28 Apr Type 2 Diabetes: Telephone-Based Peer Support Improved Risk Factors
MedicalResearch.com Interview with:
Juliana C. N. Chan, MBChB MD FHKAM FRCP
Professor Juliana Chan is Professor of Medicine and Therapeutics, Director, Hong Kong Institute of Diabetes and Obesity and International Diabetes Federation Centre of Education at the Chinese University of Hong Kong, Prince of Wales Hospital and Chief Executive Officer of Asia Diabetes Foundation Hong Kong.
MedicalResearch.com: What are the main findings of the study?
Dr. Chan: In this 1-year randomized study, we asked the question whether type 2 diabetic patients receiving team-based integrated care augmented by information technology would further improve in their glycemic control if given additional peer support through the telephone. All patients underwent comprehensive risk assessment guided by the web-based JADE portal which generated personalized risk report with attained treatment targets and decision support. After 1 year, all patients improved significantly in all risk factors including A1c with improved treatment adherence, self efficacy and psychological wellbeing. Although the peer support group did not further improve in A1c, short-stay hospitalization rates were substantially reduced by 50% , especially amongst those with emotional distress. These patients accounted for 20% of the intervention group, in whom peer support further reduced psychological distress and treatment non-adherence.
MedicalResearch.com: Were any of the findings unexpected?
Dr. Chan: We have not expected the marked benefits of this integrated care program which have rendered the effect of peer support on A1c negative. Apart from providing information on risk profiles, the JADE portal also generated written messages and trends of risk factor control to improve self efficacy and reduce clinical inertia. At baseline, 50% of patients were non-adherent to their medications, which was reduced by 50% at 1 year. These findings highlight the benefits of changing clinic setting and using a team approach, augmented by information technology, to improve health literacy and promote shared decision making. However, even with this care reorganization, there remain patients who will benefit from ongoing peer support with reduced treatment non-adherence, psychological distress and hospitalization rates.
MedicalResearch.com: What should clinicians and patients take away from your report?
Dr. Chan: There are two key messages from this study.
First, care organization goes a long way in helping our patients to improve self care and risk factor control.
Second, psychological distress is an important factor for major outcomes such as hospitalization which requires ongoing community support, especially in high risk patients. People with diabetes have multiple medical and psychological needs. In most settings, every year, an average patient with diabetes has less than 1 hour of contact time with their care team while it takes many hours for him/her to accept his/her condition and learn how to self manage. Thus, despite the advancement in technology, short consultation time, poor treatment adherence, clinical inertia, suboptimal self care, frequent default and care fragmentation are major barriers in translating evidence to practice. To overcome these interlinked challenges, doctors may consider changing their practice setting and use paramedical staff to help them systematically collect information to identify unmet needs, improve health literacy and empower patients, which will also help them individualize treatment targets and personalize care. The JADE Program is a care prototype which has incorporated these principles with positive outcomes. That said, there are difficult-to-treat patients who require a more holistic approach, such as peer support, to complement medical care.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Chan: Firstly, there are many tools such as biomarkers, medications, devices which we can now use to help our patients. The challenge is to develop integrated and pragmatic solutions to select the right patient for the right interventions to be given by the right people and at the right time. Such solutions may vary from different settings depending on infrastructure, professional capacity, health care system and funding model. Nonetheless, our results and others suggest that improving practice environment to facilitate case management and patient empowerment with ongoing data collection and evaluation are key factors for consideration.
Secondly, information technologists are encouraged to work closely with clinicians to design electronic medical system which does not only store information, but manage and integrate them to help patients and doctors make decisions.
Thirdly, treating diabetes is helping a person to live with his/her condition for the rest of his/her life. Here, more research in understanding the cognitive and psychological factors which motivate them to seek medical advice, change behaviors and adhere to therapy is critically important.
Finally, cost-effective analysis of these programs will be needed in order to change clinical practice and influence policy.
Juliana C. N. Chan, MD; Yi Sui, PhD; Brian Oldenburg, PhD; Yuying Zhang, MB; Harriet H. Y. Chung, MSc; William Goggins, PhD; Shimen Au, BNurs; Nicola Brown, MSc; Risa Ozaki, MBChB; Rebecca Y. M. Wong, MSc; Gary T. C. Ko, MD; Ed Fisher, PhD; for the JADE and PEARL Project Team
JAMA Intern Med. Published online April 28, 2014. doi:10.1001/jamainternmed.2014.655