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Telehealth program for Medicaid patients with type 2 diabetes lowers hemoglobin A1C
Abstract
Diabetes telehealth research to date has provided minimal description of its clinical
protocols, including strategies used to foster behavior change and procedures to
deliver diabetes self-management education (DSME) and medical care. Also, there
has been a focus on time-limited research interventions but little on working clinical
programs. We describe here an effective diabetes telehealth program (House-
Calls) that serves an urban Medicaid population living with poorly-controlled type
2 diabetes (T2DM). We also discuss barriers to the future scalability and long-term
sustainability of such programs that our health care system will need to overcome
if we are to provide population-level telehealth solutions for the growing epidemic
of T2DM.
Key Points
• T2DM affects 7.8 percent of the U.S. population, with only 7 percent of these
individuals meeting the guidelines for control of hyperglycemia, hypertension, and
dyslipidemia.
• HouseCalls uses a system of in-home remote monitoring devices- blood glucose
(BG) meters and blood pressure (BP) monitors- that upload readings electronically
to a secure website. A nurse-led team provides telephone support: rapid feedback
regarding the remote monitoring data, self-care advice, education, and timely clinical
follow-up.
• Data from 330 urban dwelling, T2DM Medicaid patients showed a clinically and
statistically significant improvement in mean glycosylated hemoglobin (HbA1c) of
-1.8 percent (SD = 2.2).
• Despite such positive outcomes, practical barriers exist that threaten the scalability
and long-term financial viability of T2DM telehealth. Emerging models, including
HouseCalls, provide evidence that telehealth can improve access and quality of
care, and reduce health care costs.
Supplementary resources (2)
Data
March 2015
Data
March 2015
... 9 Moreover, patients with diabetes need to understand their disease and become involved in their own treatment and modify many lifestyle behaviors in order to self-manage their condition. 13,14 Remote monitoring (sometimes known as real-time monitoring) systems have been introduced to aid the process of self-managing T2DM. 15 In addition, these monitoring systems move toward integrating commercially available technologies into healthcare systems. ...
... Most participants rated these functions of the services as useful/ extremely useful. were conducted in South Korea (Kim et al., 30 Cho et al., 31,37 Kim and Jeong, 32 Kim, 33 and Kim et al. 38 ), five studies in the United States (Stone et al., 23 Stamp et al., 14 Durso et al., 29 Katz et al., 42 and Tang et al. 43 ), three in the United Kingdom (Larsen et al., 11 Turner et al., 34 and Istepanian et al. 35 ), and two in Taiwan (Chen et al. 40 and Guo et al. 44 ). Single studies were conducted in Spain (Rodrigues-Idigoras et al. 36 ), Poland (Bujnowska-Fedak et al. 39 ), and India (Kesavadev et al. 41 ). ...
... All participants recruited were adults, and the duration of the experiments ranged from 6 to 70 weeks. Seven studies were pre-post design, 14,29,30,32,33,42,44 out of which three divided the participants into an intervention group (IG) and a control group (CG). One was an interrupted time-series study, 11 and two were cohort studies, 34,41 one of which was a retrospective study. ...
This systematic review aims to evaluate evidence for viability and impact of Web-based telemonitoring for managing type 2 diabetes mellitus. A review protocol included searching Medline, EMBASE, CINAHL, AMED, the Cochrane Library, and PubMed using the following terms: telemonitoring, type 2 diabetes mellitus, self-management, and web-based Internet solutions. The technology used, trial design, quality of life measures, and the glycated hemoglobin (HbA1c) levels were extracted. This review identified 426 publications; of these, 19 met preset inclusion criteria. Ten quasi-experimental research designs were found, of which seven were pre-posttest studies, two were cohort studies, and one was an interrupted time-series study; in addition, there were nine randomized controlled trials. Web-based remote monitoring from home to hospital is a viable approach for healthcare delivery and enhances patients' quality of life. Six of these studies were conducted in South Korea, five in the United States, three in the United Kingdom, two in Taiwan, and one each in Spain, Poland, and India. The duration of the studies varied from 4 weeks to 18 months, and the participants were all adults. Fifteen studies showed positive improvement in HbA1c levels. One study showed high acceptance of the technology among participants. It remains challenging to identify clear evidence of effectiveness in the rapidly changing area of remote monitoring in diabetes care. Both the technology and its implementations are complex. The optimal design of a telemedicine system is still uncertain, and the value of the real-time blood glucose transmissions is still controversial.
... Multimedia Appendix 3 provides a histogram of dropout rates. There were 14% (6/41) studies with dropout rates 10% or lower, and 3 (7%, 3/41) with dropout rates greater than 50% [30,35,36,67]. A regression analysis revealed that there is no strong correlation (R 2 =.0639) between the study period and dropout rates. ...
