Diabetes intervention in the information age

Guardian-Reported Impact of the COVID-19 Pandemic on the Lifestyle of Children with Diabetes Mellitus

INTRODUCTION

The coronavirus disease-2019 (COVID-19) pandemic has had an unprecedented impact on the lives and lifestyles of people of all ages worldwide. Lifestyle has an essential role in the management of diabetes mellitus in children.

METHODS

The study was carried out at a tertiary care centre in India. A telehealth survey was conducted among the parents/guardians of children with diabetes to study the impact of the COVID-19 pandemic. The survey evaluated the effects on lifestyle, diabetes management and challenges in connecting to a new telemedicine programme.

RESULTS

The survey was completed by guardians of 91 patients. The mean age of the patients was 13.0 ± 3.8 years in boys and 11.9 ± 4.5 years in girls. Fifty-seven per cent of them were boys, and 63.7% stayed in rural areas. The pandemic has resulted in a significant increase in screen time and sleep duration. The median non-educational screen time has gone up from 1.00 (0.5-2.0) to 2.50 (1.0-4.0) h. The mean sleep duration in children increased from 9.1 ± 1.4 to 9.7 ± 1.4 h. Telemedicine services have been established with minimum resources, but they have limitations, and awareness about them is also limited.

CONCLUSION

The COVID-19 pandemic has made the lifestyle of children with diabetes more sedentary. Some of them have also faced challenges with regard to diabetes-related supplies and management. It would be fair to anticipate more complications related to this sedentary lifestyle in the future and work towards identifying and treating them.

Accuracy of Automatic Carbohydrate, Protein, Fat and Calorie Counting Based on Voice Descriptions of Meals in People with Type 1 Diabetes

The aim of this work was to assess the accuracy of automatic macronutrient and calorie counting based on voice descriptions of meals provided by people with unstable type 1 diabetes using the developed expert system (VoiceDiab) in comparison with reference counting made by a dietitian, and to evaluate the impact of insulin doses recommended by a physician on glycemic control in the study’s participants. We also compared insulin doses calculated using the algorithm implemented in the VoiceDiab system. Meal descriptions were provided by 30 hospitalized patients (mean hemoglobin A1c of 8.4%, i.e., 68 mmol/mol). In 16 subjects, the physician determined insulin boluses based on the data provided by the system, and in 14 subjects, by data provided by the dietitian. On one hand, differences introduced by patients who subjectively described their meals compared to those introduced by the system that used the average characteristics of food products, although statistically significant, were low enough not to have a significant impact on insulin doses automatically calculated by the system. On the other hand, the glycemic control of patients was comparable regardless of whether the physician was using the system-estimated or the reference content of meals to determine insulin doses.

Teletransmission system supporting intensive insulin treatment of out-clinic type 1 diabetic pregnant women. Technical assessment during 3 years’ application

A telematic system supporting intensive insulin treatment of pregnant type 1 diabetic out-clinic patients was implemented and technical efficiency of the system was evaluated over long-term ambulatory application. The system consists of a patient teletransmission module (PTM) and a central clinical control unit (CCU). The PTM contains a one-box blood glucose meter and electronic logbook, a modem and a dial-up or cellular phone set. The CCU consists of a PC computer with a modem and DIAPRET – an original program designed to monitor the intensive insulin treatment. The system was installed in the Clinic of Gastroenterology and Metabolic Disease, MA Warsaw and was tested for 166 ± 24 days on 15 pregnant type 1 diabetic women. Telemonitoring of the patient data was done automatically. No major technical problems with proper operation or handling of the system was noted. Total effectiveness was 69.3 ± 13.0% and technical effectiveness 91.5 ± 6.1%. The efficacy of the system was not significantly influenced by patient intelligence level, education level or place of residence (p < 0.05). Significant improvement of metabolic control was noted during application of the system. In conclusion, the telematic system we developed and implemented should have a positive influence on the quality of diabetes treatment during pregnancy.

Impact of Information Technology-Based Interventions for Type 2 Diabetes Mellitus on Glycemic Control: A Systematic Review and Meta-Analysis

BACKGROUND

Information technology-based interventions are increasingly being used to manage health care. However, there is conflicting evidence regarding whether these interventions improve outcomes in people with type 2 diabetes.

OBJECTIVE

The objective of this study was to conduct a systematic review and meta-analysis of clinical trials, assessing the impact of information technology on changes in the levels of hemoglobin A_1c (HbA_1c) and mapping the interventions with chronic care model (CCM) elements.

METHODS

Electronic databases PubMed and EMBASE were searched to identify relevant studies that were published up until July 2016, a method that was supplemented by identifying articles from the references of the articles already selected using the electronic search tools. The study search and selection were performed by independent reviewers. Of the 1082 articles retrieved, 32 trials (focusing on a total of 40,454 patients) were included. A random-effects model was applied to estimate the pooled results.

RESULTS

Information technology-based interventions were associated with a statistically significant reduction in HbA_1c levels (mean difference -0.33%, 95% CI -0.40 to -0.26, P<.001). Studies focusing on electronic self-management systems demonstrated the largest reduction in HbA_1c (0.50%), followed by those with electronic medical records (0.17%), an electronic decision support system (0.15%), and a diabetes registry (0.05%). In addition, the more CCM-incorporated the information technology-based interventions were, the more improvements there were in HbA_1c levels.

CONCLUSIONS

Information technology strategies combined with the other elements of chronic care models are associated with improved glycemic control in people with diabetes. No clinically relevant impact was observed on low-density lipoprotein levels and blood pressure, but there was evidence that the cost of care was lower.

Designing of Intelligent Multilingual Patient Reported Outcome System (IMPROS)

Background:

By self-reporting outcome procedure the patients themselves record disease symptoms outside medical centers and then report them to medical staff in specific periods of time. One of the self-reporting methods is the application of interactive voice response (IVR), in which some pre-designed questions in the form of voice tracks would be played and then the caller responses the questions by pressing phone’s keypad bottoms.

Aim:

The present research explains the main framework of such system designing according to IVR technology that is for the first time designed and administered in Iran.

