Expanding Technology-Enabled, Nurse-Delivered Chronic Disease Care : A Pragmatic, Randomized, Effectiveness-Implementation Trial.
Date
2026-06
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Abstract
Background
Comprehensive telehealth is used effectively for treatment-resistant chronic diseases in certain integrated health systems but has seldom been implemented in systems that provide mainly fee-for-service (FFS) care.Objective
To examine the effectiveness and implementation of comprehensive telehealth delivered in an FFS environment for patients with uncontrolled type 2 diabetes (T2D) and comorbid hypertension.Design
Pragmatic, randomized, effectiveness-implementation trial. (ClinicalTrials.gov: NCT05120544).Setting
6 academic primary care or endocrinology clinics.Participants
Participants had both T2D with hemoglobin A1c (HbA1c) persistently at 8.0% or higher for at least 6 months and hypertension with at least 1 systolic blood pressure (BP) above 140 mm Hg or diastolic BP above 90 mm Hg in the past year.Intervention
Two 12-month, mobile monitoring-enabled interventions: a self-monitoring control program and a nurse-delivered, comprehensive telehealth program incorporating self-management support and medication management.Measurements
Primary (HbA1c) and secondary outcomes were evaluated at 12 months. Implementation analyses evaluated fidelity and barriers to intervention delivery.Results
Participants were 64% female and 68% Black. The mean age was 54.5 years, mean HbA1c 9.8%, and mean BP 135/81 mm Hg. The estimated mean change in HbA1c from 0 to 12 months was -0.7 percentage points with self-monitoring and -1.1 percentage points with comprehensive telehealth; the estimated mean between-group difference in HbA1c change at 12 months was -0.4 percentage points (95% CI, -1.0 to 0.3 percentage points). Between-group differences in change in secondary outcomes did not reach statistical significance, except for diabetes self-care (0.4 [CI, 0.0 to 0.9], favoring comprehensive telehealth). The comprehensive program was delivered with suboptimal fidelity (median encounters per participant, 9; fidelity threshold, ≥12); analyses identified barriers to program delivery.Limitation
Generalizability to dissimilar populations and systems lacking telehealth infrastructure may be limited.Conclusion
Comprehensive telehealth did not substantially lower HbA1c relative to control in this study. Population factors, intervention and control program design, and barriers to FFS implementation of comprehensive telehealth may have contributed to these findings.Primary funding source
National Institute of Nursing Research and Duke Clinical & Translational Science Institute.Type
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Publication Info
Crowley, Matthew J, Allison A Lewinski, Qing Yang, Daniel Hatch, Anushka Palipana, Hayden B Bosworth, Brystana G Kaufman, Ranee Chatterjee, et al. (2026). Expanding Technology-Enabled, Nurse-Delivered Chronic Disease Care : A Pragmatic, Randomized, Effectiveness-Implementation Trial. Annals of internal medicine. 10.7326/annals-26-00132 Retrieved from https://hdl.handle.net/10161/34910.
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Scholars@Duke
Allison A. Lewinski
I am a health services researcher and implementation scientist with a joint appointment at the Duke University School of Nursing (DUSON) and the Durham Veterans Affairs Health Care System (VHA). My expertise spans diabetes distress, qualitative research methods, and virtual care delivery (including telehealth and digital health).
My research examines how virtual care interventions can reduce distress, improve self-management, expand access to evidence-based care, and enhance patient and population health outcomes. I focus on patient-, provider-, and system-level factors that influence the use and effectiveness of virtual care. This work has been funded by competitive grants, published in high-impact journals, presented at national conferences, and used to inform health system decision-making. I am frequently sought by colleagues locally and nationally for expertise in diabetes distress, qualitative methods, and virtual care strategies for grants, projects, and manuscripts.
I strive to improve outcomes for individuals with chronic illness by developing equitable, sustainable virtual care solutions and evaluating their implementation. To optimize these interventions, I apply qualitative and implementation science approaches to ensure alignment among patient needs, care modalities, disease states, and social contexts. My work addresses critical questions: for whom and for what purposes are these interventions effective, in which contexts, and at what points in the care continuum. Ultimately, my research advances the implementation and adoption of virtual care to reduce psychosocial distress and improve health outcomes through patient-clinician interactions and system-level innovations.
Qing Yang
Dr. Qing Yang is Research Professor and Biostatistician at Duke School of Nursing. She received her PhD in Biostatistics from University of California, Los Angeles. Dr. Yang’s statistical expertise is longitudinal data analysis and time-to-event data analysis. As a biostatistician, she has extensive experience collaborating with researchers in different therapeutic areas, including diabetes, cancer, cardiovascular disease and mental health. Her current research interests center on advanced latent variable models applied to symptom cluster research, intensive longitudinal data from mobile health studies, and the development of static and dynamic risk prediction models.
See my personal Github website.
Anushka Palipana
Dr. Anushka Palipana is a Biostatistician in the Health Statistics and Data Science division at the Duke University School of Nursing. She earned her Ph.D. in Statistics from the University of Cincinnati and her B.Sc. in Statistics from the University of Peradeniya, Sri Lanka. Her research interests encompass longitudinal modeling, survival analysis, and the joint modeling of longitudinal and survival data, with a focus on their applications in health science.
Prior to joining Duke University School of Nursing, Dr. Palipana was a postdoctoral research fellow at Cincinnati Children's Hospital Medical Center (CCHMC). At CCHMC, her research involved designing and analyzing medical monitoring investigations and integrating geo- and bio-markers to enhance the prediction and early detection of disease progression in conditions such as lymphangioleiomyomatosis and cystic fibrosis.
Dr. Palipana has authored numerous peer-reviewed journal articles published in methodological and clinical journals, including CHEST, Biometrics, Pediatric Pulmonology, PLoS One, and the Journal of Cystic Fibrosis, among others.
Hayden Barry Bosworth
Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities.
Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.
Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy
Brystana G. Kaufman
Areas of Expertise: Health Economics, Health Policy, and Health Services Research
Dr. Kaufman is a health services researcher focused on improving the value of care for older adults with complex care needs, such as serious illness or developmental disability. She brings expertise in causal inference as well as Medicaid and Medicare value-based payment models to inform evidence-based program design. Her work prioritizes the evaluation of health disparities for underserved communities and seeks to inform whole-person models of care that integrate traditional clinical services with behavioral health, socioeconomic and social supports to address older adults’ diverse needs and reflect their preferences for care. She worked with the CMS Innovation Center as a 2022-2023 Health and Aging Policy fellow, and she is core faculty with the Duke-Margolis Institute for Health Policy.
Dr. Kaufman received her Master of Science in Public Health and PhD in Health Policy and Management from the Gillings School of Global Public Health at the University of North Carolina-Chapel Hill.
Ranee Chatterjee
Jashalynn German
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