A better prescription for diabetes care

Norma “Marie” Myers Simpson, BSN, RN, CDE, Inpatient Diabetes Educator, CHRISTUS St. Frances Cabrini Hospital

Diabetes is a nationwide epidemic impacting the lives of over 30 million individuals in the United States and amassing an annual financial toll of nearly $176 billion. Hospitals and health systems of all sizes feel the weight of these statistics and are actively seeking solutions to better manage outcomes and position for value-based care.

As a diabetes educator, I have a front-row seat to the challenges associated with treating this complex, chronic disease. The reality is that traditional approaches to chronic care management fall short of impact because they often overlook the most important element in treating diabetes: The patient.

CHRISTUS St. Frances Cabrini Hospital

Recently, the American Diabetes Association and American Association of Diabetes Educators published the 2017 National Standards for Diabetes Self-Management Education and Support outlining recommendations and guidelines aimed at enhancing patient-centered care for diabetics. Technology-based engagement platforms and systems were specifically outlined as important tools for improving the outlook.

The 281-bed CHRISTUS St. Frances Cabrini Hospital, based in Alexandria, Louisiana, recently deployed an innovative diabetes management solution to improve care and patient engagement. Built on a real-time feedback loop, providers and patients collaborate via a mobile telemedicine model to improve insulin dosing and achieve sustainable outcomes.

Challenges of diabetes management

Diabetes is a complex disease for both providers and patients to manage, as various factors contribute to fluctuations in blood sugar, such as dietary intake, stress and physical activity levels. When diabetes is uncontrolled, patients often suffer from severe A1c levels that exacerbate complications and lead to costly medical interventions, such as hospitalization and emergency department visits. Common diabetic issues that lead to the revolving-door effect in today’s hospitals include serious healthcare conditions such as major cardiovascular diseases and lower-extremity amputation, as well as hypoglycemia and hyperglycemic crisis.

It’s not uncommon for patients with a new diabetes diagnosis to get off on the wrong foot with their condition. Many patients are initially prescribed medications that do not target all organs involved in managing blood sugar which can lead to deteriorated health conditions—and the need for insulin

Insulin is used as a last resort if oral medications fail to reduce blood sugar levels, and its addition to treatment regimens significantly increases the complexities of care. To effectively manage the disease, physicians and patients must continually monitor the condition and address factors that alter insulin levels. This ongoing process typically requires that patients calculate each insulin dose based on the time of day, food consumed, or activity performed. If the wrong calculation is made, a patient can experience further deterioration or an adverse drug event.

Although insulin can significantly improve a patient’s health, diabetics can still have a negative perception of the medication. Some may avoid taking it once prescribed, or choose non-adherence to their care plan, creating additional challenges in treatment.

Providers strive to effectively control patients’ blood sugar levels but are challenged because the average diabetic patient is only seen by a primary care provider approximately 2.5 hours per year. The lack of critical support and frequent check-ins with clinicians or diabetes educators prevents adherence to, and success of, insulin regimens created to control blood sugar. For instance, patients may fail to record their blood sugar in designated log books due to frustration from continuously high blood sugar levels. In turn, providers struggle to determine if medications are working properly without the appropriate data. In truth, the harsh reality is that some patients simply cannot prevent detrimental fluctuations in their blood sugar without the right tools in place and require additional doses of insulin to fuel their cells and provide energy.

Implementing telehealth solutions

As outlined in the 2017 National Standards, technological-engagement solutions such as mobile telemedicine applications aid healthcare organizations in their quest to improve diabetes care and outcomes. For instance, CHRISTUS Health utilizes DoseDr, a mobile diabetes management application developed to send medication reminders and physician-reviewed instructions to patients in real time.

Patients simply enter their blood sugar levels into the application and receive the correct insulin dose to take. Patient-reported data is aggregated and regularly analyzed by the applications’ physicians who make small frequent titrations as needed to support an effectively tailored regimen. This process enhances patient-provider communication, while improving A1c levels and patient engagement.

Similar to insulin pumps, the solution simplifies insulin calculations and provides patients with the confidence that they are taking the precise amount of insulin in each instance. In turn, administration of correct doses of insulin help to prevent adverse medication events. As the solution collects this data, patients’ primary care providers can analyze the logs and determine the impacts of varying levels of insulin on blood sugar to improved and sustainable outcomes.

Consider the following scenario:

An insulin-dependent diabetic patient eats lunch, such as a turkey sandwich, a small bag of chips, and a small apple, with water to drink. Without the telemedicine app, the patient would check their blood glucose and log it down to show their health care provider at a later date. Then they would subtract their glucose target from their glucose level and divide that answer by their individual correction factor. For instance, if the blood glucose was 270mg/dl, the target glucose was 120mg/dl, and the correction factor is 30, the calculation would equal 5. As such, the patient would need 5 units of insulin to correct their blood glucose into target range.

After that calculation, the patient would have to count the carbohydrates in the meal and divide the number of carbohydrates by their insulin-to-carb-ratio to determine how many units of insulin to take to cover their meal. For example, if the insulin-to-carb-ratio is 15, the patient would divide the total number of carbohydrates by 15 to know how many units of insulin to take for the meal (60 in this case divided by 15 equals 4, so 4 units of insulin would be needed to cover the meal). The number of units to cover their meal would then be added to the number of units of insulin needed to bring down their blood glucose to their target range. This tedious process lends to frustrations and common errors.

In contrast, insulin pump patients simply enter their glucose levels and the number of carbohydrates they are about to eat into the insulin pump, and the pump calculates the total amount of insulin needed. Similarly, the mobile telemedicine solution performs the same calculations based on the healthcare provider’s settings to tell the patient exactly how much insulin to inject. The person with diabetes simply checks their blood glucose, enters the value into DoseDr, enters how many carbohydrates they are eating, and, the solution tells them how much insulin to take.

Impacts of utilization

By involving patients in their healthcare, promoting accountability and supporting them with on-demand access to physicians, CHRISTUS is realizing notable improvement to patient engagement and adherence to care plans. For instance, a pilot study highlighting the use of the DoseDr diabetes solution showed promising results. The retention rate for the study was 76%. Of those people who stuck with it, engagement was 100%: Every patient used the app every day. And those people, after 90 days, reduced their A1c levels from 8.6 to 6%.

One patient with uncontrolled diabetes realized significant benefits after utilizing a telehealth solution. The patient had a history of failing to comply with her care plan, and consumed large quantities of sugar-sweetened beverages, such as soda, on a daily basis. Due to alarming health conditions, she was eventually recommended to use an insulin pump. Through consistent use of the telehealth application, the patient lowered her A1c level to below 7%, lost approximately 35 pounds and improved her overall health, effectively eliminating the need for an insulin pump and other costly medical interventions. The platform enabled her to analyze her logs to recognize how lifestyle and dietary habits impacted her blood sugar, while also helping her to confidently take the correct dose of insulin.

After three visits to the emergency room, another patient was introduced to the diabetes management application to help manage her condition. Discouraged by her high blood sugar, the patient failed to check and record her levels to ensure she received appropriate doses of insulin. She also began to experience additional health conditions, which resulted in her absence from work. Motivated by the solution’s reminders, accountability factor, and ability to titrate insulin, the patient successfully reduced her blood sugar levels, returned to work and avoided costly emergency department visits and hospitalizations.

By helping to engage and support diabetic patients to better manage their condition, healthcare organizations can leverage telehealth solutions to reduce costs, improve outcomes and enhance the quality of life for millions.

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