Methods:

Interactive Voice Response system was composed by two main parts of hardware and software. Hardware section includes one or several digital phone lines, a modem card with voice playing capability and a PC. IVR software on the other hand, acts as an intelligent control center, records call information and controls incoming data.

Results:

One of the main features of the system is its capability to be administered in common PCs, utilizing simple and cheap modems, high speed to take responses and it’s appropriateness to low literate patients. The system is applicable for monitoring chronic diseases, cancer and also in psychological diseases and can be suitable for taking care of elders and Children who require long term cares. Other features include user-friendly, decrease in direct and indirect costs of disease treatment and enjoying from high level of security to access patients’ profiles.

Conclusions:

Intelligent multilingual patient reported outcome system (IMPROS) by controlling diseases gives the opportunity to patients to have more participation during treatment and it improves mutual interaction between patient and medical staff. Moreover it increases the quality of medical services, Additional to empowering patients and their followers.

Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus

BACKGROUND

Diabetes is one of the commonest chronic medical conditions, affecting around 347 million adults worldwide. Structured patient education programmes reduce the risk of diabetes-related complications four-fold. Internet-based self-management programmes have been shown to be effective for a number of long-term conditions, but it is unclear what are the essential or effective components of such programmes. If computer-based self-management interventions improve outcomes in type 2 diabetes, they could potentially provide a cost-effective option for reducing the burdens placed on patients and healthcare systems by this long-term condition.

OBJECTIVES

To assess the effects on health status and health-related quality of life of computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus.

SEARCH METHODS

We searched six electronic bibliographic databases for published articles and conference proceedings and three online databases for theses (all up to November 2011). Reference lists of relevant reports and reviews were also screened.

SELECTION CRITERIA

Randomised controlled trials of computer-based self-management interventions for adults with type 2 diabetes, i.e. computer-based software applications that respond to user input and aim to generate tailored content to improve one or more self-management domains through feedback, tailored advice, reinforcement and rewards, patient decision support, goal setting or reminders.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the abstracts and extracted data. A taxonomy for behaviour change techniques was used to describe the active ingredients of the intervention.

MAIN RESULTS

We identified 16 randomised controlled trials with 3578 participants that fitted our inclusion criteria. These studies included a wide spectrum of interventions covering clinic-based brief interventions, Internet-based interventions that could be used from home and mobile phone-based interventions. The mean age of participants was between 46 to 67 years old and mean time since diagnosis was 6 to 13 years. The duration of the interventions varied between 1 to 12 months. There were three reported deaths out of 3578 participants.Computer-based diabetes self-management interventions currently have limited effectiveness. They appear to have small benefits on glycaemic control (pooled effect on glycosylated haemoglobin A1c (HbA1c): -2.3 mmol/mol or -0.2% (95% confidence interval (CI) -0.4 to -0.1; P = 0.009; 2637 participants; 11 trials). The effect size on HbA1c was larger in the mobile phone subgroup (subgroup analysis: mean difference in HbA1c -5.5 mmol/mol or -0.5% (95% CI -0.7 to -0.3); P < 0.00001; 280 participants; three trials). Current interventions do not show adequate evidence for improving depression, health-related quality of life or weight. Four (out of 10) interventions showed beneficial effects on lipid profile.One participant withdrew because of anxiety but there were no other documented adverse effects. Two studies provided limited cost-effectiveness data - with one study suggesting costs per patient of less than $140 (in 1997) or 105 EURO and another study showed no change in health behaviour and resource utilisation.

AUTHORS' CONCLUSIONS

Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup. There is no evidence to show benefits in other biological outcomes or any cognitive, behavioural or emotional outcomes.

What we can really expect from telemedicine in intensive diabetes treatment: 10 years later

During the last 10 years many new telematic systems aiming at support of diabetes treatment have been designed and developed. Most systems that were applied in clinical randomized trials used the classical approach, with data transfers from patients performed usually once every few days. In the few available meta-analyses of these trials, a significant improvement of the mean hemoglobin A1c was demonstrated in patients using telematic systems. However, the magnitude of this improvement in comparison with the control groups was lower than expected. This conclusion was confirmed by results of the IDEATel study involving more than 1,600 patients over a period of 5 years. It might by hypothesized that in some groups of patients continuous telecare with frequent contacts between patients and the care provider during each day should be required. This hypothesis is confirmed by the results of the clinical trials applying real-time diabetes monitoring systems. However, the increased frequency of the data transfers and checkups requires a new model for technology-supported care. The new model should connect together the ubiquitous data transfer with an automatically selected optimal frequency, the automatic assessment of the data coupled with quicker feedback from the decision support system or from the provider, and selection of the optimal time for the patient's face-to-face visit in the clinic. All this new future implementations together with already confirmed advantages of the telematic support, such as the increase of self-confidence of the patient, will hopefully give real benefits for the patients.

Bringing the artificial pancreas home: telemedicine aspects

The design and implementation of telemedicine systems able to support the artificial pancreas need careful choices to cope with technological requirements while preserving performance and decision support capabilities. This article addresses the issue of designing a general architecture for the telemedicine components of an artificial pancreas and illustrates a viable solution that is able to deal with different use cases and is amenable to support mobile-health implementations. The goal is to enforce interoperability among the components of the architecture and guarantee maximum flexibility for the ensuing implementations. Thus, the design stresses modularity and separation of concerns along with adoption of clearly defined protocols for interconnecting the necessary components. This accounts for the implementation of integrated telemedicine systems suitable as short-term monitoring devices for supporting validation of closed-loop algorithms as well as devices meant to provide a lifelong tighter control on the patient state once the artificial pancreas has become the preferred treatment for patients with diabetes.

Review of electronic decision-support tools for diabetes care: a viable option for low- and middle-income countries?

