMIS) representing different domains. We purposefully sampled patients ~6-12 weeks post-SAB/GNB and conducted 2 rounds of cognitive interviews to refine the survey by exploring patients' understanding of items and answer selection as well as relevance for capturing HRQoL.Results
We interviewed 17 SAB/GNB patients. Based on the first round of cognitive interviews (n = 10), we revised the survey. After round 2 of cognitive interviewing (n = 7), we finalized the survey to include 10 different PROMIS short forms/measures of the most salient HRQoL domains and 2 adapted questions (41 items total) that were found to adequately capture HRQoL.Conclusions
We developed a survey from well-established PRO measures that captures what matters most to SAB/GNB patients as they recover. This survey, uniquely tailored to bloodstream infections, can be used to assess these meaningful, important HRQoL outcomes in clinical trials and in patient care. Engaging patients is crucial to developing treatments for bloodstream infections.Item Open Access Patients' Experiences With Staphylococcus aureus and Gram-negative Bacterial Bloodstream Infections: A Qualitative Descriptive Study and Concept Elicitation Phase To Inform Measurement of Patient-reported Quality of Life.(Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 2021-07) King, Heather A; Doernberg, Sarah B; Miller, Julie; Grover, Kiran; Oakes, Megan; Ruffin, Felicia; Gonzales, Sarah; Rader, Abigail; Neuss, Michael J; Bosworth, Hayden B; Sund, Zoë; Drennan, Caitlin; Hill-Rorie, Jonathan M; Shah, Pratik; Winn, Laura; Fowler, Vance G; Holland, Thomas LBackground
Although Staphylococcus aureus and gram-negative bacterial bloodstream infections (SAB/GNB) cause substantial morbidity, little is known regarding patient perceptions' of their impact on quality of life (QOL). Guidance for assessing QOL and disease-specific measures are lacking. We conducted a descriptive qualitative study to gain an in-depth understanding of patients' experiences with SAB/GNB and concept elicitation phase to inform a patient-reported QOL outcome measure.Methods
We conducted prospective one-time, in-depth, semi-structured, individual, qualitative telephone interviews 6- 8 weeks following bloodstream infection with either SAB or GNB. Patients were enrolled in an institutional registry (tertiary academic medical center) for SAB or GNB. Interviews were audio-recorded, transcribed, and coded. Directed content analysis identified a priori and emergent themes. Theme matrix techniques were used to facilitate analysis and presentation.Results
Interviews were completed with 30 patients with SAB and 31 patients with GNB. Most patients were at or near the end of intravenous antibiotic treatment when interviewed. We identified 3 primary high-level concepts: impact on QOL domains, time as a critical index, and sources of variability across patients. Across both types of bloodstream infection, the QOL domains most impacted were physical and functional, which was particularly evident among patients with SAB.Conclusions
SAB/GNB impact QOL among survivors. In particular, SAB had major impacts on multiple QOL domains. A combination of existing, generic measures that are purposefully selected and disease-specific items, if necessary, could best capture these impacts. Engaging patients as stakeholders and obtaining their feedback is crucial to conducting patient-centered clinical trials and providing patient-centered care.Item Open Access Understanding veterans' experiences with lung cancer and psychological distress: A multimethod approach.(Psychological services, 2024-03) Ramos, Katherine; King, Heather A; Gladney, Micaela N; Woolson, Sandra L; Coffman, Cynthia; Bosworth, Hayden B; Porter, Laura S; Hastings, S NicolePsychological distress while coping with cancer is a highly prevalent and yet underrecognized and burdensome adverse effect of cancer diagnosis and treatment. Left unaddressed, psychological distress can further exacerbate poor mental health, negatively influence health management behaviors, and lead to a worsening quality of life. This multimethod study primarily focused on understanding veterans' psychological distress and personal experiences living with lung cancer (an underrepresented patient population). In a sample of 60 veterans diagnosed with either nonsmall cell lung cancer (NSCLC) or small cell lung cancer (SCLC), we found that distress is common across clinical psychology measures of depression (37% [using the Patient Health Questionnaire, PHQ-9 measure]), anxiety (35% [using the Generalized Anxiety Disorder, GAD-7 measure]), and cancer-related posttraumatic stress (13% [using the Posttraumatic Stress Symptom Checklist measure]). A total of 23% of the sample endorsed distress scores on two or more mental health screeners. Using a broader cancer-specific distress measure (National Comprehensive Cancer