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Service Delivery Innovation Profile

Telemedicine-Based Diabetes Management Program Focusing on Education and Eye Exams Improves Self-Management Capabilities and Outcomes For Low-Income Rural Patients


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Snapshot

Summary

Diabetes TeleCare is a disease management program that provides remote education and eye screenings to low-income individuals in rural South Carolina via telemedicine technology. The goal is to help patients adhere to the American Diabetes Association guidelines related to physician assessments, medication adherence, blood glucose monitoring, and attention to diet and exercise. An evaluation found that the program increased eye examination rates, reduced blood glucose and cholesterol levels, improved self-management behaviors, and led to high levels of patient satisfaction.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial of 165 patients that measured a number of key outcomes along with post-implementation reports from participants on self-management behaviors and satisfaction.
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Developing Organizations

University of South Carolina (USC), School of Medicine, Department of Ophthalmology
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Date First Implemented

2005
This program was part of a 4-year study that ended in 2008.begin pp

Patient Population

Vulnerable Populations > Impoverished; Racial minorities; Rural populationsend pp

Problem Addressed

Diabetes is a common condition that increases the risk for a variety of health problems, including blindness, kidney failure, amputation, hypertension, and stroke. In some cases, these problems lead to death. Individuals who live in rural areas are more likely to suffer from complications, in part due to the difficulty of accessing routine screenings and other services that could help to prevent them.
  • A common, dangerous disease: Diabetes is a condition in which a person’s body does not produce or use insulin properly. Roughly 400,000 South Carolinians have the disease; more than 1,000 (1,136 in the latest statistics) die each year, making diabetes the seventh leading cause of death in the state.1 Those diagnosed with diabetes also have an increased risk of blindness, kidney failure, heart attacks, strokes, and amputations.2
  • Disproportionately affecting minorities and rural residents: Diabetes disproportionately affects minorities in South Carolina. The prevalence of diabetes is higher among blacks (13.8 percent) than among whites (8.2 percent). The prevalence among black men (13.2 percent) was 67 percent higher than that among white men (7.9 percent) and blacks had a much higher hospitalization rate for diabetes than whites. There is also a striking racial disparity in the rates of emergency room visits for diabetes. In 2006, the rate of emergency room visits for diabetes as the primary diagnosis among blacks was more than five times the rate among whites. Compared with the data in 1997, the rate of emergency room visits increased among blacks and the racial disparity increased in rate.2
  • Largely unrealized benefits of prevention: Many diabetes-related complications can be prevented with appropriate treatment. For example, diabetic retinopathy is the main cause of blindness and vision impairment in the general population.3 Yet blindness caused by diabetic retinopathy can often be prevented through photocoagulation, which uses lasers to treat problems within the eye.4 Many individuals with diabetes who live in rural and ethnically diverse communities do not receive regular eye examinations due to barriers such as transportation.3

What They Did

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Description of the Innovative Activity

Diabetes TeleCare is a disease management program that provides remote education and eye screenings to primarily low-income individuals in rural South Carolina via telemedicine technology. The goal of the program is to help patients adhere to the American Diabetes Association guidelines related to physician assessments, medication adherence, blood glucose monitoring, and attention to diet and exercise. Key elements of the program are described below:
  • Monthly telemedicine-enabled education sessions: During 12 monthly educational sessions, a team consisting of a nurse/certified diabetes educator and a dietitian located at University of South Carolina use two-way teleconferencing to teach self-education and promote self-management, including adherence to American Diabetes Association guidelines, with a focus on proper diet and glucose control. Program participants come to a local community health center (CareSouth, located in Bennettsville, SC) to attend these sessions.
  • Telemedicine eye screenings: As a part of this program, a facilitator at the community health center obtains patients' retinal images using a nonmydriatic retinal camera. The image is sent via fax to the Wilmer Eye Institute at Johns Hopkins University to be read by qualified ophthalmologists. Results are faxed back, with those patients requiring a referral being scheduled to see a local ophthalmologist.

Context of the Innovation

The University of South Carolina School of Medicine's Department of Ophthalmology provides specialty eye care, including care for eye-related diseases and complications. The program was developed in response to the lack of patient access to diabetes self-management programs in South Carolina's many rural areas.

Did It Work?

