Achieving Chronic Care Equity by Leveraging the Telehealth Ecosystem (ACCTIVATE): A Multilevel Randomized Controlled Trial Protocol
Main Article Content
Abstract
Background: Racial/ethnic and socioeconomic disparities in diabetes and hypertension outcomes persist in the United States (U.S.), and worsened during the COVID-19 pandemic. This was in part due to suboptimal implementation of telehealth in U.S. safety-net settings alongside the pre-existing “digital divide” – structural determinants that limit access to digital tools by marginalized communities. To improve health equity, it is critical that health systems in the U.S. integrate principles of digital and health literacy for more equitable chronic disease care.
Methods: We are conducting a 2x2 factorial randomized controlled trial, in partnership with a Community Advisory Board, assessing a multi-level intervention addressing barriers that affect the equitable use of telehealth amongst low-income patients in San Francisco County. Patient-level support is provided through the evidence-based strategies of health coaching and digital navigation (“digital coaching”); clinic-level support includes equity dashboards, patient advisory councils, and practice facilitation. We are randomizing 600 low-income, racially/ethnically diverse English and Spanish-speaking patients with uncontrolled diabetes to receive digital coaching (n=200) vs. usual care (n=400) for 3 months; and 11 public health primary care clinics to clinic support vs. usual care for 24 months. We aim to evaluate the impact of patient and clinic level interventions to determine individual effectiveness and potential synergistic impact on clinical and process measures related to diabetes and telehealth outcomes.
Results: The study's primary clinical outcome is change in patient-level Hemoglobin A1C (A1c); the primary process outcome is patient portal usage. Secondary clinical outcomes include changes in patient-level systolic blood pressure (SBP) and microalbuminuria (UACR), and changes in clinic-level A1c, SBP, and UACR. Secondary process outcomes assess patient-level changes in digital literacy, medication adherence, patient activation, and visit show rates, and clinic-level measures of telehealth adoption.
Discussion: The ACCTiVATE trial tests a multi-level intervention developed through a stakeholder-engaged research approach and user-centered design to be feasible and acceptable for impacted communities. If efficacious, ACCTiVATE may provide a scalable model to improve chronic health outcomes and telehealth equity among marginalized racial/ethnic populations experiencing structural and interpersonal access barriers.
Article Details
How to Cite
OMOMUKUYO, Adenike et al.
Achieving Chronic Care Equity by Leveraging the Telehealth Ecosystem (ACCTIVATE): A Multilevel Randomized Controlled Trial Protocol.
Medical Research Archives, [S.l.], v. 12, n. 11, nov. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6087>. Date accessed: 12 dec. 2024.
doi: https://doi.org/10.18103/mra.v12i11.6087.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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5. Grotto I, Huerta M, Sharabi Y. Hypertension and socioeconomic status. Curr Opin Cardiol. 2008;23(4):335-339. doi:10.1097/HCO.0b013e3283021c70
6. Meng YY, Diamant A, Jones J, et al. Racial and Ethnic Disparities in Diabetes Care and Impact of Vendor-Based Disease Management Programs. Diabetes Care. 2016;39(5):743-749. doi:10.2337/dc15-1323
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13. Chudasama YV, Gillies CL, Zaccardi F, et al. Impact of COVID-19 on routine care for chronic diseases: A global survey of views from healthcare professionals. Diabetes Metab Syndr. 2020;14(5):965-967. doi:10.1016/j.dsx.2020.06.042
14. Patel SY, Mehrotra A, Huskamp HA, Uscher-Pines L, Ganguli I, Barnett ML. Variation In Telemedicine Use And Outpatient Care During The COVID-19 Pandemic In The United States. Health Aff Proj Hope. 2021;40(2):349-358. doi:10.1377/hlthaff.2020.01786
15. Uscher-Pines L, Sousa J, Jones M, et al. Telehealth use among safety-net organizations in California during the COVID-19 pandemic. JAMA. 2021;325(11):1106-1107. doi:10.1001/jama.2021.0282
16. Ackerman SL, Sarkar U, Tieu L, et al. Meaningful use in the safety net: a rapid ethnography of patient portal implementation at five community health centers in California. J Am Med Inform Assoc JAMIA. 2017;24(5):903-912. doi:10.1093/jamia/ocx015
17. Remote Patient Monitoring in the Safety Net: What Payers and Providers Need to Know.
18. Khoong EC, Olazo K, Rivadeneira NA, et al. Mobile health strategies for blood pressure self-management in urban populations with digital barriers: systematic review and meta-analyses. Npj Digit Med. 2021;4(1):1-12. doi:10.1038/s41746-021-00486-5
19. Bray EP, Holder R, Mant J, McManus RJ. Does self-monitoring reduce blood pressure? Meta-analysis with meta-regression of randomized controlled trials. Ann Med. 2010;42(5):371-386. doi:10.3109/07853890.2010.489567
20. Mobile Fact Sheet. Pew Research Center. January 31, 2024. Accessed September 4, 2024. https://www.pewresearch.org/internet/fact-sheet/mobile/
21. Lopez AB Gustavo López and Mark Hugo. Digital Divide Narrows for Latinos as More Spanish Speakers and Immigrants Go Online. Pew Research Center. July 20, 2016. Accessed September 4, 2024. https://www.pewresearch.org/race-and-ethnicity/2016/07/20/digital-divide-narrows-for-latinos-as-more-spanish-speakers-and-immigrants-go-online/
22. Khoong EC, Butler BA, Mesina O, et al. Patient interest in and barriers to telemedicine video visits in a multilingual urban safety-net system. J Am Med Inform Assoc JAMIA. 2021;28(2):349-353. doi:10.1093/jamia/ocaa234
23. Tieu L, Schillinger D, Sarkar U, et al. Online patient websites for electronic health record access among vulnerable populations: portals to nowhere? J Am Med Inform Assoc JAMIA. 2017;24(e1):e47-e54. doi:10.1093/jamia/ocw098
24. Tieu L, Sarkar U, Schillinger D, et al. Barriers and Facilitators to Online Portal Use Among Patients and Caregivers in a Safety Net Health Care System: A Qualitative Study. J Med Internet Res. 2015;17(12):e275. doi:10.2196/jmir.4847
25. Alkureishi MA, Choo ZY, Rahman A, et al. Digitally Disconnected: Qualitative Study of Patient Perspectives on the Digital Divide and Potential Solutions. JMIR Hum Factors. 2021;8(4):e33364. doi:10.2196/33364
26. Jain V, Al Rifai M, Lee MT, et al. Racial and Geographic Disparities in Internet Use in the U.S. Among Patients With Hypertension or Diabetes: Implications for Telehealth in the Era of COVID-19. Diabetes Care. 2021;44(1):e15-e17. doi:10.2337/dc20-2016
27. Sharma AE, Khoong EC, Sierra M, et al. System-Level Factors Associated With Telephone and Video Visit Use: Survey of Safety-Net Clinicians During the Early Phase of the COVID-19 Pandemic. JMIR Form Res. 2022;6(3):e34088. doi:10.2196/34088
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