CONTEXT

Diabetes care is complex, requiring motivated patients, providers, and systems that enable guideline-based preventative care processes, intensive risk-factor control, and positive lifestyle choices. However, care delivery in low- and middle-income countries (LMIC) is hindered by a compendium of systemic and personal factors. While electronic medical records (EMR) and computerized clinical decision-support systems (CDSS) have held great promise as interventions that will overcome system-level challenges to improving evidence-based health care delivery, evaluation of these quality improvement interventions for diabetes care in LMICs is lacking. OBJECTIVE AND DATA SOURCES: We reviewed the published medical literature (systematic search of MEDLINE database supplemented by manual searches) to assess the quantifiable and qualitative impacts of combined EMR-CDSS tools on physician performance and patient outcomes and their applicability in LMICs.

STUDY SELECTION AND DATA EXTRACTION

Inclusion criteria prespecified the population (type 1 or 2 diabetes patients), intervention (clinical EMR-CDSS tools with enhanced functionalities), and outcomes (any process, self-care, or patient-level data) of interest. Case, review, or methods reports and studies focused on nondiabetes, nonclinical, or in-patient uses of EMR-CDSS were excluded. Quantitative and qualitative data were extracted from studies by separate single reviewers, respectively, and relevant data were synthesized.

RESULTS

Thirty-three studies met inclusion criteria, originating exclusively from high-income country settings. Among predominantly experimental study designs, process improvements were consistently observed along with small, variable improvements in risk-factor control, compared with baseline and/or control groups (where applicable). Intervention benefits varied by baseline patient characteristics, features of the EMR-CDSS interventions, motivation and access to technology among patients and providers, and whether EMR-CDSS tools were combined with other quality improvement strategies (e.g., workflow changes, case managers, algorithms, incentives). Patients shared experiences of feeling empowered and benefiting from increased provider attention and feedback but also frustration with technical difficulties of EMR-CDSS tools. Providers reported more efficient and standardized processes plus continuity of care but also role tensions and "mechanization" of care.

CONCLUSIONS

This narrative review supports EMR-CDSS tools as innovative conduits for structuring and standardizing care processes but also highlights setting and selection limitations of the evidence reviewed. In the context of limited resources, individual economic hardships, and lack of structured systems or trained human capital, this review reinforces the need for well-designed investigations evaluating the role and feasibility of technological interventions (customized to each LMIC's locality) in clinical decision making for diabetes care.

Mobile telecare system for intensive insulin treatment and patient education. First applications for newly diagnosed type 1 diabetic patients

The aim of the work was to develop and to evaluate the clinical efficiency of a mobile telecare system implementing teleconsultations based on the continuous transmission of patient-collected data directly to the physician and to the clinic. The developed TeleMed system consists of the patients' and the diabetologist's mobile units, the diabetologist's clinic and home workstations and the clinical server. The evaluation of the system was performed on a group of 13 newly diagnosed type 1 diabetic patients, during a single-arm study with 3-days run-in period, including a one-day intensive educational program, and 3-week study period, when the intensive insulin treatment was conducted without visits of patients to the clinic. The MBG dropped from 7.2 +/- 1.7 mmol/L before the study to 6.1 +/- 1.0 mmol/L in the third week of the study (P = 0.02) and the J-index from 30.2+/-19.2 to 19.7+/-7.7 (P = 0.04). Hemoglobin A1c decreased from 11.8 +/- 3.3% to 8.6 +/- 1.2% (P = 0.0002) in one month. The total daily insulin dose declined from 39.9 +/- 8.5 U to 20.0 +/- 9.6 U (P = 0.000006). The number of hypoglycemia episodes per patient per day decreased by 66% (P = 0.08) and the number of hyperglycemia episodes was reduced by 47% (P < 0.0001). The TeleMed facilitates not only efficient realization of the intensive insulin treatment but also successful remote patient training and education. No formal patient satisfaction study was done. However, some of the findings indicate that the application of the developed system increases patient self-confidence and quality of life.

Averting iatrogenic hypoglycemia through glucose prediction in clinical practice: progress towards a new procedure in diabetes

BACKGROUND

Hypoglycemia is a risk factor common to all insulin therapy. The hypothesis is that efforts to reduce or prevent this adverse side effect may fail because providers generally lack the resources to predict not only future blood glucose levels but also future risks of hypoglycemia. This lack has been remedied. A controlled study was undertaken to test the hypothesis.

METHODS

Twenty-two insulin dependent subjects suffering more than one (1) episode/week of hypoglycemia with similar insulin regimens, similar diabetes education and similar self-management training participated in this study. For all subjects, a remote monitoring resource (registry and database) was used to capture daily SMBG and afford a return path for provider interventions and decision support. Identical telemedical methods were used which differed only for the provider either by the presence (prediction group) or by the absence (control group) of an on-screen, visual display of predicted glycemia and predicted risks of hypoglycemia. The study lasted 2 months.

RESULTS

Over an average of 41 days from baseline to follow up and while using the glycemic prediction resource, providers intervened more effectively in the prediction group reducing rates of hypoglycemia nine-fold (P<0.0001) and insulin therapy by just -9 U/day (P<0.01). Mean pre-meal glycemia was not compromised. Over 61 days from baseline to final follow up but without glycemic predictions in the control group, providers' interventions were less effective and resulted in no net changes in rates of hypoglycemia, daily insulin therapy, or mean pre-meal glycemia.

CONCLUSIONS

Given knowledge of future glycemia and future risks of hypoglycemia, providers in clinical practice can now avert iatrogenic hypoglycemia in less than 2 months. A shared diabetes data center furnishing remote data capture and decision support is fundamental to the implementation of this as a new clinical procedure in diabetes.

A novel method for assessing insulin dose adjustments by patients with diabetes

BACKGROUND

Insulin treated diabetic patients often do not adjust their insulin doses. We developed a method to provide a quantitative and qualitative assessment of this behavior.

METHODS

Fourteen patients provided logbook pages of their self-monitoring of blood glucose (SMBG) data and insulin doses. We compared the actual decisions of patients in real-life to what they would decide on the same SMBG, as an a posteriori exercise. We also compared these decisions and those proposed by 6 diabetologists on the same sets of data to the recommendations made by HumaLink, an automated insulin dosage system.