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Results

A randomized controlled trial (RCT) found that the program increased eye examination rates, reduced blood glucose and cholesterol levels, improved self-management behaviors, and led to high levels of patient satisfaction.
  • Increased eye screenings: Eighty-one percent of those participating in the remote disease management program received eye examinations, compared with 39 percent in a control group receiving usual care. In other words, program participants were twice as likely to obtain an eye examination than those receiving usual care.
  • Lower blood glucose levels: Program participants reduced their hemoglobin A1c levels by almost two full points, from 9.2 to 7.4, over a 12-month period and from 9.2 to 7.6, over a 24-month period. By contrast, those in the control group saw a statistically insignificant decline from 8.7 to 8.1.
  • Lower cholesterol levels: Levels of "bad cholesterol" (low-density lipoprotein) fell from 108.6 to 94.5 among program participants over a 12-month period, as compared with a much smaller drop in the control group (from 107.1 to 106.2).
  • Improved self-management: Many of the improvements highlighted above are due to better self-management of diabetes. Participants reported that the disease management program helps them comply with their medication regimen (72.6 percent reported this at 6 months, 84 percent at 12 months); be more physically active (90.3 and 92 percent); eat healthier and make better food choices (95.2 and 100 percent); monitor blood glucose levels on a regular basis (71 and 84 percent); and be more likely to get an annual eye examination (93.6 and 96 percent).
  • High levels of satisfaction: The program was rated "excellent" or "very good" by 90.3 and 84 percent of respondents at 6 and 12 months, respectively. All respondents felt comfortable with the videoconference classes, with only a small minority (17.7 percent at 6 months and 16 percent at 12 months) believing that the intervention would be better if the classes were in person. About 87 percent of participants at 6 months, and 92 percent at 12 months, reported that they would like to continue the program for another year, and all participants indicated that they would recommend the program to others with diabetes.
  • Somewhat sustainable improvements: Eighty study participants completed a visit at 24 months to evaluate the sustainability of the improvement in outcomes in the year after the program ended (as of March 2009). Analysis of these participants found that the improvements in hemoglobin A1c persisted, although the level of improvement was smaller than that achieved at the end of the program. Further analyses will be conducted to look at predictors of sustained improvement and cost-effectiveness.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial of 165 patients that measured a number of key outcomes along with post-implementation reports from participants on self-management behaviors and satisfaction.

How They Did It

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Planning and Development Process

Key steps in planning and developing this telemedicine program included the following:
  • Developing relationship with community health center: Representatives from the University of South Carolina met with center leaders to understand their needs and internal care processes.
  • Building a patient base: The department of ophthalmology took the lead in recruiting patients, relying heavily on its substantial experience in recruiting patients to participate in similar types of research studies.
  • Upgrading technology at community health center: Researchers and information technology staff at the University of South Carolina assessed the current technology infrastructure at the community health center and upgraded it as needed, including installing larger bandwidth and more high-speed Internet capabilities (e.g., T1 lines).
  • Training: A licensed practical nurse who served as a facilitator in the community health center received training on use of the videoconferencing equipment and on how to collect data and administer questionnaires using a standardized protocol.

Resources Used and Skills Needed

  • Staffing: Program staff include a nurse/certified diabetes educator who assisted with the monthly sessions and a university-based ophthalmologist who reviewed eye examination results as needed.
  • Costs: The 4-year study cost $2.4 million, including development, implementation, operations, and evaluation.
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Funding Sources

National Institute of Diabetes and Digestive and Kidney Diseases (U.S.)
The program was funded by a 4-year, $2.4 million grant from the National Institute of Diabetes, Digestive, and Kidney Diseases, part of the National Institutes of Health. This grant supported program operations until the end of 2008.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Secure appropriate resources: Have adequate staff and facilities to run the program, including data management capabilities. Streamline and, if necessary, upgrade telemedicine systems to ensure that they meet program needs.
  • Get to know partner organization(s): Spend upfront time gaining familiarity with the leaders and staff at the partner organization(s) where the sessions will be held, as it is critical to understand their current processes and needs.

Sustaining This Innovation

  • Monitor results: Track the progress of participants throughout the program (and after it ends if possible).
  • Continue to cultivate relationships with partner organization(s): Maintain periodic contact between staff at the "host site" and the partner organization(s), as building trust is critical to long-term success. After a slow start, University of South Carolina researchers immersed themselves into the community health center, building strong relationships with both providers and patients.

More Information

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Contact the Innovator

Richard M. Davis, MD
Professor
Department of Ophthalmology
University of North Carolina
Phone: (919) 843-3736
E-mail: richard_davis@med.unc.edu

Innovator Disclosures

Dr. Davis has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Davis R, Fowler S, Bellis K, et al. Telemedicine improves eye examination rates in individuals with diabetes. Diabetes Care. 2003;26(8):2476. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/full/26/8/2476.

Cavallerano A, Cavallerano J, Katalinic P, et al. A telemedicine program for diabetic retinopathy in a Veterans Affairs Medical Center—the Joslin Vision Network Eye Health Care Model. Am J Ophthalmol. 2005;139(4):597-604. [PubMed]

Footnotes

1 American Diabetes Association Web site. Available at: http://www.diabetes.org.
2 Burden of Diabetes in South Carolina, 2009. Available at: http://www.scdhec.gov/administration/library/CR-009477.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).
3 Davis R, Fowler S, Bellis K, et al. Telemedicine improves eye examination rates in individuals with diabetes. Diabetes Care. 2003;26(8):2476. [PubMed] Available at: http://care.diabetesjournals.org/cgi/content/full/26/8/2476.
4 Definition of Photocoagulation. MedicineNet.com Web site. Available at: http://www.medterms.com/script/main/art.asp?articlekey=9809.
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Original publication: September 08, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 14, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.