Clinical Studies
Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes?

https://doi.org/10.1016/S0002-9343(99)00298-3Get rights and content

Abstract

PURPOSE: We sought to evaluate the effect of automated telephone assessment and self-care education calls with nurse follow-up on the management of diabetes.

SUBJECTS AND METHODS: We enrolled 280 English- or Spanish-speaking adults with diabetes who were using hypoglycemic medications and who were treated in a county health care system. Patients were randomly assigned to usual care or to receive an intervention that consisted of usual care plus biweekly automated assessment and self-care education calls with telephone follow-up by a nurse educator. Outcomes measured at 12 months included survey-reported self-care, perceived glycemic control, and symptoms, as well as glycosylated hemoglobin (Hb A1c) and serum glucose levels.

RESULTS: We collected follow-up data for 89% of enrollees (248 patients). Compared with usual care patients, intervention patients reported more frequent glucose monitoring, foot inspection, and weight monitoring, and fewer problems with medication adherence (all P ≤0.03). Follow-up Hb A1c levels were 0.3% lower in the intervention group (P = 0.1), and about twice as many intervention patients had Hb A1c levels within the normal range (P = 0.04). Serum glucose levels were 41 mg/dL lower among intervention patients than usual care patients (P = 0.002). Intervention patients also reported better glycemic control (P = 0.005) and fewer diabetic symptoms (P <0.0001), including fewer symptoms of hyperglycemia and hypoglycemia.

CONCLUSIONS: Automated calls with telephone nurse follow-up may be an effective strategy for improving self-care behavior and glycemic control, and for decreasing symptoms among vulnerable patients with diabetes.

Section snippets

Patient enrollment

Participants were enrolled from two general medicine clinics of a county health care system. Research assistants reviewed medical records of patients with scheduled appointments to identify adults with a diagnosis of diabetes mellitus or an active prescription for a hypoglycemic agent. We excluded patients who were >75 years of age, had a diagnosed psychotic disorder, disabling sensory impairment, or life expectancy of <12 months, or whose primary language was neither English nor Spanish. For

Results

Of the 588 patients identified as potentially eligible, 46 patients were excluded at the request of their physician, 148 declined participation, and 114 were not enrolled for some other reason (eg, they left the clinic before they could be approached). The remaining 280 patients were enrolled. Compared with patients who were potentially eligible but not enrolled, enrollees were somewhat more likely to be female (51% versus 59%, P = 0.04) and somewhat younger (mean age [± SD] 57 ± 10 years

Discussion

The results of this randomized, controlled trial suggest that automated telephone assessment and self-care education calls with nurse follow-up improved patients’ self-care and glycemic control, and decreased their symptom burden. These improvements were achieved with an average of less than 6 minutes per month of nurse-patient contact. Through automated telephone assessments, the nurse was able to use time more judiciously, focusing on the patients who most needed assistance. The automated

Acknowledgements

We thank Eunice Coeter and the clinicians and patients of the Moorpark Clinics, Santa Clara Valley Medical Center; Carol Gangitano, MSN, for her contribution as intervention nurse; and Edgar O. Alvarez, Dara J. Amboy, and Vivian Schiedler for assistance with translation, data collection, and data processing.

References (43)

  • J.M Malone et al.

    Prevention of amputation by diabetic education

    Am J Surg

    (1989)
  • C.D Naylor

    Grey zones of clinical practicesome limits to evidence-based medicine

    Lancet

    (1995)
  • The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus

    NEJM

    (1993)
  • Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications trial

    JAMA

    (1997)
  • Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)

    Lancet

    (1998)
  • Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34)

    Lancet

    (1998)
  • S.M Kurtz

    Adherence to diabetes regimensempirical status and clinical implications

    Diabetes Educ

    (1990)
  • A.B Bindman et al.

    Preventable hospitalizations and access to health care

    JAMA

    (1995)
  • S Greenfield et al.

    Patients’ participation in medical careeffects on blood sugar control and quality of life in diabetes

    J Gen Intern Med

    (1988)
  • E.J Perez-Stable et al.

    The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes

    Med Care

    (1997)
  • J.E Anderson et al.

    Telephone coverage and measurement of health risk indicatorsdata from the National Health Interview Survey

    Am J Public Health

    (1998)
  • Phoneless in America. (Statistical Brief). Washington, DC: US Bureau of the Census;...
  • M Weinberger et al.

    Can the provision of information to patients with osteoarthritis improve functional status? A randomized, controlled trial

    Arthritis Rheum

    (1989)
  • R.F Debusk et al.

    A case-management system for coronary risk factor modification after acute myocardial infarction

    Ann Intern Med

    (1994)
  • J Wasson et al.

    Telephone care as a substitute for routine clinic follow-up

    JAMA

    (1992)
  • M Weinberger et al.

    A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitusimpact on glycemic control and health-related quality of life

    J Gen Intern Med

    (1995)
  • R.E Aubert et al.

    Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial

    Ann Intern Med

    (1998)
  • E.D Tanke et al.

    Automated telephone reminders in tuberculosis care

    Med Care

    (1994)
  • G Christ et al.

    Monitoring quality-of-life needs of cancer patients

    Cancer

    (1990)
  • J.S Searles et al.

    Self-report of drinking using touch-tone telephoneextending the limits of reliable daily contact

    J Stud Alcohol

    (1995)
  • D Mahoney et al.

    An automated telephone system for monitoring the functional status of community-residing elders

    Gerontologist

    (1999)
  • Cited by (0)

    Supported by the Clinical Research Grants Program of the American Diabetes Association and by the Health Services Research and Development Service and Mental Health Strategic Health Group, Department of Veterans Affairs.

    View full text