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Evid Based Nurs 9:21 doi:10.1136/ebn.9.1.21
  • Treatment

Web based care management improved glucose control in patients with poorly controlled diabetes


 
 Q Does web based care management improve glucose and blood pressure control, compared with usual care, in patients with poorly controlled diabetes?

METHODS

GraphicDesign:

randomised controlled trial.

GraphicAllocation:

{concealed}.*

GraphicBlinding:

{unblinded}.*

GraphicFollow up period:

3, 6, 9, and 12 months.

GraphicSetting:

Department of Veterans Affairs Boston Healthcare System in Boston, Massachusetts, USA.

GraphicPatients:

104 English speaking patients >18 years of age (mean age 63 y, 99% men) who had poorly controlled diabetes (HbA1c concentration ⩾9.0%), were willing to use a computer and glucose and blood pressure monitoring devices, had access to a telephone, and had a primary care provider associated with the hospital. 49% of patients were using insulin. 71% had not previously used the internet.

GraphicIntervention:

all patients attended a half day educational session on diabetes self management. 52 patients were allocated to usual care plus web based care management. They were given a notebook computer with free internet access and computer training and support; a glucose meter (with individualised recommendations for home glucose testing); and a blood pressure monitor (with encouragement to monitor their blood pressure 3 times per wk). A special care management website provided educational modules, accepted uploads from the glucose and blood pressure monitors, and displayed the results in graphic and tabular form. It also provided an internal messaging service to and from the care manager (an advanced practice diabetes nurse), who reviewed the data and made recommendations to patients and their primary care providers based on treatment algorithms. 52 patients were allocated to usual care alone (ongoing care by their primary care provider as needed).

GraphicOutcomes:

change in HbA1c concentration and blood pressure.

GraphicPatient follow up:

81% of patients completed follow up; all patients were included in the intention to treat analysis, with last outcome carried forward for those with missing data.

MAIN RESULTS

HbA1c concentrations decreased from baseline in both groups at all time points, but the decline was greater in the web based care management group than in the usual care group (p<0.05). By the end of the trial, the groups did not differ for the proportion of patients who were hypertensive (systolic blood pressure ⩾140 mm Hg or diastolic blood pressure ⩾90 mm Hg) {54% v 71%, p = 0.07}.*

CONCLUSION

In patients with poorly controlled diabetes, a web based care management intervention plus usual care improved glucose control more than usual care alone.

Commentary

  1. Anne Phillips, RGN, MSc
  1. University of York
 York, UK

      With an epidemic of diabetes projected over the next 10 years,1 the development of internet educational resources could be a useful adjunct to other modes of diabetes education delivery. The study by McMahon et al is timely, as web based educational resources are increasing in diabetes care.

      Many of the existing web based resources have been developed for healthcare professionals, whereas this study evaluated a resource developed for patients with poorly controlled diabetes. Practitioners are seeking ways to increase their effectiveness in diabetes patient education and to promote patients’ self empowerment and management abilities.2 This intervention seems to support these objectives.

      Strengths of the study are the rigorous design and the innovative and comprehensive use of technology, including education, health monitoring, and 2-way electronic communication with a case manager. However, the sample size was relatively small. Furthermore, because of the characteristics of the healthcare institutions from which the sample was drawn, the generalisability is restricted. The sample was virtually all men and the participants were older (mean age 63 y) and better educated (>60% college educated) than one might expect.

      The feasibility of implementing such an intervention is limited by the availability of computer equipment, software, training, support, and internet access. In addition, healthcare agencies may not have the human resources required to mount this labour intensive strategy. An advanced practice nurse with certification as a diabetic educator monitored patients’ health status, made treatment recommendations, communicated with primary care providers, and responded to patients within 1 working day. In addition, if patients did not log on to the website during any 2 week period, a study coordinator prompted them (by telephone) to do so.

      Considering the small sample size, limited generalisability, and feasibility challenges, this intervention is not likely to be implemented in clinical practice at present. However, web based interventions are pointing the way as computers become more available.

      References

      Footnotes

      • * Information provided by author.

      • * Calculated from data in article.

      • For correspondence: Dr P R Conlin, Veterans Affairs Boston Healthcare System, Boston, MA, USA. paul.conlin{at}med.va.gov

      • Sources of funding: Department of the Army Cooperative Agreement, Department of Veterans Affairs, Health Services Research and Development Program, and National Institutes of Health.

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