TELEHEALTH: Encouraging Patient-Centered Communication in Clinical Video Telehealth Visits

• Sponsor: VA Office of Research and Development (U.S. Fed)
• Overall Status: Completed
• CT.gov ID: NCT02522494
• Collaborator: (none)
• Enrollment: 102
• Locations: 3
• Arms: 2
• Actual Duration (Months): 45
• Patients Per Site: 34
• Patients Per Site Per Month: 0.8

Study Details

Study Description

Brief Summary

Diabetes is common, it is expensive, and it is a chronic condition. Estimates put the prevalence of diabetes at almost 20 percent in VA patients. Poorly controlled diabetes leads to a number of complications including cardiovascular disease, blindness, amputation, and end stage renal disease. Adherence to medication regimens (as well as lifestyle factors such as diet and exercise) is important to achieve diabetes care goals. Adherence to recommended care is related at least in part to effective communication in medical encounters. This project is designed to test a video intervention to improve patients' communication behaviors. Providers will also receive a pamphlet with specific recommendation to improve communication skills. The project will assess the impact of the training programs on communication and outcomes. The study is designed to help make patient care more patient-centered, which is one of the six aims for improvement in the IOM Report, Crossing the Quality Chasm and is a goal of VA transformation efforts.

Condition or Disease	Intervention/Treatment	Phase
Diabetes Mellitus	Behavioral: Pamphlet; Behavioral: Video	N/A

Detailed Description

Background: Clinical video telehealth (CVT) offers the opportunity for more efficient access to high quality primary and specialist care for Veterans. Enthusiasm for CVT is especially high in the VA given geographical separation between many Veterans and their providers at VA Medical Centers. However, because CVT encounters are by nature less personal than in-person visits, communication during CVT visits may be more challenging for both patients and providers resulting in less patient-centered communication. Less personal visits may have less exchange of information, lower satisfaction, less trust, and poorer outcomes. Indeed, research comparing CVT with in-person consultations found that patients in CVT visits were more passive and that CVT interactions were dominated by providers when compared with in-person visits.

This project will leverage prior work from two HSR&D-funded pilot projects to improve provider - patient communication for Veterans with type 2 diabetes mellitus. In a short-term project, SHP-08-182, the investigators conducted focus groups to elicit and understand patients' barriers to communicating with their providers. This qualitative work was used in a subsequent pilot project, PPO-08-402 to develop an educational video to encourage Veterans to use active participatory communication in their visits to providers. This work was successfully completed and the product is a 10-minute video that, in testing, was found to be acceptable and feasible to show to VA patients immediately preceding their medical encounters.

Objectives: The investigators goal in this project is develop and test a video intervention and to also develop pamphlets for patients and providers to encourage active and positive communication in CVT medical interactions. The investigators goal was developed with and is supported by the project's operational partner the Office of Telehealth Services and is integral to the goal to ensure patient-centered care in new models of care. Patient-centered communication in medical interactions is critical and plays an important, but often overlooked, role in the delivery of health services.

There are two aims. First, the investigators will develop educational interventions to encourage patients and providers to use active communication behaviors during CVT visits. Second, the investigators will conduct a randomized trial of the video and pamphlet (intervention) vs. pamphlet alone (comparison) in a two-arm randomized effectiveness trial. The investigators will evaluate for improvement in visit outcomes including patient and provider measures of patient-centered care and communication, reduction in several common barriers to clinical improvement, and improved medication adherence measures and hemoglobin A1c. In addition, the investigators will assess the mediators and moderators of the relationship of the intervention condition to outcomes.

Methods: The project will have two phases. In the initial phase of the proposed project the investigators will develop the video intervention. Video development will include qualitative interviews with stakeholders and patients regarding CVT barriers and perceived benefits. The investigators will use several existing resources and an expert panel of co-investigators and consultants to bring these elements together and produce the intervention. In phase 2 the investigators will conduct a randomized trial of the intervention, evaluating for improvement in a number of outcomes.

Impacts: The educational tools will be deliverables that could be used prior to CVT visits to improve communication and could serve as a paradigm for developing communication aids for other medical conditions and other clinical settings. The investigators will evaluate whether the educational intervention will help improve communication and will be associated with better visit and intermediate outcomes. Educational tools that encourage more patient-centered communication during CVT encounters may allow more rapid acceptance of CVT, thereby improving access to healthcare and enhancing the operational mission of the project's partner.

