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Stone RA (CHERP Pittsburgh), Cheng C
(CHERP Pittsburgh), Sevick MA
(CHERP Pittsburgh), Rao RH
(VA Pittsburgh Healthcare System), Hough LJ
(VA Pittsburgh Healthcare System), Macpherson DS
(VA Pittsburgh Healthcare System), Franco CM
(VA Pittsburgh Healthcare System), Anglin RA
(VA Pittsburgh Healthcare System), Obrosky DS
(CHERP Pittsburgh), DeRubertis FR
(VA Pittsburgh Healthcare System)
Objectives:
Phase I of the DiaTel study demonstrated that Active Care Management with Home Telemonitoring (ACM+HT) for 6 months was more effective than Care Coordination (CC) in reducing hemoglobin A1c (HbA1c) in diabetic veterans with poor glycemic control. The objective of Phase II was to ascertain the intensity of subsequent management required to sustain these improvements at 12 months.
Methods:
Phase I of the DiaTel Study was a randomized controlled trial of 137 veterans with diabetes and poor glycemic control who received primary care at the VA Pittsburgh Healthcare System between June 2004 and December 2005. Consenting eligible veterans were randomized to either ACM+HT or CC. In ACM+HT, the Viterion 100 TeleHealth Monitor was used to relay home blood glucose measurements to a nurse practitioner (NP) who actively managed medications. CC was standard primary care enhanced by monthly telephone calls from a study nurse, with referrals to a primary care provider (PCP) as needed. Consenting participants were re-randomized after completing Phase I: 46 ACM+HT participants were re-randomized to either CC+HT (i.e. ACM+HT without the active medication management) or CC, and 55 CC participants were re-randomized to either CC or usual care (UC) by their PCP. All were followed for an additional 6 months. Effectiveness of the intervention was assessed in terms of pairwise mean differences in HbA1c at 12 months and differential changes over time.
Results:
Mean HbA1c levels at 12 months were inversely related to the intensity of the intervention, i.e., lowest (8.0%) for ACM+HT- > CC+HT, 8.2% for ACM+HT- > CC, 8.7% for CC- > CC, and highest (8.8%) for CC- > UC. There were no significant within-group or differential changes between 6 and 12 months (p > 0.10 for each).
Implications:
Marked improvements in glycemic control among ACM+HT participants at 6 months were sustained 6 months after discontinuation of active medication management by a NP. There were no apparent benefits of continued transmission of glucose data via a home telemedicine device. Smaller improvements in glycemic control among CC participants during DiaTel Phase I also were sustained, even upon return to UC.
Impacts:
Improvements in HbA1c obtained after 6 months of ACM+HT were sustained at 12 months with interventions of decreased intensity.
