Diabetes Remote Patient Monitoring and Education in a Rural Setting

Diabetes is a complex and chronic disease that can be extremely difficult for individuals to manage, especially without the support of a specialized diabetes healthcare team. Diabetes education services can help provide much-needed support, but only about half of people with diabetes have ever received formal diabetes education. Remote patient monitoring (RPM) is a method used to remotely transfer medical data between patients and healthcare providers, allowing for more convenient care and support. This quality improvement (QI) project aimed to develop a diabetes RPM program for adults with diabetes in rural Utah. This QI project focused on the process of creating a diabetes RPM program then trialing it with a small sample of individuals to determine if it was feasible, usable, and if participants were satisfied. The program site was in rural Uintah, Duchesne, and Daggett Counties for patients of Uintah Basin Healthcare (UBH). Six adults with diabetes utilizing insulin pumps were enrolled in the six-week program. The UBH Certified Diabetes Care & Education Specialist (CDCES) assisted participants with creating a UBH patient portal account and remotely uploading their insulin pumps from home weekly for the primary care provider (PCP) to review. The CDCES also sent diabetes education resources to participants via the patient portal each week. Resources included recorded diabetes education videos covering the topics of healthy coping, healthy eating, being active, taking medications, monitoring, problem solving, and reducing risks. In addition, participants completed standardized pre- and post-intervention surveys including the Type 1 Diabetes Distress Scale and the Revised Brief Diabetes Knowledge Test. The standardized Diabetes Treatment Satisfaction Questionnaire and a free-response feedback survey were also included in the post-intervention surveys. Although this study was underpowered to detect a change in patient-reported outcome measures over the six-week study period, these data were used to provide a description of the sample characteristics. At the conclusion of the six-week intervention, key findings included high participant program satisfaction and a high retention rate. Participants reported the program made communication easier for those who would otherwise need to travel long distances to meet with a healthcare provider and diabetes educator. Overall, the participants had moderately high knowledge scores pre- to post-intervention. The program was feasible, especially since handouts and recorded education videos can be used for future diabetes RPM participants. In this project, videos and processes were developed to conduct a diabetes RPM program. Initial results indicate the program was feasible, usable, and acceptable. More study in a larger sample is needed to determine if this diabetes RPM program can improve glycemic and psychosocial outcomes in people with diabetes in rural Utah.

1 Diabetes Remote Patient Monitoring and Education in a Rural Setting AnneMarie Rousseau and Nancy A. Allen College of Nursing: University of Utah NURS 7703: DNP Scholarly Project III May 9, 2022 2 Abstract Background: Diabetes is a complex and chronic disease that can be extremely difficult for individuals to manage, especially without the support of a specialized diabetes healthcare team. Diabetes education services can help provide much-needed support, but only about half of people with diabetes have ever received formal diabetes education. Remote patient monitoring (RPM) is a method used to remotely transfer medical data between patients and healthcare providers, allowing for more convenient care and support. This quality improvement (QI) project aimed to develop a diabetes RPM program for adults with diabetes in rural Utah. Methods: This QI project focused on the process of creating a diabetes RPM program then trialing it with a small sample of individuals to determine if it was feasible, usable, and if participants were satisfied. The program site was in rural Uintah, Duchesne, and Daggett Counties for patients of Uintah Basin Healthcare (UBH). Six adults with diabetes utilizing insulin pumps were enrolled in the six-week program. The UBH Certified Diabetes Care & Education Specialist (CDCES) assisted participants with creating a UBH patient portal account and remotely uploading their insulin pumps from home weekly for the primary care provider (PCP) to review. The CDCES also sent diabetes education resources to participants via the patient portal each week. Resources included recorded diabetes education videos covering the topics of healthy coping, healthy eating, being active, taking medications, monitoring, problem solving, and reducing risks. In addition, participants completed standardized pre- and post-intervention surveys including the Type 1 Diabetes Distress Scale and the Revised Brief Diabetes Knowledge Test. The standardized Diabetes Treatment Satisfaction Questionnaire and a free-response feedback survey were also included in the post-intervention surveys. Although this study was underpowered to detect a change in patient-reported outcome measures over the six-week study period, these data were used to provide a description of the sample characteristics. Results: At the conclusion of the six-week intervention, key findings included high participant program satisfaction and a high retention rate. Participants reported the program made communication easier for 3 those who would otherwise need to travel long distances to meet with a healthcare provider and diabetes educator. Overall, the participants had moderately high knowledge scores pre- to post-intervention. The program was feasible, especially since handouts and recorded education videos can be used for future diabetes RPM participants. Conclusions: In this project, videos and processes were developed to conduct a diabetes RPM program. Initial results indicate the program was feasible, usable, and acceptable. More study in a larger sample is needed to determine if this diabetes RPM program can improve glycemic and psychosocial outcomes in people with diabetes in rural Utah. 4 Diabetes Remote Patient Monitoring and Education in a Rural Setting Problem Description Diabetes is a complex and chronic disease of the endocrine system. It is typically caused by the lack of insulin production or the inefficiency of insulin absorption. Insulin is a hormone produced by the pancreas that regulates blood glucose levels. Regardless of the diabetes type and cause, the disease results in elevated blood glucose levels. Chronic hyperglycemia is known to cause long-term diabetes-related damage of body organs. The eyes, heart, nerves, feet, and kidneys are especially affected (National Kidney Foundation, 2020). Because of the complexity and risks of complications, people with diabetes can benefit from the support of a specialized diabetes healthcare team. Diabetes can be extremely difficult to manage, especially without the support of a specialized diabetes healthcare team. Insulin-dependent diabetes requires daily administration of insulin, frequent blood glucose monitoring, carbohydrate counting for all food consumed, hypoglycemia treatment, appropriate timing of exercise, regular visits with the diabetes healthcare team, and the ability to problemsolve when blood glucose levels inevitably fall outside desired target ranges. Additionally, many people with diabetes do not have the emotional support they need for the overwhelming responsibilities that diabetes requires (Davies, 2021). Diabetes education services can help provide this much-needed support, but only 55% of people with diabetes have ever received formal diabetes education (Office of Disease Prevention and Health Promotion, n.d.). Remote