... All the articles included in the systematic review had their own internal biases. Mainly, remote health approaches rely heavily on the data submitted by the patients [67,70,76]. These data can be willingly distorted or abstained by patients. ...
Background
Diabetes self-management involves adherence to healthy daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption.
Objective
The objective of our study was to identify and classify barriers to adoption of remote health for management of type 2 diabetes.
Methods
The following 6 electronic databases were searched for articles published from 2010 to 2015: MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier). The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of 2 to review and extract data from identified papers. Information collected included study characteristics, outcomes, dropout rates, technologies used, and barriers identified.
Results
A total of 53 publications on 41 studies met the specified criteria. Lack of data accuracy due to input bias (32%, 13/41), limitations on scalability (24%, 10/41), and technology illiteracy (24%, 10/41) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations, whereas limitations on scalability were more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. In total, 40.5% (60/148) of identified barrier instances impeded patient engagement, which is manifest in the large dropout rates cited (up to 57%).
Conclusions
The barriers identified represent major challenges in the design of remote health interventions for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high dropout rates, and new interventions are needed to identify and assist those at the greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financial sustainability.
... The combined HBPTM + NCM intervention we are evaluating is the 'House Calls' program offered through the New York City Heath and Hospitals Corporation (HHC). This established telehealth program utilizes an interactive web-based system to integrate HBPTM with personalized care, education and disease management from experienced nurses and has been shown to achieve significant reductions in BP [41]. There is evidence suggesting that the combination of home BP monitoring and NCM may be more effective in reducing BP than either intervention alone, particularly with respect to sustainability of effects [42,43]. ...
Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension.
A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing.
The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence.
ClinicalTrials.gov NCT02011685 . Registered 10 December 2013.
Background:
We examined the usability, satisfaction, and clinical impact of a 3-month diabetes telehealth intervention for poorly controlled type 2 diabetes (T2D) patients. The urban community health center sample (n=30) was 56.7% female, mean age of 60.6 years, 56.7% high school education or higher, and 73% African American and 26% Latino.
Materials and methods:
We integrated an electronic pillbox into an existing diabetes remote home monitoring (RHM) device suite comprising a Bluetooth(®) (Bluetooth SIG, Kirkland, WA)-enabled blood glucose meter and an automatic blood pressure monitor connected to a cellular hub for data upload to our clinical application. This telehealth program involved minimal clinician training and functioned as a nonurgent patient self-management support service to increase the scope of clinic services. Telehealth nurse interventionists received regular RHM data alerts and called patients by phone at scheduled intervals. A graphical report summarizing patient RHM data was sent to providers to inform clinical decision making during a scheduled clinic visit at the 3-month follow-up.
Results:
The results showed consistently high levels of RHM device use during the intervention period, high ratings of usability and program satisfaction from patients, and high ratings of provider satisfaction with the program. There was a clinically and statistically significant improvement in blood glucose control at 3 months, such that hemoglobin A1c improved 0.6% from a baseline level of 8.3% (p<0.05).
Conclusions:
These findings provide encouraging empirical support for the usability and clinical value of a diabetes telehealth program integrating a user-friendly cellular pillbox and clinical decision support tools that was delivered to an urban poor T2D clinic population.
Background:
In this new era after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the literature on lessons learned with electronic health record (EHR) implementation needs to be revisited.
Objectives:
Our objective was to describe what implementation of a commercially available EHR with built-in quality query algorithms showed us about our care for diabetes and hypertension populations in four safety net clinics, specifically feasibility of data retrieval, measurements over time, quality of data, and how our teams used this data.
Methods:
A cross-sectional study was conducted from October 2008 to October 2012 in four safety-net clinics located in the Midwest and Western United States. A data warehouse that stores data from across the U.S was utilized for data extraction from patients with diabetes or hypertension diagnoses and at least two office visits per year. Standard quality measures were collected over a period of two to four years. All sites were engaged in a partnership model with the IT staff and a shared learning process to enhance the use of the quality metrics.
Results:
While use of the algorithms was feasible across sites, challenges occurred when attempting to use the query results for research purposes. There was wide variation of both process and outcome results by individual centers. Composite calculations balanced out the differences seen in the individual measures. Despite using consistent quality definitions, the differences across centers had an impact on numerators and denominators. All sites agreed to a partnership model of EHR implementation, and each center utilized the available resources of the partnership for Center-specific quality initiatives.
Conclusions:
Utilizing a shared EHR, a Regional Extension Center-like partnership model, and similar quality query algorithms allowed safety-net clinics to benchmark and improve the quality of care across differing patient populations and health care delivery models.
ResearchGate has not been able to resolve any references for this publication.