Support Diabetes Self-Care On A National Basis Dr. Sheldon Silver Credit Valley Hospital, June 20, 2007

H A1C Glycosylated hemoglobin

Adapted from Stratton IM, et al. UKPDS 35. BMJ 2000; 321:405–412. UKPDS: decreased risk of diabetes-related complications associated with a 1% decrease in A1C Percentage decrease in relative risk corresponding to a 1% decrease in A1C ** Any diabetes- related endpoint 21% ** Diabetes- related death 21%** All cause mortality 14% * Stroke 12% ** Peripheral vascular disease † 43% ** Myocardial infarction 14% ** Micro- vascular disease 37% ** Cataract extraction 19% Observational analysis from UKPDS study data † Lower extremity amputation or fatal peripheral vascular disease *P = 0.035; **P <

A Solution for Improving Outcomes Motivate the patient to take responsibility for their own care Easy to use Inexpensive > significant cost savings Improve the MD – patient or RN – patient therapeutic relationship Efficient use of the MD’s / RN’s time

Wireless Diabetes Management Protocol Wireless Diabetes Management Protocol Patient’s phone is loaded with a program & ID# Enter blood sugar readings. The data is sent back electronically and wirelessly to their MD; Data consists of only an ID# and blood sugar as well as date and time of reading No identifying data; privacy is protected; Avoids hoarding of data. MDs/RNs monitor data on Palm / RIM / PC Action plan sent back to patient. Excellent MD/RN – patient relationship Community team approach with DCC & CCAC

Action Request i.e. ”Keep up the good work” Diabetes Management System (Bayer WinGlucofacts & INET Sync) Nurse Patient Privacy: No identifiable information is transmitted. People w/Diabetes Supporting Diabetes Self Care Receive Sugar Levels Send Action Request Enter Sugar Level GlycemiCare Server Prevent Diabetes Related Complications with Better Control of Glycemic Levels, Measured by HA1C

Pilot Projects 1. The first project ending in July 2005 tested the program in a family practice. The pilot project lasted ~3 months with 5 patients. 2. A second project ended in February 2007, working with a diabetes care centre. Twenty patients completed the pilot. 3. In November 2006 a third pilot project began with family physicians across Ontario. 4. A fourth project is planned to start in Chicago Illinois in 2007

Pilot Project: Diabetes Care Centre, Credit Valley Hospital (CVH) Pilot was support with an Education Grant Funded by Bayer Diabetes Care Division Pilot started in 2006 with approval from CVH Ethics Review Broad. 25 patients enrolled and 20 completed. 15 patients participated > 3 months, 7 patients => 5 months. 20 patients submitted both pre and post HA1C.

HA1C Results INET Wireless Diabetes Program Patient Change in HAIC Levels Change in HAIC Pre-PilotPost-Pilot

Patient Survey Prior to the pilot 10 of 20 patients recorded their readings once a day or more. After the pilot 19 of 20 patients recorded daily.

Patient Survey Eleven patients said it was “much better” than the previous method (log book.), saying the main reason was it made them accountable or kept them honest (5.) Almost all of the respondents (19) said the program made a “moderate” to “substantial impact” on their ability to control their sugar levels. Eleven were “very” or “extremely” interested in continuing the program and 16 said they would recommend it to their physicians.

Diabetes Care Centre (CVH) Lessons Learned In Supporting Patient Transition To Self-Care For newly diagnosed people with diabetes, the patient should be assessed for their willingness and readiness to learn additional information. Often, it is better to wait for follow-up sessions to introduce this program as an additional support for them. Introduce the program to nurses that are familiar with current technology tools such as the Internet, , word, spreadsheets and calendars. Access systems to provide reminder alerts in the nurses schedules to prevent missing incoming data (i.e. using calendaring system such as outlook to activate an alert on a daily basis.) Do not replace all communication methods with a wireless program; find the best mix, i.e. use the wireless program to receive data as a complement to the telephone, for use when providing clinical advice.

To Scale This Chronic Disease Management Program Nationally Looking at the enrollment challenge. Physicians’ awareness of the program. Must be intuitive to both the healthcare team and patients.

Three Easy Steps To Program Enrollment 1. program instructions to MDs and/or Diabetes Care Centres. 2. Instruction can be printed for patients. 3. Enroll patients by checking databases or during regular visits.

Patient Cellphone Instructions

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