patient monitoring (RPM) is a method used to remotely transfer medical data between patients and healthcare providers (Center for Connected Health Policy, 2021). This allows for more convenient care and support. A study completed by Michaud et al. (2018) emphasizes the value of RPM in adult patients with diabetes. Participants in this study were 955 people with diabetes admitted to a medical center for any reason between 2014 to 2017 who then utilized a 3-month RPM program after discharge (Michaud et al., 2018). The authors found that HbA1c levels, body mass index, and patient 5 engagement had statistically significant improvements (P < 0.001 in all cases) following their threemonth RPM intervention. RPM can be beneficial for both healthcare providers and patients. For patients, especially in rural areas, RPM provides increased access to care. Patients also become more engaged in their care which can empower them to be more engaged in their treatment plans (Cole, 2021). For providers, RPM can allow for the collection of better-quality data since the information is not easily manipulated and does not rely on the patients’ historian skills (Cole, 2021). Uintah, Duchesne, and Daggett Counties are located in rural eastern Utah and are home to 56,970 people (U.S. Census Bureau, 2021). They also have some of the highest rates of diabetes in Utah with a prevalence of 11.2%, 8.4%, and 7.7%, respectively, compared to the neighboring urban Wasatch County that has a 6.2% diabetes prevalence (Centers for Disease Control and Prevention [CDC], 2020a). Uintah Basin Healthcare (UBH) is a foundation that serves the community of these rural counties through its medical center, six clinics, emergency medical services, rehabilitation and senior care center, home health, hospice, medical equipment, walk-in clinic, occupational health, women’s health, dialysis, and two pharmacies (UBH, 2020). Clinic and hospital services include: cancer care and infusion center; wound care and hyperbaric medicine; ears, nose, and throat clinic; anesthesia; intensive care unit; medical surgical unit; obstetrics; physical and occupational therapy; laboratory services; radiology; respiratory care; sleep center; robotic surgery; and the diabetes education and training program (UBH, 2021). UBH is also a federally-qualified health center (FQHC) with two designated Rural Health Clinics (RHC) in Duchesne County, Utah. According to the Utah Department of Health (UDOH) (2018), the purpose of RHCs is to increase access to primary care services for Medicare and Medicaid patients in rural areas. These certified clinics must be located in an area with a health professional shortage and/or a medically underserved population (UDOH, 2018). Currently, the UBH diabetes education and training program has two Certified Diabetes Care and Education Specialists (CDCES). This program is accredited through the Association of Diabetes Care and Education Specialists (ADCES) and offers individual training sessions for people with type 1 diabetes, 6 type 2 diabetes, prediabetes, and gestational diabetes. Session topics include the evidence-based ADCES7 Self-Care Behaviors: healthy coping, healthy eating, being active, medications, monitoring, problem solving, and reducing risks (ADCES, 2021). Insulin pump and continuous glucose monitor (CGM) training services are also available. There are, however, no specialized diabetes healthcare providers or endocrinologists serving the people of the Uintah Basin. Due to geographic health disparities in rural communities, people with diabetes in these areas have decreased access to specialized healthcare. This results in increased travel time and expense for diabetes specialty appointments and/or the need to rely on overworked primary care providers (PCP) for complex diabetes management needs. Because of this geographic health disparity, the UBH CDCESs are especially important members of the person with diabetes’ healthcare team. According to the Certification Board for Diabetes Care and Education (CBDCE) (2021a), a CDCES is “a standard of excellence for the delivery of quality diabetes care and education.” A CDCES must complete and pass a rigorous certification process to show he or she has specialized knowledge in several different aspects of diabetes management (CBDCE, 2021a). To address the geographic health disparity and allow the CDCES to become a more involved member of the healthcare team, RPM would allow the CDCES to support people with diabetes in-between clinician appointments to provide additional diabetes education and support. Since diabetes technology continues to advance, especially with insulin pumps and continuous glucose monitors, RPM can serve as a strategy to educate and support people with diabetes who use this advancing technology. The CDCES has a critical role in providing technology education and support to people with diabetes using technology-enabled care (Greenwood et al., 2021). Compared to multiple daily injections, insulin pump therapy allows patients to more closely match insulin delivery to their physiologic needs and provides flexibility with meals and in social situations (Berget et al., 2019). However, insulin pumps are not commonly prescribed in the primary care setting (Martens et al., 2021) and can be complex and overwhelming for people with diabetes and PCPs to manage. There is a need for virtual diabetes specialty services for people with diabetes utilizing insulin pumps who do not have access to nearby services from 7 a specialized diabetes healthcare provider. A diabetes RPM program could improve patient outcomes when delivered by a CDCES. Available Knowledge According to the 2020 National Diabetes Statistics Report (CDC, 2020b), 34.2 million people had diabetes (10.5% of the United States population). A total of 88 million people older than age 18 had prediabetes (or 34.5% of the United States adult population). These individuals are all at risk for developing diabetes-related complications if blood glucose levels are not appropriately managed. Risk factors for complications include elevated HbA1c, increased blood pressure, high non-HDL cholesterol, and being a current smoker (CDC, 2020c). Having a HbA1c of <7.0%, blood pressure <140/90 mmHg, non-HDL cholesterol of <130mg/dL, and being a nonsmoker are recommended goals to reduce the risk of diabetes-related complications. Unfortunately, only 19.2% of people with diabetes are meeting all of these goals (CDC, 2020c). Virtual technologies for RPM can significantly improve glycemic management in patients with type 1 and type 2 diabetes (Carlson et al., 2021). Remote interactions with the healthcare team increase patients’ access to clinical care (Carlson et al., 2021). This is especially important in rural communities with less access to healthcare. Because the use of RPM for delivering diabetes education is still early in its adoption phase, new strategies are needed to address the large number of people with diabetes who are not meeting diabetes management goals. Rationale The Andragogy Learning Theory by Knowles (1970) is the theoretical framework used to guide intervention development for this project. This framework describes four principles of effective methods for adult learning. The first principle is the shift from dependence to independence. RPM can help increase participant knowledge and independence. The second principle is the use of learning from accumulated experience. RPM allows for reflection on personal experiences to help shape future diabetes management. The third principle is that learning must be related to personal growth and development. The RPM curriculum is based on the ADCES7 Self-Care Behaviors and provides resources to improve 8 personal diabetes outcomes (ADCES, 2021). The fourth principle is that