Study Design

• Study Type: Interventional
• Actual Enrollment: 102 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Double (Care Provider, Outcomes Assessor)
• Primary Purpose: Health Services Research
• Official Title: Encouraging Patient-Centered Communication in Clinical Video Telehealth Visits
• Actual Study Start Date: Jul 1, 2016
• Actual Primary Completion Date: Dec 31, 2019
• Actual Study Completion Date: Mar 31, 2020

Arms and Interventions

Arm	Intervention/Treatment
Active Comparator: Intervention Patients randomized to the intervention will view the video	Behavioral: Pamphlet; An educational intervention delivered prior to patients' visits with primary care physicians.; Other Names: Speak Up for Telehealth ; Behavioral: Video; An educational intervention delivered prior to patients' visits with primary care providers.; Other Names: Speak Up Video for Telehealth
Other: Pamphlet alone Patients randomized to the pamphlet alone will only receive the pamphlet	Behavioral: Pamphlet; An educational intervention delivered prior to patients' visits with primary care physicians.; Other Names: Speak Up for Telehealth

Outcome Measures

Primary Outcome Measures

1. HgbA1c [At the baseline (Pre-CVT visit interview) and post-intervention (Post-CVT visit interview). All available values were restricted to one year before Baseline (Pre-Visit Interview) and from 30 days to 6 months past Post-CVT visit Interview.]

   HgbA1c is regarded as the standard laboratory measurement (blood test) for assessing the control of diabetes over approximately three months preceding the test. HgbA1c is usually checked several times a year in patients with poorly controlled diabetes.

2. Communication Self-efficacy [At the baseline (Pre-CVT visit interview) and post-intervention (interview within one week past CVT visit)]

   Communication Self-Efficacy (pre and post visit) is the degree to which a patient feels able to interact with his/her provider in order to provide information about problems, obtain desired information about diagnosis, treatment and prognosis, and participate in formulating a plan. The Perceived Efficacy in Physician-Patient Interactions scale (PEPPI) is a valid and reliable measure of patients' perceived self-efficacy in interacting with physicians (alpha 0.83). The short form of the PEPPI (PEPPI-5) has 5-items. Score on the PEPPI-5 ranges from 5-25. Higher scores reflect a better perceived self-efficacy in interacting with physicians.

3. Consultation Care Measure (CCM) [post-intervention (interview within 1 week after CVT visit)]

   Consultation Care Measure (CCM) assesses patient-centered care and patient-centered communication. Patients rate such factors as their providers' (1) communication and partnership, (2) personal relationship, (3) health promotion, (4) positive and clear approach to problem, (5) interest in effect on life on a 21-item scale, each item scores from 1 (strongly disagree) to 5 (strongly agree). Scores can range from 21 to 105. The higher scores mean a better patients' experiences with their provider.

4. Adherence (Self-reported) [4 weeks after the CVT visit]

   Self-reported adherence is measured using a brief questionnaire - a general measure of adherence to providers' recommendations and includes 5 items and is scored on a 6-level Likert-type scale ranging from "none of the time" to "all of the time". Scores range from 0-100 (after normalizing the standard 6-30 range) with higher numbers reflecting better adherence. Adherence using this measure is assessed with a brief telephone survey 4 weeks following the visit.

5. Medication Adherence (MPR) [6 months]

   Medication adherence will be assessed with a medication possession ratio (MPR) for diabetes medications.

6. Adherence at 1 Year [1 year]

   Medication adherence will be assessed with a medication possession ratio (MPR) for diabetes medications.

7. Consultation and Relational Empathy (CARE) [Post-intervention (interview within one week past CVT visit)]

   Consultation and Relational Empathy (CARE) Measure - is a tool for measuring patients' perceptions of relational empathy in the consultation. In this 10-item questionnaire patients rate the statements about their doctor's understanding their concern, showing care, and etc. during the recent CVT visit on a scale from 1 to 5 where 1 is "poor" and 5 is "excellent". Scores can range from 10 to 50. The higher score means a better patient's perception of empathy in consultation.

8. Communication Ratings [Post-intervention (interview within one week after CVT visit)]

   The questionnaire assesses patients' ratings of their own participatory communication behavior and patients' ratings of their providers' communication. It is a 15-item scale with 3 sub-scales. Patients' ratings of their (1) providers' informativeness and the extent to which the patient understands that information (information sub-scale) are measured with 5-items; (2) patients' ratings that the provider values and respects them is measured with 5-items; and (3) patients' ratings of their own communication is measured with 5-items. This questionnaire has high internal consistency. The scale is scored from 1 (completely disagree) to 7 (completely agree). The total scores range from 15 to 105. The higher scores indicate a better quality of communication.

