Are there time and cost savings by using telemanagement for patients on intensified insulin therapy?

Abstract

Background: Patients with insulin dependent diabetes require frequent advice if their metabolic control is not optimal. This study focuses on the fiscal and administrative aspects of telemanagement, which was used to establish a supervised autonomy of patients on intensified insulin therapy. Methods: A prospective, randomised trial with 43 patients on intensified insulin therapy was conducted. Travelling distance to the diabetes centre was 50 min one way; all patients had undergone a diabetes education course with lessons in dose adaptation. Patients were randomly assigned to telecare (n=27) or conventional care (n=16). They used BG-meters with a storage capacity of 120 values (Precision QID™ Abbott/Medisense) and transmitted their data over a combined modem/interface via telephone line to the diabetes centre. Data were displayed and stored by a customised software (Precision Link Plus™, Abbott/Medisense). Advice for proper dose adjustment was given by telephone. Results: Average time needed for instruction in the telemedical system was 15 min. Data were transmitted every 1–3 weeks and a teleconsultation was performed by phone every 2–4 weeks, depending on the extent of specific problems. On average, personal visits in the control group were performed once a month. Physician's time expenditure for telemanagement, compared to conventional advice was moderately higher (50 vs. 42 min per month). A substantial amount of time on the patients side could be saved through replacing personal communications by telephone contacts and data transmission reduction (96 vs. 163 min/month including data transmission time). Setting up an optimal telemanagement scenario, a cost analysis was carried out yielding savings of ≈650 EURO per year per patient. HbA_1c dropped significantly from 8.2 to 7.0% after 8 months of observation, but there was no significant difference between the intervention and control groups. Major technical problems with the telematic system did not occur during the study. Conclusions: Telemanagement of insulin-requiring diabetic patients is a cost and time saving procedure for the patients and results in metabolic control comparable to conventional outpatient management.

Introduction

Modern insulin therapy of patients with type-1 and -2 diabetes mellitus is guided by the results of recent studies concluding that near normoglycemic metabolic control reduces or retards the incidence of late complications of the disease [1]. To achieve optimal metabolic control, the joint efforts of patients, physicians and the care team as a whole are necessary. Best results have been achieved by performing intensified insulin therapy. The principle of this form of insulin therapy basically consists of separate substitution of basal long acting and prandial short acting insulin, using predefined target ranges for blood glucose values and correction limits for adapting the dose of the short acting insulin with every injection. A training program for dose adaptation included in a structured diabetes education program is considered mandatory for patients starting intensified insulin therapy. Because of the near normoglycemic blood glucose targets, hypoglycaemias tend to be more frequent in these patients, partly with subsequent hyperglycemias (Somogyi-effect) and metabolic control may even become unstable, preferentially in long standing disease.

On the other hand, novel insulin preparations must be considered progress towards a better adaptation to the real insulin requirements at night and before meals. Patients are enabled to optimise their insulin therapy by permanently fine-tuning insulin dosage according to varying life conditions, such as physical activity, concurrent illness, shift-working, etc. Although the specific training programs for intensified insulin therapy are designed to give patients autonomy and ability for self-management of the disease, additional supervision by a competent care team is frequently necessary, particularly if the problems mentioned above are present and/or therapy goals are not achieved. This additional supervision and advice is mostly needed for a limited period of time only, until good metabolic control is achieved or re-achieved under daily living conditions and the patient feels confident enough to take over responsibility for the therapy. Consultations with the diabetes specialist can then be tapered to regular 3-monthly or twice yearly routine visits.

A variety of computer applications have been developed for documentation, processing and display of diabetes-data [2]. Technological progress in recent years has made it possible to transfer self-monitored blood glucose values, stored together with date and time in memory meters, to a remote diabetes specialist using simple, modern telecommunication techniques and remote data transfer. Advice can be given to patients without the need for direct personal contact, potentially saving time and expenditure. Repetitive application of these methods in chronic disease is called telecare. Before these techniques can be established as routine methods, however, including reimbursement by the care providers, an evaluation is important regarding medical outcome, cost-efficiency and patient satisfaction/quality of life.

In our study, patients with diabetes mellitus on intensified insulin therapy were divided into two groups by randomisation, one using telecare and the other conventional outpatient care. Each group was under relatively tight medical supervision and therapeutic goals and efforts did not differ between groups in order to achieve optimal metabolic control in all of the patients.