Using information technology to tailor diabetes care
A tracking system can tailor care and boost self-management in patients with diabetes.
Diabetes mellitus is a prevalent chronic disease that affects 28.9 million American adults. Diagnosed cases of diabetes were responsible for $245 billion in total costs in the United States in 2012, $176 billion in direct medical costs, and $69 billion in indirect costs of disability, time lost from work, and premature mortality.1 Undiagnosed cases of diabetes, pre-diabetes, and gestational diabetes add to these costs.1 The annual healthcare costs of patients who have diabetes with macrovascular comorbidities are statistically significantly higher, with costs of lost productivity reaching $2388 annually per patient.2
Among adults, type 2 diabetes accounts for approximately 90% to 95% of all diagnosed cases of diabetes.3 Type 2 diabetes is associated with older age, obesity, a family history of diabetes, a history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity.3
In the battle against this widespread and expensive disease, communication between primary care providers and patients is key. Information technology (IT) can be used by providers as a practice intervention to enhance communication with patients with diabetes and so enable them to improve their self-management. Specifically, a tracking system can serve as a visual tool for both providers and patients.
This article discusses the use of one tracking mechanism for diabetes management that helps to control the confounding factors that may affect outcomes. This tracking system—the Chronic Disease Electronic Management System (CDEMS)—was selected because it tailors care and fosters self-management principles to achieve patient participation and diabetic control.
Active patient participation
Diabetes, like other chronic illnesses, is very complex and derives from much more than biological mechanisms alone. In a meta-analysis of articles on type 2 diabetes and psychological and behavioral factors among patients that affect care, Cobden et al4 found that “medication adherence, persistence, treatment satisfaction, patient preferences, and psychological well-being are interrelated; well-studied; and directly or indirectly affect clinical outcomes, health events, resource use, and costs, notably in real-world settings” (p 143). Their findings illustrate the importance of a patient's participation in care.
Education or training in self-management is a key step in improving health outcomes and quality of life. It focuses on self-care behaviors, such as maintaining healthful eating habits, being active, and monitoring blood sugar. This training is a collaborative process in which primary care providers help people with or at risk for diabetes gain the knowledge and problem-solving and coping skills needed to self-manage the disease and its related conditions successfully. Patients with diabetes benefit from self-monitoring, decision making that is based on the results of monitoring, and informed interactions with healthcare providers.5 Tailoring interventions with patients has been extensively used to improve health behaviors by encouraging good dietary and physical habits, weight loss, and smoking cessation, but it has not yet been shown to improve the self-management behaviors of patients with chronic conditions such as diabetes.6
IT and diabetes
IT is increasingly being included in the management of diabetes. Yet, few studies have shown that IT improves diabetes outcomes. In their systematic review of studies using HbA1C level as their primary outcome measure, Costa et al7 concluded that the results of IT-based interventions for diabetes management may have been confounded by other factors that influenced outcome, such as variations in sample characteristics, providers' level of computer literacy and experience, IT method of delivery, and patients' knowledge of diabetes. Therefore, they recommended that confounding variables be acknowledged and controlled as possible and that outcome measures be used that are relevant to the population under study.
Chronic disease electronic management system
The tracking system used in this project was the Chronic Disease Electronic Management System (CDEMS), based on the Chronic Care Model. CDEMS is a software application that was developed by the Washington State Diabetes Prevention and Control Program in 2002. This application is a Microsoft Access database designed to assist medical providers in tracking the care and outcomes of patients with chronic health conditions. CDEMS is precoded to track diabetes, asthma, and adult preventive health but can be customized to define measures for monitoring other chronic conditions.
Multiple items may be tracked, including demographic data, laboratory test results, medications, and preventive health interventions. Patient data are entered into the CDEMS at the time of a patient interaction. From the program, graphs of patient trends for key indicators help both patients and their medical providers to improve long-term outcomes. CDEMS is used in practice in two ways: 1) to describe the characteristics and outcomes of an individual provider's group of patients with diabetes and 2) at the level of individual patients, to graph personal data so that it can be used for self-management, education, and support.