9. Human Connection Scale [At the baseline (Pre-CVT visit interview) and post-intervention (Post-CVT visit interview)]

   Human Connection Scale is a 15-item questionnaire that measures the extent to which patient feel a sense of mutual understanding, caring, and trust with their physicians. The scale is a valid and reliable measure of therapeutic alliance between patients and their physicians. The score from 1 to 4 is used where 1 is "not at all" and 4 is "extremely". The scores range from 15 to 60. The higher scores indicate higher therapeutic alliance between patients and physicians.

10. Resistance to Treatment Questionnaire (RTQ) [4 weeks past CVT visit]

    Resistance to Treatment Questionnaire (RTQ) identifies the reasons for resistance to treatment and its intensity among patients with diabetes. 20-item questionnaire consists of four themes (lack of faith or dissatisfaction, emotional reasons, specific problems, factors connected to despair or failure) containing 5 items each; each item is scored from 1 (strongly disagree) to 5 (strongly agree). The scores range from 20 to 100. The higher scores mean more barriers to treatment (a worse outcome).

Secondary Outcome Measures

1. Trust in Provider Questionnaire [At the baseline (Pre-CVT visit interview) and post-intervention (interview within one week after CVT visit)]

   Trust in Provider is an important characteristic of provider-patient relationships and is assessed with a questionnaire. Trust is measured pre- and post-CVT visit using a 9-item measure. The scale is scored on a 7-point Likert scale using the anchors "strongly disagree" and "strongly agree". The scores range from 9 to 63. The higher scores mean a better trust in provider.

2. Patient Satisfaction [four weeks after CVT visit]

   Patient Satisfaction is assessed as the extent to which the patient is content with the relationship with her/his provider, in terms of the quality of information exchanged during medical encounters, and in terms of the demeanor of the provider toward the patient (courtesy, respectfulness, sensitivity, taking time and not being rushed). This is a 4-item survey, patient's satisfaction is scored from 1 (not at all satisfied) to 7 (extremely satisfied). The scores range from 5 to 35. The higher score indicates a better patient satisfaction.

3. Participatory Decision-Making [At the baseline (Pre-CVT visit interview) and post-intervention (Post-CVT visit interview)]

   Participatory Decision-Making Style represents the degree to which providers involve patients in decision making. We measure patients' ratings of providers' participatory decision-making style using a 4-item scale evaluated by Heisler et al. in a study of veterans with diabetes. The authors found it to be associated with better patient understanding of diabetes and self-management practices. The survey scores how often provider involves patient in decision-making on a scale from 1 to 5, where 1 is "none of the time" and 5 is "all of the time". Scores range from 4 to 20. Higher scores mean a better outcome.

4. Diabetes Self-Efficacy [At the baseline (Pre-CVT visit interview) and post-intervention (interview within one week after CVT visit)]

   The investigators used a 4-item scale to measure patients' confidence in their ability to manage their diabetes. The survey scores patients' perception of how well they can handle their diabetes on a scale from 1 to 7, where 1 is "not at all true" and 7 is "very true". The scores range from 4 to 28. The higher score is validated as a predictor of better glycemic control. The higher scores mean a better confidence in managing diabetes.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 18 Years and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Diagnosis of type 2 diabetes mellitus,

• Hemoglobin A1c not controlled,

• Adults,

• Age 18 or older

Exclusion Criteria:

• Dementia,

• Lives in skilled nursing facility,

• Terminal medical condition,

• Drug-induced diabetes,

• Blind or deaf.

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	Rocky Mountain Regional VA Medical Center, Aurora, CO	Aurora	Colorado	United States	80045
2	Jesse Brown VA Medical Center Community-Based Outpatient Clinic Lake Side Divison, Chicago, IL	Chicago	Illinois	United States	60611
3	Jesse Brown VA Medical Center, Chicago, IL	Chicago	Illinois	United States	60612

Sponsors and Collaborators

• VA Office of Research and Development

Investigators

• Principal Investigator: Howard S. Gordon, MD BS, Jesse Brown VA Medical Center, Chicago, IL

Study Documents (Full-Text)

• Study Protocol and Statistical Analysis Plan - Feb 5, 2019

More Information

Publications

None provided.

