Nurse practitioner provided home telemonitoring and medication management improves glycemic control in primary care patiemts with type 2 diabetes more than monthly care coordination telephone call
- Correspondence to Kathryn H Bowles
Room 340 Fagin Hall, 418 Curie Blvd., Philadelphia, PA 19104-4217, USA;
This study adds to the growing body of evidence that telemonitoring has positive effects on glucose control. The investigators tested the efficacy of home telemonitoring with active medication management by a nurse practitioner, compared to telephonic monthly coordination by a diabetic educator on glycemic control in veterans with type 2 diabetes and baseline Hbg A1C levels >7.5%. The sample included veterans who received primary care for at least a year at the Veterans Administration Healthcare System in Pittsburgh, Pennsylvania, between June 2004 and December 2005.
The study was a randomized controlled trial, with the control group receiving a monthly telephone call for diabetes education and self-management review. The experimental group received that, plus they transmitted blood glucose, blood pressure and body weight, using the Viterion 100 TeleHealth Monitor, and a nurse practitioner adjusted their diabetes, blood pressure and lipid medications as needed. Measures of HgbA1C were taken at baseline and 3 and 6 months later. The mean baseline HgbA1C measures were 9.4% and 9.6% in the control and telehealth groups, respectively. The telehealth group achieved statistically significant reductions in HgbA1C at 3 and 6 months, compared to the control group.
This study makes a unique contribution because of the innovative methodology it suggests, that is, using nurse practitioners to quickly manage the medications in response to abnormal telehealth data. Other studies with successful outcomes are the IDEATel trial using telemonitoring with nurse case management,1 and a meta-analysis of 12 randomized controlled trials comparing telehealth glucose monitoring to usual care concluded a positive effect on Hemoglobin AIC levels with telehealth, whereas telephone interventions compared to usual care had mixed results.2 A matched cohort study conducted at another VA facility with diabetics achieved reductions in all cause and diabetes-related readmissions in the telehealth group compared to usual care over 2 years.3
The investigators carefully considered potential confounding variables in their analyses and examined the relationship between the number of medication changes, the frequency of telemonitoring and outcomes. They found no relationship between these factors. They also appropriately targeted patients for enrollment who had high baseline HgbA1C levels. However, they did not indicate how many had high blood pressure or high lipids. The intervention was unable to improve these levels, and without knowing the sample size for these conditions it is hard to know why. The study was powered to detect a change in HgbA1C and not blood pressure or lipid control. Future studies might target patients specifically with high levels of all of these conditions to identify the greatest benefit from telemonitoring.
Insulin doses were increased approximately 18 units higher in the telemonitoring/nurse-practitioner group. The analysis showed no significant correlation between the frequency of insulin adjustment and glucose control; however, the reader wonders whether there was a correlation between the dose of insulin and glycemic control. The investigators did not address this issue. A gap remains in understanding whether better control is achieved because of the monitoring, the education or the medications used. The intervention group received continuous home messaging with reminders and education, but the content of the messages were not adequately described. The reader also does not know the content covered by the diabetic educator during the monthly calls. Was there any difference in what the nurse practitioner taught or advised versus the diabetic educator? The control group kept daily logs of their weight, blood pressure and glucose, but the study team did not discuss how well patients' adhered to keeping the logs and whether medication changes were made on the basis of the information provided.
The Active Care Management Home Telemonitoring study is an innovation in telehealth management of diabetic patients that showed positive impact on glycemic control. Although the study design makes it difficult to pinpoint the exact mechanism of the effect, the components of the intervention are feasible to replicate. Future research with this intervention should include a cost analysis and target patients with high blood pressure, abnormal lipid panels and hyperglycemia to fully assess the impact of nurse-practitioner-led telehealth management on evidence-based diabetic care. Another publication by this team about the details of the intervention would also be useful to assist with replication.
Conflicting interests None.