who can help me?

New Technologies to Advance Self-Management Support in Diabetes Not just a bunch of cool apps!

T he article by Walker et al. (1) in this issue of Diabetes Care highlights how new applications of existing

modes of communication and the use of new technologies can improve the deliv- ery of care for patients with diabetes. In this case, care was successfully brought to a poorly controlled patient group using the medium of live telephone calls. New types of technology-based interventions focus on the use of the telephone, Internet, mobile communicators, pagers, web-based programs, and email to assess and monitor patient health status, address symptoms and behaviors, and foster changes in vari- ous aspects of disease management—in this case better medication adherence and im- proved glycemic control.

The purpose of these emerging sys- tems is to expand programs of self- management support (SMS), a generic term applied to strategies that provide pa- tients with the information, tools, and support they need to take care of their health problems (2,3). The development and application of a spectrum of interven- tions that involve new media expand evidence-based methods of patient monitoring and intervention that tradi- tionally have taken place within the clin- ical setting to real-world environments in ways that are congruent with patient life- style, age, and cultural setting (3,4). The underlying assumption is that such pro- grams can be more successful, sustain- able, and cost- and time-efficient than traditional approaches and that they have the potential to reach high risk patient populations that generally do not come to their doctor’s office for regular care (3,5). These SMS programs vary in complexity, from simple telephone-based programs of symptom monitoring to highly elaborate, web-based programs with complex branching algorithms that assist patients with improving self-care over time (6). The increased popularity of these pro- grams, coupled with real-world questions about their practical usability in clinical care, cost, sustainability, and effective- ness, cause us to reflect on how such pro-

grams should be translated for general use and integrated into care for patients with diabetes. Now that the field has matured by the variety of available evidence-based technological SMS programs currently available, the need to establish criteria for translation into the real-world of clinical care is apparent (4). Sadly, too often such programs are supported by time-limited external resources, and even if proven ef- fective, they are shelved when the project is completed because they cannot easily be integrated and supported by ongoing care systems.

In this editorial, we provide a per- spective for surveying this expanding field by reviewing a template of five inter- related questions that summarize the ma- jor translational issues for SMS programs based on new technologies (Table 1). Without such consideration, we risk not taking full advantage of the unique strengths and not avoiding the potential drawbacks of these programs to improve outcomes for patients with diabetes.

What is the specific purpose of the SMS program? What is often missing in the selection and use of SMS systems in clinical care is the clear targeting of specific goals: what ex- actly is the target of the program and how will it be achieved? Are there multiple SMS goals to be addressed or is the focus more narrowly drawn? For example, the telephone-based intervention designed by Walker et al. was concisely focused on reducing A1C, as are many SMS systems for patients with diabetes. In this case, however, a specific proximal mechanism of change was designed into the interven- tion: enhancing medication adherence. Many existing SMS programs are devel- oped without this kind of clear outcome targeting, meaning that a specific behav- ioral domain and a sequencing of behav- ioral change goals are not identified at the outset. SMS programs are often devel- oped to address only the distal goal of improved glycemic control by using a proximal goal of weight reduction, in-

creased physical activity, or medication adherence. Proximal change goals, how- ever, are rarely assessed comprehensively or seen as major outcomes in their own right, because the primary aim is change in A1C, the distal goal. This is an impor- tant consideration, because it is entirely possible that the proximal goal, in this case medication adherence, could have been achieved without being followed by achievement of the distal goal, in this case a reduction in A1C. When this occurs, the intervention is often deemed a failure, even though the actual behavioral change targeted was achieved. Many factors affect glycemic control, and changes in one po- tential influence may be insufficient to significantly affect A1C, especially over the course of time involved in clinical tri- als. As a general rule, it is crucial to judge the effectiveness and utility of a specific SMS intervention by observing changes to both proximal and distal targets, and not to rely solely on changes to a distal out- come that can be influenced by multiple factors, such as A1C.

A related issue is time frame: can the change targeted be achieved by a defined but time-limited intervention, or will it require a longer-lasting program that in- cludes a greater investment in patient en- gagement, intervention, and support? For example, Walker et al. found that changes in medication adherence were achievable within the limited time frame of the study. In contrast, major reductions in body weight, the target of many SMS interven- tions with new technologies, require much longer time periods, supplemented by ongoing programs to maintain weight loss over time. Many SMS programs using new technologies demonstrate initial suc- cess and then stop, with a subsequent re- turn to preintervention levels because they did not consider that achieving and maintaining behavioral change is not a one-time experience. Both diabetes and disease management are chronic condi- tions requiring ongoing support and in- tervention, which can be a major strength of new technologies if addressed and in-

E d i t o r i a l s E D I T O R I A L ( S E E W A L K E R E T A L . , P . 2 )

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corporated into the SMS program at the outset. In the current example, it remains unclear if the documented improvement in medication adherence can be sustained and whether the SMS program will need to be altered to assist with maintenance of medication adherence over time.