RESULTS

1) Patients in real-life modified their insulin doses least often. However, given a chance to make these decisions a posteriori, they modified their insulin doses more often. HumaLink proposed changes even more often, and diabetologists were the most aggressive in changing insulin doses. 2) The decisions proposed by the patients in real-life or a posteriori and by the diabetologists were compared to the recommendations made by HumaLink, using a decisions analysis grid (DAG). For these three groups, full disagreement with HumaLink (patient or physician increases while HumaLink decreases and the opposite) was observed for less than 5% of the cases. 3) By comparison to HumaLink, patient decisions seemed guided by the desire to avoid hypoglycemia. By contrast, decisions by diabetologists seemed often to be guided by the desire to avoid hyperglycemia.

CONCLUSION

These methods provide an objective evaluation of insulin dose adjustments by patients with diabetes and may be useful to assess the effectiveness of educational programs.

Telecare in a structured therapeutic education programme addressed to patients with type 1 diabetes and poor metabolic control

OBJECTIVE

To assess the effects of telecare on the results of intensive follow-up in T1D patients with poor metabolic control.

METHODS

After initial evaluation, 40 T1D were randomised to either a Telecare (TG) or Conventional Group (CG). Patients had an intensive 6-month follow-up and helped to make decisions concerning treatment self-management. The TG had 12 appointments: 9 telematic with the GlucoBeep system+3 ambulatory. The CG had 12 outpatient appointments. At 0, 6 (end of study) and 12 months, metabolic control, self-management and quality of life were evaluated. Cost analysis was made at study end.

RESULTS

Thirty patients completed the study (16 TG, 14 CG). Intention to treat analysis included 19 TG and 16 CG. Improvement in HbA(1c) was similar in both groups TG: 8.4+/-1.2%; 7.5+/-1.4%; 7.6+/-0.9%, p=0.008; CG: 8.9+/-1.3%; 7.7+/-0.9%; 7.6+/-0.7%, p=0.001; with a decrease in hypoglycaemic events and improvement in self-management and quality of life. Patient costs were lower in the TG versus CG in appointment length (0.25h versus 0.5h). However, 30% of the diabetes team and patient appointments were longer than expected due to technical difficulties: (0.25h versus 1h).

CONCLUSIONS

Intensive telematic follow-up achieves similar results to those of intensive face-to-face follow-up with lower patient costs. However, communication technology must be improved.

A systematic review of interactive computer-assisted technology in diabetes care. Interactive information technology in diabetes care

BACKGROUND

Excellent diabetes care and self-management depends heavily on the flow of timely, accurate information to patients and providers. Recent developments in information technology (IT) may, therefore, hold great promise.

OBJECTIVE

To determine, in a systematic review, how emerging interactive IT has been used to enhance care for adults with type 2 diabetes.

METHOD

Eligible studies were randomized controlled trials (RCTs) and observational studies (both before-after designs and post-intervention assessments) focused on computer-assisted interactive IT that included > or =10 adults with diabetes (> or =50% type 2) and reported in English. We searched 4 electronic databases (up to 2003) using terms for diabetes and technology, reviewed bibliographies, and handsearched Diabetes Care (January 1990 to February 2004). Two reviewers independently selected articles and worked serially on data extraction with adjudication of discrepancies by consensus.

RESULTS

There were 26 studies (27 reports): internet (n=6; 3 RCTs), telephone (n=7; 4 RCTs), and computer-assisted integration of clinical information (n=13, 7 RCTs). The median (range) sample size was 165 (28 to 6,469 participants) for patients and 37 (15 to 67) for providers; the median duration was 6 (1 to 29) months. Ethnic minorities or underserved populations were described in only 8 studies. Six of 14 interventions demonstrated moderate to large significant declines in hemoglobin A1c levels compared with controls. Most studies reported overall positive results and found that IT-based interventions improved health care utilization, behaviors, attitudes, knowledge, and skills.

CONCLUSIONS

There is growing evidence that emerging IT may improve diabetes care. Future research should characterize benefits in the long term (>1 year), establish methods to evaluate clinical outcomes, and determine the cost-effectiveness of using IT.

Helping patients improve their health-related behaviors: what system changes do we need?

A large gap separates actual clinical outcomes of patients with chronic disease from optimal outcomes. This gap may be attributable to physician problems (physicians unaware of practice guidelines), patient problems (patients who choose not to follow medical advice) or system problems (physicians lack time to assist patients in managing their chronic condition). A goal for chronic illness care is to assist people with chronic conditions to become informed, activated patients. Patients who are informed and activated (activated = participating in health-related decisions) have better health-related behaviors and clinical outcomes. Primary care is often conducted within a 15-minute, multi-agenda visit between physician and patient. Such a structure has led to (1) patients being inadequately informed about their chronic conditions and (2) patients being passive recipients of medical advice rather than active participants in medical decisions. The result has been poorly informed, passive patients. This situation constitutes a system problem. Three redesign elements have the potential to address this system problem: (1) Pre-activating patients prior to the clinical visit appears to encourage more active patients and--in one study--improved clinical outcomes. (2) Planned visits, with a care manager spending time with patients, individually or in groups, providing education and medical management, have been shown to improve clinical outcomes. (3) Regular sustained follow-up, by face-to-face visits, telephone, or electronic means, is associated with healthier behaviors. Not all patients receiving disease management through redesigned primary care will adopt healthier behaviors because many factors outside the medical care system influence personal choices. However, until the medical care system regularly offers adequate information and encourages collaborative decision-making, it is improper to place the responsibility for unhealthy behaviors onto patients.

How good is your glucose control?

BACKGROUND

Glycemic control is fundamental to the management of diabetes and maintenance of health. Popular measures of performance in glycemic control include A1c and self-monitoring of blood glucose (SMBG). As measures of performance, A1c has perspective, but it fails to recognize hypoglycemia, while SMBG lacking overall perspective finds use mainly by patients to simply evaluate their glycemic status and current response to therapy. An additional, preferably visual, measure of performance in diabetes management in general and glycemic control in particular is needed.