Network), 67% of our sample scored above the clinical cutoff (i.e., ≥ 3), and in the follow-up symptom checklist of the National Comprehensive Cancer Network measure, a majority endorsed feeling sadness (75%), worry (73%), and depression (60%). Qualitative analysis with a subset of 25 veterans highlighted that psychological distress is common, variable in nature, and quite bothersome. Future research should (a) identify veterans at risk for distress while living with lung cancer and (b) test supportive mental health interventions to target psychological distress among this vulnerable veteran population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).Item Embargo Using Patient Reported Outcomes to Inform Health Care Research and Practice(2024) Norman, KatherineUse of patient-reported outcomes (PROs) in addition to clinical (e.g., biomarkers, vitals, etc.) and organizational (e.g., admission, cost, etc.) outcomes are critical for integrating the patient perspective into medical product development, treatment algorithms, evaluation of care quality, measures of health-related quality of life, and more. Key regulatory bodies including Centers for Medicare and Medicaid Services, Patient-Centered Outcomes Research Institute, National Institute of Health Pragmatic Trial Collaboratory, Agency for Healthcare Research and Quality, and The United States Food and Drug Administration have urged for incorporation of PROs, typically in the form of PRO measures (PROMs) into clinical care and research trials as a means to increase patients’ perspectives into treatment development and delivery. While production and use of PROs and PROMs in research trials and clinical practice has exponentially increased, there remains a significant lack of knowledge of PRO and PROM adoption, administration, and interpretation to inform endpoints for research and clinical care. Therefore, this dissertation seeks to address the evidence gap by exploring various applications of health measures across different patient populations and settings to contribute information that will ultimately foster patient-centered, measurement-based care. The three components of this dissertation are outlined below to describe the range of patient populations, health contexts, and study designs used to provide doctoral level training in implementation strategies for health measurement and health services research. In the first project, we sought to determine which Patient Reported Outcome Measurement Information System (PROMIS) measures are associated with high-impact chronic pain (HICP) in patients status post shoulder arthroplasty (TSA) and propose cutoff scores to help guide future care recommendations. Identification of complex pain conditions, particularly HICP, is of growing interest among patients receiving total joint arthroplasty to better tailor pain interventions, as well as improve postoperative outcomes and quality of life. We performed a secondary analysis of a cohort of patients (n=227) who received a TSA at a single, academic medical center. Generalized linear models (GLM) estimated HICP from each PROMIS measure of physical function, pain interference, sleep disturbance, anxiety, and dyspnea individually, then in a combined model. Area under the curve (AUC) was calculated using receiver operator characteristic curves to assess accuracy of each PROMIS measure to estimate HICP status for patients receiving TSA. Bivariate GLM models and mean difference analyses revealed individuals with HICP had worse PROMIS scores in every included domain (all p-values <0.01). Only pain interference (AUC= 0.964) and physical function (AUC= 0.907) PROMIS measures met criteria (AUC>0.850) to accurately predict HICP. Cross validation and sensitivity analyses were performed to assess for differences among sociodemographic and surgical factors, and indicated little change in GLM models and cutoff scores for PROMIS measures. Further application and evaluation of these cutoff scores can be used to assist in refining assessment of outcomes for patients receiving TSA in registries, research trials, and clinical care. In the second project, we sought to perform a systematic review to understand what measures have been used to assess health-related quality of life (HRQoL) in patients experiencing acute bacterial skin and skin structure infection (ABSSSI) to guide measurement selection. ABSSSI can diminish patients’ HRQoL. The goal of this project was to identify and describe how HRQoL has been assessed in patients with ABSSSI in the literature to inform measurement selection for clinical antibacterial trials. We searched MEDLINE (PubMed), Embase (Elsevier), and CINAHL (EBSCO) for articles published between database inception and an updated search on October 14, 2022. We identified 37 articles that employed 42 distinct measures: 26 generic measures assessing HRQoL across