Better Living with Technology: Enhanced Communication and Diabetes Care

Takeaway Points:

1. Emphasis on the patient-centered medical home as a health care delivery model will increase the use of communication technologies in diabetes care
2. Greater use of these technologies requires that endocrinologists assess the ways in which each is most effective
3. A number of studies have been published testing communication technology’s affect on various measures of diabetes care. Researchers from the University of Warwick performed a meta analysis of these papers.
4. The quality and focus of the research was too varied for the authors to make any hard conclusions about any particular technology.
5. The authors suggest that these technologies could help adolescents and young adults enact long-term behavior change.

Debate over the future of health care delivery in the United States introduced many people to the idea of the patient-centered medical home. This collaborative delivery of health care is touted as an optimal model because it is supposed to foster better communication between disparate parties responsible for the care of one individual, as well as increase the responsibility of patients for their own care.

This is especially important in chronic conditions such as diabetes which must affect numerous other body systems and require continuous monitoring throughout the day. While the medical community awaits the development of the continuous glucose monitor, the next best things are technologies that communicate patient data remotely to physicians who use it to enhance their decision-making.

Because of their potential impact on disease management, it is imperative that their effectiveness and appropriateness be evaluated. To that end, a team from the University of Warwick’s Health Sciences Research Institute performed a meta analysis of studies involving “communication technologies (eg, mobile telephony, forums, e-mail)” to establish whether they “can be used to transfer digital information between healthcare professionals and young people who live with diabetes.”

Their work was published in BMC Endocrine Disorders on January 6, 2011.

They searched 20,925 publications across nine electronic databases, ultimately identifying 19 that met inclusion criteria. Eighteen technologies were assessed, but the team established “five categories of communication technologies” under which each of these fell: video- and tele-conferencing; mobile telephony; telephone support; novel electronic communication devices for transferring clinical information; Web-based discussion boards.

• Video- and tele-conferencing “was targeted at young people who had difficulty in attending the clinic regularly and were unable to maintain glycaemic control.”
• Mobile telephony involved the use of text messaging systems that “offered the user feedback, information, tips, and reminders with regards to self-management tasks” and sent “personalised messages with specific diabetes health advice” after processing “diabetic condition data, received through SMS and general packet radio service (GPRS).”
• Telephone support involved either pediatric diabetes educators providing “assistance and support” or a behavioral health program designed “to effectively communicate with young people who live in geographically remote areas.”
• Novel electronic communication comprised synchronized glucometers, a software package synchronized with insulin pumps, web-based education, online communication, and remote glucose monitoring, all of which collected data in order to provide feedback to a health care provider.
• The Web-based discussion board “was targeted at older adolescents and young adults.” Moderated by a diabetes educator, new education material was introduced weekly focusing on “goal-setting exercises, personalized feedback, group discussions, and role-playing.”

“A total of 978 young people (males = 523, females = 355) with diabetes [type 1 and type 2] were included in this review…The mean age was 15.9 (SD = 4.3yrs).”

Clinical outcomes
Six of ten randomly-controlled trials “showed a positive improvement in HbA1c following the intervention…with four studies reporting detrimental increases in HbA1c levels in one or both intervention groups.” Though “two studies found a significant difference in HbA1c between the intervention and a comparison group” the authors note that “there was no defining commonality in studies that reported HbA1c increases or decreases.”

Improvements in HbA1c levels were noted in five non-randomly controlled trials, “but not all were significant.” “An Internet-based insulin pump monitoring system was associated with improved glycaemic control in children with type 1 diabetes,” while telehealth reduced HbA1c levels by 2.4% and 3.5% in two participants and “reduced the number of hypoglycemias” in a separate study; another telehealth effort was not able to improve or maintain metabolic control in five participants.

When it came to “behavioural and psycho-social outcomes,” a telecommunication program was the only to report “clear improvements in quality of life, patient-caregiver interaction, and an increase in the perceived importance of glycaemic control.” Importantly, that same study “reported a decrease in perceived mastery in the control group and a decrease in family problem-solving in the intervention group, demonstrating the balances that need to be considered with increased clinician communication.”

A text message program was, however, able to improve self-efficacy scores and “patient’s perception of quantity of support but had no impact on diabetes knowledge score.” An “electronic data collection and transfer device” was also able to enable continuity of care and improve access and activities.

15 of 18 studies “reported that communication technologies increased the frequence of contact between patient and healthcare professional; although much of this contact was a requirement of the intervention.” Two of these papers (Internet-based insulin pump monitoring system, computerized diary) “reported a significant correlation between improvements in HbA1c and increased contact;” five (text messaging systems, and telecommunication) did not.

Only two trials (telehealth and remote glucose monitoring) “reported cost reduction” and unfortunately, “no papers reported outcomes relating to: transparency of care; delivery guidelines; or equity in access to health care.”

Conclusions
While the authors “found some evidence of the impact of communication technologies” on various aspects of health care delivery, they were unable to draw many conclusions about the efficacy of any specific technologies because of the “substantial variation in the quality of the papers” and “inconsistencies in the reported findings and difficulties in categorizing technologies to allow reliable comparison.”

Accordingly the authors hesitate to read too much into their findings, but give tepid support to the idea “that a combination of enhanced self-efficacy with motivation and knowledge may enable adolescents and young adults to change their health behaviours, which in turn, may change their clinical outcomes (e.g. HbA1c).” As expected, they recommend that further research be performed to better illuminate the relationship between communication technologies and diabetes care.