METHODS

To form a visual measure of performance, a graphical method of analysis from the statistician's toolbox (known as the lag plot) was adapted. It can utilize SMBG data sets from any source, including memory meters and registry databases in call centers. Data are retrieved, processed, formatted, and then plotted on a PC screen or printer. The resulting lag plots visually characterize the performance of glucose control achieved over periods (selectable by the user) from days to months. Supporting numerical statistics provide rigorous outcome measures that correlate with glycated hemoglobin.

RESULTS

Clinical use of the lag plot is illustrated in seven case studies spanning the range from no diabetes, through glucose intolerance, early-onset type 2 diabetes mellitus, type 1 diabetes, intensified therapy, pump therapy, and finally islet cell transplantation. Visual comparisons before and after action/referral show impacts of interventions, incidences of hypoglycemia, and changes in the polyglycemia of unstable diabetes. Statistical significance of observed changes are quantified.

CONCLUSIONS

The simple lag plot can empower patients and their providers to identify problems in glycemic control, seek proactive action, adopt beneficial strategies, evaluate outcomes, and, most importantly, rule out interventions with no benefit.

A systematic review of telemedicine interventions to support blood glucose self-monitoring in diabetes

AIMS

To evaluate evidence for feasibility, acceptability and cost-effectiveness of diabetes telemedicine applications.

METHODS

MEDLINE, EMBASE, PSYCHINFO, CINAHL, Cochrane, and INSPEC were searched using the terms diabetes and telemedicine for clinical studies using electronic transfer of blood glucose results in people with diabetes. The technology used, trial design and clinical outcome measures used were extracted for trials and prospective cohort studies. Randomized controlled trials with HbA(1c) as an outcome were pooled using standard meta-analytical methods.

RESULTS

We identified 539 papers among which 32 papers described 10 prospective cohort studies, 12 parallel group randomized controlled trials (RCT), three crossover trials, and one non-parallel group trial. Only two studies described full details of randomization, blinding of outcomes and dropouts and withdrawals. Electronic transfer of glucose results appears feasible in a clinical setting. Only two of the RCTs included more than 100 patients, and only three extended to 1 year. Only one study was designed to show that telemedicine interventions might replace clinic interventions without deterioration in HbA(1c). Results pooled from the nine RCTs with reported data did not provide evidence that the interventions were effective in reducing HbA(1c) (-0.1%, 95% CI -0.4% to 0.04%).

CONCLUSIONS

Telemedicine solutions for diabetes care are feasible and acceptable, but evidence for their effectiveness in improving HbA(1c) or reducing costs while maintaining HbA(1c) levels, or improving other aspects of diabetes management is not strong. Further research should seek to understand how telemedicine might enhance educational and self-management interventions and RCTs are required to examine cost-effectiveness.

Impact of MyCareTeam for poorly controlled diabetes mellitus

OBJECTIVE

Web-based diabetes management can be used to provide frequent interactions between patients and providers and thus result in improved glycemic control.

METHODS

In a single-center, prospective feasibility study, 16 poorly controlled patients with either type 1 or 2 diabetes mellitus were enrolled to assess the impact of using MyCareTeam, a web-based diabetes management application, for diabetes management. Patients were asked to transfer their blood glucose data electronically, maintain exercise logs, and communicate with their provider via MyCareTeam. The provider gave clinical interventions to optimize blood glucose control and provided feedback via MyCareTeam. Diabetes, nutrition, and exercise information was also available via MyCareTeam.

RESULTS

A significant reduction of over 2.22% points in hemoglobin A1C was seen for the total patient population. Differences between moderate/heavy users (n = 8) versus light/never users (n = 8) of MyCareTeam were evaluated for intergroup differences based upon utilization. Moderate/heavy users had a significant 6-month A1C reduction of 3.15 percentage points compared with a reduction of 1.28 percentage points in light/never users. Other secondary end points were improved as well, including systolic blood pressure, diastolic blood pressure, total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides. However, as expected, body mass index levels increased because of aggressive diabetes management with insulin therapy.

CONCLUSIONS

These results demonstrate a significant treatment effect from the MyCareTeam application. A larger randomized control trial is under way at the Boston Veterans Administration Healthcare System. If these results are confirmed as expected, then web-based diabetes management may prove to be the link to achieving target American Diabetes Association glycemic goals in patients with poorly controlled diabetes.

Computerised decision-support tools in diabetes care: hurdles to implementation

In this Diabetes Information Technology & WebWatch column hurdles to the use of computerised decision-support tools in clinical diabetes care will be considered. The clinical background with respect to insulin-dependent (type 1) diabetes mellitus and the Diabetes Control and Complications Trial is reviewed, and an overview is given of various computer applications. The use of decision-support tools is discussed, and the importance of identifying the proposed user, e.g., health-care professional, student, or patient, is highlighted. Validation/evaluation issues are considered as important topics that remain to be properly addressed for many decision-support prototypes. The column concludes by highlighting that in this era of evidence-based medicine well-conducted, rigorous evaluation and validation studies are required to inform decisions about whether or not to make use of current computerised decision-support prototypes.

Patient confidentiality, data security, and provider liabilities in diabetes management

From inception, the electronic patient record has raised issues of data protection and patient confidentiality. These privacy issues have become more complicated with the introduction of electronic links to patient information held in databases sited on local and wide area networks. The first purpose of this paper is to review, from the provider's perspective, the issues surrounding patient confidentiality, data security, and consequential provider liabilities. The second is to propose possible immediate strategies and long-term solutions. Clinical procedures in diabetes practice create patient data from confidential information. This information is owned by the patient, received by the provider, enriched by a professional interpretation, and merged with other data into health records. Ownership, privacy, accountability, and responsibility issues are raised. Consequential data security and patient privacy are easily met by storage in a locked box or file cabinet. Conversion of such records into digital data in databases on local and wide area networks markedly increases the provider's exposure to liabilities. Current methods for securing remote data exist. These involve user authentication and secure transmission, but remote data storage is far less secure than a locked box. New tools for the secure storage of patient data are outlined. These involve encryption and decryption by the provider alone. A suite of computer protocols is presented that can restore security equivalent to a "locked box" and thus reduce liabilities for the provider. Providers should protect the privacy of their patients by encrypting all data that are stored in remote repositories. The tools to do this are urgently needed. A standardized digital protocol for verifying user identities, preserving patient confidentiality, and controlling data security by encryption will fully mitigate provider liabilities. Standardization and economies of scale promise future cost containment.

