Spotlight on tech engagement strategies

Several recent studies looked at technological strategies to increase diabetes patients' engagement in care.

One study, published by the Journal of General Internal Medicine on Sept. 22, looked at use of telehealth by Veterans Health Administration patients with diabetes who were ages 70 years or older in 2019 and 2021 (n=410,640), including a high-need, high-risk subgroup (n=18,414). About half (51%) received telehealth-based care in addition to in-person care. The patients who used both types of care had significantly more encounters in 2019 than those who only saw clinicians face-to-face (mean, 6.2 telehealth visits plus 10.6 in-person visits vs. 4.9 in-person visits), and in 2021, they had slightly higher HbA1c levels and higher rates of hospitalization and ED visits. However, after adjustment, only the difference in hospitalizations was significant. “The current study indicates that older adults utilizing hybrid [telehealth] care comprise a group with more complex care needs compared to those who only utilize [face-to-face] care,” said the study authors, speculating that telehealth may be used to supplement in-person care for complex patients. The study “highlights the importance of this modality to promote better health outcomes and may be counter to a message implying that frail older adults are not as interested in telehealth,” they wrote, calling for “expansion of telehealth services for older adults with multimorbidity and underserved communities.”

The second study, published by the Journal of General Internal Medicine on Oct. 1, assessed a technology-intensified diabetes intervention in the southeastern U.S. Participants, who all identified as Black and had an HbA1c level of 8% or higher, were randomized to usual care (n=105) or to receive a telemonitoring device for daily uploads of blood glucose readings and 12 weeks of telephone-delivered diabetes education and skills training (n=95). Most (88.5%) were 70 years of age or older, and 85.3% had an annual household income less than $50,000. Although there was a 90% retention rate at 12 months and slightly greater improvement HbA1c at three months in the intervention group, by 12 months there was no statistically significant reduction in HbA1c level in the intervention group compared to usual care. “These findings suggest more intense interventions are needed to improve glycemic control in African American adults with poorly controlled type 2 diabetes,” said the study authors, who specifically recommended incorporating medication titration as an additional component to the home telemonitoring intervention.

The third study, published by Annals of Family Medicine on Sept. 22, reported on an electronic system to support referrals to a diabetes prevention program (DPP) by clinicians treating patients with prediabetes or a history of gestational diabetes. The tool, which was announced to primary clinicians in two emails, enabled them to click and send the patient's name, contact information, diagnosis, reason for referral, and most recent HbA1c level to prevention staff, who would contact patients and register them for a DPP info session. This retrospective evaluation of the tool found that 1.4% of eligible patients (433 of 30,595) were referred. An additional 144 patients who were not identified by the tool were also referred to DPP and therefore included in the study outcomes. Overall, 27% of referred patients attended a DPP information session and 21% enrolled in a DPP class. Of 350 targeted primary care clinicians, 30% used the system and referral rates varied from one to 46 referrals per clinician. The study authors concluded that the intervention “is a promising, scalable strategy to connect patients with prediabetes to community DPPs,” noting that health systems that use Epic could implement the intervention themselves.

Finally, a meta-analysis, published by Primary Care Diabetes on Oct. 4, looked at randomized controlled trials of online health management interventions for type 2 diabetes. It found 44 such trials that included 27,178 patients (16,972 in intervention groups and 10,206 controls). Pooling the results, researchers found that online health management interventions significantly improved HbA1c levels, fasting blood glucose, postprandial blood glucose, systolic blood pressure, diastolic blood pressure, and waist circumference. There were also improvements in dietary behavior, physical activity, and self-efficacy, but not in body weight, body mass index, or lipids. According to subgroup analyses, interventions that were delivered by physicians, targeted patients ages 60 years or older, or used digital coaching for less than six months were more effective. The study authors called for longer-term studies to evaluate the durability of effects, as well as research into patient acceptability, adherence, and cost.