Quality of diabetes care among patients managed by teleconsultation

Abstract

We studied a new teamwork-based teleconsultation model for treating patients with diabetes, where a specialist in diabetes care, a diabetes nurse and a patient attended by videoconference. The study series consisted of all the patients (n = 101) at three health centres in northern Finland whose care was provided by a single physician at a remote diabetes clinic. A total of 101 patients with diabetes (19 of type 1 and 82 of type 2) were studied at baseline and at 10–14 months after the first consultation. Mean HbA_1c was 8.0% at baseline and 7.6% at follow-up (P = 0.007). The proportion of patients with poor glycaemic control decreased from 32% to 13%. Mean LDL cholesterol was 3.3 mmol/L at baseline and 2.7 mmol/L at follow-up (P < 0.001). The percentage of patients with optimum lipid levels increased from 20% to 50%. Mean systolic blood pressure was 146 mmHg at baseline and had decreased by 6 mmHg at follow-up (P = 0.004). The percentage of patients with poor blood pressure control decreased from 19% to 8%. The most common changes in medication were the introduction or modification of insulin treatment and the introduction of statin and antihypertensive drugs and acetylsalicylic acid. Although the study was uncontrolled, there were improvements in glucose and LDL cholesterol levels and blood pressure in patients who were managed by teleconsultation.

Introduction

The prevalence of type 2 diabetes mellitus is increasing in Finland as well as in the other western countries.^1,2 Type 2 diabetes imposes a major economic burden on society.³ Furthermore, poor control of both type 1 diabetes⁴ and type 2 diabetes⁵ has been shown to be associated with more complications. In order to improve the treatment of patients with diabetes, and also to prevent type 2 diabetes, a programme for the prevention and treatment of diabetes (DEHKO) was launched in 2000 under the coordination of the Finnish Diabetes Association.⁶

The lack of physicians in remote health centres has made it difficult to improve the treatment of patients with diabetes in Finland. Therefore, a new model for treating patients with diabetes was implemented in northern Finland in 2005. The model is based on teamwork, where a specialist in diabetes care, a diabetes nurse and a patient attend at the same time through a videoconference. This method of diabetes care has not been used before in Finland. Patients with diabetes are well suited to treatment by teleconsultation.⁷ However, it remains unknown if the control of diabetes can be improved by using teleconsultation as the only treatment method.

The aim of the present study was to evaluate the effect of the new model on diabetes control.

Methods

Parts of the Oulu Arc Subregion in northern Finland are sparsely populated. The subregion consists of six municipalities with a total population of approximately 30,000. Initially, the implementation of the new teleconsultation model was started in three municipalities (Pudasjärvi, Utajärvi and Vaala), which had a population of approximately 16,000.

Each municipality had a diabetes nurse, who was in charge of the patients' care and was trained to examine the patients. During a teleconsultation, the diabetes nurse and the patient were in a consultation room in the local health centre, and the remote physician was in Oulu (Institute of Health Sciences, University of Oulu, henceforth called the ‘remote clinic’). Videoconferencing took place via the PCs of the physician and the nurses. The videoconferencing system worked on the secure network of the Oulu Arc Subregion.

It was possible for both the physician and the nurses to use electronic patient records and an electronic stethoscope in real-time. The distances between the physician's and the nurse's offices were 30–90 km, depending on the municipality where the patient lived.

The study series consisted of all the patients (n = 101) at three health centres whose care was provided by a single physician at the remote diabetes clinic between 27 January and 21 June 2005. The patients with diabetes were referred to the appointments by the local diabetes nurses, and the patients represented only part of all patients with diabetes in each health centre. The appointments following the initial teleconsultation appointment were scheduled by the remote physician.

Eighty-one percent (n = 82) of the patients in the remote clinic suffered from type 2 diabetes and 19% (n = 19) from type 1 diabetes. They were analysed as a single group. The follow-up data were collected 10–14 months (mean 364 days) after the first teleconsultation appointment. Thus, the follow-up teleconsultation appointments took place between 25 November 2005 and 22 August 2006. The mean age of the patients was 62 years (SD 14) at the time of the first teleconsultation appointment. The duration of diabetes was extracted from the patient records.

