Support Diabetes Self-Care Support Diabetes Self-Care On A National BasisOn A National Basis

Dr. Sheldon Silver

Credit Valley Hospital, June 20, 2007

HHA1CA1C

Glycosylated hemoglobin

Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412.

UKPDS: decreased risk of diabetes-related complications UKPDS: decreased risk of diabetes-related complications associated with a 1% decrease in A1Cassociated with a 1% decrease in A1C

UKPDS: decreased risk of diabetes-related complications UKPDS: decreased risk of diabetes-related complications associated with a 1% decrease in A1Cassociated with a 1% decrease in A1C

Per

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Any diabetes-related endpoint

21%

**

Diabetes-related death

21% **

All cause

mortality

14%*

Stroke

12%

**

Peripheral vascular disease†

43%

**

Myocardial infarction

14%

**

Micro-vascular disease

37%

**

Cataract extraction

19%

Observational analysis from UKPDS study data

†Lower extremity amputation or fatal peripheral vascular disease*P = 0.035; **P < 0.0001

21.935.864%

6.915.2

210%

20.925.823%

1.32.2

69%

5.511.6

111%

World2000 = 159 million2025 = 280 million

Increase 76%

102.2189.485%

Number of Diabetics: 2000-2025

Numbers are millions

Hoy et al.

A Solution for Improving A Solution for Improving OutcomesOutcomes

Motivate the patient to take responsibility for their own care

Easy to useInexpensive > significant cost savingsImprove the MD – patient or RN – patient

therapeutic relationshipEfficient use of the MD’s / RN’s time

Wireless Diabetes Wireless Diabetes Management ProtocolManagement Protocol

Patient’s phone is loaded with a program & ID# Enter blood sugar readings. The data is sent back electronically and wirelessly to their MD; Data consists of only an ID# and blood sugar as well as date

and time of reading No identifying data; privacy is protected; Avoids hoarding of data. MDs/RNs monitor data on Palm / RIM / PC Action plan sent back to patient. Excellent MD/RN – patient relationship Community team approach with DCC & CCAC

Action Request i.e. ”Keep up the good work”

Diabetes Management System (Bayer WinGlucofacts & INET Sync)

Nurse

Patient Privacy: No identifiable information is transmitted.

Peoplew/Diabetes

Supporting Diabetes Self Care

Receive Sugar Levels

Send Action Request

Enter Sugar Level

GlycemiCare Server

Prevent Diabetes Related Complications with Better

Control of Glycemic Levels, Measured by HA1C

Pilot ProjectsPilot Projects

1. The first project ending in July 2005 tested the program in a family practice. The pilot project lasted ~3 months with 5 patients.

2. A second project ended in February 2007, working with a diabetes care centre. Twenty patients completed the pilot.

3. In November 2006 a third pilot project began with family physicians across Ontario.

4. A fourth project is planned to start in Chicago Illinois in 2007

Pilot Project: Diabetes Care Centre, Pilot Project: Diabetes Care Centre, Credit Valley Hospital (CVH)Credit Valley Hospital (CVH)

Pilot was support with an Education Grant Funded by Bayer Diabetes Care Division

Pilot started in 2006 with approval from CVH Ethics Review Broad.

25 patients enrolled and 20 completed. 15 patients participated > 3 months, 7 patients =>

5 months. 20 patients submitted both pre and post HA1C.

HA1C ResultsHA1C ResultsINET Wireless Diabetes Program

Patient

Change in HAIC Levels

Change in HAICPre-Pilot Post-Pilot

1 0.083 0.071 -0.012

2 0.067 0.065 -0.002

3 0.105 0.096 -0.009

4 0.072 0.080 0.008

5 0.073 0.071 -0.002

6 0.068 0.066 -0.002

7 0.050 0.049 -0.001

8 0.112 0.057 -0.055

9 0.082 0.079 -0.003

10 0.117 0.075 -0.042

11 0.077 0.059 -0.018

12 0.073 0.070 -0.003

13 0.077 0.063 -0.014

14 0.057 0.057 0.000

15 0.096 0.072 -0.024

16 0.080 0.078 -0.002

17 0.099 0.058 -0.041

18 0.081 0.070 -0.011

19 0.088 0.064 -0.024

20 0.081 0.075 -0.006

Patient SurveyPatient SurveyPrior to the pilot 10 of 20 patients recorded their readings once a Prior to the pilot 10 of 20 patients recorded their readings once a day or more. After the pilot 19 of 20 patients recorded daily.day or more. After the pilot 19 of 20 patients recorded daily.

Patient SurveyPatient Survey

Eleven patients said it was “much better” than the previous method (log book.), saying the main reason was it made them accountable or kept them honest (5.)

Almost all of the respondents (19) said the program made a “moderate” to “substantial impact” on their ability to control their sugar levels.

Eleven were “very” or “extremely” interested in continuing the program and 16 said they would recommend it to their physicians.

Diabetes Care Centre (CVH) Lessons Learned Diabetes Care Centre (CVH) Lessons Learned

In Supporting Patient Transition To Self-CareIn Supporting Patient Transition To Self-Care

For newly diagnosed people with diabetes, the patient should be assessed for their willingness and readiness to learn additional information. Often, it is better to wait for follow-up sessions to introduce this program as an additional support for them.

Introduce the program to nurses that are familiar with current technology tools such as the Internet, e-mail, word, spreadsheets and calendars.

Access systems to provide reminder alerts in the nurses schedules to prevent missing incoming data (i.e. using calendaring system such as outlook to activate an alert on a daily basis.)

Do not replace all communication methods with a wireless program; find the best mix, i.e. use the wireless program to receive data as a complement to the telephone, for use when providing clinical advice.

To Scale This Chronic Disease To Scale This Chronic Disease Management Program NationallyManagement Program Nationally

Looking at the enrollment challenge.Physicians’ awareness of the program.Must be intuitive to both the healthcare team

and patients.

Three Easy Steps To Program Three Easy Steps To Program EnrollmentEnrollment

1. E-mail program instructions to MDs and/or Diabetes Care Centres.

2. Instruction can be printed for patients.

3. Enroll patients by checking databases or during regular visits.

Patient Patient Cellphone Cellphone InstructionsInstructions

Thank YouThank You