Evaluation and results
The initiative was evaluated by a randomized controlled trial (RCT) with the control group receiving traditional care. Prior to the RCT we had undertaken a proof of concept trial (publication attached). We then used the user feedback to improve the system and conducted a feasibility trial in a real-life setting for a nurse-led insulin dose adjustment service.
Data at 6-months from the RCT showed a significant improvement in HbA1c from baseline of 1.1 per cent in the intervention arm compared with a 0.1 per cent worsening in the control group (p-value < 0.05) and a 30 per cent substitution of routine in-person visits.
The participants in the intervention group was highly satisfied - this was assessed using a 22-item questionnaire service user technology acceptance questionnaire (SUTAQ). All the sub-scale mean scores (1) enhanced care (2) increased accessibility (3) the model as substitution to routine care (4) satisfaction (5) privacy and discomfort and (6) care personnel concerns favoured the intervention arm.
Qualitative feedback were generally positive towards MDMS with the main themes of convenience ( ease of access to the diabetes educator, time and effort saved in managing diabetes) and improved self-awareness, leading to better diabetes management emerging. Areas that could be improved included predominantly technical issues ( Bluetooth connectivity and App related), more feedback regarding monitored data, and tailoring the automated text message feedback to the knowledge level of the participant. Most participants felt strongly that the overall experience with the new care model was positive and is captured in this quote from one participant – “I am very happy with the service speaking to only three people makes it more personal, not having to write down records is a major plus and less time coming into clinic as most of the help can be given over phone”.
Lessons learnt
- eHealth solutions for management of diabetes is acceptable to the patients, improve clinical outcomes (glycaemic control) as compared with traditional specialist care and can improve the efficiency of the outpatient clinics by substitution of routine in-person visits.
- The role of the care-coordinator is crucial in getting this model to work.
- Culture change is essential for clinicians to embrace this innovative model.
- Technology should work smoothly for increased uptake by clinicians and should be embedded within existing electronic health records to decrease physician workload.
- Need to change from existing fee-for-service models for adoption is essential.
- Sustainability in the long-term might require constant adaptation of technology to address consumer needs through co-design and 'digital phenotyping'.
References
This model was an innovative concept that rethinks the traditional clinic-based visit model and based on previous studies showing eHealth interventions for diabetes are effective.
Kitsiou, S.; Paré, G.; Jaana, M.; Gerber, B. Effectiveness of mHealth interventions for patients with diabetes: An overview of systematic reviews. PLoS ONE 2017, 12, e0173160.
Dobson R, Whittaker R, Jiang Y, Maddison R, Shepherd M, McNamara C, et al. Effectiveness of text message based, diabetes self management support programme (SMS4BG): two arm, parallel randomised controlled trial. BMJ. 2018;361:k1959.
Faruque LI, Wiebe N, Ehteshami-Afshar A, Liu Y, Dianati-Maleki N, Hemmelgarn BR, et al. Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials. CMAJ. 2017;189(9):E341-E64.
Lee SWH, Chan CKY, Chua SS, Chaiyakunapruk N. Comparative effectiveness of telemedicine strategies on type 2 diabetes management: A systematic review and network meta-analysis. Scientific reports. 2017;7(1):12680.