multiple or singular domains, 14 condition-specific measures including repurposed dermatologic HRQoL metrics or measures relevant to surgical sites, and 2 author-developed questionnaires assessing treatment-related HRQoL. All findings were mapped to the Wilson and Cleary Model of HRQoL to explore domains of HRQoL captured in the evidence. We found reduced HRQoL for patients experiencing ABSSSI, which usually exhibited rapid onset and resolution related to symptom intensity. Pain had the greatest negative impact on HRQoL, and the most common HRQoL domain impacted was physical functioning. Progress has been made yet we did not identify a repurposed or novel tool that best captures HRQoL in patients with ABSSSI. For the final project of this dissertation, we sought to compare and contrast the health care experience for patients experiencing complicated urinary tract infections (cUTI) and their associated treating providers to inform future research on integration of patient reported outcome measures into patient-provider communication. Complicated urinary tract infections result in over 626,000 hospitalizations annually in the United States, yet little is known about the care experience of patients with cUTI and interactions with medical providers during care episodes. The perspectives of both patients receiving care for their cUTI and the providers navigating this complex condition are critical for informing how to increase patient perspective in research and clinical care. We used qualitative analysis to describe the care experience from patients who experienced a cUTI and care delivery from the perspective of their associated providers, and examine findings for similarities and differences. Single, semi-structured, individual, qualitative interviews were conducted via telephone or Zoom with all included patients and providers. We interviewed 12 patients and 16 providers, comprising 8 patient-provider dyads dyad (1 patient and corresponding (1) clinician) and 4 patient-provider triads (1 patient and corresponding (2) clinicians). Patient interviews averaged 44 (range 20–74) minutes and clinician interviews 21 (range 11–31) minutes. We used both structural and content analysis within and across interviews with patients and their treating providers, and organized findings using rapid, matrix-based techniques. Four concepts were identified: 1) time spent, 2) unknowns of care, 3) care coordination, and 4) discharge optimization. We found that increased or frequent interactions between patients and providers improved the care experience; however, a shared understanding of prognosis or cause for cUTI was critical for building patient-provider relationships. Additionally, there is a need for tools and strategies that promote care coordination across providers and settings, as well as a need to augment discharge preparedness and follow-up care. More research is needed to understand how PRO and/or PROMs can help to address concepts identified in this analysis.
Item Open Access Veterans' Interpretation of Diabetes Distress in Diabetes Self-Management: Findings From Cognitive Interviews.(The science of diabetes self-management and care, 2021-10) Lewinski, Allison A; Shapiro, Abigail; Bosworth, Hayden B; Crowley, Matthew J; McCant, Felicia; Howard, Teresa; Jeffreys, Amy S; McConnell, Eleanor; Tanabe, Paula; Barcinas, Susan; Coffman, Cynthia J; King, Heather APurpose
The purpose of this project was to identify additional facets of diabetes distress (DD) in veterans that may be present due to the veteran's military-related experience.Methods
The study team completed cognitive interviews with veterans with type 2 diabetes mellitus (T2DM) to examine how they answered the Diabetes Distress Scale (DD Scale), a tool that assesses DD. The DD Scale was used because of its strong associations with self-management challenges, physician-related distress, and clinical outcomes.Results
The veterans sample (n= 15) was 73% male, mean age of 61 (SD = 8.6), 53% Black, 53% with glycosylated hemoglobin level <9%, and 67% with prescribed insulin. The DD Scale is readily understood by veterans and interpreted. Thematic analysis indicated additional domains affecting DD and T2DM self-management, including access to care, comorbidities, disruptions in routine, fluctuations in emotions and behaviors, interactions with providers, lifelong nature of diabetes, mental health concerns, military as culture, personal characteristics, physical limitations, physical pain, sources of information and support, spirituality, and stigma.Conclusions
This study describes how a veteran's military experience may contribute to DD in the context of T2DM self-management. Findings indicate clinicians and researchers should account for additional domains when developing self-management interventions and discussing self-management behaviors with individuals with T2DM.