• Responsible Party: VA Office of Research and Development
• ClinicalTrials.gov Identifier: NCT02522494
• Other Study ID Numbers: SDR 12-282
• First Posted: Aug 13, 2015
• Last Update Posted: Aug 4, 2022
• Last Verified: Mar 1, 2022

• Individual Participant Data (IPD) Sharing Statement: No
• Plan to Share IPD: No
• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No
• Product Manufactured in and Exported from the U.S.: No

Study Results

Participant Flow

Recruitment Details	Total number of patients enrolled in randomized trial - 102.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Period Title: Overall Study
STARTED	51	51
Post-CVT Visit Interview	37	48
4-Week Follow Up	37	46
COMPLETED	37	46
NOT COMPLETED	14	5

Baseline Characteristics

Arm/Group Title	Intervention	Pamphlet Alone	Total
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.	Total of all reporting groups
Overall Participants	37	48	85
Age (Count of Participants)
<=18 years	0 0%	0 0%	0 0%
Between 18 and 65 years	13 35.1%	19 39.6%	32 37.6%
>=65 years	24 64.9%	29 60.4%	53 62.4%
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	65 (8.37)	65 (9.38)	65 (8.91)
Sex: Female, Male (Count of Participants)
Female	0 0%	2 4.2%	2 2.4%
Male	37 100%	46 95.8%	83 97.6%
Ethnicity (NIH/OMB) (Count of Participants)
Hispanic or Latino	12 32.4%	16 33.3%	28 32.9%
Not Hispanic or Latino	25 67.6%	31 64.6%	56 65.9%
Unknown or Not Reported	0 0%	1 2.1%	1 1.2%
Race (NIH/OMB) (Count of Participants)
American Indian or Alaska Native	4 10.8%	2 4.2%	6 7.1%
Asian	1 2.7%	0 0%	1 1.2%
Native Hawaiian or Other Pacific Islander	0 0%	1 2.1%	1 1.2%
Black or African American	0 0%	0 0%	0 0%
White	32 86.5%	45 93.8%	77 90.6%
More than one race	0 0%	0 0%	0 0%
Unknown or Not Reported	0 0%	0 0%	0 0%
Region of Enrollment (Count of Participants)
United States	37 100%	48 100%	85 100%

Outcome Measures

1. Primary Outcome

Title	HgbA1c
Description	HgbA1c is regarded as the standard laboratory measurement (blood test) for assessing the control of diabetes over approximately three months preceding the test. HgbA1c is usually checked several times a year in patients with poorly controlled diabetes.
Time Frame	At the baseline (Pre-CVT visit interview) and post-intervention (Post-CVT visit interview). All available values were restricted to one year before Baseline (Pre-Visit Interview) and from 30 days to 6 months past Post-CVT visit Interview.

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
pre-CVT visit	8.5 (1.76)	8.5 (1.20)
post-CVT visit	7.99 (1.28)	8.2 (1.26)

2. Primary Outcome

Title	Communication Self-efficacy
Description	Communication Self-Efficacy (pre and post visit) is the degree to which a patient feels able to interact with his/her provider in order to provide information about problems, obtain desired information about diagnosis, treatment and prognosis, and participate in formulating a plan. The Perceived Efficacy in Physician-Patient Interactions scale (PEPPI) is a valid and reliable measure of patients' perceived self-efficacy in interacting with physicians (alpha 0.83). The short form of the PEPPI (PEPPI-5) has 5-items. Score on the PEPPI-5 ranges from 5-25. Higher scores reflect a better perceived self-efficacy in interacting with physicians.
Time Frame	At the baseline (Pre-CVT visit interview) and post-intervention (interview within one week past CVT visit)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
pre-CVT visit	22.81 (4.61)	21.64 (5.94)
post-CVT visit	22.94 (4.76)	22.75 (5.89)

3. Primary Outcome

Title	Consultation Care Measure (CCM)
Description	Consultation Care Measure (CCM) assesses patient-centered care and patient-centered communication. Patients rate such factors as their providers' (1) communication and partnership, (2) personal relationship, (3) health promotion, (4) positive and clear approach to problem, (5) interest in effect on life on a 21-item scale, each item scores from 1 (strongly disagree) to 5 (strongly agree). Scores can range from 21 to 105. The higher scores mean a better patients' experiences with their provider.
Time Frame	post-intervention (interview within 1 week after CVT visit)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
Mean (Standard Deviation) [units on a scale]	90.22 (16.30)	84.08 (21.43)

