Feasibility of using videoconferencing to provide diabetes education: a pilot study

Introduction

The prevalence of diabetes has been rising steadily in the US and almost 24 million people or 8% of the population have the disease. The majority of adults diagnosed with diabetes (90–95%) have Type 2 diabetes. ¹ Research suggests that patients with formal diabetes education, compared to those without, have superior self-care skills and increased compliance behaviours indicated by lower blood glucose and glycosylated haemoglobin (HbA_1c) levels. ² In people at high risk for diabetes, healthy eating habits and moderate physical activity were found to reduce the incidence of diabetes by 58% over a three-year period. ³

Many people living in rural areas do not have the time to travel or a means of transportation to attend comprehensive education programmes. Thus, telemedicine has the potential to connect diabetes patients with specialized healthcare services and to improve their care. ⁴

Diabetes self-management education is an essential part of treatment and useful in facilitating positive health-care outcomes. ⁵ Nutritional counselling provided by a dietician through telemedicine is a method of education that allows patients with diabetes to obtain helpful ideas about diet and nutrition, information about weight loss techniques, exercise therapies and health-care objectives. Earlier research has suggested that a single nutrition counselling session can have a positive effect on blood values and body-mass index for diabetes and cardiovascular patients. ⁶

The Kansas University Center for Telemedicine and Telehealth has provided diet and nutrition consultations via telemedicine for nearly a decade. We wanted to compare the efficacy of two different ways of delivering nutritional therapy by videoconferencing. Our research questions were:

Are the outcomes from a group diabetes education session delivered by videoconferencing improved by additional individual counselling sessions delivered by videoconferencing?

Methods

Adult patients aged 18–75 years who had been previously diagnosed with Type 2 diabetes were invited to participate in the study. Participants were a convenience sample of diabetes patients from the local rural community who were regularly treated at the clinic. They were invited to participate in the study by a single nurse via telephone. Patients who had profound visual or hearing impairment were excluded as were patients who did not have transportation to the clinic. The study was approved by the appropriate ethics committee and written consent was obtained from participants.

All videoconferencing units used IP communication, at a minimum bandwidth of 384 kbit/s. There was a dietician at the Kansas University Center for Telemedicine and Telehealth. No Internet resources or other materials were provided. Patients were randomized to an intervention group (videoconferencing group session with two individual videoconferencing follow-ups) or a control group (videoconferencing group session only). Laboratory assessments of HbA_1c and total cholesterol were made at the initial visit.

Results

Thirty-two participants consented to be part of the study. Only data from patients who completed pre- and post-laboratory assessments and attended all nutritional counselling sessions were used. Complete data were collected on 13 intervention and 13 control patients and included in the final data analysis. Each group had 8 men and 5 women. The mean ages of the intervention group (66 years) and control group (65 years) were not significantly different (P = 0.76). There was no significant difference in body-mass index between the groups (P = 0.22).

At the start of the study, the mean HbA_1c level of the control group was 7% lower than that of the intervention group. After 16 weeks, HbA_1c decreased from 7.24% to 7.15% in the intervention group and from 6.70% to 6.51% in the control group. The control group showed a significantly larger fall in HbA_1c levels than the intervention group (F = 4.6, P = 0.043). While the total cholesterol concentrations decreased in both groups, the changes were not significant (Table 1).

There was a positive correlation between the number of nutritional visits via videoconferencing and the HbA_1c (r = 0.40, P < 0.05) and total cholesterol (r = 0.12, P = 0.56) at 16 weeks.

The diabetes quality-of-life survey comprised three parts: Satisfaction, Impact and Worry. Both groups showed a decrease in level of satisfaction with how they managed their diabetes between the initial and final assessment. In addition, both groups showed an increase in how diabetes affected their lives between the initial and final assessment. The patients' level of worry increased between the initial and final assessment (Table 2).

For the intervention group only, there was a significant positive correlation at the initial assessment between the patients' level of satisfaction and how they perceived diabetes to affect their lives (r = 0.66, P < 0.001). However, there was no correlation at the final assessment.

Patient satisfaction with their telemedicine experience was very positive overall (Table 3). Final telemedicine assessment surveys in the intervention group revealed that 93% of patients were ‘extremely’ or ‘somewhat’ satisfied with their telemedicine experience and 100% of participants in each group stated that they would participate in nutrition counselling by videoconference again and would recommend the service to others. Finally, there was a positive correlation between how comfortable patients felt with videoconferencing and how convenient they perceived the encounter to be (r = 0.82, P < 0.001).

Patients were not provided with any other educational resources or media during the study. None of the participants reported receiving diabetes education in any other format and based on the limited availability of health resources in the small community, it is believed that the participants' primary resource for diabetes management information was provided through the present study.

Discussion

In the present study patients were very satisfied with the videoconferencing experience. They felt comfortable talking with someone by videoconference, they found the encounter to be convenient and felt that the lack of physical contact was acceptable. Previous studies have shown that lipid management reduces cardiovascular complications by 20–50% and even a 1% reduction in HbA_1c can decrease the microvascular complications associated with diabetes by 40%. ¹ The findings of the present study show that providing diabetes education sessions via videoconference is a feasible approach to improving HbA_1c and total cholesterol levels.

Our results are consistent with other recent studies involving technological applications for managing diabetes. ^7,8 Our findings revealed that HbA_1c levels decreased in the control group and the intervention group, with a significantly larger fall in the control group. This suggests that an initial therapy session via videoconferencing alone may be sufficient to help patients manage diabetes. However, the study utilized a small sample size and further work is required before the results can be generalised.

A strong relationship was found between the patients' level of satisfaction with how they managed diabetes and how they perceived it to affect their lives in the initial assessment but not in the final assessment. Diabetes is a major chronic illness associated with acute and long term complications that can lead to disability and even death. ⁸ In addition, diabetes education is designed to teach patients about the serious effect that diabetes can have on their health. Thus, it was not surprising that patients were less satisfied and perceived diabetes to affect their lives more in the post-assessment after they had received education. These results show that videoconferencing is a viable method for communicating information about diabetes management.

One limitation of the study was the small number of patients involved. Future studies are needed that use larger sample sizes. Lengthening the study period to include more individual nutritional therapy sessions may produce better results in the intervention group. In addition, additional studies might consider matching participants (not randomizing) based on laboratory values at the beginning of the study in order to have equal (or near equal) implementation points. Laboratory assessments several weeks or months prior to any nutritional counselling intervention to gather baseline clinical indicators may yield more consistent results.