The treatment balance data of the 101 patients were evaluated retrospectively. Based on Finnish law,⁸ no ethical approval was considered necessary. The key indicators were haemoglobin A_1c (HbA_1c), low-density lipoprotein cholesterol (LDL), systolic blood pressure, body mass index, smoking and use of acetylsalicylic acid. The differences between the baseline and follow-up values were evaluated. Also, the corresponding information on microalbuminuria was obtained. Micro- and macroalbuminuria were defined based on the international recommendation.⁹ In addition, drug treatment and changes in it during the follow-up period were assessed.

Statistical analyses were performed using SPSS (v14.0) for Windows. Analysis of variance (ANOVA) was used to compare the changes in the HbA_1c level between groups stratified according to disease duration and glycaemic control at baseline.

Results

HbA_1c, LDL cholesterol and systolic blood pressure were measured for almost all of the patients at baseline and follow-up (Table 1), but other key indicators were measured in fewer patients.

Table 1

Proportion of patients with indicators of diabetes care measured at baseline and at follow-up in the teleconsultation treatment model

Indicator	Proportion measured at baseline (%) (n = 101)	Proportion measured at follow-up (%) (n = 101)
HbA_1c	99	100
LDL cholesterol	91	94
Systolic blood pressure	94	96
Body mass index	72	75
Smoking	62	69
Use of acetylsalicylic acid	54	74

The mean HbA_1c was 8.0% at baseline and 7.6% at follow-up, a significant decrease (P = 0.007). The results for the key indicators defined by DEHKO (HbA_1c, low density lipoprotein cholesterol, systolic blood pressure, body mass index) are shown in Tables 2 and 3. The proportion of patients with poor glycaemic control (HbA_1c >9.0%) decreased from 32% to 13%. When the patients were stratified by the duration of diabetes, the change in the mean HbA_1c level was significant in those with long (over 10 years) duration of the disease (change –0.6%, P = 0.012) (Table 4). When stratified according to glycaemic control at baseline, mean HbA_1c decreased significantly in the patients whose HbA_1c level was 7.6–9.0% (change –0.5%, P = 0.044) or >9.0% (change –1.7%, P < 0.001) at baseline. Mean HbA_1c increased in the patients with good glycaemic control (HbA_1c level <7.5%) at baseline (Table 5). The difference in the change of HbA_1c between the groups stratified according to glycaemic control at baseline was significant (P < 0.001).

Table 2

Mean values of the key indicators

Indicator	Mean (SD) at baseline (n = 101)	Mean (SD) at follow-up (n = 101)	Change of mean (P value* for change)
HbA_1c (%)	8.0 (1.9)	7.6 (1.5)	–0.4 (0.007)
LDL cholesterol (mmol/L)	3.3 (0.9)	2.7 (0.8)	–0.6 (<0.001)
Systolic blood pressure (mmHg)	146 (22)	140 (16)	–6 (0.004)
Body mass index (kg/m²)	30.6 (6.3)	30.4 (6.7)	–0.2 (0.58)

*Paired t-test

Table 3

Proportion of patients within the limits defining ‘good’ and ‘poor’ treatment according to the DEHKO criteria

Indicator	Limit for good treatment	Patients at baseline (%) (n = 101)	Patients at follow-up (%) (n = 101)	Limit for poor treatment	Patients at baseline (%) (n = 101)	Patients at follow-up (%) (n = 101)
HbA_1c (%)	≤7.5	44	53	>9.0	32	13
LDL cholesterol (mmol/L)	≤2.6	20	50	>3.5	33	12
Systolic blood pressure (mmHg)	≤130	30	29	>160	19	8
Body mass index (kg/m²)	≤25	19	23	>30	46	45

Table 4

Changes in HbA_1c levels according to the duration of diabetes (missing data for two patients)

