A Research Journey: Moving to 

Implementation and Improving Outcomes 

for Veterans

Hayden B. Bosworth, PhD 

Durham VA Medical Center

Veterans Health 

Administration 
Acknowledgements

• Our veterans and the Veterans Health 

Administration

• VA HSR&D for funding this work

– Research Career Scientist Award VA 3/1/08-

2/28/13 

– Senior Research Career Scientist Award 3/1/13-

2/28/20 
Chronic 

Illness

Obesity

Smoking

Alcohol 

Abuse

Medication 

Nonadherence

Poor Lifestyle & Chronic Disease Epidemic

•3 

Obesity 

• >160 million U.S. are overweight , 

pre-obese, or obese.

• 70% veterans overweight/obese

• Obesity increases the risk of 

hypertension, type 2 diabetes, and 

lipid concentrations.

Alcohol Abuse

• > 14 million suffer from alcohol abuse 

or alcoholism. 

• Heavy drinking can cause heart, liver 

and pancreas problems, as well as 

increase the risk of developing certain 

cancers. 

Smoking 

• 47 million U.S. are smokers.

• Smoking is responsible for 80% of 

COPD (emphysema and chronic 

bronchitis) deaths.

Medication non-adherence

• Non-Adherence is an annual $290 

billion problem 

• 50% of do not take their medication 

as instructed 
Chronic Disease Management

• Chronic illness contributes to the majority of 

U.S. health expenditures (>$1.25 trillion a 

year) 

– the life expectancy in the U.S. is actually 

declining

• Among VA patients, 72% have one or more 

chronic health conditions 

– compared with 40–50% of other U.S. adults
Chronic Disease Management

• Improving chronic disease is important 

as VA strives to meet the demands of the 

aging Veteran cohort and care for 

younger Veterans. 
Importance of Chronic Disease Management

• Off-load primary care visits

• Create new models of care – increase access

• Support for performance incentive goals

• Improves quality measures
Health Decision Model

Community

TREATMENT ADHERENCE 

Provider Characteristics

Communication Medication 

Style Regimen

Treatment Intensity of Guidelines Therapy Adherence

Beliefs about Therapy

Medical Environment

Bosworth HB, Olsen MK, Oddone EZ. 

(2006). Am Heart J 149:795-803.l

Bosworth HB & Oddone EZ. (2002). 

J Nat Med Ass. 94; 236-248

Patient Characteristics

Perceived Cognition

Risks

Coping & Literacy

Stress

Comorbidities Side Effects

Mental Health

OUTCOME 

Policy
Key tools to personalize and tailor 

intervention programs 

• Tailoring ≠ targeted communication strategies 

– Targeted communications are developed to appeal to 

subgroups, based on characteristics such as race or gender 

– Tailored communications involves collected data so that 

unique messages can be created or “tailored” for that 

individual 

– Can tailor on multiple variables such as level of motivation, 

cultural preferences, and past behaviors 
Patient Interventions & Content

•Over 80 tested diseases states & conditions as well as 33 behavioral, 

educational and assessment topics.

Disease State & Condition Assessment, Behavior & Education 

Anxiety Hypertension Aging and Falls Opiate Use/Misuse

Apnea Hyperthermia Alcohol Use/Misuse Pain Assessment

Asthma (Adult) Hypoglycemia Behavioral Economics Patient-Initiated Interaction

Asthma (Pediatric) Insomnia Breast Cancer (Screening) Patient-Physician Interaction 

Breast Cancer Irritable Bowel Syndrome (IBS) Cancer (Screening) Pharmacist Medication Evaluation

Cholesterol Menopause Caregivers Post Hospitalization Transition

Chronic Kidney Disease (CKD) Mental Well-being Complementary Health Risk Communication

COPD Migraines Diet Risky Behaviors

CVD (General) Multiple Sclerosis (MS) Drug/Substance Abuse Safety 

CVD (Women) Osteoporosis Environmental Triggers Self monitoring

Dementia Oxygen Therapy/Respitory Exercise Sickle Cell Knowledge

Depression Pain Management Genetic Testing Side Effects

Diabetes PTSD Health Wellness Assessment Smoking & Tobacco Cessation

Glaucoma/Vision Sickle Cell Hydroxurea Use (HU) Social Support

Heart Failure Stress Medication Adherence Weight loss

Hepatitis B & C Stroke Memory Wellness

HIV Mental Well-being
Study Name

(sample size)

Veterans Study to Improve Control of 

Hypertension – 

V-STITCH

(n = 588)

Take Control of Your Blood Pressure Study – 

TCYB

(n = 636)

Hypertension Intervention Nurse 

Telemedicine Study – 

HINTS

(n = 593)

Study Sample • Hypertensive veterans

• Enrolled from primary care

• Hypertensive community patients

• Enrolled from university and community clinic

• Hypertensive veterans with inadequate BP 

control

• Enrolled from primary care

Retention Rate • 84% (24 months) • 75% (24 months) • 85% (18 months)