Design, methods, and evaluation directions of a multi-access service for the management of diabetes mellitus patients

Recent advances in information and communication technology allow the design and testing of new models of diabetes management, which are able to provide assistance to patients regardless of their distance from the health care providers. The M2DM project, funded by the European Commission, has the specific aim to investigate the potential of novel telemedicine services in diabetes management. A multi-access system based on the integration of Web access, telephone access through interactive voice response systems, and the use of palmtops and smart modems for data downloading has been implemented. The system is based on a technological platform that allows a tight integration between the access modalities through a middle layer called the multi-access organizer. Particular attention has been devoted to the design of the evaluation scheme for the system: A randomized controlled study has been defined, with clinical, organizational, economic, usability, and users' satisfaction outcomes. The evaluation of the system started in January 2002. The system is currently used by 67 patients and seven health care providers in five medical centers across Europe. After 6 months of usage of the system no major technical problems have been encountered, and the majority of patients are using the Web and data downloading modalities with a satisfactory frequency. From a clinical viewpoint, the hemoglobin A1c (HbA1c) of both active patients and controls decreased, and the variance of HbA1c in active patients is significantly lower than the control ones. The M2DM system allows for the implementation of an easy-to-use, user-tailored telemedicine system for diabetes management. The first clinical results are encouraging and seem to substantiate the hypothesis of its clinical effectiveness.

A telemedicine support for diabetes management: the T-IDDM project

In the context of the EU funded Telematic Management of Insulin-Dependent Diabetes Mellitus (T-IDDM) project, we have designed, developed and evaluated a telemedicine system for insulin dependent diabetic patients management. The system relies on the integration of two modules, a Patient Unit (PU) and a Medical Unit (MU), able to communicate over the Internet and the Public Switched Telephone Network. Using the PU, patients are allowed to automatically download their monitoring data from the blood glucose monitoring device, and to send them to the hospital data-base; moreover, they are supported in their every day self monitoring activity. The MU provides physicians with a set of tools for data visualization, data analysis and decision support, and allows them to send messages and/or therapeutic advice to the patients. The T-IDDM service has been evaluated through the application of a formal methodology, and has been used by European patients and physicians for about 18 months. The results obtained during the project demonstration, even if obtained on a pilot study of 12 subjects, show the feasibility of the T-IDDM telemedicine service, and seem to substantiate the hypothesis that the use of the system could present an advantage in the management of insulin dependent diabetic patients, by improving communications and, potentially, clinical outcomes.

Interactive voice response: review of studies 1989-2000

A systematic review of the use of interactive voice response (IVR) was conducted. IVR is a telephone interviewing technique in which the human speaker is replaced by a high-quality recorded interactive script to which the respondent provides answers by pressing the keys of a touch telephone (touchphone). IVR has numerous advantages, including economy, autonomy, confidentiality, access to certain population groups, improved data quality, standardized interviewing, multilingual interfaces, and detailed longitudinal assessments. Despite this, there have been few applications of IVR. Previous studies have been in the areas of information services, reminder calls, monitoring, assessment, experimentation, interventions, and surveys. Areas that have received little attention have been the systematic evaluation of voice, multilingual interfaces, touchphone prevalence, survey response rates, use by the elderly, and acceptability.

Telemedicine as a tool for intensive management of diabetes: the DIABTel experience

This paper presents the current features of the DIABTel telemedicine system and the evaluation outcomes of its use in clinical routine. This telemedicine system is designed to complement the daily care and intensive management of diabetic patients through telemonitoring and telecare services. The system comprises a patient unit (PU) used by patients in their day-to-day activities and a Medical Workstation used by physicians and nurses at hospitals. Both applications offer tools to collect, manage, view and interpret data and to exchange data and messages. The system was evaluated for usability, telemedical protocols, metabolic control and quality of life. This evaluation consisted in a 6-month cross-over pilot study with ten Type I diabetic patients. The results of the evaluation allowed assessment of the telemedicine protocols in terms of the number of communications/patient (21.6+/-7.7); days between communications (5.4+/-2.66); messages sent by physicians (118 text messages); and data and messages transmitted by patients (3524 blood glucose readings, 1649 day-to-day insulin adjustments, 24 exercise reports, ten diet modifications and 63 text messages). Physicians performed more therapeutic changes during the DIABTel period than in the control period. There was a trend towards HbA1c improvement during DIABTel use with no incidence in the number of hypoglycaemias. This pilot study demonstrates the feasibility of the DIABTel system in clinical routine use and its potential benefits for diabetes care: improving the availability of information necessary for therapy adjustments; offering new physician-patient communication tools; increasing patient empowerment and education; and showing a positive trend towards improving the metabolic control of patients. Further studies are needed to validate these findings and to promote telemedicine as an opportunity to better diabetes care.

Controlled multicenter study on the effect of computer assistance in intensive insulin therapy of type 1 diabetics

This paper describes the results of a controlled multicenter study on the effect of the computer assistance in the intensive insulin therapy. The patient collective consisted of 50 diabetics, randomly divided in two groups with 25 patients per group. The Multiple Subcutaneous Injection (MSI) group was treated with the usually intensive regimen. The treatment in the Computer Assisted Meal Related Insulin Therapy (CAMIT) group was performed with the aid of a specialized pocket computer. Only in the CAMIT group during the study we observed a significant decrease: in the mean blood glucose (BG) with 1.6+/-0.4 mmol/l (P<0.05), in the BG amplitudes by 1.0+/-0.3 mmol/l (P<0.05), and in the hypoglycemia frequency-from 2.0+/-0.4 to 1.2+/-0.3 (P<0.01) hypoglycemic episodes weekly. The HbA(1) values fell in the MSI group by 3.7+/-3.7% and in the CAMIT group significantly by 15.6+/-2.2% (P<0.05). Consequently, the computer-assisted intensive insulin therapy resulted in an improved metabolic control.