Duration of diabetes	All patients/Type 1 diabetes patients (n)	Mean (SD) HbA_1c level at baseline	Mean (SD) HbA_1c level at follow-up	Change of HbA_1c mean (P value* for the change)
Under 5 years	31/3	7.7 (2.0)	7.2 (1.5)	−0.5 (0.17)
5–10 years	32/3	7.6 (1.6)	7.5 (1.3)	−0.2 (0.49)
Over 10 years	36/3	8.6 (1.9)	7.9 (1.6)	−0.6 (0.012)

*Paired t-test

Table 5

Changes in HbA_1c levels according to treatment balance

Glycaemic control (HbA_1c) at baseline	All patients /Type 1 diabetes patients (n)	Mean (SD) HbA_1c level at baseline (n = 101)	Mean (SD) HbA_1c level at follow-up (n = 101)	Change of HbA_1c mean (P value* for the change) (n = 101)
Good ≤7.5%	43/3	6.3 (0.7)	6.8 (1.1)	+0.5 (0.004)
Intermediate (7.6–9.0%)	23/5	8.1 (0.5)	7.6 (1.1)	−0.5 (0.044)
Poor >9.0%	33/11	10.2 (1.1)	8.5 (1.6)	−1.7 (<0.001)

*Paired t-test

At baseline, 32% of the patients for whom microalbuminuria had been measured had a positive test result, while the corresponding proportion at follow-up was 35%.

The proportion of patients using only dietary treatment decreased from 12% to 10% during the follow-up. At baseline, 39% of the patients used only oral antidiabetic medication and 25% used only insulin. At follow-up, the corresponding percentages were 38% and 19%. The proportion of patients using both oral antidiabetic medication and insulin increased from 24% to 33%. Most frequently, long-acting insulin treatment was started (for 9.3% of the patients who had not been using insulin before) or the dose was increased (for 47.0% of the patients using long-acting insulin).

The proportion of patients using statin increased from 36% to 87% during the follow-up. The corresponding percentages of patients on antihypertensive treatment were 49% and 72%.

Discussion

Improved glucose and LDL cholesterol levels and blood pressure was achieved in many of the patients with diabetes who participated in the teleconsultation project. At one-year follow-up, the proportion of patients with non-optimum levels of glucose, LDL cholesterol and systolic blood pressure decreased significantly. Based on previous studies,^4,5,10–12 these are important results in the prevention of diabetic complications.

Although the mean HbA_1c level did not decrease by more than 0.4% in the whole study group, the proportion of patients with poor glycaemic control decreased significantly, and the improvement of HbA_1c was most impressive in those with the worst glycaemic control at baseline. Even a slight reduction of HbA_1c level is important because several studies have shown that decreasing hyperglycaemia is an effective means of reducing long-term diabetic complications.^5,13–16 According to the UKPDS study, each 1% reduction in HbA_1c is associated with a 37% decrease in the risk of microvascular complications, a 21% decrease in deaths and a 14% decrease in myocardial infarctions.^5,17 Several previous studies have shown that the HbA_1c level is more resistant to therapeutic change in patients whose disease has lasted for many years.¹⁴ However, in the present study the reduction of HbA_1c was significant only among the patients with a long duration of disease. The improved outcomes were associated with an introduction or modification of insulin treatment. It can be assumed that general practitioners are not experienced in the use of insulins.¹⁸ Therefore, in our opinion, the maximum benefit of teleconsultation can be achieved in treating patients with type 1 diabetes as well as patients with long-lasting type 2 diabetes with poor glycaemic control.