Which patients are to be targeted? The greater the effort devoted to defining the patient population of interest, the better the outcomes, the higher the accep- tance rate, and the lower the attrition (7). Tailoring SMS interventions for specific patient groups increases the probability of obtaining positive results. For example, simply making a web-based program available to everyone may be beneficial because it is inclusive, but the lack of tai- loring will often exclude many of the most needy or high risk patients who could profit most from the intervention. The cri- teria identified for inclusion in the pro- gram reported by Walker et al. were specific: these were patients who were

poorly controlled, rarely came for care, identified with a respected institution (their Union), and were generally from a single ethnic group. Much effort was de- voted to using cultural cues to engage these patients, and the Union was used as a common, trusted institution to enhance reach. The success of these efforts was re- vealed by high patient uptake and rela- tively low attrition over time. Even the choice of media was carefully considered: this was a sample that might best be en- gaged via live contact through the tele- phone rather than, for example, through interactive voice recognition (IVR) tech- nologies or web-based/email programs, even though they are far less expensive to deliver. A comparable program for pa- tients from another ethnic group or from another education level might best be de- signed quite differently. One-size-fits-all SMS programs may be relatively inexpen- sive for an entire patient panel, but they are often highly inefficient with respect to high risk patients who need them the

most. At minimum, we suggest that the following patient characteristics should be considered when making use of new technologies: age, sex, ethnicity, educa- tion, severity of disorder or symptoms, level of risk, and experience with and preference for different media.

Which media and media characteristics will be utilized? Many currently available SMS systems us- ing new technologies are complex and so- phisticated in terms of available options and ability to be customized both within and across different media. Some empha- size programs to engage patients in the process and to assist in the maintenance of gains over time (8). Still others allow for “stepped interventions,” for different levels of intervention intensity based on patient need or preference, or for multiple interventions, with patients choosing the specific goals and subprograms (9). Al- though this sophistication is attractive, much of it will be often underused when the program is translated into clinical practice with a large, diverse panel of pa- tients. Most patients access only a limited number of features in complex SMS pro- grams (10,11). Although many programs are elegant, the usability, accessibility, and targeting of specific goals for both pa- tients and care teams may be best (12).

Not all media are equally effective for all types of SMS programs, and careful consideration needs to be directed at de- ciding which medium is best for which intervention and for which patients. For example, IVR technology has been used successfully for symptom monitoring and for relatively short and simple communi- cations between patient and care team, such as clinical status reporting (13). However, IVR programs can be tedious and repetitious for more complex tasks, where web-based audio and visual cues can be more helpful and patients can re- main engaged for longer time periods. Consequently, there needs to be a careful match between each specific SMS pro- gram target, the clinical population iden- tified, and the medium selected for use. A single intervention program cannot easily be translated across different media with the assumption that one can be substi- tuted for another. And not all patients with diabetes will be equally attracted to the same program.

Another important issue concerns the amount of live versus automated patient contact included in the program. Al- though costs are generally higher with

Table 1—SMS Questions

1. What is the specific purpose of the SMS program? a. What are the proximal and distal goals? Is the focus behavior change, clinical status, or

symptom monitoring? b. Can behavior change and maintenance be achieved in a time-limited way, or will it be

gradual, requiring ongoing support? c. Is the SMS goal comprehensive or highly targeted (intensive vs. extensive intervention)?

2. Which patients will be targeted? a. Demographics: age, ethnicity, gender. b. Severity of disorder or symptoms. c. Level of risk. d. Level of media experience and preference (personal and cultural).

3. Which media and media characteristics will be utilized? a. Media (web, email, telephone, etc.)? b. How many bells and whistles (level of program complexity). c. Is this a stepped intervention, does one program fit all? d. What is the ratio of human to technological contact (balancing the cost of human

contact)? e. How much emphasis is there on patient engagement and maintenance?

4. Will the SMS program be integrated into the patient’s ongoing clinical care? a. Where does the program come from (the practice, health plan, employer, or stand-alone

source)? b. Too what degree is the program built around relationships between patients and HCPs

or staff? Or is this a carved-out, stand-alone program? c. How and by whom (clinicians, staff, patients) will the information generated by the

program be used? d. How will the program be framed for patients, clinicians, and practice staff?

5. Costs. a. Who will support the program financially, e.g., clinical practice, health plan, patient,

medical group? b. What are the development costs? c. What are the initial costs for customizing and implementing the program in each setting? d. What are the ongoing costs of use over time (information technology staff to maintain

the program, clinical staff to make use of the information, etc.)? e. Are there patient costs?

