Patients with diabetes and elevated hemoglobin A1c (HbA1c) are at risk for diabetes-related complications. Care-management may be helpful in these patients, by providing direct contact between such high-risk patients and the healthcare system. Web-based systems have previously shown promise as a means of neutralizing access barriers such as scheduling and travel to appointments and may be of particular help in improving diabetes care.
We examined the efficacy of two methods of diabetes education and care management: (1) a traditional model that involved telephone contact and face-to-face encounters (2) a web-based model with access to a diabetes care management web site. We compared these interventions to a study group that received no education or care management but was provided with a computer and access to diabetes self-management websites.
This study employed a randomized, parallel group design involving patients with diabetes mellitus and an elevated HbA1c ( 8.5%). Participants assigned to web-based care management received a notebook computer, Internet access and interacted with a care manager through a diabetes education and care management website. Participants receiving telephone-based care management interacted with a care manager using telephone and face-to-face contact. Both care management models employed medication algorithms to improve glucose and BP control. These care management groups were compared to a study group that had no care management but received a notebook computer and Internet access with their "home page" containing links to a series of diabetes self-management websites (i.e. computer only group). The primary outcome measures were HbA1c, blood pressure, and scores on the Problem Areas in Diabetes (PAID) questionnaire, each measured over 12-months.
The study enrolled 151 participants. Participants were 60 years old, 95% were male, 90% had completed high school education, and 49% had diagnosed diabetes for >10 years, with baseline HbA1c 9.9%. HbA1c declined significantly and substantially in all groups over the course of the study. At 12 months, HbA1c was: telephone-based care management (n = 51): 8.5%; web-based care management (n = 51): 8.3%; computer only group (n = 49): 8.4%; P = 0.79). Similar findings were observed for systolic blood pressure and scores on PAID questionnaires, which were not significantly different among groups at 12 months.
This study shows that among patients with elevated HbA1c, care management does not contribute substantively to improvements in glucose, blood pressure and diabetes-related stress and depression. Each of the care management groups performed similarly to the computer only group. These data suggest that diabetes education and empowerment may be more important than care management per se and have greater impact on glucose control and psychosocial well-being among patients with elevated HbA1c.
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