Kudos to Ryan Shaw, associate professor, and Matthew Crowley, of the School of Medicine and their entire team for the submission of their NIH R01 application entitled: "EXpanding Technology-Enabled, Nurse-Delivered Chronic Disease Care (EXTEND)." This proposal requests funding for a five-year period with a start date of July 1, 2021.

When the self-management demands of chronic diseases like diabetes and hypertension exceed patients’ self-management capacity, poor control ensues. For many patients, clinic-based chronic disease care provides insufficient self-management support, resulting in clinic-refractory chronic diseases. As an example, ~15% of all patients with type 2 diabetes maintain a hemoglobin A1c (HbA1c) ≥8.0% for ≥1 year despite clinic-based care; this may be defined as ‘persistent poorly-controlled diabetes mellitus’ (PPDM). PPDM does not respond to clinic-based care because the factors that underlie PPDM are not effectively addressed with the infrequent patient-provider contact achievable in clinic. Importantly, >85% of patients with PPDM have comorbid hypertension, which further exacerbates outcomes in this high-risk group. Without better treatment options, patients with PPDM and hypertension will inevitably accrue preventable complications and costs.

Telehealth could improve management of clinic-refractory chronic diseases relative to clinic-based care because it facilitates patient-provider contact and better supports self-management. Our prior work shows that nurse-delivered telehealth interventions combining telemonitoring, self-management support, and medication management can lower HbA1c even among clinic-refractory patients with PPDM. Excitingly, emerging mobile monitoring technologies could enhance telehealth for clinic-refractory chronic diseases by generating multiple streams of health data to facilitate patient self-management, or by integrating such data into nurse-delivered telehealth interventions. While COVID-19 has heightened interest in telehealth, key evidence gaps yet prevent the practical use of mobile monitoring-enabled telehealth for clinic-refractory chronic diseases.

This proposal, EXpanding Technology-Enabled, Nurse-Delivered Chronic Disease Care (EXTEND), will address current barriers and gaps preventing practical use of mobile monitoring-enabled telehealth for clinicrefractory chronic diseases, using PPDM with comorbid hypertension as the initial target condition. Because these patients are already refractory to usual care, this study proposes an active comparator randomized trial (N=220) testing the effectiveness of two 12-month telehealth interventions: 1) EXTEND-Monitoring, or mobile monitoring alone; and 2) EXTEND-Nursing, a nurse-delivered intervention incorporating mobile monitoring, self-management support, and medication management. In order to guide further scaling and dissemination of the EXTEND interventions, a rigorous, multi-method evaluation will: 1) interview stakeholders regarding implementation barriers and facilitators; and 2) compare intervention costs against potential reimbursement mechanisms. Finally, the value of combining data from mobile monitoring and electronic health records to predict patient safety events will be examined in the cohort over 24 months.

This high-impact proposal will address a pressing clinical problem in a manner that is generalizable to other conditions. Critically, the COVID-19 pandemic has further intensified the urgency of this work.

Thank you to all those who gave their time and expertise in guiding the application process as well as to all those who helped to prepare for this submission.