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IIR 95-084 – HSR&D Study

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IIR 95-084
Automated Calls with Nurse Follow-Up to Improve Diabetes Ambulatory Care
John D. Piette PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: January 1997 - December 1999

BACKGROUND/RATIONALE:
Regular outpatient follow-up is important for all diabetes patients, with some needing frequent attention because their health is unstable, their treatment regimen is complex, or their social supports are inadequate. However, many patients live with access barriers that limit their use of outpatient services, fail to attend outpatient appointments, and experience worse outcomes than trials of aggressive management suggest is possible. Although labor-intensive, telephone care programs are one potential strategy for bringing diabetes management services into patients’ homes and improving their glycemic control. Automated telephone disease management (ATDM) systems can augment telephone care by providing frequent monitoring and health education to large patient panels while focusing clinicians’ attention on individuals who need it most. Although this technology has shown some promise, it has not been rigorously evaluated, particularly in VA.

OBJECTIVE(S):
This study evaluated Automated Telephone Disease Management (ATDM) calls with telephone nurse follow-up as a means of improving the quality of VA diabetes care. Specifically, we will determine whether this service improves patients' glucose control; improves other important outcomes such as their quality of life, satisfaction with care, and health service use; improves health behaviors such as self-monitoring of blood glucose, fat intake, and medication adherence; and has effects that vary across patient subgroups.

METHODS:
Patients with diabetes mellitus using hypoglycemic medication were enrolled during outpatient visits to a university-affiliated VA health care system and randomized to usual care or bi-weekly ATDM assessment and self-care education calls with follow-up by a nurse educator. The intervention process was evaluated by examining patients’ patterns of ATDM use and the reliability and validity of information they provided. Telephone surveys were used to measure intervention effects at 12-months on patients’ self-care, symptoms, satisfaction with care, and perceived access barriers. The impact on VA utilization was evaluated using electronic utilization databases, and glycemic control was measured using laboratory tests. A total of 292 patients were randomized and 272 (93%) provided data at 12-months. Intervention patients completed ATDM assessments consistently throughout the observation period and the assessments identified groups of intervention patients with varying degrees of health risk at baseline. Compared to control patients, intervention patients at 12-months reported more frequent glucose self-monitoring, fewer access problems, and greater satisfaction with care (all p = 0.05). Intervention patients were more likely than controls to have been seen in podiatry clinics (53% versus 31%, p = 0.003) and diabetes specialty clinics (31% versus 17%, p = 0.03) during the study. The intervention did not influence mean endpoint HgA1c levels overall. However, among patients with baseline HgA1c = 8%, mean endpoint values among intervention and control patients were 8.7% and 9.2%, respectively (p = 0.05); intervention effects were even greater among patients with baseline HgA1c = 9%. Moreover, intervention patients at follow-up reported fewer symptoms of poor glycemic control than patients receiving usual care (3.6 versus 4.4, p = 0.03).

FINDINGS/RESULTS:
We concluded that ATDM was a feasible and clinically valuable means of monitoring patients’ health and self-care, improved VA patients’ access to guideline-recommended services, and improved outcomes including symptom burden, satisfaction with care, and glycemic control.

IMPACT:
The patient management tool we developed and evaluated could improve diabetes self-care behavior and outcomes. It also could improve patients’ access to care and prevent costly acute episodes of illness resulting from inadequate follow-up. VA’s National Diabetes Program and the Indian Health Service are considering implementation pilots of this intervention as part of usual care.

PUBLICATIONS:

Journal Articles

  1. Piette JD, Weinberger M, Kraemer FB, McPhee SJ. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: a randomized controlled trial. Diabetes Care. 2001 Feb 1; 24(2):202-8.
  2. Piette JD. Satisfaction with automated telephone disease management calls and its relationship to their use. The Diabetes educator. 2000 Nov 1; 26(6):1003-10.
  3. Piette JD. Perceived access problems among patients with diabetes in two public systems of care. Journal of general internal medicine. 2000 Nov 1; 15(11):797-804.
  4. Piette JD. Interactive voice response systems in the diagnosis and management of chronic disease. The American journal of managed care. 2000 Jul 1; 6(7):817-27.
  5. Piette JD. Patient education via automated calls: a study of English and Spanish speakers with diabetes. American journal of preventive medicine. 1999 Aug 1; 17(2):138-41.
  6. Piette JD, McPhee SJ, Weinberger M, Mah CA, Kraemer FB. Use of automated telephone disease management calls in an ethnically diverse sample of low-income patients with diabetes. Diabetes Care. 1999 Aug 1; 22(8):1302-9.
  7. Piette JD. Satisfaction with care among patients with diabetes in two public health care systems. Medical care. 1999 Jun 1; 37(6):538-46.
Conference Presentations

  1. Piette JD, Weinberger M, Kraemer FB, McPhee SJ. Do automated calls with nurse follow-up improve self-care and glycemic control among VA patients with diabetes? Results of a randomized controlled trial. Paper presented at: VA HSR&D National Meeting; 2000 Mar 22; Washington, DC.
  2. Piette JD. Applications of computer technologies. Paper presented at: American Diabetes Association Annual Scientific Session; 1999 Jun 1; San Diego, CA.
  3. Piette JD. The impact of automated calls with nurse follow-up on patient-centered outcomes of diabetes care. Paper presented at: Addiction Health Services Research Conference; 1999 Jun 1; Chicago, IL.
  4. Piette JD, McPhee SJ, Crapo LM, Kraemer FB, Mah CA, Alvarez EO, Amboy DJ, Gangitano C. Automated calls with nurse follow-up improves diabetes self-care and glycemic control. Paper presented at: American Diabetes Association Annual Scientific Session; 1999 Jun 1; San Diego, CA.
  5. Piette JD. Access to care among adults with diabetes in VA and county clinics. Paper presented at: VA HSR&D National Meeting; 1999 Feb 1; Washington, DC.
  6. Piette JD, Weinberger M, McPhee SJ, Crapo LM, Kraemer FB, Mah CA, Alvarez EO, Amboy DJ, Gangitano C. The impact of automated calls with nurse follow-up on patient centered outcomes of diabetes care. Paper presented at: American Diabetes Association Annual Scientific Session; 1999 Feb 1; San Diego, CA.
  7. Piette JD. Promises and pitfalls of disease management - a view from the academic side. Paper presented at: American College of Physicians Northern California Regional Annual Meeting; 1998 Oct 1; San Francisco, CA.
  8. Piette JD. Reports by diabetic patients using automated telephone disease management calls: Concordance with data from medical records, laboratory tests & interviews. Paper presented at: Building Bridges for Child Health Research Annual Conference; 1998 May 7; Oakland, CA.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Diabetes, Primary care
MeSH Terms: Diabetes Mellitus, Primary Health Care, Disease Management