Computer-generated patient education materials: do they affect professional practice? A systematic review

A systematic search of seven electronic databases was done to identify randomized controlled trials that assessed the effect of computer-generated patient education material (PEM) on professional practice. Three studies met the authors' criteria. All three studies involved preventive care. All used a complex intervention of which computer-generated PEM was a major component. Improvements in practice were seen in all studies, although these gains were generally modest. One study showed improvement in patient outcomes. Mann-Whitney statistics calculated for the studies' outcome measures ranged from 0.48 to 0.66, equivalent to risk differences of -4 to 32 percent. Computer-generated PEM seems to have a small, positive effect on professional practice. The small number of included studies and the complex nature of the interventions makes it difficult to draw conclusions about the ability of computer-generated PEM to change professional practice. Future work should involve well-defined interventions that can be clearly evaluated in terms of effect and cost.

Meta-analysis of the effect of the use of computer-based systems on the metabolic control of patients with diabetes mellitus

The purpose of this study was to evaluate, through a meta-analysis study, whether the use of computer-based systems reported in the literature improves the metabolic control of diabetic patients. On the retrieved papers, a set of meta-analysis studies were performed: first the difference of HbA1c between cases and controls at follow-up was evaluated (sign test); then the difference between cases and controls in the total variation of HbA1c from the beginning to the end of the trial was considered (method of effect sizes). The latter methodology was reapplied also on three more homogeneous article subgroups. The sign test was performed on 16 papers: in two of them, the HbA1c level was higher in the intervention group than in the control group at follow-up: it is unlikely that this is a random occurrence (p < 0.01). The method of effect sizes was first applied to 13 papers, as in the others some needed data were missing: the results obtained showed a statistically significant amelioration of metabolic control in the intervention group in comparison to the control group (p < 0.01). A progressive reinforcement of this outcome was obtained on the trial subgroups. Our study supports the hypothesis that the use of computer-based systems can be an effective means of improving metabolic control. The differential benefit obtained in the amelioration of HbA1c does not justify, by itself, the applicability of such systems into clinical practice; additional investigations should be carried out to evaluate the enhancement of other clinical and organizational indicators.

The impact of initiatives in education, self-management training, and computer-assisted self-care on outcomes in diabetes disease management

The purpose of this work is to elucidate the advantages and disadvantages arising from three distinct diabetes disease management initiatives in a managed care setting. The initiatives included (1) education alone, (2) education with self-management training, and (3) education with computer-assisted self-care. Outcomes of interest were changes in glycated hemoglobin (HbA1c), body weight, and costs of care in each cohort of care recipients. A total of 978 health plan members with diabetes within a mixed model HMO were included in the initiatives for improving blood glucose control. HbA1c was measured at baseline and at 3 and 12 months, body weight at baseline and 12 months, and costs of care over 1 year. Costs were derived from suppliers and the health plan. The design is a longitudinal observation study. With the edu-cation-alone initiative, costs, HbA1c, and body weight were unchanged. When education is supplemented with ongoing self-management training, HbA1c fell 1.1% (p < 0.01), body weight rose by 11 kg (p < 0.01), and costs for care increased by $18 per member per month. When education is supplemented with ongoing computer-assisted self-care, HbA1c also dropped by 1.1% (p < 0.01), body weight was unchanged (p > 0.4), and costs for care were $1.31 per member per month. All initiatives improved glycated hemoglobin. Other outcomes must therefore be considered. Among the initiatives, this study elucidated significant differences in body weight and costs. Therefore, in choosing a diabetes disease management program, it would appear that costs should be the primary consideration and methodologies that control body weight should be a priority.

What we can really expect from telemedicine in intensive diabetes treatment: results from 3-year study on type 1 pregnant diabetic women

Existing standards of the management of the diabetic patients are not efficient enough, and further improvement is needed. The major objective of this paper is to present and discuss the therapeutic effectiveness of an intensive care telematic system designed and applied for intensive treatment of pregnant type 1 diabetic women. The developed system operates automatically, every night transferring all the data recorded during the day in the patient's glucometer memory to a central clinical unit. In order to assess the efficiency of the designed and developed system, a 3-year randomized prospective clinical trial was conducted, using the study group and the control group, each consisting of 15 pregnant type 1 diabetic women. All patients were treated by the same diabetologist. In the presented analysis, two indices calculated weekly were used for the assessment of glycemic control: MBG represents mean blood glucose level, and the universal J-index is sensitive to the glycemic level and glycemic variations. The most important results from the study concern: (a) better glycemic control in the study group in comparison with the control group during the course of treatment, as assessed by the average differences of the MBG and J indices calculated weekly (n = 24) (deltaMBG = -3.2 +/- 4.3 mg/dL, p = 0.0016, deltaJ = -1.4 +/- 2.3, p = 0.0065); (b) much more similar results in glycemic control among members of the study group compared to each other, than among members of the control group compared to each other, as indicated by significantly lower variations of the applied glycemic control indices (SDMBG: 11.9 vs. 18.7 mg/dL, p = 0.0498; SDJ: 6.5 vs. 10.9, p = 0.0318); (c) the observed tendency of a better glycemic control for patients with a lower level of intelligence (IQ < 100) supported by the telematic system in comparison with all other assessed groups of patients. The last result was not statistically significant (p > 0.05). This telematic intensive care system improved the effectiveness of diabetes treatment during pregnancy. It also allows the diabetologist's strategy to be much more precise than if it were conducted without telematic support. This telematic system is inexpensive and simple in use.