% Minority • 40% African American • 50 African American • 49% African American

Literacy Level • 38% <9th Grade • 28% <9th grade • 38% <9th grade

Recent Randomized Trials of Chronic Disease 

Management

Study Name

(sample size)

Hypertension Telemedicine 

Nurse Implementation Project 

for Veterans

HTN – IMPROVE 

(target n = 1,500)

 

CITIES

(target n = 500)

Telephone-Based SelfManagement for OsteoArthritis in 

Veterans 

SeMOA

(n = 515)

Couples Partnering for Lipid 

Enhancement Strategies 

(CouPLES) 

(n = 255)

Study Sample HTN-IMPROVE is a 3 part study

• Veterans at 3 sites with 

hypertension

• Veterans with >20% CVD risk • Veterans with physician diagnosed, 

symptomatic knee or hip 

osteoarthritis

• Enrolled from primary care

• Veterans with elevated LDL-C and 

their spouses 

• Enrolled from primary care

% Minority • n/a • 53% African American • 46% African American • 35% African American

•More than 3500 individuals enrolled 
Veterans Study to Improve the 

Control of Hypertension

The V-STITCH Study

VA Health Services Research

Investigator Initiated Award, 2001-06
The V-STITCH Study

• A randomized controlled trial testing a nurse 

administered, telephone interventions designed to 

improve BP control

• Durham VAMC General Medicine Clinics

• Patients with hypertension on medications

• 24-month intervention and follow-up
Patient Characteristics (N=588)

Male 98% 

Mean age 63 years (21-87) 

White 57% 

African American 40% 

High school or less 51% 

Inadequate income 23% 
Nurse Behavioral Intervention vs. None

Secondary Analysis

700.

lo

60

rt

0.

n Co

50

BP

0. 40 0.

0 6 12 18 24

RN Behavioral

N=294

P=0.03

No RN

N=294

Time in Months
Compliance with Nurse Telephone 

Intervention 

• Patients completing all 12 scheduled study 

calls: 85%

• Average length of call: 3 minutes

(SD 2.5 min)
Average Behavioral Intervention 

Costs Per Patient over 24 months

Cost Patients Overseen by Nurse

Category

Number of 1120 840 560

Patients

Direct $70 $94 $141

Costs/per ($61-$81) ($82-$109) ($123-$163)

patient
Summary

• Brief telephone intervention improved BP control 

by 21% at 24 months

– 12.6% improvement compared to the nonbehavioral group

• No increase in clinic utilization

• Cost effective
Hypertension Intervention 

Telemedicine Study 

(HINTS) 

Department of Veterans Affairs,

Grant IIR 04-426 (2005-2008)

Career Scientist Award 08-027 (2008-2013)
Hypertension Intervention Nurse Telemedicine 

Study (HINTS)

Design

• An 18-month randomized controlled trial 

• 593 veterans enrolled; 49% African Americans

• Focus on patient self-management 

– The nurse administered patient intervention 

– Home BP monitoring

– Medication management by MDs
Baseline Characteristics (N=593)

Mean age (range) 64 (30-89) 

Male 92% 

White 49% 

African American 48% 

Not high school graduate 13% 

Low literacy level (< 9th grade) 38% 

Inadequate income 18% 
Hypertension Intervention Nurse Telemedicine 

Study (HINTS)

Summary Results

• Among veterans with poor baseline BP 

control

– Systolic BP decreased in the combined group by 

14.8 mm Hg (95% CI: -21.8, -7.8) at 12 months 

– Systolic BP decreased 8.0 mm Hg (95% CI: -15.5, -0.5) at 18 months. 
Estimated SBP with 95% Confidence Regions among the 

Subgroup with Inadequate BP Control at Baseline (n=243)
Patient Perspective

59 Male White Non-DM Baseline Final Chg in BP 48 Female Black Non- Baseline Final Chg in BP

136/101 116/85  20/16 Dm 140/104 117/79  23/25

Do you think you BP changed: 

•Yes it has changed, I was having 

BP readings in the >200/100 

sometimes > at the hospital 

before, now they are much lower 

around 120/90s. 

. 

What things were particularly 

helpful about the study? 

•That they seemed truly concerned 

and that made me want to do 

better. 

•More involved in my own care, felt 

I was part of the process.

Do you think your health is improved: 

•Study made me more aware of BPs, 

medications (what they do & consequences 

of not taking them. 

Of all the topics discussed, what was most 

helpful. 

•Basically about BP, how to monitor and keep 

an eye on it. The emphasis on eating 

properly, losing weight, exercising and 

watching cholesterol to prevent MI, or Stroke. 
How to translate trials into implementation? 

