Feedback Loops and Teachable Moments: The Future Diabetes Care Paradigm

The current paradigm of office visits every three months for PWDs (people with diabetes) is not the right model (nor is it for other similar chronic conditions).  The management of diabetes requires a patient to make dozens of daily self-management decisions.  “How much insulin should I give for this slice of pizza?  Do I need to eat a snack to prevent my blood sugar from going low before I go for a jog?”  Diabetes related questions and issues do not occur on an every-three month basis in synch with this current model for office visits.  They are predictably unpredictable.  Accordingly, to best serve our patients, our system must be flexible and nimble.

In the current model, I see a PWD in my office and let’s say, for example, that we decide together to make a change to his insulin to carbohydrate dosing ratio.  He then leaves my office and we wait three months to reconvene and see if that dosing plan change is working or not.  It’s not that it takes three months to decide.  We could probably know within a week or two if the change is working.  It’s just that healthcare isn’t set up that way.  Our entire world now, in every industry and facet of life, is about data, analytics, and metrics.  Other industries have learned that rapid feedback loops are effective.  Adjusting a PWD’s insulin to carbohydrate dosing ratio should be no different.  By the time he comes back to my office three months later, the opportunity for learning may already have been lost.  Neither one of us has gotten timely and relevant feedback about our decisions.  We may have lost the opportunity for a teachable moment.  Healthcare needs to develop a new model where these feedback loops are much tighter and much faster, actually capitalizing on opportunities for teachable moments.  (Sidebar: One doctor who realized this years ago was Dr. Jordan Shlain, who founded HealthLoop)  Research studies show that PWDs are more successful and confident with managing their diabetes when they feel like they have the backup and support of their clinical providers looking over their shoulders to make sure things are going ok.  If we were to design the system from scratch to accomplish these goals, we probably would not have built it to rest on the concept of office visits every three months.

So, what should be the future model of a Diabetes and Endocrinology clinical practice?  Here’s what I imagine my practice looking like in the (hopefully near) future.  Instead of having 16 office visit slots per day of 30 minutes each, I imagine myself seeing 5 patients a day for 45-60 minutes each, allowing us to take our time working together in person and truly addressing the needs and goals of the patient.  These longer visits are essential for a patient new to my practice, a patient with a complicated or unknown diagnosis, a patient with complications or a major change in their disease state, or for discussing major changes in therapeutic course or strategy.  The rest of my day will be spent using a dashboard to do remote population management, looking for trouble spots among my patient population and focusing in on those, and doing telemedicine, connecting with patients through video-chats to make more minor adjustments and to do brief “check ins.”  Ten minutes spent with a patient at the point where there is a teachable moment like a low blood sugar from walking the dog might be more effective than a standard 30 minute office visit every three months.  We’ll have to test this hypothesis, of course, but we must try it.

This is why I’m brimming with so much enthusiasm and excitement about working with the non-profit, Tidepool, who is building an open data platform and a new generation of software applications for the management of type 1 diabetes.  Tidepool will provide us with the technology infrastructure to reach this vision of more frequent feedback loops and teachable moments.  I’m also very excited about the work that my UCSF colleagues, Drs. Ralph Gonzales and Nat Gleason, are doing to pilot the use of telephone visits and e-visits with patients in place of office visits.  Their work is paving the way toward demonstrating efficacy of e-visits, helping to achieve payer reimbursement so that such a model can take root.

Telemonitoring intervention for diabetes has durable effect: Extension of DiaTel study

Published in an Online First this week by JAMIA was the extension of the original DiaTel study published in Diabetes Care in 2010.  The original study ran from 2005-2007, and patients were randomized to an “Active Care Management” (ACM) arm or a “Care Coordination” (CC) arm.  The ACM arm transmitted blood glucose values daily, with a nurse practitioner adjusting their medications every 24-72 hours following ADA guidelines.  The CC group received a monthly care coordination phone call offering diabetes self-management education and a referral to their primary care provider for medication adjustment.  At 3 months, A1c reductions in the ACM group were 1.7% versus 0.7% in the CC group and at 6 months this was sustained at 1.7% versus 0.8% (p<0.001 for each of these).