Information technology and home glucose clamping

Persons with diabetes are responsible for the day-to-day control of their glycemia. To assist patients in discharging this responsibility and help them achieve and sustain improvements in self-blood glucose control, we developed information technology capable of executing algorithms for "clamping glucose" at home. Algorithms for laboratory glucose clamping were translated and adapted for use by patients. The procedures were supported by a central computer and registry. Interaction with the algorithms from home required the patient to handle only a touch-tone telephone, which accessed voice response hardware in the central computer. Patients reported self-measured blood glucose levels or hypoglycemia symptoms together with dietary changes, planned exercise, stress, illness or other lifestyle events. In response, they received self-management instructions and dosing decision support. Metabolic end points were measured. System beta testing in active patients was for 1 year. Patients (n = 142) used the algorithms for their daily self-management, accumulating 1,651 patient-months of follow-up. Almost 100,000 telephone calls were received. Patients benefited. Prevalence of diabetes related crises (hyperglycemia > 400 mg/dL, hypoglycemia < 50 mg/dL or symptoms without measurement) fell approximately twofold (p < 0.05) and glycated hemoglobin levels fell 1.3% (p < 0.001), while body weight was stable. Providers benefited from the timely receipt of standardized reports to monitor the progress of their patients. Earlier intervention was possible. Information technology facilitated home glucose clamping whereby patients with diabetes received timely assistance, advice and decision support for crucial self-control of blood glucose levels. This empowered patients to achieve independence and improve diabetes self-management.

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings

BACKGROUND

Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care.

OBJECTIVES

To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles.

SELECTION CRITERIA

Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes.

REVIEWER'S CONCLUSIONS

Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.

Diabetic patients management exploiting case-based reasoning techniques

In this paper we propose a case-based decision support tool, designed to help physicians in 1st type diabetes therapy revision through the intelligent retrieval of data related to past situations (or 'cases') similar to the current one. A case is defined as a set of variable values (or features) collected during a visit. We defined taxonomy of prototypical patients' conditions, or classes, to which each case should belong. For each input case, the system allows the physician to find similar past cases, both from the same patient and from different ones. We have implemented a two-steps procedure; (1) it finds the classes to which the input case could belong; (2) it lists the most similar cases from these classes, through a nearest neighbor technique, and provides some statistics useful for decision taking. The performance of the system has been tested on a data-base of 147 real cases, collected at the Policlinico S. Matteo Hospital of Pavia. The tool is fully integrated in the web-based architecture of the EU funded Telematic management of Insulin Dependent Diabetes Mellitus (T-IDDM) project.

The promise of technology in the management of the patient with diabetes

The advent of technology has brought many improvements in the management of individual aspects of the care of the patient with diabetes. However, the best management requires communication between systems to enable the clinician to coordinate these various aspects. This article reviews examples of the application of technology to the individual aspects of care. It also discusses the problems and promise of technology to improve overall care management.

Building telemedicine systems for supporting decisions in diabetes care: a report from a running experience

This paper describes some issues that should be investigated to implement telemedicine systems designed for effectively supporting decisions in diabetic patients management, namely situation assessment, information sharing, and knowledge management. The solutions and experiences carried on in this field within a European Union (EU)-funded project, called T-IDDM (Telematic Management of Insulin Dependent Diabetes Mellitus), are reported.

Compartmental models for glycaemic prediction and decision-support in clinical diabetes care: promise and reality

This paper reviews and critically appraises the application of compartmental models for generating glycaemic predictions and offering clinical decision support in diabetes care. Comparisons are made with alternative algorithmic-based approaches. Unresolved issues raised for model-based techniques include the relative lack of input data necessary for generating reasonable blood glucose predictions, and the high level of uncertainty associated with such predictions which limits their use as guides for therapeutic insulin-dosage adjustments. It is concluded that compartmental model-based approaches, while not offering much benefit for clinical/therapeutic application, will have a role to play as research tools and for educational use. By contrast it is proposed that algorithmic-based approaches, especially in conjunction with telemedicine and Internet applications, are likely to see growing use for day-to-day therapeutic decision support. Randomised controlled clinical trials however will be required, together with other evaluation efforts, before algorithmic-based approaches-like any other clinical technique-can be widely adopted into routine medical practice.

Interactive educational simulators in diabetes care

Since the Diabetes Control and Complications Trial demonstrated the substantial benefits of tight glycaemic control there has been renewed interest in the application of information technology (IT) based techniques for improving the day-to-day care of patients with diabetes mellitus. Computer-based educational approaches have a great deal of potential for patients use, and may offer a means of training more health-care professionals to deliver such improved care. In this article the potential role of IT in diabetes education is reviewed, focusing in particular on the application of compartmental models in both computer-based interactive simulators and educational video games. Close attention is devoted to practical applications-available today-for use by patients, their relatives, students and health-care professionals. The novel features and potential benefits of such methodologies are highlighted and some of the limitations of currently available software are discussed. The need for improved graphical user interfaces, and for further efforts to evaluate such programs and demonstrate an educational benefit from their use are identified as hurdles to their more widespread application. The review concludes with a look to the future and the type of modelling features which should be provided in the next generation of interactive diabetes simulators and educational video games.

Telemedicine for diabetes care: the DIABTel approach towards diabetes telecare

Telemedicine is modifying classical health care by providing effective solutions to an increasing number of new situations. This article summarizes the potential benefits made available by this technology in diabetes care, and describes in detail how the new DIABTel Telemedicine Service complements the daily care of diabetic patients. The basic functions of the telemedicine system include telemonitoring of patient's blood glucose data and self-management actions, and remote care from doctors to diabetic patients. The system's architecture comprises two main components: the Medical Workstation, a PC-based system to be used by physicians and nurses in Diabetes Day Centre units in hospitals, and the Patient Unit, a palmtop-computer to be used by patients in their day to day activities. Both components, in an integrated approach, offer tools to doctors and patients for data collection and management, viewing and interpretation modules, data/message exchange services and an interactive glucose/insulin simulator for educational purposes. The DIABTel telemedicine diabetes care procedure aims: (1) to improve communication of the patient with the hospital-based diabetologist, in between the patient's visits to the clinic; (2) to allow doctors to assess the patient's condition on a frequent basis (every week); (3) to help patients with management in the daily care of diabetes, and (4) to provide patients with a service of 'supervised autonomy', to increase patient's independence without decreasing the necessary continual support and supervision from the doctor. Finally, we discuss the practical problems, limitations and vital issues regarding implementation of the telemedicine service.