Telemedicine improved diabetic management

Military Medicine, Aug 2000 by Mease, Alan

Effective control of diabetes is known to delay or prevent the end-organ complications of this disease. Can telemedicine improve a patient's ability to self-manage diabetes? Twenty-eight patients entered a study comparing home telemedicine consultation with standard outpatient care. A nurse case manager contacted the telemedicine group once a week under the direction of a primary care physician, who contacted the telemedicine group once a month. Laboratory studies and total body weight were measured at the beginning and at the end of the 3-month study. The hemoglobin Alc (HbA^sub 1c^) and total body weight improved significantly in the intervention (telemedicine) group, as shown by a 16% reduction in mean HbAlc level (from 9.5 to 8.296) and a 4% mean weight reduction (from 214.3 to 206.7 pounds). Based on our experience, we present a functionally based telemedicine classification system to improve the application of electronic medicine in future studies.

Introduction

Despite the success of our health care system in managing acute illness, modern health care for chronic disease is fragmented, expensive, and less effective. 1.2 Chronic illnesses such as diabetes account for 75% of all deaths and result in the majority of health care expenditures in the last year of life (Table I).3 Optimal care of patients is informed, preventive self-care. However, most of our health care systems measure success in rendering medical care through hospital-based metrics, which really represents a failure to provide preventive care. How technology can enhance self-care, wellness, and disease prevention can be proven only by carefully designed outcome studies of patients with chronic diseases such as diabetes. There are 10.2 million U.S. citizens who are confirmed to be diabetic, with an estimated additional 5.4 million undiagnosed cases.4 Medical costs for people with diabetes are four times higher than costs for their nondiabetic counterparts.4

The purpose of this study is to explore how telemedicine can provide improved and cost-effective care for patients with a diagnosis of type 2 diabetes. According to the American Diabetes Association (ADA), nearly 16 million U.S. citizens, or approximately 6% of the total U.S. population, are likely to have the disease,4 and more than 18% of the U.S. population between the ages of 65 and 74 years are afflicted with diabetes. The burden of diabetes can be seen by looking at utilization data available from the Healthcare Cost and Utilization Project. The average cost at hospital discharge for a patient with a primary diagnosis of diabetes without complications was $4,626 in calendar year 1994.4 These same patients experienced an average length of stay of 5.50 days. Of even greater interest is the health care utilization of patients with a primary diagnosis of diabetes with complications. The average hospital stay for these patients was 7.04 days, and the average total cost at hospital discharge was $10,935 in 1994. The ADA estimated that $98 billion in total medical expenditures were attributable to diabetes in 1997.5 The ADA estimate of direct costs alone was $44 billion in that year. The remaining $54 billion is composed of premature mortality and disability costs.

Two recent clinical studies have reported results that are particularly relevant to our study. The first study reports that the involvement of nurses, physicians, and managers in a continuous quality improvement process can improve patients' blood sugar control in some health maintenance organization primary care settings.6 This study used hemoglobin Al. (HbA,j levels as a basic measure of health care status. The second study reports a positive relationship between HbA,c levels greater than 6% and outcomes.' Direct patient costs increased significantly for every 1% HbA,c level increase above 7%. The study reports that for successive 1% increases in HbA^sub 1C^ above 6% to the 7, 8, 9, and 10% HbA^sub 1C^ levels, cumulative direct charges to the patient increased 4, 10, 20, and 30%, respectively. This study concludes:

Economic data suggest that clinicians should assign high importance to low HbA^sub 1C^ results and aggressively maintain the HbA,c status of patients who have low HbA^sub 1C^ values. For economic as well as clinical reasons, it may be beneficial to lower HbA^sub 1C^ when it is >89 and to reduce the cardiovascular risk factors. Me medical charge data suggest that investment in clinical systems to improve diabetes care may benefit both payers and patients.6

It can be seen by these studies that the expense of diabetes is relatively high and that the costs are almost equally split between direct medical costs and the "consequence costs" of sequelae of the disease (premature morbidity and mortality). Clinicians and researchers are developing programs that emphasize proactive care to treat and prevent disease and complications. In diabetic studies, the use of HbA^sub 1C^ has emerged as a standard metric to capture patient health status and, to a lesser degree, to predict the effectiveness of intervention.

The Diabetes Control Complications Trial, conducted by the National Institutes of Health, evaluated the safety and benefits of intensive blood sugar control in type I diabetes. The findings showed that reduction and control of blood glucose levels delayed the onset and progression of long-term diabetes complications. These complications include retinopathy, nephropathy, and neuropathy. Because of these findings and other studies that suggest that control of blood glucose levels is effective in reducing costs, the ADA specifically established guidelines that address blood glucose control.8 The ADA recommends that diabetic patients achieve HbA^sub 1C^ levels within 2% of normal and endorses the utility of disease and case management.