knowledge must be practical and applicable to the learner and be more centered on performance rather than subjects. RPM curriculum includes practical tips for common diabetes-related scenarios that can help them perform better with their diabetes self-management. According to Dawson et al. (2020), there is an association between increased diabetes knowledge and improvements in patient outcomes such as HbA1c and medication engagement. Knowledge can be an empowering tool to help people better manage their diabetes. Receiving meaningful and engaging education from a CDCES can benefit people with diabetes. When the Andragogy Learning Theory is used as a framework for patient education, it allows the adult leaner to process and personally apply the information (Sanchez & Cooknell, 2017). The development of a diabetes RPM program in rural Utah provided educational tools using techniques and formats appropriate and effective for adult learning. Specific Aims The purpose of this project and report was to determine if increased communication between the CDCES and person with diabetes increased participants’ knowledge of diabetes management recommendations and decreased levels of diabetes-related distress. A secondary purpose was to address geographic health disparities and social determinants of health by implementing this project in a rural setting. Methods Context This RPM intervention took place in rural Uintah, Duchesne, and Daggett Counties in rural Utah. Participants were residents of these counties and had a PCP with UBH who manages their diabetes. The intervention itself took place remotely with virtual communication between the participants in one location and the CDCES in a separate location using UBH’s patient portal software. Leadership from this project came from the CDCES who is a registered nurse employed with UBH. There were no additional diabetes RPM programs available at the time to compete with or support this project. Additionally, the 9 online UBH patient portal is an important yet commonly underutilized tool that was the selected method of remote monitoring among patients, the CDCES, and PCPs in this program. Interventions First, adult patients utilizing insulin pumps prescribed and managed by PCPs with UBH were identified using an electronic health record (EHR) report. Next, the CDCES called all potential participants and invited them to participate. Once patients were identified, each received an invitation phone call with information about enrolling in the RPM project. If participants didn’t answer the phone, a voicemail was left with enrollment information. Up to three phone calls were placed for each potential participant. Eligibility was then determined through the following predetermined inclusion criteria: adult > 18 years; diagnosis of type 1 diabetes or insulin-requiring type 2 diabetes; utilization of insulin pump therapy; resident of Uintah, Duchesne, or Daggett Counties, Utah; and home internet access with personal UBH patient portal account (or ability to create one). The CDCES remotely helped participants set up a patient portal account if they did not already have one. Then the CDCES also sent a REDCap survey link through the patient portal to participants for them to complete the pre-intervention surveys—the Type 1 Diabetes Distress Scale (T1-DDS) and the Revised Brief Diabetes Knowledge Test (DKT2) (Appendix A). Existing diabetes education curriculum based on the ADCES7 Self-Care Behaviors (ADCES, 2021) was adapted to a virtual format and sent weekly via the online patient portal with the anticipation of diabetes knowledge improvement after the intervention (see Figure 1). It was anticipated that weekly communication and advice from the CDCES would help decrease participant levels of diabetes-related distress. After this project was implemented and completed, program outcomes were evaluated as well as feasibility, usability, and acceptability of the program. The importance of how the RPM program addressed rural health disparities was also considered, such as increasing access to healthcare, availability regardless of socioeconomic status, and improving health behaviors. Once all pre-intervention surveys were completed, the CDCES sent weekly diabetes education handouts and instructional videos to participants to help increase their knowledge of diabetes. The 10 following topics were selected for the six-week program based on the ADCES7 Self-Care Behaviors (ADCES, 2021): 1) Healthy coping; 2) Healthy eating; 3) Being active; 4) Taking medication and monitoring; 5) Problem solving; and 6) Reducing risks. The weekly educational outline can be found in Figure 1. Once participants completed the surveys, the CDCES sent weekly educational ADCES7 SelfCare Behavior handouts (ADCES, 2021) via the patient portal and developed a diabetes RPM YouTube channel with existing diabetes education topics transferred to a virtual video format. The link to each weekly video was sent via the patient portal with the weekly educational content and handouts. Also on a weekly basis, the CDCES viewed the insulin pump uploads of each participant and evaluated the data for trends in hypo- or hyperglycemia. When trends were recognized, the CDCES messaged the participant with questions to help further understand these trends. For example, if a participant had a consistent hyperglycemic trend between 6:00pm and 9:00pm, the CDCES inquired whether carbohydrate-counting was going well or needed improvements, if the person was remembering to take insulin for dinner, and if the insulin was being delivered at least 15 minutes before eating. If all questions were answered in the affirmative, the CDCES would then consult the PCP for recommendations on an insulin-to-carb ratio change to allow for more insulin at dinnertime. If not, the CDCES would help address participant barriers to accurate carbohydrate-counting and 15-minute premeal insulin administration. The CDCES helped participants recognize personal successes and potential areas of improvement with each weekly upload. The CDCES then helped participants set weekly behavioral goals to improve glucose time-in-range. Participants were instructed to upload their insulin pumps each week from home so the CDCES had access to pump data remotely. UBH has professional clinic upload accounts for all three insulin pumps. With the participants’ permission, these professional accounts can add personal upload accounts so when a patient uploads from home it can be accessed virtually by the healthcare team. For clinics desiring to reproduce this project, each insulin pump company can be contacted directly for assistance with setting up individual professional clinic upload accounts. 