Diabetes Management: The Holy Grail of Self-Management Goes On-line

Chen, Chauang, et. all publishing an original paper in JMIR titled “Evaluating Self-Management Behaviors of Diabetic Patients in a Telehealthcare Program: Longitudinal Study Over 18 Months“. The goal of the study was to identify behaviors of patients with diabetes as it relates to online application, measure impact of teleheathcare, and determine changes in glycosylated hemoglobin level. Managing diabetes even for the most committed patient is a daily and ongoing task. And for those less committed it takes real effort. This is a long well designed study that cannot be easily summerized. 

The study examined 7 self-care activities and was run for 18 months used a third generation mobile telecommunications glucometer, online self management system, and phone constant service. This is a rather robust system and one that I am not sure is readily available. 

The online system was based on personal health record criteria where patients health data and personal information are captured and managed by the patients. This is interesting from a learning perspective since we can assume these patients are seeking solutions to the problems they have and are motivated as adult learners. 

Asynchronous text messages were provided and patients and caregivers could use the online diabetes self-managment system or SMS text messaging. The online system included blood glucose, BP, heart rate, weight, insulin injection, daily diet, and daily physical activities. The data entry was made as simple as possible. 

The online diabetes self-management system included the monitoring items and the diabetes-related information, such as blood glucose, blood pressure, heart rate, body weight, insulin injection, daily diet, and daily physical activities. Information that was measured with equipment that did not have transmission networks required manual input. Dietary intake could be recorded through the use of either text or images. Additional information to enable self-management and goal setting for glucose control were generated (eg, the mean, median, standard deviation, and maximum and minimum daily blood glucose values). The variations in blood glucose and other parameters are presented together graphically to enable the user to observe the effect of each behavior. The frequency of self-monitoring of blood glucose (SMBG) was recorded and compared with the set goals to determine whether adjustments were needed. Body mass index (BMI) was calculated, and the suggested calorie intake and ingredient volume for each meal were displayed. An additional care-provider interface was designed so that caregivers could get a quick overview of patient status. Case managers were able to log in and view the data uploaded by the patients, identify abnormal events, and make phone calls. The online diabetes self-management system sent an SMS text message to care providers when the data exceeded the alerting range.

This study provided a teleconsultant service to support patients with diabetes self-management. The case managers for this study, including a nurse and a dietitian, were the care providers who interacted with the patients from a distance. They were responsible for monitoring patient status, answering questions about self-care activities, regularly keeping in touch with the patients through telephone calls or text messages, and encouraging them to perform self-management. The care plans and goal setting were formulated through a discussion with each patient during his or her enrollment. The case managers monitored the data uploaded by the patients. They gave advice and reminded the patients to perform self-care activities. In this study, the case managers were not involved in medication adjustments. They did, however, collate patient data and bring the information to the clinic when the patient returned for an appointment. They communicated with physicians to suggest adjustments when needed.

This study showed that using a sophisticated technological design supported the patients with diabetes in self-management. It appears that telehealthcare is effective in enhancing blood glucose monitoring, and the patients in the program showed improvements in glycemic control. The self-care behaviors affected patient outcomes and the changes in behavior required time to show effects. Telehealthcare has a positive effect on patients with diabetes, and it may encourage more technological interventions for diabetes care.

From my perspective this is a terrific study that’s examining healthcare in two of the more difficult areas, diabetes and the elderly. That is no mean feat on any level. The fact they were successful is telling. But it is worth noting that this was sophisticated study using technology and telephonic support. And the time to see results was extended. The ease to duplicating this on a large scale will be a challenge but it should not stop us from doing it since diabetes and obesity will be significant issues in cost and healthcare for America.