Using Health Information Technology to Prevent and Treat Diabetes

Patients with diabetes often need a complex set of services and support ranging from glucose monitoring, insulin and other medication management, psychotherapy and social support, to physical activity promotion, nutrition counselling and more. To be successful, patients must not only understand their condition, but also obtain the skills and attitudes to set goals, solve problems, monitor outcomes and overcome barriers to action. Patients and clinicians need to work together so patients with diabetes can adopt and sustain the health-promoting behaviours so necessary to assure good outcomes. Information technology is transforming the way patients receive education and support and clinicians need to utilise these approaches to maximise their reach and effectiveness. Providers are increasingly expected to coordinate care for a panel of patients who live with incurable chronic conditions such as diabetes. Clinicians will have to collaborate with their patients and focus on improving their behaviours, because treating diabetes and other chronic conditions requires more than medication. Providers will need to put emphasis on supporting patients in the ongoing process of adopting and sustaining health-promoting habits. Integrating these supports into a patient’s therapeutic regimen presents challenges that need to be addressed through a variety of strategies. Regrettably, given the significant time constraints of a busy medical practice, healthcare providers often do not have the time to adequately support all aspects of an effective behaviour change intervention. That is where information technology can have some of its greatest impact. This chapter will present papers in which information technology has been used to improve the quality of care for patients with diabetes, to enable clinicians to more effectively manage their patients and to help patients self-manage their diabetes. van Bastelaar KM 1,2 , Pouwer F 3 , Cuijpers P 2,4 , Riper H 5 , Snoek FJ 1,2 1 Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands, 2 Institute for Health and Care Research (EMGO Institute), VU University Medical Center, Amsterdam, The Netherlands, 3 Department of Medical Psychology and Neuropsychology, and 4 Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, Tilburg, The Netherlands, and 5 Department of Clinical Psychology, VU University, Amsterdam, The Netherlands, Netherlands Institute of Mental Health and Addiction (Trimbos), Utrecht, The Netherlands Diabetes Care 2011; 34 : 320–5 Aims: This study was an attempt to determine whether an internet-based intervention could successfully use an approach proven effective in person cognitive behaviour therapy (CBT), coping with depression, developed by Lewinsohn to improve depression symptoms in depressed patients with type 1 (T1D) or type 2 (T2D) diabetes. Primary outcomes were depressive symptoms. Secondary outcomes were diabetes-specific emotional distress and glycaemic control. Methods: A total of 255 adult patients with clinical depression were randomised into the web-based intervention or to a 12-week waiting list control group. Assessments in the intervention group were scheduled after the participant completed or stopped the intervention and 1 month later. The web-based programme contained eight consecutive lessons that provided written and spoken information and videos of depressed patients explaining how they learned from the course. Coaches (certified psychologists) provided standardised concise and constructive feedback on homework assignments in <3 days. The feedback was meant to help the patient understand and apply CBT skills in their daily lives. Patients on the waiting list completed assessments 8 and 12 weeks post randomisation and were provided access to the web-based intervention 12 weeks post randomisation. Results: The web-based CBT intervention was effective in reducing depressive symptoms and reduced diabetes-specific emotional distress but had no beneficial effect on glycaemic control. Conclusions: This study demonstrated that web-based CBT can effectively lessen depressive symptoms for patients with T1D and T2D. It also demonstrated that a theory and research based in-person intervention can be successfully transformed for delivery via the internet. Comment: It is encouraging to see that clinicians, researchers and technologists are embracing the approach that takes lessons learned from the non-technology world (e.g. in-person interventions) and transforms these successful approaches into effective interventions. While somewhat discouraging, it is not surprising that no changes in diabetes control were found given the short length of the study. The next phase in the research agenda is to identify the characteristics of individuals who are most likely to benefit from this approach and to determine the cost-effectiveness of these types of interventions. This information will be key as clinicians try to bring technology-enabled interventions to the widest and most appropriate audience possible. Richardson CR 1,2 , Buis LR 3 , Janney AW 1 , Goodrich DE 2 , Sen A 1,4 , Hess ML 1 , Mehari KS 1 , Fortlage LA 1 , Resnick PJ 5 , Zikmund-Fisher BJ 6,7 , Strecher VJ 8 , Piette JD 2,6,9 1 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA, 2 Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA, 3 College of Nursing – Adult Health, Wayne State University, Detroit, MI, USA, 4 Department of Statistics, University of Michigan, Ann Arbor, MI, USA, 5 School of Information, University of Michigan, Ann Arbor, MI, USA, Department of Medicine, University of Michigan, Ann Arbor, MI, USA, Department of Health and Health University of Michigan, Ann Arbor, MI, USA, 8 Center for Health Research, University of Michigan, Ann Arbor, MI, USA, and Diabetes Research and Center, University of Michigan, Ann Arbor, MI, 12 : Aims: This randomised control to determine web-based access to other to their physical activity the of a web-based physical activity Methods: with of or were in a intervention that provided intervention and goals, and were to their and to in a to and were randomised to have no or access to a web-based that on social support, encouraging social of and use of of the intervention. 