11 Participants with the Tandem t:slim X2™ insulin pump have the option to use the t:connect mobile app that connects via Bluetooth to their pump (Tandem Diabetes Care, 2022). This allows for automatic uploads to their t:connect® account without the need to manually perform an insulin pump upload. The CDCES helped patients using the Tandem pump to set up their personal t:connect® account using the t:connect mobile app that connects to the pump for automatic uploads. With written permission from the patient, each personal t:connect® account was added to the secure UBH cloud-based t:connect healthcare provider (HCP) account for the CDCES to access pump data and send to the participant’s PCP. Participants with the Medtronic MiniMed™ 700-series insulin pumps also have the option to do automatic uploads via the MiniMed™ Mobile app (Schmitz, 2020). The CDCES helped patients using this 700-series pump set up their CareLink™ Personal account using the MiniMed™ Mobile app that connects to the pump via Bluetooth for automatic uploads. With written permission from the patient, each CareLink™ Personal account was added to the secure UBH clinic CareLink™ Professional account for the CDCES to access pump data and send to the patient’s PCP. While those with the Medtronic MiniMed™ 600-series pumps do not have access to automatic pump uploads using an app, it is possible for them to manually upload to CareLink™ Personal from home. The only participant with a 600-series pump in this RPM program was already familiar and experienced with home uploads, so additional assistance from the CDCES was not needed. Clinics planning to implement a similar RPM program can either personally contact or instruct the participant to contact Medtronic CareLink™ software support for home uploading assistance. Participants using the Omnipod DASH® insulin delivery system also have the option to use mobile apps named Glooko® and PodderCentral® for automatic pump uploads (Krieg, 2021). The CDCES helped patients using the Omnipod DASH® system set up their personal Glooko® and PodderCentral® accounts using the corresponding mobile apps and then connected them to the participants’ Omnipod DASH™ personal diabetes manager (PDM) for automatic uploads. With written permission from the patient, each personal Glooko® account was added to the secure UBH clinic Glooko® Professional account for the CDCES to access pump data and send to the patient’s PCP. 12 The CDCES virtually accessed the participants’ insulin pump data each week and sent a PDF report to the PCP via the EHR, Cerner. The report was simultaneously linked to the patient’s EHR and sent directly to the participant via the patient portal. The CDCES noted trends in glucose levels and insulin delivery patterns, and, if needed, suggested adjustments to the PCP such as basal rate, insulin-tocarb ratio, and correction factor adjustments based on the uploaded data. If adjustments were recommended and approved by the PCP, the CDCES contacted the participant via the patient portal with instructions on which changes to make and how to make them. Participants made their own adjustments based on these PCP-approved recommendations and responded via the patient portal once the adjustments were made. Participants were also able to message the CDCES with non-emergent questions throughout the program using the online patient portal. At the conclusion of the six-week RPM program, participants were sent the REDCap survey with the T1-DDS and DKT2 questionnaires via the patient portal as well as the standardized Diabetes Treatment Satisfaction Questionnaire (DTSQ) to measure satisfaction and the CDCES-developed a fivequestion rural health free-response feedback survey measure usability (Appendix B). The team for this project included the CDCES registered nurse and each participant’s PCP. The role of the PCP was to recommend and approve insulin pump settings adjustments if needed and to be an active member of the participant’s healthcare team. The role of the CDCES was to support people with and affected by diabetes, as well as help individuals and families understand and manage diabetes, set and achieve behavior and treatment goals, and to improve health outcomes (CBDCE, 2021b). By creating and facilitating this diabetes RPM program, the CDCES provided additional necessary support for individuals with diabetes in a rural area with limited access to specialized diabetes care. Study of the Intervention The approach for assessing the impact of the intervention in this quality improvement project was to compare pre- and post-intervention surveys completed by participants. Standardized patient surveys were used as data collection tools to compare levels of diabetes-related distress (T1-DDS) and diabetes knowledge (DKT2) before and after the RPM intervention. The surveys were sent from the CDCES using 13 an electronic message in the UBH patient portal to each participant that included a REDCap survey link for the pre-intervention T1-DDS and DKT2 surveys. In addition, the post-intervention survey included questions about participant satisfaction with the RPM program and how the program addressed rural health disparities. Prior to this project, there was no established way for people with diabetes to remotely share their insulin pump data or communicate virtually with their UBH healthcare team. Instead, people were required to follow-up in person with the PCP or the CDCES in order to receive needed help with insulin pump settings adjustments and diabetes care and education. Measures T1-DDS is a 28-item instrument that utilizes a 6-point Likert scale with response options ranging from (1) “not a problem” to (6) “a very significant problem” (Fisher et al., 2015). The tool is designed for adults with type 1 diabetes, but can also be utilized by people with type 2 diabetes using insulin. The seven subscales of the T1-DDS include powerlessness, management distress, hypoglycemia distress, negative social perception distress, eating distress, physician distress, and family/friend distress (Fisher et al., 2015). The overall distress score is based on the average Likert scale response from the 28 items. Average scores < 2.0 indicate little or no distress, between 2.0 and 2.9 indicate moderate distress, and > 3.0 indicate high distress (Fisher et al., 2015). Three scales were used to measure and demonstrate the validity of the T1-DDS, including the Patient Health Questionnaire-8 (PHQ-8) that assesses depressive symptoms, the World Health Organization-5 (WHO-5) that assesses quality of life, and the Worry subscale of the Hypoglycemia Fear Survey-II (HFS-W) that assesses worries and concerns related to hypoglycemia (Fisher et al., 2015). Additionally, good reliability was indicated through alpha coefficients (total scale =.91) (Fisher et al., 2015). The Revised Brief Diabetes Knowledge Test (DKT2) has a 14-item general test and a 9-item insulin use subscale with a total of 23 questions (Fitzgerald et al., 2016). The general test portion is appropriate for adults with type 1 or type 2 diabetes, and the insulin use subscale is appropriate for adults with type 1 diabetes and type 2 diabetes using insulin. The questions in the DKT2 are formatted to a 14 fourth-grade reading level and take approximately 15 minutes to complete (Fitzgerald et al., 2016). The questions are formatted as multiple-choice in a numerical scale, and scores are obtained by adding the number of correct responses. The reliability of the general test and the insulin use subscale was demonstrated by the coefficient alphas (alphas ≥ .70) (Fitzgerald et al., 2016). The validity was measured through the comparison of scores by diabetes types, treatment types, educational level, and diabetes duration (Fitzgerald et al., 2016). This outcomes measure was selected because it is a standardized tool for measuring levels of diabetes knowledge for adults with type 1 or type 2 diabetes using insulin. Feasibility was measured by evaluating whether the project provided sufficient value to address the problem of geographic health disparities for people with diabetes in rural locations using postintervention survey data. This survey included five short-answer questions in a free text format. Time spent communicating with patients was also documented to evaluate feasibility of continuing the project in the future. Satisfaction was measured through post-intervention results of the validated and standardized DTSQ that was administered once following completion of the six-week RPM project. This survey contains eight items with six questions (Factor 1) measuring satisfaction with personal understanding of diabetes, treatment satisfaction, and likelihood of continuing treatment on a seven-point Likert scale (Saisho, 2018). Responses range from a “very dissatisfied/inconvenient” score of zero up to a “very satisfied/convenient” score of six (Saisho, 2018). The sum of these six items was used to calculate a DTSQ score with higher scores indicating higher satisfaction with treatment with a range of zero to 36. The final two items (Factor 2) measure the burden of hypo- and hyperglycemia with zero being “none of the time” to six being “most of the time.” For these two items, lower scores indicate more ideal blood glucose levels. This tool is highly reliable with a Cronbach alpha score of 0.90 (Saisho, 2018). This tool was selected because it has been shown to reliably measure treatment satisfaction for patients with type 1 and type 2 diabetes internationally. Usability was also evaluated through descriptive statistics of participant DTSQ scores. Implementation time required for CDCES and participant retention rate were also evaluated. 