The evidence base…the management of diabetes

Mike Clark and Nick Goodwin

The impact of telehealth in the management of people with diabetes is well documented. An early assessment of WSDAN’s evidence database, available in the summer, revealed more than 40 published pieces of high-quality research, from which it can be concluded that there is potential for improving the care management of diabetics through telehealth. The evidence is not uniformly positive, however, particularly on cost-effectiveness.

In this feature, the first of a regular series on the evidence base, we showcase three new pieces of high-quality evidence on telehealth and the management of diabetes from overseas.

Assessing the mortality risk for diabetes patients in a home telehealth programme 1

In the USA, the Veterans Health Administration (VHA) runs a programme called Care Coordination Home Telehealth (CCHT), which uses home monitoring to improve access to health care for veterans with diabetes and other chronic diseases. The programme feeds back information from the monitoring system daily to care co-ordinators (usually a nurse practitioner or registered nurse), who can then arrange institutional acute or ambulatory care.

VHA have sponsored a series of evaluations of the CCHT programme and found that it was associated with a significant reduction in hospitalisation at 12 and 24 months after enrollment and an improvement in health-related quality of life and was cost effective for at least one-third of the participants with diabetes [2-5].

A new study1 assessed the effectiveness of the CCHT programme in reducing mortality. This randomised controlled trial followed 387 ethnically and racially diverse individuals with diabetes for four years and compared them with a retrospective control group of the same number. The study found that the intervention group survived longer than the control group, suggesting that the daily management of patients with diabetes through home monitoring by a registered nurse reduces mortality.

From all their research on CCHT, the VHA conclude that telemonitoring is one of the most cost-effective ways of helping individuals manage their own health successfully, avoiding the need for doctor visits and hospitalisation while also improving health.

Telemedicine system for diabetes improves patient-reported well-being 6

Control of serum glucose levels is important for the reduction of complications in people with diabetes;  poor patient compliance is known to be a problem in controlling these levels. Researchers in Israel used telemedicine to improve glucose control. The study covered 35 adults with Type 1 and Type 2 diabetes, of whom 17 received remote glucose monitors with transmitters. The researchers looked at metabolic parameters and used a survey questionnaire to assess patients’ quality of life.

No significant differences were found in post-treatment parameters, although serum glucose levels were slightly elevated in the control group compared to the telemedicine group. However, significantly more patients in the telemedicine group compared to the control group reported being clinically free of symptoms and having no hypoglycemic or hyperglycemic events.

Patients in the telemedicine group reported experiencing significantly less anxiety, treatment difficulty, depression, disease-associated life complications, and feelings of impotence or ineptitude and significantly greater improvement in personal control over glucose, weight, and overall diabetes. The researchers concluded that patient care can be enhanced through telemedicine.

Comparison of a ‘diabetes phone’ and an internet-based glucose monitoring system 7

Researchers in Korea compared the use of a mobile phone with an integrated glucometer with an internet-based glucose monitoring system in a three-month study of 69 people with Type 2 diabetes. Readings were automatically transferred via the phone to web-based charts,and patients received medical advice by SMS text. After three months, the HbA1c levels of both groups had decreased significantly and levels of patient satisfaction and adherence to medical advice were similar.

Researchers considered that the diabetes phone was as effective for glucose control as the previously studied internet-based monitoring system and was good for patient satisfaction and adherence. The study reflects on a general issue, picked up by Mike Clark, in a related feature on sustaining innovation.

Future editions of the ‘evidence base’ in the coming months will focus on the management of heart disease and COPD. 

Mike Clark and Nick Goodwin are co-project leads for WSDAN

References and links:

1 Chumbler N, Chuang H, Wu S, Wang X, Kobb R, Haggstrom D,Jia H (2009). Mortality risk for diabetes patients in a care coordination, home-telehealth programme. J Telemed Telecare; 15: 98-101.

2Chumbler N, Vogel W, Garel M, Qin H, Kobb R, Ryan P (2005). Health services utilization of a care coordination/home-telehealth program for veterans with diabetes: a matched-cohort study. J Ambul Care Manage; 28:230–40.

3Barnett TE, Chumbler NR, Vogel WB, Beyth RJ, Qin H, Kobb R (2006). The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: a 2-year follow-up. Am J Manag Care;12:467–474.

4Chumbler NR, Neugaard B, Kobb R, Ryan P, Qin H, Joo Y (2005). Evaluation of a care coordination/home-telehealth program for veterans with diabetes: health services utilization and health-related quality of life. Eval Health Prof ;28:464–78.

5Barnett TE, Chumbler NR, Vogel WB, Beyth RJ, Ryan P, Figueroa S (2007). The cost-utility of a care coordination/home telehealth program for veterans with diabetes. J Telemed Telecare ;13:318–21.

6Boaz M, Hellman, K and Wainstein M (2009). An automated telemedicine system improves patient-reported well-being. Diabetes Technology and Therapeutics; 11: 181-186.

7Jae-Hyoung Cho, Hye-Chung Lee, Dong-Jun Lim, Hyuk-Sang Kwon and Kun-Ho Yoon (2009). Mobile communication using a mobile phone with a glucometer for glucose control in Type 2 patients with diabetes: as effective as an Internet-based glucose monitoring system. J Telemed Telecare; 15:77-82.