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It on the of social support, and Methods: The and characteristics of for an social theory based physical activity and the to Health were were to the by through social and and through and were and with physical and a total of they also a of daily and Results: to the to in the were was were in the and were The had good and for behaviour they social support for these changes and in social support and use of behaviours were of physical activity and nutrition was also a good of of physical activity and but not of and support and behaviour through and social support had through Conclusions: and in interventions will be behaviours put of some and diabetes. The of physical activity and nutrition interventions on the to which they to for behaviour and the to which these interventions help social support for of these interventions also on the to which they a for goals, and feedback on Comment: This study of a of of a web-based programme demonstrated for with nutrition can a in outcomes. 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To be to have these a and approach improve delivery of effective patient and behaviour change and improve outcomes. Health Center, Veterans Medical Center, Care Aims: To the Veterans Health with to their identify outcomes and for other in Methods: The a and papers and of intervention that on outcomes. Results: The is the and most healthcare in the and medical and more than the challenges the is healthcare services to an increasingly of are of with and in where to is the on an with – – for more than a the has healthcare delivery the of in healthcare in support of chronic management, delivery through and and through medical information was found to be ongoing of patient symptoms is as in chronic care (e.g. for or to patient access to healthcare and access to patient medical Conclusions: has been a focus for delivery has been used to monitoring, medical information and intervention to with The of interventions for the of patient and the ongoing technology of patients and providers are challenges to Comment: the Veterans Health has demonstrated that it is of the in the effective use of technology to improve patient care and patient outcomes. the is a with are to change the has been to of – with the and individuals can a are and are , , H 4 , , , , 1 , 1 , 3 , KS 3 , , 1 Department of Medical University 2 Department of Medicine, University 3 Department of Medicine, University College of Medicine, 4 School of Health, USA, 5 Department of University Department of Medicine, and Research Diabetes Care 2011; 34 : Aims: To determine patients with will have outcomes a based intervention. Methods: The a clinical patients were to receive care to the glucose or to the healthcare group The to an medical in which medical are given through the patient’s Patients receive a with a that to a the are to the an the Clinical and by The was the of patients Results: of the was from to in the group and from to in the with to in the control group. The of patients with was in the in the group and in the control group Conclusions: The glycaemic control with than and care and effective and diabetes in patients with T2D. Comment: the the of the next Department of and of Institute and of Medical and Medical 2011; : Aims: To the effect of interventions on glycaemic control in patients with diabetes. Methods: The papers from through in which the study use of for diabetes of and for intervention group or the in intervention and had of the study randomised (e.g. or medical or The a and of the papers to the effect of use on glycaemic control in diabetes Results: A total of were for the The of intervention the with of use of the and in-person support in to use was not of the intervention were with of support provided for and glucose of and medication of of and were daily or more often in or more often in and with in that interventions for diabetes reduced by a of a of patients in than T1D patients The effect of intervention not by other participant characteristics or intervention strategies. Conclusions: from the provided that intervention to significant in glycaemic control and in diabetes for on The study that individuals is is the a technology-enabled programme is for a – in this patients than with – it is more likely to be This is study with the increasingly that are of technology for their While a of the are the only the had in was the use of as a delivery This from the of and approaches to a – it is that to this to the the interventions and diabetes outcomes – not This is given the time it takes to and a quality research study. This is all the more by the of technology – and of While clinicians need good interventions for their also need to that the approach used the which have been to be effective – time to the characteristics and support for and and social and support a therapeutic are the intervention is most likely to be 1 , 2 , 1 , A 3 , 1 , P 4 , 5 , , , A 8 , , A 3 1 Department of Diabetes and the 2 Department of University 3 Department of University 4 University 5 Department of Department of University 8 and University Diabetes Care 2011; 34 : Aims: To that the that insulin via the effectively insulin with or support, in T1D Methods: is a that via an and the patient with into glucose and physical glucose for on glucose and to medical for a adult patients with T1D on a insulin regimen with were randomised to use of a insulin with or use of the with short 2 weeks but no the of the study. The of web-based of the glucose and insulin via from the Results: in the group was than in care group The group The a in and a used was no in the of or in medical time for or patients in the care and the group 5 more than the and group Conclusions: The with a to control in T1D patients more medical time and a for the patient than Comment: This study the that patients are to self-manage their T1D they are provided with information and access to a this technology was in patients with the and information to more effectively manage their This study also that patients change their behaviour is in the of a therapeutic that can be by technology – in this a with clinical information – clinicians can be not only more effective but a 1,2 , , 4 , 1 , 4 , 3 , 4 , 4 1 Medical University, USA, 2 Department of Veterans Affairs Medical Center, USA, 3 Research USA, 4 University, USA, and 5 State Diabetes Care 2011; 34 : Aims: To determine with diabetes obtain of benefit from a intervention. Methods: for Diabetes and randomised and with diabetes to receive with a diabetes and glucose weeks or The of of glucose and and access to by the Diabetes and of social Results: was a in in the to the care group. were in in and in had the and the greatest in the intervention not 5 were with more glucose and and had than was not with and had than Conclusions: were in this of with diabetes. The intervention was with in glycaemic in who had the that has the to help in diabetes and improve outcomes. Comment: It is encouraging to see but