15 Analysis Descriptive statistics were used to describe the study sample. Mean pre- and post-intervention survey scores and standard deviations were measured using descriptive statistics. Surveys with less than 70% completion were not included in the analysis. Ethical Considerations No potential competing interests or conflicts of interest noted in this project. This project was considered quality improvement (QI) in nature and thus not subject to the University of Utah Institutional Review Board oversight. Results Demographics First, adults with diabetes utilizing insulin pumps were identified using an EHR report (see CONSORT Figure 2). There were 41 potential participants associated with 12 UBH providers who were identified after completing this report. The five highest pump-prescribing PCPs were selected for RPM involvement with a combined total of 29 potential patient participants. Due to time constraints of the CDCES, only five providers were selected so the sample size would not be too large. These five providers were then informed via email about this RPM program, given a list of their insulin pump patients from the EHR report, and asked which patients on the list they would like invited to participate. After two weeks there were four PCPs who responded with a combined total of 23 patient recommendations—seven with a Tandem t:slim X2™ pump, seven with an Omnipod DASH® insulin delivery system, and nine with a Medtronic MiniMed™ 600- or 700-series pump. Each of these patients also used a continuous glucose monitoring system—either Dexcom G6, Medtronic Guardian™, or FreeStyle Libre 2. After contacting potential participants, 11 of the 23 people were interested in enrolling (Figure 2). Of these 11, six met the inclusion criteria and were enrolled in the RPM program. Of the six enrollees, 83.3% were female and 100% were White. They were an average age of 49.5 years (± 11.9) with average diabetes duration of 15.3 years (± 11.2). Additional participant demographics can be found in Table 1. Patient Reported Outcome Measures 16 The average T1-DDS score among the six participants was 2.2 prior to the intervention and 2.1 following the intervention indicating moderate diabetes-related distress (Table 2). The average DKT2 score was 83.7% pre- and 83.7% post-intervention indicating moderately-high levels of diabetes knowledge (Table 3). Feasibility, Usability, and Satisfaction Feasibility was measured by evaluating whether the project provided sufficient value to address the problem of geographic health disparities for people with diabetes in rural locations using postintervention survey data. This survey included five short-answer questions in a free text format. Time spent communicating with participants was also documented to evaluate feasibility of continuing the project in the future. Data uploads, interpretation, and patient/provider communication took an average of 1.5 hours per week for six weeks, including time recording the weekly educational videos. The CDCES was paid $30 per hour, so the total cost was roughly $270 to implement. An evaluation of the usability of the RPM program was conducted. Five of the six participants consistently opened weekly patient portal messages sent by the CDCES. There were 67 views of these videos throughout the intervention period, suggesting participants watched some more than once. Satisfaction was measured using the DTSQ. Of the six participants, two completed the DTSQ. Scores included satisfaction of 28/36 (77.8%) and 35/36 (97.2%) (Table 4). The higher score indicates greater satisfaction. One individual had high diabetes treatment satisfaction and one individual had moderately-high diabetes treatment satisfaction. Positive feedback from participants and PCPs was also received in support of conducing another round of diabetes RPM within the UBH system. In the CDCES-created rural health free-response feedback survey, when asked how this RPM program addresses rural health disparities, participants indicated in the open-ended questions that the program made communication easier for those who would otherwise need to travel long distances to meet with a healthcare provider and diabetes care and education specialist. One participant mentioned how the 17 virtual platform saved several trips to the UBH clinic that would have otherwise been 100 miles roundtrip had the same education been provided in-person. Participants also noted how the program helped them improve health behaviors. One participant called this RPM program the “best medical experience I’ve had.” One barrier mentioned was forgetting to check patient portal messages. Overall, positive feedback was provided from those who completed the rural health free-response feedback survey. Missing Data Of the six original enrollees, five completed the post-T1-DDS, four completed both the post-T1DDS and the post-DKT2, and two completed the post-intervention surveys in their entirety, including the T1-DDS, DKT2, DTSQ, and free response feedback survey. Although the scores were paired, each response remained anonymous to the CDCES, so phone calls could not be made to remind specific individuals to complete the post-intervention surveys if they had not yet completed them. This led to gaps in post-intervention survey data. Discussion Summary The aim of this QI project was to implement a diabetes RPM program in a rural community. We developed six videos and provided diabetes care and education after an analysis of participants’ insulin pump and glucose data. The sample size was small but provided experience with delivering the RPM program. Interest in the study was expressed by about half of the referred patients with the remaining sample either not responding to enrollment contact or declining to participate. Of those who participated, five of the six consistently opened the weekly patient portal messages that included links to YouTube videos created for this RPM program. There were 67 views of these videos throughout the intervention period, suggesting participants watched some more than once. In addition to these weekly patient portal messages, participants remained engaged by reaching out to the CDCES via the patient portal with additional diabetes-related questions. This intervention had frequent participant engagement and a high retention rate throughout the six-week program. 