Abstract
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The ability to take greater control of diabetes management from the convenience of one's home computer or smartphone is very attractive. Not only does it offer promise of greater autonomy over disease management and potential for greater self-efficacy over diabetes-related decisions but also a streamlining of healthcare professional time and resources as more individuals take advantage of quick calls rather than clinic attendance. Similarly, for busy primary care healthcare professionals who are increasingly providing specialist clinics across different diseases, for example, cardiac clinic, asthma clinic, and diabetes clinic, reliable and effective tools that can relieve some of their heavy burden can only be a good thing.
A challenge, however, with this exciting new world of opportunity is knowing what approach to take. Whether a medical model focusing on insulin adjustment and avoidance of adverse effects 4 –6 or a psychosocial support tool focusing on minimizing diabetes-related burden or improving lifestyle flexibility. 2,5,6 Or, a third option of trying to incorporate both aspects into one tool and balancing the two. Not dissimilar in fact to the reality of the lived experience of people with diabetes, who blend these two often competing aspects of diabetes in everyday self-management.
A number of key questions remain unanswered in my mind. To what extent do web-based tools facilitate shared decision making and goal setting between healthcare professionals? Do they improve patient autonomy, self-reliance, enhanced knowledge, and problem-solving skills, or are they simply a device trying to improve compliance, or just a convenience tool? What is the uptake and sustainability of such tools both by people with diabetes and by healthcare professionals? Furthermore, how does such a tool accommodate the moving goalpost that is the progressive nature of type 2 diabetes, requiring intensification of therapy over time? 7 For whom are web-based tools most effective? Are there any subgroups of people with diabetes who would benefit most? What happens to those people who can't or won't use these tools? Do they offer an unprecedented opportunity for support with optimal diabetes self-management or do they simply reinforce healthcare access inequalities between those with high levels of health and tech literacy to the detriment of those with low levels of literacy, health literacy, and poor access to such devices. Latest figures from Ofcom, the United Kingdom communications regulator, show that although two-thirds of people now own a smartphone, 3 a third do not.
The INNOVATE trial, assessing the long-acting insulin glargine titration web tool LTHome (commercial name MyStar WebCoach), is one such example of a rules-based algorithm providing insulin titration advice directly to the patient. 8 The tool was developed to support healthcare providers in recommending dose progressing of basal insulin with a view to future versions having mobile options and glucometer-embedded facility. This has the potential to reduce the burden on healthcare professionals and potentially improve efficiency in delivery of healthcare while at the same time improving outcomes for people with diabetes. The trial, a pilot randomized study, set out to demonstrate noninferiority to the enhanced usual therapy (EUT) diabetes education program.
The authors took computer literate adults with type 2 diabetes with suboptimal glycemic control and home access to a personal computer, who were scheduled to either initiate basal insulin or increase their dose of basal insulin. Participants were randomized to either the LTHome or EUT arms for 12 weeks [see article for full study details]. Interestingly, although results did not demonstrate noninferiority of the LTHome intervention, they did demonstrate high patient satisfaction with the intervention with reduced fear of hypoglycemia (P = 0.04) and reduced diabetes-related distress (P = 0.04). Furthermore, there was a significant reduction in mean number of additional healthcare provider visits in the LTHome arm (0.13) compared with the EUT arm (1.22) P = < 0.01).
Although it may at first appear that this pilot study was unsuccessful and I would not argue this in terms of achieving its primary goal, there is a much more interesting story hidden underneath. The burden on healthcare professionals is increasing with demand, more patients to support but not more time in the day. Any intervention that can significantly reduce the number of additional visits has to be a good thing and it would seem that Harpreet et al. have demonstrated some success in this regard. Furthermore, it is often argued that we should look beyond HbA1c as a primary outcome 9 in clinical trials in which a psychosocial or other outcome may be more helpful in answering the question. Taking this perspective, perhaps a measure of psychosocial functioning, quality of life, or functional health status may be a useful primary outcome as benefits here are associated with improved biomedical outcomes. The psychosocial outcomes, although secondary, were clearly successful. Most participants in the LTHome arm felt empowered by using the system and 79% stated they are “very likely to recommend it to other people with diabetes.” We urge the research team to reconsider the primary outcome in a future larger trial and power the study based on a patient-reported outcome with HbA1c as a secondary outcome. Notwithstanding, we very much look forward to reading about the results of that study.
Footnotes
Author Disclosure Statement
No competing financial interests exist.