4. Primary Outcome

Title	Adherence (Self-reported)
Description	Self-reported adherence is measured using a brief questionnaire - a general measure of adherence to providers' recommendations and includes 5 items and is scored on a 6-level Likert-type scale ranging from "none of the time" to "all of the time". Scores range from 0-100 (after normalizing the standard 6-30 range) with higher numbers reflecting better adherence. Adherence using this measure is assessed with a brief telephone survey 4 weeks following the visit.
Time Frame	4 weeks after the CVT visit

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
Mean (Standard Deviation) [units on a scale]	78.51 (21.53)	75.98 (26.43)

5. Primary Outcome

Title	Medication Adherence (MPR)
Description	Medication adherence will be assessed with a medication possession ratio (MPR) for diabetes medications.
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

The data was not collected because it was not possible to calculate useful medication possession ratios. Many patients in our study were on insulin which is a liquid and is not a unit dose. Further many patients take insulin on a sliding scale. Calculating the MPR was therefore not a useful measure in this study.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	0	0

6. Primary Outcome

Title	Adherence at 1 Year
Description	Medication adherence will be assessed with a medication possession ratio (MPR) for diabetes medications.
Time Frame	1 year

Outcome Measure Data

Analysis Population Description

The data was not collected because it was not possible to calculate useful medication possession ratios. Many patients in our study were on insulin which is a liquid and is not a unit dose. Further many patients take insulin on a sliding scale. Calculating the MPR was therefore not a useful measure in this study.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	0	0

7. Primary Outcome

Title	Consultation and Relational Empathy (CARE)
Description	Consultation and Relational Empathy (CARE) Measure - is a tool for measuring patients' perceptions of relational empathy in the consultation. In this 10-item questionnaire patients rate the statements about their doctor's understanding their concern, showing care, and etc. during the recent CVT visit on a scale from 1 to 5 where 1 is "poor" and 5 is "excellent". Scores can range from 10 to 50. The higher score means a better patient's perception of empathy in consultation.
Time Frame	Post-intervention (interview within one week past CVT visit)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
Mean (Standard Deviation) [units on a scale]	44.65 (7.75)	40.39 (10.73)

8. Primary Outcome

Title	Communication Ratings
Description	The questionnaire assesses patients' ratings of their own participatory communication behavior and patients' ratings of their providers' communication. It is a 15-item scale with 3 sub-scales. Patients' ratings of their (1) providers' informativeness and the extent to which the patient understands that information (information sub-scale) are measured with 5-items; (2) patients' ratings that the provider values and respects them is measured with 5-items; and (3) patients' ratings of their own communication is measured with 5-items. This questionnaire has high internal consistency. The scale is scored from 1 (completely disagree) to 7 (completely agree). The total scores range from 15 to 105. The higher scores indicate a better quality of communication.
Time Frame	Post-intervention (interview within one week after CVT visit)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
Mean (Standard Deviation) [units on a scale]	94.24 (13.54)	88.67 (18.55)

9. Primary Outcome

Title	Human Connection Scale
Description	Human Connection Scale is a 15-item questionnaire that measures the extent to which patient feel a sense of mutual understanding, caring, and trust with their physicians. The scale is a valid and reliable measure of therapeutic alliance between patients and their physicians. The score from 1 to 4 is used where 1 is "not at all" and 4 is "extremely". The scores range from 15 to 60. The higher scores indicate higher therapeutic alliance between patients and physicians.
Time Frame	At the baseline (Pre-CVT visit interview) and post-intervention (Post-CVT visit interview)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
pre-CVT visit	49.73 (13.19)	49.28 (12.05)
post-CVT visit	52.44 (10.63)	49.35 (12.77)

10. Primary Outcome

Title	Resistance to Treatment Questionnaire (RTQ)
Description	Resistance to Treatment Questionnaire (RTQ) identifies the reasons for resistance to treatment and its intensity among patients with diabetes. 20-item questionnaire consists of four themes (lack of faith or dissatisfaction, emotional reasons, specific problems, factors connected to despair or failure) containing 5 items each; each item is scored from 1 (strongly disagree) to 5 (strongly agree). The scores range from 20 to 100. The higher scores mean more barriers to treatment (a worse outcome).
Time Frame	4 weeks past CVT visit

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
Mean (Standard Deviation) [units on a scale]	42.59 (11.06)	45.13 (13.99)

