The Problem
Due to its devastating complications, diabetes mellitus doubles patient mortality and medical expenditures. Fortunately, achieving diabetes control slows or prevents the development of diabetes complications. However, due to a variety of behavioral, biological, and system-related factors, many patients never achieve adequate diabetes control despite receiving clinic-based diabetes care. Patients with “persistent poorly-controlled diabetes mellitus” (PPDM), which we define as maintenance of hemoglobin A1c (HbA1c) >8.5% despite clinic-based diabetes management, are left with an elevated level of risk for complications and costs that would be modifiable with improved control. Persisting with insufficiently effective clinic-based care models for PPDM perpetuates poor outcomes and high costs, making this patient population a priority for quality improvement.
Telemedicine, or use of information exchanged via electronic communications for healthcare purposes, can enhance diabetes care by facilitating telemonitoring (remote data collection), medication management, and self-management support. Based on prior research, telemedicine approaches hold great promise as a means to reduce the burden of PPDM. However, healthcare systems have seldom implemented telemedicine-based diabetes management as part of routine care, even for patients with PPDM. As a result of this “implementation gap,” clinicians are left with little recourse when clinic-based diabetes care proves insufficiently effective.
Our Solution
We bridged the telemedicine implementation gap for clinic-refractory diabetes, with the aim of improving outcomes for patients with PPDM. We have combined three evidence-based approaches – telemonitoring, medication management, and self-management support – into a single telemedicine intervention that will be delivered to Primary Care patients using a Duke University Health System (DUHS)-tailored approach. By capitalizing on new reimbursement opportunities for telemedicine-based chronic disease management, DM-TNG will be a self-sustaining component of Duke’s diabetes population management strategy, and will be amenable to scaling throughout DUHS. Ultimately, we hope that DM-TNG will help reduce the morbidity and costs of poor diabetes control where such improvements are most needed.
Impact
HbA1c improved by a statistically non-significant 0.23% among engaged patients by the end of the observation period, far less than the 1.0% versus usual care (and 1.9% among engaged patients) we saw in our VA work.
We also gathered valuable formative data to guide refinement and future implementation of Epic-integrated, telemedicine-based diabetes care within DUHS; identified reasons and opportunities for improving care pathways for uncontrolled diabetic patients; and developed two innovative, Epic-integrated platforms for delivering telemedicine care within DUHS.