proven most likely to be This study was help in that will not do with intervention other than in-person and or will successfully use technology to improve their This completed in used is can only the study were with and approaches such as to monitor and information glucose and to a patient’s and and The is – after PJ 1 , 1 , 1 , 2 , 1 , 1 , 1 , 3 1 Research and Medical USA, 2 School of University of USA, and 3 University of Ann 2011; : Aims: To the of an diabetes clinical support on the outcomes of patients with Methods: The a from to in Patients were randomised to receive or not to receive an based clinical support to improve care for patients or were than Diabetes in the and changes in for patients not changes in for patients with to or with and short for patients not Results: in the study were with care and the patients with diabetes. The intervention group used the based support of all by with diabetes. The intervention group diabetes patients had effect to of control and of control but not than patients of randomised to the control of the study. intervention group were or with the and use of the support for more than 1 after feedback and to its use were Conclusions: based diabetes clinical support glucose control and some aspects of control in with T2D. Comment: This a – how to improve the quality of care provided to patients with diabetes. of but they will not reach their they are not with support as in this for a of to the and of the approach the variety of for the patient to more in or medical and technology-enabled support that a patient self-manage or diabetes. see some in outcomes. 1 , 2 , 2 , 3 , 4 , 5 1 Department of University of USA, 2 Department of and School of Health, University of USA, 3 Department of Medicine, University of Michigan, Ann Arbor, MI, USA, 4 University and 5 Department of School of Health, University of Diabetes Care : Aims: To a diabetes education intervention via on outcomes for adult patients with diabetes from an Methods: The a randomised clinical of Diabetes by a and diabetes in the of a in Diabetes is a intervention via with and The addressed the and be a with care and management, and and social support, it all Results: were randomised to the intervention or to care a significant in in the Diabetes group from to and 12 and with care and was reduced 12 in the Diabetes group with not of the study was reduced from to 12 and in the Diabetes group and with care and in a post of a of the randomised who completed a Conclusions: effectively access to successfully a by a and that control and reduced in an and which have been to the of the intervention participant of to be with the care and successful the group by This and programme successfully some of the often barriers to effectively support patients their diabetes. This is all the more the is and in this in all it is to which of the approach were the most is that technology-enabled social to social support to these types of the phase and after the programme is P Institute of Diabetes Diabetes 2011; 5 : Aims: To the and cost-effectiveness of support for in diabetes Methods: The a of from adult patients with who used or not use the programme of the is of the programme and was developed to improve the quality and cost-effectiveness of diabetes care and for patients with T1D or T2D. is from the of It an in of the of a given patient on the and of therapeutic by in and a regimen that glucose control. The of the are as for the of into diabetes the is with glucose and a and information healthcare in with by the Diabetes Management System, The was based on from the of in diabetes were with diabetes and patients were as or to or not on of the Results: A total of patients for more than 1 in the these had glucose or more and a and were in the to the completed by the was an of The of was to The were found for patients with and the for patients with and was by to of in an of to The an of participant in the Conclusions: in with has to improve the of diabetes Comment: This study addressed the of of patient diabetes control with support to clinicians so they can help patients manage their diabetes. This is an of an in that it can help clinicians do their to and changes in outcomes clinicians must support patients so they can the patients with diabetes need to all the Patients need the to help with the they are a patient to not of which is but the of which determine a patient’s The for to such information and support will the patients the education and help they need to on their 1 , 1 , 2 , 1 , 1 , 1 , 1 , 3 , H 1 , 4 , 1 , H 1 1 Department of Medicine, University of Institute of Clinical Medicine, 2 Department of Clinical and Research Center, University 3 Department of Medicine, University, and 4 Department of and Health University of of Aims: To the or effect of the in Methods: The a to identify from through which the effect of web-based on on were they were randomised a all were who were as or by the they of a group and control the intervention and physical the of the was or and the effect was by The completed a of the changes in the group in with the control group were with a Results: A total of were the had a but significant effect with control with the control that the as an to care was effective but that it as a for support was effect on control was the of the was but was not the was The effect was with and was in with of 12 or more. 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It was that some the in the for was is that this of could to for and the of the for this Comment: It is encouraging that who used the had some more is the that who also in-person support more than who not receive in-person This in be it how interventions are and the to use technology-enabled interventions. that the will not be so will that some and can have significant the of in-person Patients with diabetes need a complex set of services and This chapter a of the how information technology can help patients can the services and supports they need to or manage their diabetes. of the key that from these papers from is that the of the of services and supports into the diabetes regimen can be successfully overcome through support interventions that are and A of the and of diabetes is on the skills and behaviours of the and education and support is so in good outcomes. that are for patient based on or and time are most likely to the Patients and are more likely to adopt behaviours the approach is in the of a therapeutic and an effective medical care on the of the information technology to the delivery of and to complex clinical challenges such as the of diabetes. 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