Automated Calls With Nurse Follow-Up to Improve Diabetes Ambulatory Care
Condition: Diabetes
MeSH terms: Diabetes Mellitus
Study type: Interventional
Phase: Phase 3

Summary: 
      Regular outpatient follow-up is important for all diabetes patients, with some needing
      frequent attention because their health is unstable, their treatment regimen is complex, or
      their social supports are inadequate. However, many patients live with access barriers that
      limit their use of outpatient services, fail to attend outpatient appointments, and
      experience worse outcomes than trials of aggressive management suggest is possible. Although
      labor-intensive, telephone care programs are one potential strategy for bringing diabetes
      management services into patients� homes and improving their glycemic control. Automated
      telephone disease management (ATDM) systems can augment telephone care by providing frequent
      monitoring and health education to large patient panels while focusing clinicians� attention
      on individuals who need it most. Although this technology has shown some promise, it has not
      been rigorously evaluated, particularly in VA.
    

Detailed description: 
      Background:

      Regular outpatient follow-up is important for all diabetes patients, with some needing
      frequent attention because their health is unstable, their treatment regimen is complex, or
      their social supports are inadequate. However, many patients live with access barriers that
      limit their use of outpatient services, fail to attend outpatient appointments, and
      experience worse outcomes than trials of aggressive management suggest is possible. Although
      labor-intensive, telephone care programs are one potential strategy for bringing diabetes
      management services into patients� homes and improving their glycemic control. Automated
      telephone disease management (ATDM) systems can augment telephone care by providing frequent
      monitoring and health education to large patient panels while focusing clinicians� attention
      on individuals who need it most. Although this technology has shown some promise, it has not
      been rigorously evaluated, particularly in VA.

      Objectives:

      This study evaluated Automated Telephone Disease Management (ATDM) calls with telephone nurse
      follow-up as a means of improving the quality of VA diabetes care. Specifically, we will
      determine whether this service improves patients' glucose control; improves other important
      outcomes such as their quality of life, satisfaction with care, and health service use;
      improves health behaviors such as self-monitoring of blood glucose, fat intake, and
      medication adherence; and has effects that vary across patient subgroups.

      Methods:

      Patients with diabetes mellitus using hypoglycemic medication were enrolled during outpatient
      visits to a university-affiliated VA health care system and randomized to usual care or
      bi-weekly ATDM assessment and self-care education calls with follow-up by a nurse educator.
      The intervention process was evaluated by examining patients� patterns of ATDM use and the
      reliability and validity of information they provided. Telephone surveys were used to measure
      intervention effects at 12-months on patients� self-care, symptoms, satisfaction with care,
      and perceived access barriers. The impact on VA utilization was evaluated using electronic
      utilization databases, and glycemic control was measured using laboratory tests. A total of
      292 patients were randomized and 272 (93%) provided data at 12-months. Intervention patients
      completed ATDM assessments consistently throughout the observation period and the assessments
      identified groups of intervention patients with varying degrees of health risk at baseline.
      Compared to control patients, intervention patients at 12-months reported more frequent
      glucose self-monitoring, fewer access problems, and greater satisfaction with care (all p =
      0.05). Intervention patients were more likely than controls to have been seen in podiatry
      clinics (53% versus 31%, p = 0.003) and diabetes specialty clinics (31% versus 17%, p = 0.03)
      during the study. The intervention did not influence mean endpoint HgA1c levels overall.
      However, among patients with baseline HgA1c = 8%, mean endpoint values among intervention and
      control patients were 8.7% and 9.2%, respectively (p = 0.05); intervention effects were even
      greater among patients with baseline HgA1c = 9%. Moreover, intervention patients at follow-up
      reported fewer symptoms of poor glycemic control than patients receiving usual care (3.6
      versus 4.4, p = 0.03).

      Status:

      Completed.
    

Intervention name(s): Automated telephone health status assessments with nurse follow-up.
Intervention type(s): Procedure
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment