Diabetes self-management support using mHealth and enhanced informal caregiving☆
Introduction
Inadequate self-management of blood glucose and blood pressure in type 2 diabetes is prospectively associated with chronic hyperglycemia, microvascular complications, and heart disease (Alberti & Zimmet, 1998). Although outcomes can improve with care management (Anderson, Funnell, Aikens, et al., 2009), comprehensive services are often unavailable due to limitations in the availability of personnel, appropriate technologies for between-visit monitoring, and reimbursement for telephone contacts (Piette, 1997). Mobile health (mHealth) refers to the use of mobile devices to support medical care and public health. It appears that mHealth services, including interactive voice response (IVR) calls (in which a person responds to re-recorded prompts from a calling computer using their telephone keypad), may help address these barriers to effective care (Piette, 2007, Schwartz, 1998).
Another strategy to improve outcomes is to enhance patients’ social support for self-management. In-home caregivers often lack the tools needed to systematically monitor changes in patients’ diabetes-related health status and support their self-care (Rosland, Heisler, Janevic, et al., 2013); and many caregivers are at risk for burnout (Armour, Norris, Jack, Zhang, & Fisher, 2005). Moreover, many patients live alone, with up to 7 million Americans receiving “long-distance” caregiving (Talley & Crews, 2007). In order to enable geographically-distant supportive individuals to be more involved and effective, we developed an mHealth service using IVR to provide patient monitoring and self-care support between clinician contacts.
In this report, we describe the implementation of this program in primary care settings. Patients with diabetes received weekly automated IVR monitoring and self-care support calls designed to assess self-monitoring of blood glucose (SMBG), medication and dietary adherence, blood glucose levels, blood pressure levels, foot inspection, and overall functioning. If the patient reported a difficulty in any of these key areas, the system provided the patient with pre-recorded self-management education corresponding to the area of difficulty. In addition, the system provided automated updates on patients’ status to an informal caregiver living outside the patient’s home, and notified the primary care team when the patient reported clinically significant problems. To better understand program implementation, we investigated sociodemographic indices, physical functioning, depressive symptoms, diabetes related distress, and functional health literacy as predictors of variation in: (a) patient engagement and the frequency, and (b) the types of clinical feedback generated by the service.
Section snippets
Patient eligibility and recruitment
Patient participants were recruited from 16 Department of Veterans Affairs (VA) outpatient clinics in Michigan, Illinois, Indiana, and Ohio between March 2010 and December 2012. Eligibility criteria were: an ICD-9 diagnosis of type 2 diabetes; ≥ 1 outpatient VA primary care visit in the prior 12 months; and ≥ 1 current VA prescription for an antihyperglycemic medication. We excluded patients with diagnoses indicating cognitive impairment or severe mental illness or who were living in a supervised
Participant characteristics
Of 422 eligible patients, 303 (71.8%) consented to participate (108 in the three month program and 195 in the six month program, see Table 1). The typical participant was a Caucasian male, as would be expected in the VA population. The majority were at least 60 years old, and 30% were at least 70 years old. Forty-seven percent of participants had no more than high school education, 26% had annual household incomes < $15,000, 67% were married or cohabitating, and 18% were employed (which is
Discussion
This report describes our implementation of an mHealth service using IVR monitoring and self-management support in a large sample of older adults with type 2 diabetes. To summarize, most solicited patients participated, 39% of whom co-participated with an informal caregiver. Attrition was low, and unrelated to patients’ sociodemographic characteristics, suggesting that even vulnerable patients will engage in this type of service. The vast majority of attempted weekly IVR calls were successfully
Author contributions
JEA researched the data and wrote the manuscript. KZ and RT reviewed and edited the manuscript and contributed to the Discussion. JDP planned the study, reviewed and edited the manuscript, and contributed to the Discussion.
Acknowledgments
JDP is a VA Senior Research Career Scientist. KZ and RT are supported by VA Career Development Awards (grant # CD2 07-206-1 to K.Z. and grant # CDA-09-206 to R.T.). Other financial support came from the Michigan Diabetes Translational Research Center (grant # P30DK092926) and grant # R18DK088294 from the National Institute of Diabetes and Digestive and Kidney Diseases. The views expressed in this manuscript are those of the authors and do not necessarily represent the opinions of the Department
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Conflict of interest: None.