18 Interpretation This is the first documented QI project, to our knowledge, aimed at addressing geographic health disparities for people with diabetes in rural communities by implementing a diabetes RPM program. This diabetes RPM project impacted individuals with diabetes utilizing insulin pumps in Duchesne, Uintah, and Daggett Counties in rural Utah by promoting a different delivery method for diabetes selfmanagement education and training to be more accessible to people with diabetes. This delivery method decreased participants’ travel cost and time. UBH serves people in the entire Uintah Basin, which includes rural Uintah, Duchesne, and Daggett counties. These counties account for almost 8,500 square miles and a population of almost 57,000 people (U.S. Census Bureau, 2021). Without the option for remote delivery of diabetes education, patients otherwise need to drive potentially hundreds of miles round-trip to receive diabetes care and education support. Insulin pumps also aren’t routinely uploaded in the primary care setting (O’Donovan et al., 2021). On a system level, utilizing diabetes RPM by providing insulin pump support between appointments benefits the PCP by assisting with the otherwise time-consuming burden of training staff to upload insulin pumps and generate reports. With RPM, the CDCES initiates the upload, interprets insulin pump device data, and sends results and recommendations to the provider outside of scheduled in-person appointments. Overall, this RPM project was feasible, usable, and had high satisfaction. Data uploads, interpretation, and patient/provider communication took an average of 1.5 hours per week for six weeks, including time recording the weekly educational videos. The CDCES was paid $30 per hour, so the total cost was roughly $270 to implement. The videos can be used again for future diabetes RPM groups, so costs will be less following the initial pilot program. The trade-offs of this cost include providing people with diabetes some assistance with their insulin pumps and communication with a diabetes healthcare professional to support them until they can see the CDCES and/or PCP in person. There were differences between observed and anticipated outcomes. It was anticipated that diabetes RPM would show an improvement in both diabetes-related distress and diabetes knowledge scores. One main reason for not seeing improvements in both categories was likely the small sample size. 19 Six people began the program, but only five completed all six weeks with completion of the pre- and post-intervention surveys. Similar to our study retention rate of 83%, a systematic literature review by Lepard et al. (2015) found that average retention for diabetes self-management interventions in rural areas was 80% for remote delivery compared to 72% for in-person delivery. This high retention rate suggests that once individuals were in the program, they were interested in staying with the program. Limitations The small sample size can be attributed to methods used for recruiting participants. The diabetes RPM program was not widely known and potential enrollees may not have understood the potential personal impact of the six-week intervention when first contacted about participation. Additionally, only participants who had a primary care provider with UBH were invited. There are many other primary care providers throughout Duchesne, Uintah, and Daggett Counties who likely have patients with diabetes utilizing insulin pumps. Another reason for the small sample size was timing of the intervention which took place over the Thanksgiving, Christmas, and New Year’s holidays due to time constraints of the CDCES facilitating the program. Participants were also not invited if they had PCPs who seldom prescribed insulin pumps. This is a future opportunity to affect participants that might have the highest need. Because of the small sample size, only descriptive statistics could be used. The project also only focused on adults with diabetes utilizing insulin pumps, so it is unknown if those with diabetes without insulin pumps would have benefited similarly or would have had greater improvements in pre- and postintervention survey data. Additionally, the entire sample was comprised of White adults, which may affect the generalizability of the study to other ethnic groups. The pre- and post-intervention survey results were paired but remained anonymous to the CDCES so it was not possible to identify which individuals completed the post-intervention surveys. As a result, the CDCES could not identify those who had not completed all of the post-intervention surveys. This led to many gaps in post-intervention data. In an effort to minimize and adjust for limitations, all participants were contacted with a reminder to complete the post-intervention surveys. 20 Conclusions This diabetes RPM project was useful in providing diabetes education and insulin pump support to people with diabetes in Uintah, Duchesne, and Daggett Counties in rural Utah. The virtual platform was also useful to the CDCES facilitating the program because it was asynchronous and the timing of data interpretation was flexible. The high retention rate also indicated interest when a participant was enrolled in the program. The facilitators of this project include an identified process to assist patients in setting up electronic patient portal and insulin pump upload accounts. There is an intent to continue this project in the future, and UBH does have the resources to implement and support this project with its accredited Diabetes Self-Management Education & Training (DSME/T) program. The clinic manager expressed an interest in implementing the recommended next steps in this project, including a refinement of the RPM program. The UBH clinic has the resources to support the project because the videos have been developed and there are existing RPM billing codes that can be used to financially support the program. The next steps are to implement a second cohort for the UBH diabetes RPM program. There were several people with diabetes identified in the program’s initial enrollment period who were interested in participating but were unable to due to timing reasons. Positive feedback from participants and PCPs was received in support of conducing another round of diabetes RPM within the UBH system. Additionally, this program could be conducted in another rural primary care setting to improve availability of diabetes support services for people using insulin pumps. It could also be used in the same rural setting for people with diabetes who do not use insulin pumps. Remote delivery of diabetes education could be particularly helpful for people with newly-diagnosed type 1 or type 2 diabetes or for those who have had diabetes for years but need a refresher on diabetes management recommendations. This virtual program could also be useful for women with gestational diabetes who need to very carefully monitor their glucose levels throughout their pregnancies. Because of this diabetes RPM program, healthcare providers at UBH can have better objective data for managing their patients’ diabetes. They would otherwise need to rely on patients’ historian skills 21 to understand glycemic patterns since they do not download data from insulin pumps or CGM routinely. With objective data, PCPs are more aware of patients’ challenges with managing diabetes. More study is needed in a larger sample to determine if there is improvement in HbA1c, time-in-range, and psychosocial outcomes. Acknowledgements We thank our colleague, Dr. Laura Shane-McWhorter, who supported this project by providing insight and expertise on remote patient monitoring and diabetes care and education. 22 References Association of Diabetes Care & Education Specialists (2021). The ADCES7 self-care behaviors: The framework for optimal self-management. Retrieved from https://www.diabeteseducator.org/practice/practice-tools/app-resources/the-aade7-self-carebehaviors-the-framework-for-optimal-self-management Berget, C., Messer, L. H. & Forlenza, G. P. (2019). A clinical overview of insulin pump therapy for the management of diabetes: Past, present, and future of intensive therapy. Diabetes Spectrum, 32(3), 194-204. https://doi.org/10.2337/ds18-0091 Carlson, A. L., Martens, T. W., Johnson, L., & Criego, A. B. (2021). Continuous glucose monitoring integration for remote diabetes management: Virtual diabetes care with case studies. Diabetes Technology & Therapeutics, 23(Suppl. 