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more live than automated patient contact, deciding to utilize less live contact with some patient groups may not be cost- efficient. The ideal balance of live to tech- nological contact is often based on the patient’s cultural context, level of risk, age, and life context. To reduce cost, per- sonal contact can be utilized initially and then decreased over time, depending on patient need, once a relationship with the live program representative has been es- tablished. And patient preference can be utilized in tailoring a program—some pa- tients actually prefer fully automated sys- tems, whereas others firmly do not. For example, one highly experienced com- puter user surprisingly rejected a web- based program: “I spend my entire day working on the computer and when I get home I don’t even want to look at my PC.” Although a totally automated program may be effective for a subset of the popu- lation, a well-balanced, flexible, patient- tailored level of live contact generally appeals to a wider audience and may prove to be most effective in terms of cost and clinical outcome.

How will the SMS program be integrated into the patient’s ongoing clinical care? How integrated and seamless is the SMS system with respect to the broader deliv- ery of the patient’s diabetes care? Most currently available SMS programs are free-standing; they are not easily inte- grated within office-based electronic health records and other automated clin- ical care systems, or patients seek them out on their own, which leaves the SMS activity completely separated from the care team. Still others are offered by an employer or a health insurance plan with no direct linkage to the diabetes care team. In the study reported by Walker, et al., the SMS program was designed to op- erate independently of the patient’s regu- lar care team. When translated into the real-world of clinical care, how would health care practitioners (HCPs) know about such a system and make effective use of it when caring for individual patients?

The growing interest in integrated systems of care, modeled after the Patient- Centered Medical Home (14 –16), sug- gests a need to provide more coordinated and informed services in collaboration with patient need and preference. As these new models of primary care have gained acceptance and traction, practices are showing increased interest in integrat-

ing SMS programs of various types into their care. Free-standing or carved-out SMS programs stand in sharp contrast to these recent developments and raise con- cerns about the pitfalls of fragmented care, especially for high risk patients with diabetes. In general, patients are far more likely to continue with an SMS program over time when it is based on a positive relationship with their HCP and when it is viewed as an extension of their care (17). We argue that SMS programs for diabetes need to be linked to the broader system of patient care so that both patients and pro- viders are fully informed about SMS activ- ities and care can be fully coordinated and integrated.

Deciding upon the adoption of an SMS system that uses new technologies also requires careful consideration of work flow— how the information derived from the system will be collected, summa- rized, and used in the clinical setting. Who in the office will monitor patient SMS activities recorded by the program? How will the information be documented in the medical record? How will it be practically summarized for use during the next clinical encounter or red-flagged for a more immediate response? SMS infor- mation adds to already high staff de- mands to integrate a great deal of clinical information needed for good diabetes care (18).

What is the development and implementation cost and how will the SMS program be supported long-term? The intervention reported by Walker et al. was funded by grants from National Insti- tutes of Health and the Union pension fund. From a translation perspective, no information is provided about the overall costs of program development, imple- mentation, and long-term use. In the real world of clinical care, it often remains un- clear who will shoulder the various substantial costs of SMS programs: the clinic, the medical group, the health care plan, the employer, the patient? And how will the program be framed for the pa- tient—is this their doctor’s program, their health plan’s program, their employer’s program? This framing, based in part on who designs and pays for it, can have sub- stantial effects on patient follow-through and outcome. It is important that SMS outcome studies track and report infor- mation regarding the cost of develop- ment, implementation, and maintenance to inform decisions regarding the optimal

deployment of the program on an ongo- ing basis.

CONCLUSIONS — SMS programs for patients with diabetes make use of the full range of electronic media, from sim- ple automated telephone monitoring to more complex, web-based lifestyle change programs. Most of these programs have evolved outside of the traditional care system and others were developed internally but often lack the resources to be maintained over time. Care systems have been relatively slow to adopt SMS programs and to integrate them into more comprehensive care for patients with dia- betes. The pressing need to deliver cost- effective, population-based care that reaches out to the individual needs of pa- tients with diabetes calls for practitioners to become proactive in selecting and cus- tomizing efficient, semi- and fully auto- mated SMS programs. The program described in the paper by Walker, et al. serves as an excellent model, but it also raises important questions. Using a vari- ety of different media, these programs have the potential for expanding care from traditionally delivered office-based encounters to care that reaches into the patient’s home and community. These programs require that clinicians engage in active and systematic consideration of the patients who might use it, the specific SMS behaviors that are targeted for change, the type of media that will be used, the time frame of the program, who will pay for it, and how the program will be integrated into a broader program of comprehensive diabetes care.

LAWRENCE FISHER, PHD, ABPP1

W. PERRY DICKINSON, MD2

From the 1Department of Family and Community Medicine, University of California, San Fran- cisco, San Francisco, California, and the 2Depart- ment of Family Medicine, University of Colorado Health Sciences Center, Aurora, Colorado.