• Less than 3 site studies

– Often single site

• Less than 650 patients

• Intermediate outcomes

– Physiologic (BP control, BP, A1C)

– Patient reported (HRQOL, Satisfaction, Adherence)

• Underpowered for cost, utilization, and sometimes 

even primary outcome!
Hypertension Telemedicine 

Nurse Implementation Project 

for Veterans

Funded by VA HSR&D

HTN IMPROVE 
Summary of HTN-IMPROVE 

Methods 

- 3 sites implementing the behavioral telephone program among veterans 

with poor BP control

- 9 control sites (collecting secondary data only) 

• Phase I 

 - Evaluating barriers and facilitators for implementing the behavioral 

program at each of the 3 intervention sites.

• Phase II 

- Examining the impact of the program by comparing 12-month pre/post 

changes in BP control for veterans who receive the program compared to 

individuals from the 9 control sites. 

• Phase III

- Examine the implementation costs of disseminating the telephone based 

behavioral program. 
The NC Medicaid Study
NC Medicaid Study

• 558 Medicaid patients 

• Self management program focused on 

improving lifestyle and medication 

adherence 

• Improvement of medication possession 

from: 

– 55% 12 months prior to program enrollment 

to 77% 12 months post initiation of the 

program 
Challenges 

• Scalability 

• ROI/cost

• IT

• Competing needs

• Sustainability

• Evaluation

– Identifying partners

– Integrating into regular work of clinic

– Measuring success
Where is the future?

• Chronic disease growing in prevalence

• Self management programs require intersection of 

behavior/social contextual environment

• Need for increasing sophistication of analyses and 

methodologies

• Ability to work in an inter/multidisciplinary environment

• Ensuring we provide our stakeholders what they need

• Investing in our future
Matt Crowley Kelly Muir

Ryan Shaw Leah Zullig

Dee Melnyk
Eugene Oddone Kelli Allen

George Jackson Corrine Voils Steve Grambow

Morris Weinberger Maren Olsen

David Edelman
Felicia McCant Susanne Danus Celine Koropchak Pam Gentry Cindy Rose

Alice Neary

Debbie Makhanova

Julie Johnson

Teresa Howard

Sarah Gonzales

Leah Zullig

Josh Pathman

Avi Alkon

Kim Porter

Nancy Pierce

Dana Tucker

Beth Armstrong

Cynthia Lunceford


Acknowledgements

Alkon, Aviel Goldstein, Karen McCant, Felicia Sperber, Nina

Allen, Kelli Dominick Gonzales, Sarah McDuffie, Jennifer Stanwyck, Catherine

Armstrong, Beth Grambow, Steve McVay, Megan Stechuchak, Karen

Beck, Pat Grubber, Janet Melnyk, Stephanie (Dee) Steinhauser, Karen

Blakeney, Jill Hall, Rasheeda Monger, Mike Steward, Nancy

Brock, Dorothea Harris, Amy Morey, Miriam Strauss, Jennifer

Calhoun, Patrick Hastings, Susan (Nicki) Muir, Kelly Taylor, Jennifer

Chapman, Jennifer Howard, Teresa Neary, Alice Tucker, Dana

Cho, Alex Jackson, George Oddone, Eugene Tulsky, James

Coffman, Cynthia Jeffreys, Amy Okorodudu, Daniel Van Houtven, Courtney

Cribb, Scott Johnson, Julie Olsen, Maren Van Scoyoc, Lynn

Crowley, Matt Johnson, Marcus Pathman, Joshua Voils, Corrine

Danus, Susanne Juntilla, Karen Pearson, Megan Walker, Tessa

Datta, Santanu Kaufman, Amy Pierce, Nancy Wang, Virginia

Dennis, Michelle King, Heather Porter, Kim Weinberger, Morris

Dokter, Bradley Koropchak, Celine Powell, Lesa Williams, John

Edelman, David Lindquist, Jennifer Hoff Provenzale, Dawn Wright, Lisa

Fisher, Deborah Lunceford, Cynthia Rose, Cynthia (Cindy) Yancy, Will

Ganguly, Doel Maciejewski, Matthew Sanders, Linda Zullig, Leah

Gentry, Pam Makhanova, Debbie Shaw, Ryan

Gierisch, Jennifer Marbrey, Laurie Simel, David
Acknowledgements

Dawn Bravata Mike Ho Lori Bastian

Linda Williams Eve Kerr David Steffens

Rich Frankl Michele Heisler Ronnie Horner

Teresa Damush Christianne Roumie David Matchar

Mike Bowen Michele Salyers Ben Powers 

Mary Goldstein Linda McIver Carolyn Thorpe 

Eric Cheng Pauline Sieverding Ranak Trivedi

Susan Hedayati Peter Kaboli Chris Bryson

John Fortney Bonnie Wakefield Sara Krein

Donna Washington Becky Yano Jeff Whittle

David Atkins Leonard Egede
Summary

• Intervention tested in >10 separate trials with > 

6,000 patients – more ongoing

• Balance of targeting/tailoring, clinical expertise, 

cost, and dose

• Moving into the realm of implementation

– Version of the programs are being implemented in NC 

among 1.5 million Medicaid recipients.

Contact: Hayden Bosworth, PhD

Senior Career Scientist

Durham VAMC

Hayden.bosworth@VA.gov