3), S56-S65. Center for Connected Health Policy (2021). Medicaid & Medicare: Remote patient monitoring. https://www.cchpca.org/topic/remote-patient-monitoring/ Centers for Disease Control & Prevention (2020a). Diagnosed diabetes: United States diabetes surveillance system. Division of Diabetes Translation. https://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html# Centers for Disease Control & Prevention (2020b). National diabetes statistics report, 2020. 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J., & Egede, L. E. (2020). Differential relationships between diabetes knowledge scales and diabetes outcomes. Diabetes Educator, 43(4), 360-366. doi: 10.1177/0145721717713316 Fisher, L., Polonsky, W. H., Hessler, D. M., Masharani, U., Blumer, I., Peters, A. L., Strycker, L. A. & Bowyer, V. (2015). Understanding the sources of diabetes distress in adults with type 1 diabetes. Journal of Diabetes Complications, 29(4), 572-577. doi: 10.1016/j.jdiacomp.2015.01.012 Fitzgerald, J. T., Funnell, M. M., Anderson, R. M., Nwanko, R., Stansfield, R. B., & Piatt, G. A. (2016). Validation of the revised brief diabetes knowledge test (DKT2). The Diabetes Educator, 42(2), 178-187. doi: 10.1177/0145721715624968 Greenwood, D. A., Litchman, M. L, & Isaacs, D. (2021). A new taxonomy for technology-enabled diabetes self-management interventions: Results of an umbrella review. https://journals.sagepub.com/doi/abs/10.1177/19322968211036430?forwardService=showFullTe xt&tokenAccess=X5ERBBKVYXGIV2BMZJ2S&tokenDomain=default+domain&journalCode= dsta Knowles, M. S. (1970). The modern practice of adult education: From pedagogy to andragogy. Retrieved from http://www.colllearning.info/wp-content/uploads/2019/03/The-Modern-Practice-of-AdultEducation.pdf Krieg, P. (2021). How do I connect my Omnipod DASH Cloud account to Glooko Lepard, M. G., Joseph, A. L., Agne, A. A., & Cherrington, A. L. (2015). Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: A systematic literature review. Current Diabetes Reports, 15(6), 608. doi: 10.1007/s11892-015-0608-3 24 Martens, T. W., Simonson, G. D., Carlson, A. L., & Bergenstal, R. M. (2021). Primary care and diabetes technologies and treatments. Diabetes Technology & Therapeutics, 23(S2). https://doi.org/10.1089/dia.2021.2510 Michaud, T. L., Siahpush, M., Schwab, R. J., Eiland, L. A., Devany, M., Hansen, G., Slachetka, T. S., Boilesen, E., Tak, H. J., Wilson, F. A., Wang, H., Pagan, J., A., & Su, D. (2018). Remote patient monitoring and clinical outcomes for postdischarge patients with type 2 diabetes. Population Health Management, 21(5), 387-394. doi: 10.1089/pop.2017.0175 National Kidney Foundation (2000). Diabetes and your eyes, heart, nerves, feet, and kidneys. https://www.kidney.org/atoz/content/Diabetes-and-Your-Eyes-Heart-Nerves-Feet-and-Kidneys O’Donovan, A., Oser, S. M., Parascando, J., Berg, A., Nease, D. E., & Oser, T. K. (2021). Determining the perception and willingness of primary care providers to prescribe advanced diabetes technologies. Journal of Patient-Centered Research and Reviews, 8(3), 272-276. doi: 10.17294/2330-0698.1819 Office of Disease Prevention and Health Promotion (n.d). Healthy People 2030: Increase the proportion of people with diabetes who get formal diabetes education. https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes/increaseproportion-people-diabetes-who-get-formal-diabetes-education-d-06 Sanchez, L. M. & Cooknell, L. E. (2017). The power of 3: Using adult learning principles to facilitate patient education. Nursing, 47(2), 17-19, 10.1097/01.NURSE.0000511819.18774.85 Schmitz, K. (2020). CareLink software is getting a refresh! Retrieved from https://www.medtronicdiabetes.com/loop-blog/carelink-software-is-getting-a-refresh/ Tandem Diabetes Care (2022). The t:connect mobile app. Retrieved from https://www.tandemdiabetes.com/providers/products/tconnect-mobile-app Uintah Basin Healthcare (2020). Uintah Basin Healthcare Anniversary Publication. Retrieved from https://ubh.org/wp-content/uploads/sites/534/2019/08/UBH_AnniversaryPublication50.pdf Uintah Basin Healthcare (2021). Uintah Basin Healthcare Services. Retrieved from https://ubh.org/ 25 United States Census Bureau (2021). QuickFacts: Daggett County, Utah; Duchesne County, Utah; Uintah County, Utah. Retrieved from https://www.census.gov/quickfacts/fact/table/daggettcountyutah,duchesnecountyutah,uintahcount yutah/PST045221 Utah Department of Health (2018). Rural health clinics. Retrieved from https://ruralhealth.health.utah.gov/resources/rural-health-clinics/ 26 Tables and Figures Table 1 Participant Demographics Characteristic N % Age, years 30 – 39 years 1 16.7% 40 – 49 years 2 33.3% 50 – 59 years 2 33.3% 60 – 69 years 1 16.7% Female 5 83.3% Male 1 16.7% White 6 100% M SD 49.5 ± 11.9 15.3 ± 11.2 1.8 ± 1.6 Sex Race Diabetes duration, years 5 – 10 years 3 50% 11 – 20 years 2 33.3% > 20 years 1 16.7% Medtronic 2 33.3% Tandem 2 33.3% Omnipod 2 33.3% Insulin pump type Insulin pump usage, years Diabetes type Type 1 2 33.3% Type 2 4 66.7% 27 Table 2 Psychological and Behavioral Measures of Participants with Diabetes Characteristic Type 1 Diabetes Distress Scale Pre-Intervention Post-Intervention (N = 5) (N = 5) 2.2 ± 0.30 2.1 ± 0.74 Powerlessness 3.36 ± 0.68 2.72 ± 1.12 Management distress 2.35 ± 0.96 2.6 ± 1.26 Hypoglycemia distress 1.85 ± 0.80 2 ± 0.81 Negative social perceptions 1.85 ± 0.72 1.75 ± 0.88 Eating distress 3.33 ± 0.78 2.87 ± 1.28 Physician distress 1.5 ± 0.50 1.55 ± 0.57 Friend/family distress 1.35 ± 0.65 1.35 ± 0.34 28 Table 3 Diabetes Knowledge Scores of Participants with Diabetes Characteristic Revised Brief Diabetes Knowledge Test General Test Insulin use subscale Pre-Intervention Post-intervention (N = 4) (N = 4) 19.25/23 ± 2.63 19.25/23 ± 1.71 83.7% 83.7% 11.5/14 ± 2.38 12.25/14 ± 1.26 82.1% 87.5% 7.75/9 ± 1.89 7/9 ± 1.63 86.1% 77.8% Table 4 Post-Intervention Treatment Satisfaction Diabetes Treatment Satisfaction Questionnaire Participant 1 Participant 2 M (N = 1) (N = 1) (N = 2) Factor 1: Satisfaction 28/36 35/36 31.5/36 ± 5.0 (Questions 1, 4, 5, 6, 7, and 8) 77.8% 97.2% 87.5% Factor 2: Burden of hypo- and hyperglycemia 8/12 8/12 8/12 ± 0 (Questions 2 and 3) 66.7% 66.7% 66.7% 29 Figure 1 Weekly Educational Content Week 1: Welcome to RPM; Healthy Coping Week 2: Healthy Eating Week 3: Being Active Week 4: Taking Medication; Monitoring • Recognizing and managing diabetes burnout • Extended bolus feature • Carb-counting tips for eating out • Managing holiday eating • Temporary basal rates for exercise • Rapid-acting insulins (onset, peak, duration) • BG targets and HbA1c recommendations Week 5: Problem Solving • Diabetes and emergency preparedness • Infusion set troubleshooting • Sick day management Week 6: Reducing Risks • Annual labs, vaccines • Annual visit with ophthalmologist, podiatrist • Daily foot check 30 Figure 2 Consolidated Standards of Reporting Trials diagram Assessed for Eligibility among Patients from 12 Pump-Prescribing PCPs (n = 41) Patients excluded from 7 lowest pumpprescribing PCPs (n = 12) PCP excluded patients if wellmanaged without need for RPM (n = 4) Patients from 5 Highest PumpPrescribing PCPs (n = 29) Patients Recommended by PCP (n = 23) No PCP Response (n =2) Unable to contact (n = 7) Lack of Time/Not Interested (n = 5) Contacted (n = 16) Lack of Technology/Home Internet Requirements (n = 5) Enrolled (n = 6) 31 Appendix A Type 1 Diabetes Distress Scale (T1-DDS) DIRECTIONS: Living with diabetes can sometimes be tough. There may be many problems and hassles concerning diabetes and they can vary greatly in severity. Problems may range from minor hassles to major life difficulties. Listed below are 28 potential problem areas that people with diabetes may experience. Consider the degree to which each of the 28 items may have distressed or bothered you DURING THE PAST MONTH and select that appropriate number. Please note that we are asking you to indicate the degree to which each item may be bothering you in your life, NOT whether the item is merely true for you. If you feel that a particular item is not a bother or a problem for you, you would select "1". If it is very bothersome to you, you might select "6". 