The best treatment result was achieved in LDL cholesterol levels, with half of the patients showing optimum lipid levels at follow-up. Presumably, this was achieved by starting statin treatment for a considerable proportion of the patients during follow-up. Lowering of the LDL cholesterol level with statins has been shown to reduce complications, especially coronary and cerebrovascular events, in patients with diabetes.^10,19–22 The current target for LDL cholesterol in patients with type 2 diabetes is ≤2.6 mmol/L, but an even lower LDL cholesterol goal (1.8 mmol/L) is an option for high-risk patients with diabetes and overt cardiovascular disease.²³

The decrease of mean systolic blood pressure by 6 mmHg was also important, because previous studies have shown that a decrease of systolic blood pressure has a major effect on the outcome of patients with diabetes.²⁴ According to the UKPDS study, a decrease of systolic blood pressure by 10 mmHg reduced deaths of patients with diabetes by 15%, microvascular complications by 13% and myocardial infarctions by 11%.^11,12,23,25 Lowering of blood pressure is especially important in preventing the progression of nephropathy and retinopathy.^26,27

In the present study, knowledge of smoking was insufficiently recorded both at baseline and at follow-up. This is surprising in view of the fact that smoking doubles the risk of myocardial infarction at the population level.²⁸ In patients with diabetes, smoking is associated with an increased risk of morbidity and premature death caused by macrovascular complications.²⁹ Also, the recording of body mass index was not complete. Obesity is an independent risk factor for hypertension and dyslipidaemia as well as cardiovascular disease, and weight loss is recommended for all overweight (BMI 25.0–29.9 kg/m²) or obese (BMI ≥30.0 kg/m²) adults.³⁰ The proportion of smokers did not decrease during the follow-up, nor did mean body mass index. As is well known, it is difficult to make patients change their lifestyle and dietary habits.

An increased risk for developing thrombi is associated with type 2 diabetes, and acetylsalicylic acid treatment is therefore recommended for all patients. A meta-analysis showed that the use of acetylsalicylic acid therapy reduced vascular events by about one-quarter in patients with diabetes.³¹ The use of acetylsalicylic acid was surprisingly rare at baseline, but increased throughout the follow-up, being almost complete at the end.

Our result on the prevalence of nephropathy was similar to previous studies, which have shown that diabetic nephropathy occurs in 20–40% of patients with diabetes. Furthermore, diabetic nephropathy is the single leading cause of end-stage renal disease and also a well established marker of an increased risk of cardiovascular disease.³² Thirty-five percent of new dialyses and kidney transplantations in Finland are made on patients with diabetes.¹ Several means for slowing down the process of nephropathy are known.²⁶ Surprisingly, the practice of testing for microalbuminuria was not complete even at follow-up.

After the establishment of DEHKO, the new Finnish treatment guidelines for patients with diabetes were published. These guidelines include more stringent goals for HbA_1c as well as for LDL cholesterol and systolic blood pressure.¹⁵ Improvement of diabetes care as measured by the DEHKO criteria was achieved moderately well in the present study. This is remarkable in view of the fact that the patients had diabetes of more than average severity in each health centre, and the patients chosen for follow-up had poor glycaemic control at baseline.

New telemedicine technology offers the possibility of improved access to specialists in diabetes care. Both the physician and the nurse bring their own expertise to the appointment, and each learns from the other. The care can be planned and the targets and follow-up can be agreed on together with the patient. The patient is likely to feel that the physician and the nurse have become well acquainted with his or her situation, which may improve compliance. In our opinion, the new treatment model would also be suitable for providing specialist services to patients with other chronic diseases.

Teleconsultation has been somewhat more expensive than traditional care.⁷ However, efforts to prevent diabetic complications are cheaper than treatment of such complications. The emergence of complications increases the cost of care by 10- to 20-fold.³

The present study had some limitations. First, we did not have a randomized control group. Therefore, we cannot be sure if the good results were due to the new treatment model or to the expertise of the team. Second, the number of patients was rather low, which restricted the possibilities of conducting subgroup analyses. Thus further controlled studies are needed to evaluate which subgroups of patients benefit most from the new treatment model.

In conclusion, improvement of glucose and LDL cholesterol levels and blood pressure was achieved in patients with diabetes participating in the teleconsultation project. The maximum benefit of the new model of care can probably be achieved when treating patients with type 1 diabetes as well as those with long-lasting type 2 diabetes and poor glycaemic control.

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