Corresponding author: Lawrence Fisher, fisherl@ fcm.ucsf.edu.

DOI: 10.2337/dc10-1830 © 2011 by the American Diabetes Association.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http:// creativecommons.org/licenses/by-nc-nd/3.0/ for details.

Acknowledgments — L.F. is a consultant to Roche Diagnostics and Eli Lilly. No other po- tential conflicts of interest relevant to this ar- ticle were reported.

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References 1. Walker E, Shmukler C, Ullman R, Blanco

E, Scollan-Koliopoulus M, Cohen HW. Results of a successful telephonic inter- vention to improve diabetes control in ur- ban adults: a randomized trial. Diabetes Care 2011;34:2–7

2. Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self- management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002;24: 80 – 87

3. Goldstein DE. E-Healthcare: Harness the Power of Internet e-Commerce and e-Care. Gaithersburg, MD, Aspen Publishers, 2000

4. Bennett GG, Glasgow RE. The delivery of public health interventions via the Inter- net: actualizing their potential. Annu Rev Public Health 2009;30:273–292

5. Lorig KR, Sobel DS, Stewart AL, Brown BW Jr, Bandura A, Ritter P, Gonzalez VM, Laurent DD, Holman HR. Evidence sug- gesting that a chronic disease self-man- agement program can improve health status while reducing hospitalization: a ran- domized trial. Med Care 1999;37:5–14

6. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561–587

7. Carroll KM. Enhancing retention in clini- cal trials of psychosocial treatments: prac-

tical strategies. NIDA Res Monogr 1997; 165:4 –24

8. Eakin EG, Reeves MM, Marshall AL, Dun- stan DW, Graves N, Healy GN, Bleier J, Barnett AG, O’Moore-Sullivan T, Russell A, Wilkie K. Living well with diabetes: a randomized controlled trial of a tele- phone-delivered intervention for mainte- nance of weight loss, physical activity and glycemic control in adults with type 2 di- abetes. BMC Public Health 2010;10:452

9. Lauver DR, Ward SE, Heidrich SM, Keller ML, Bowers BJ, Brennan PF, Kirchhoff KT, Wells TJ. Patient-centered interven- tions. Res Nurs Health 2002;25:246 –255

10. Gerber BS, Brodsky IG, Lawless KA, Smolin LI, Arozullah AM, Smith EV, Berbaum ML, Heckerling PS, Eiser AR: Implementation and evaluation of a low-literacy diabetes ed- ucation computer multimedia application. Diabetes Care 2005;28:1574 –1580

11. Glasgow RE, Boles SM, McKay HG, Feil EG, Barrera M Jr. The D-Net diabetes self- management program: long-term imple- mentation, outcomes and generalization results. Prev Med 2003;36:410 – 419

12. García-Lizana F, Sarría-Santamera A. New technologies for chronic disease management and control: a systematic re- view. J Telemed Telecare 2007;13:62– 68

13. Goldberg LR, Piette JD, Walsh MN, Frank TA, Jaski BE, Smith AL, Rodriguez R, Mancini DM, Hopton LA, Orav EJ, Loh E, WHARF Investigators. Randomized trial of a daily electronic home monitoring sys- tem in patients with advanced heart fail- ure: the Weight Monitoring in Heart

Failure (WHARF) trial. Am Heart J 2003; 146:705–712

14. Arrow K, Auerbach A, Bertko J, Brownlee S, Casalino LP, Cooper J, Crosson FJ, En- thoven A, Falcone E, Feldman RC, Fuchs VR, Garber AM, Gold MR, Goldman D, Hadfield GK, Hall MA, Horwitz RI, Hooven M, Jacobson PD, Jost TS, Kot- likoff LJ, Levin J, Levine S, Levy R, Lin- scott K, Luft HS, Mashal R, McFadden D, Mechanic D, Meltzer D, Newhouse JP, Noll RG, Pietzsch JB, Pizzo P, Reischauer RD, Rosenbaum S, Sage W, Schaeffer LD, Sheen E, Silber BM, Skinner J, Shortell SM, Thier SO, Tunis S, Wulsin L Jr, Yock P, Nun GB, Bryan S, Luxenburg O, van de Ven WP. Toward a 21st-century health care system: recommendations for health care reform. Ann Int Med 2009;150:493– 495

15. Berenson RA, Hammons T, Gans DN, Zuckerman S, Merrell K, Underwood WS, Williams AF. A house is not a home: keep- ing patients at the center of practice rede- sign. Health Affairs 2008;27:1219 –1230

16. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary are. J Gen Int Med 2005;20:953–957

17. Parchman ML, Pugh JA, Noël PH, Larme AC. Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes. Med Care 2002;40: 137–144

18. Pincus HA. The future of behavioral health and primary care: drowning in the mainstream or left on the bank? Psycho- somatics 2003;44:1–11

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