This DiaTel Extension study was designed to see if these initial improvements could be sustained with interventions of similar or lower intensity over a six month extension period.  The study design is shown here:

Methods: The population studied was a VA (Veterans Affairs) population in Pittsburgh.  It is notable that this population does not reflect the typical US civilian population, as they were nearly 100% male, over 80% caucasian, <20% college-educated, and more than half were retired.  The primary outcome measure was HbA1c.  The mean A1c (at original DiaTel randomization) for the two groups was around 9.5%.

As you can see in the above diagram, some patients in the initial ACM group who had been transmitting glucoses daily were “stepped-down” in intensity to a “CCHT” intervention, where they continued to transmit glucose values daily but no longer had active medication management by the nurse practitioner.  Other ACM patients were “stepped-down” to the CC intervention.  Notably, no ACM patients were kept on ACM, and no ACM patients were sent all the way back to “UC” or usual care.

From the initial CC group (this is the group who got monthly phone calls), participants were randomized to continued CC, or “stepped-down” to usual care, UC.  Usual care consisted of primary care visits every 3-6 months.

The results of the study?  They did not show a benefit in continuation of the higher-intensity intervention, eg continued home telemonitoring.  The authors write that this suggests that a lower intensity of contact can be used after the initial period to maintain the same level of improvement in glycemic control.  Some of the results are shown below, from Figure 3 in the paper, and please note that the initial DiaTel study is indicated by months 0-6 below, with the extension period being months 6-12.

So what does this study mean? 

Though a very interesting, necessary, and useful study, as with most studies, there are some limitations to it, many of which are pointed out by the authors.  The population studied was a typical VA population, but this does not reflect the typical civilian US population.  Because the extension trial could only be done in original study participants, the statistical power of the study was limited.  This means that even if there was a true difference between groups, the study might not have been “powerful” enough to show it.  Interestingly, looking at the graphic in Figure 3 above, you can start to visually see a worsening in A1c in the ACM to CCHT arm of the trial, however, there was no statistical significance seen (was the lack of significance only because of insufficient power?).  The authors chose not to create an ACM to ACM group or an ACM to usual care group for the extension of the trial, so we don’t know how those would have stacked up.  We do not know what the duration of A1c lowering from an intensive telemedicine intervention would be, and we also don’t know how long the initial intensive management period needs to be in order to achieve an improvement.

The authors point out that to generalize and disseminate a telemedicine intervention like this one will require a reimbursement mechanism and consideration of cost-effective ways of deploying it.

The bottom line is that a six-month long, intensive telemedicine intervention for diabetes management appears to improve A1c in this VA population, and that A1c improvement might be sustained even when the intensity of management is reduced.

Two quick links: Telemedicine at the Joslin and iPhone app reviews

1) The Joslin Diabetes Center at Harvard is creating a telemedicine platform so that they can start doing long-distance diabetes consultations.

I’ve been doing a lot of “VTel” (VA slang for videoconferencing) at the VA this past year for diabetes consultations.  While they aren’t a perfect substitution for a face-to-face conversation, they do generally seem to get the job done and save our remote patients a lot of travel time.

2) Reviews by Marisa Moore of 10 iPhone diabetes apps.

I have not yet tried most of these applications, but my overall feeling is that the current generation of smartphone apps for diabetes are not going to take us very far.  There are several reasons for this.  The main reason, as I’ve discussed in previous posts about Glooko and the iBGStar, is that asking patients to manually enter blood sugars after doing a fingerstick is an unworkable workflow.  Also, with the way data is currently displayed, the iPhone screen is too small to glean anything useful.  A lot of apps have education modules, which may be useful, but I think to really gain traction, education will have to be personally targeted to the right patient at the right point in time.