- Using digital health tools to promote self-care may be an effective way to improve chronic disease management programs aimed at diabetes, says a new study from the Journal of Medical Internet Research.
A six-week workshop that includes individualized support from trained health coaches helped enrollees to reduce their blood sugar levels, improve their medication adherence and physical activity rates, and decrease symptoms of depression and hypoglycemia, the study showed.
Seventy-five percent of the 884 patients checking in after six months achieved improvements in at least one criteria of successful chronic disease management, while 37 percent improved in two or more categories.
Researchers from Stanford School of Medicine administered the online chronic disease management program to 1010 patients and conducted face-to-face diabetes education workshops with an additional 232 patients in Georgia, Missouri, and Indiana. Patients participating remotely filled out questionnaires via an online form or by mail, and provided blood samples for HbA1c testing through mail-in kits.
The self-management program, created by Canary Health, includes three major components: a learning center with interactive educational materials and options to create personalized action plans, a discussion center that allows patients to engage in conversations through interactive bulletin boards, and a toolkit that includes features such as diet and exercise tracking, a medication log, and links to external resources.
Certified diabetes educators and trained internet facilitators foster discussion with participants, provide encouragement, and moderate the online conversation section.
The study differed from previous structured evaluations of chronic disease management programs due to the fact that it did not have stringent inclusion or exclusion criteria. Instead of controlling for patients without multiple chronic diseases or high severity, the researchers hoped to mirror real-world circumstances by including patients across the chronic disease spectrum.
"We clearly achieved our goal in showing that evidence-based diabetes self-management programs are equally effective for a larger, more diverse group of people who would typically enroll through their health plans," said lead researcher Dr. Kate Lorig, DrPH, Director of the Stanford Patient Education Research Center.
In both the online group and the community-based workshops, patients showed measurable improvements in self-management and clinical symptoms. A six-month evaluation found that just under five percent of participants had reduced their baseline HbA1c below 9, and approximately 6 percent had reduced their symptoms of clinical depression.
At the start of the program, 38.4 percent of participants had two or more symptoms of hypoglycemia, but six months later, that number was reduced to 32.4 percent.
Medication adherence increased by around six percent, and self-reports of aerobic exercise increased by approximately the same amount.
Patients who reported more problems at the beginning of the study also seemed to also report more improvements across more categories, the researchers noted.
The participants didn’t only improve their symptoms, but also appeared to be more motivated to engage in preventative care and regular screenings. Eighty-six percent of patients who had not been screened for high cholesterol and eye, foot, or kidney problems before the program had recorded a screening within six months of completing the workshop. Fifty-four percent had completed three or more of these four tests.
"This study confirms previous evidence that empowering individuals to self-manage their condition leads to improved health outcomes,” said Dr. Neal Kaufman, MD, MPH, Chief Medical Officer of Canary Health, which calls this program Better Choices, Better Health.
The researchers suggested that chronic disease management programs that promote self-care and patient agency may be able to meet the nationwide Healthy People 2020 diabetes goals.
"These results should be a clear call for broader clinical acceptance of digital health self-management as a crucial part of transforming healthcare to a value-based model,” Kaufman said.
The Healthy People 2020 program hopes to reduce the number of new cases of diabetes and the death rate from diabetes by 10 percent by the end of the decade, and also aims to lower the number of serious complications from the metabolic disease, including lower extremity amputations. Preventative care and routine screenings, along with self-care tasks such as regular monitoring of blood sugar, are also on the agenda.
Chronic disease management programs deployed in the primary care setting or through health insurance plans are a key component of achieving these goals, yet few patients receive standardized education after a diabetes diagnosis. Less than seven percent of privately insured patients participate in formalized education within 12 months of a new diagnosis, and fewer than 60 percent have ever attended a diabetes class.
The ability to bring widely-accepted but poorly-deployed educational standards to a heterogeneous patient population – and to achieve results across a broad range of patient experience and outcome measures – is what may make studies of digital self-care programs like this one unique, added principal investigator Dr. Jay Greenberg, ScD, CEO of the National Council on Aging Services.
"The significance of this study cannot be overstated,” he said. “This is the first and only digital diabetes self-management study of this scale and scope.”