11. Secondary Outcome

Title	Trust in Provider Questionnaire
Description	Trust in Provider is an important characteristic of provider-patient relationships and is assessed with a questionnaire. Trust is measured pre- and post-CVT visit using a 9-item measure. The scale is scored on a 7-point Likert scale using the anchors "strongly disagree" and "strongly agree". The scores range from 9 to 63. The higher scores mean a better trust in provider.
Time Frame	At the baseline (Pre-CVT visit interview) and post-intervention (interview within one week after CVT visit)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
pre-CVT visit	47.08 (14.63)	45.00 (15.16)
post-CVT visit	53.27 (8.88)	50.19 (11.76)

12. Secondary Outcome

Title	Patient Satisfaction
Description	Patient Satisfaction is assessed as the extent to which the patient is content with the relationship with her/his provider, in terms of the quality of information exchanged during medical encounters, and in terms of the demeanor of the provider toward the patient (courtesy, respectfulness, sensitivity, taking time and not being rushed). This is a 4-item survey, patient's satisfaction is scored from 1 (not at all satisfied) to 7 (extremely satisfied). The scores range from 5 to 35. The higher score indicates a better patient satisfaction.
Time Frame	four weeks after CVT visit

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
Mean (Standard Deviation) [units on a scale]	24.19 (3.98)	23.35 (5.45)

13. Secondary Outcome

Title	Participatory Decision-Making
Description	Participatory Decision-Making Style represents the degree to which providers involve patients in decision making. We measure patients' ratings of providers' participatory decision-making style using a 4-item scale evaluated by Heisler et al. in a study of veterans with diabetes. The authors found it to be associated with better patient understanding of diabetes and self-management practices. The survey scores how often provider involves patient in decision-making on a scale from 1 to 5, where 1 is "none of the time" and 5 is "all of the time". Scores range from 4 to 20. Higher scores mean a better outcome.
Time Frame	At the baseline (Pre-CVT visit interview) and post-intervention (Post-CVT visit interview)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
pre-CVT visit	16.68 (4.45)	15.34 (5.34)
post-CVT visit	17.15 (4.76)	15.06 (5.10)

14. Secondary Outcome

Title	Diabetes Self-Efficacy
Description	The investigators used a 4-item scale to measure patients' confidence in their ability to manage their diabetes. The survey scores patients' perception of how well they can handle their diabetes on a scale from 1 to 7, where 1 is "not at all true" and 7 is "very true". The scores range from 4 to 28. The higher score is validated as a predictor of better glycemic control. The higher scores mean a better confidence in managing diabetes.
Time Frame	At the baseline (Pre-CVT visit interview) and post-intervention (interview within one week after CVT visit)

Outcome Measure Data

Analysis Population Description

Veterans with diabetes mellitus whose HbA1c ≥7 and whose primary care includes CVT visits at ECHCS or JBVAMC.

Arm/Group Title	Intervention	Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.	Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
Measure Participants	37	48
pre-CVT visit	22.81 (4.61)	21.64 (5.94)
post-CVT visit	22.94 (4.76)	22.75 (5.89)

Adverse Events

Time Frame	From the baseline (Pre-CVT visit interview Visit 1) to the follow-up telephone interview (four weeks past Post-CVT visit), an average of 3 months per participant. Time frame varies depending on occurrence of patients' Clinical Video Telehealth visits with their physicians in routine clinical practice.
Arm/Group Title	Intervention		Pamphlet Alone
Arm/Group Description	Patients randomized to the intervention arm worked with educational materials: 1) they view the intervention video that encouraged patients to use active communication behaviors showing positive role models overcoming common communication challenges in CVT visit, and 2) they read the pamphlet that described how to use active communication behaviors in CVT visits Both educational materials (the video and pamphlet) had been mailed to the participants. The participants worked with the educational materials prior to their scheduled CVT visit.		Patients randomized to the control arm only read the pamphlet. The same pamphlet as in the intervention group had been mailed to the control patients prior to their scheduled CVT visit.
All Cause Mortality
	Intervention		Pamphlet Alone
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/37 (0%)		1/48 (2.1%)
Serious Adverse Events
	Intervention		Pamphlet Alone
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/37 (0%)		1/48 (2.1%)
General disorders
death	/37 (NaN)		1/48 (2.1%)
Other (Not Including Serious) Adverse Events
	Intervention		Pamphlet Alone
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/37 (0%)		0/48 (0%)

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

All Principal Investigators ARE employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.