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Feeling that I am not as skilled at managing diabetes as I should be Feeling that I don’t eat as carefully as I probably should Feeling that I don’t notice the warning signs of hypoglycemia as well as I used to Feeling that people treat me differently when they find out I have diabetes Feeling discouraged when I see high blood glucose numbers that I can’t explain Feeling that my family and friends make a bigger deal out of my diabetes than they should Feeling that I can’t tell my diabetes doctor what is really on my mind Feeling that I am not taking as much insulin as I should Feeling that there is too much diabetes equipment and stuff I must always have with me Feeling like I have to hide my diabetes around other people Feeling that my friends and family worry more about hypoglycemia than I want them to Feeling that I don’t check my blood glucose level as often as I probably should Feeling worried that I will develop serious long-term complications, no matter how hard I try Feeling that I don’t get help I really need from my diabetes doctor about managing diabetes Feeling frightened that I could have a serious hypoglycemic event when I’m asleep Feeling that thoughts about food and eating control my life Feeling that my diabetes doctor doesn’t really understand what it’s like to have diabetes Feeling that my friends or family treat me as if I were more fragile or sicker than I really am Feeling concerned that diabetes may make me less attractive to employers Feeling that my friends or family act like “diabetes police” (bother me too much) Feeling that I’ve got to be perfect with my diabetes management Feeling frightened that I could have a serious hypoglycemic event while driving Feeling that my eating is out of control Feeling that people will think less of me if they knew I had diabetes Feeling that no matter how hard I try with my diabetes, it will never be good enough Feeling that my diabetes doctor doesn’t know enough about diabetes and diabetes care Feeling that I can’t ever be safe from the possibility of a serious hypoglycemic event Feeling that I don’t give my diabetes as much attention as I probably should Revised Brief Diabetes Knowledge Test (DKT2) 1. The diabetes diet is: a. The way most American people eat b. A healthy diet for most people* 32 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. c. Too high in carbohydrate for most people d. Too high in protein for most people Which of the following is highest in carbohydrate? a. Baked chicken b. Swiss cheese c. Baked potato* d. Peanut butter Which of the following is highest in fat? a. Low fat (2%) milk* b. Orange juice c. Corn d. Honey Which of the following is a “free food”? a. Any unsweetened food b. Any food that has “fat free” on the label c. Any food that has “sugar free” on the label d. Any food that has less than 20 calories per serving* A1C is a measure of your average blood glucose level for the past: a. Day b. Week c. 6-12 weeks* d. 6 months Which is the best method for home glucose testing? a. Urine testing b. Blood testing* c. Both are equally good What effect does unsweetened fruit juice have on blood glucose? a. Lowers it b. Raises it* c. Has no effect Which should not be used to treat a low blood glucose? a. 3 hard candies b. ½ cup orange juice c. 1 cup diet soft drink* d. 1 cup skim milk For a person in good control, what effect does exercise have on blood glucose? a. Lowers it* b. Raises it c. Has no effect What effect will an infection most likely have on blood glucose? a. Lowers it b. Raises it* c. Has no effect The best way to take care of your feet is to: a. Look at and wash them each day* b. Massage them with alcohol each day c. Soak them for 1 hour each day 33 12. 13. 14. 15. 16. 17. 18. 19. 20. d. Buy shoes a size larger than usual Eating foods lower in fat decreases your risk for: a. Nerve disease b. Kidney disease c. Heart disease* d. Eye disease Numbness and tingling may be symptoms of: a. Kidney disease b. Nerve disease* c. Eye disease d. Liver disease Which of the following is usually not associated with diabetes? a. Vision problems b. Kidney problems c. Nerve problems d. Lung problems* Signs of ketoacidosis (DKA) include: a. Shakiness b. Sweatiness c. Vomiting* d. Low blood glucose If you are sick with the flu, you should: a. Take less insulin b. Drink less liquids c. Eat more proteins d. Test blood glucose more often* If you have taken rapid-acting insulin, you are most likely to have a low blood glucose reaction in: a. Less than 2 hours* b. 3-5 hours c. 6-12 hours d. More than 13 hours You realize just before lunch that you forgot to take your insulin at breakfast. What should you do now? a. Skip lunch to lower your blood glucose b. Take the insulin that you usually take at breakfast c. Take twice as much insulin as you usually take at breakfast d. Check your blood glucose level to decide how much insulin to take* If you are beginning to have a low blood glucose reaction, you should: a. Exercise b. Lie down and rest c. Drink some juice* d. Take rapid-acting insulin A low blood glucose reaction may be caused by: a. Too much insulin* b. Too little insulin c. Too much food 34 d. Too little exercise 21. If you take your morning insulin but skip breakfast, your blood glucose level will usually: a. Increase b. Decrease* c. Remain the same 22. High blood glucose may be caused by: a. Not enough insulin* b. Skipping meals c. Delaying your snack d. Skipping your exercise 23. A low blood glucose reaction may be caused by: a. Heavy exercise* b. Infection c. Overeating d. Not taking your insulin 35 Appendix B Diabetes Treatment Satisfaction Questionnaire (DTSQ) The following questions are concerned with the Diabetes Remote Patient Monitoring Program and your experience over the past six weeks. Please rate your satisfaction on a scale of 1 to 6, with 1 being extremely unsatisfied and 6 being extremely satisfied. 1. How satisfied are you with your current treatment (Diabetes Remote Patient Monitoring)? 2. How often have you felt that your blood sugars have been unacceptably high recently? 3. How often have you felt your blood sugars have been unacceptably low recently? 4. How convenient have you been finding your treatment (Diabetes Remote Patient Monitoring) to be recently? 5. How flexible have you been finding your treatment (Diabetes Remote Patient Monitoring) to be recently? 6. How satisfied are you with your understanding of diabetes? 7. Would you recommend this form of treatment (Diabetes Remote Patient Monitoring) to someone else with your kind of diabetes? 8. How satisfied would you be to continue with your present form of treatment (Diabetes Remote Patient Monitoring)? Rural Health Free-Response Feedback Survey People in rural communities often have less access to specialized healthcare. Please provide your comments below about how this Diabetes Remote Patient Monitoring Program increases access to healthcare for people in rural communities. 1. How does this Diabetes Remote Patient Monitoring program improve healthcare for people in rural communities? 2. Did this Diabetes Remote Patient Monitoring program help you improve health behaviors? Please explain. 3. What did you like the most about this Diabetes Remote Patient Monitoring program? 36 4. What did you like the least about this Diabetes Remote Patient Monitoring program? 5. What suggestions do you have to improve this Diabetes Remote Patient Monitoring program?