Patients with diabetes can take more active roles in their care, and improve glycemic control, by using a personal digital assistant preinstalled with special software, according to Dr. Samuel N. Forjuoh.
Dr. Forjuoh is leading a team of central Texas researchers to determine the potential benefits of personal digital assistant (PDA) use with outpatients, with the ultimate goal of leveling the self-care playing field across socioeconomic groups.
Their recently-published pilot study revealed that the incorporation of PDA use in diabetes self-care, while feasible, poses significant challenges, said Dr. Forjuoh, professor of family and community medicine and director of research at the Scott and White Memorial Hospital in Temple, Texas.
An initial cohort of 43 subjects was provided with Diabetes Pilot software for Palm handhelds (J. Am. Board Fam. Med. 2007:20:375–84). Diabetes Pilot is made by Digital Altitudes LLC, Arlington Heights, Ill.
The PDA system enables users to record glucose measurements, insulin, and other medicines; meals; exercise; blood pressure; test results; and other notes, according to the Diabetes Pilot Web site. Among other things, the software tracks the intake of carbohydrate, calories, fat, protein, fiber, sodium, cholesterol, and other nutrients, and allows users to see trends in blood sugars with various reports and graphs.
A total of 19 participants dropped out of the study and 6 more participants did not return and/or could not be reached after making several attempts.
The 18 people who completed the PDA intervention had a mean drop in hemoglobin A1c (HbA1c) of 18%, from 9.7% at baseline to 8% after 6 months, Dr. Forjuoh said in an interview. He added that further updated results of the study, including data on exercise, foot care, and diet, are contained in a manuscript which has been accepted for online publication this May in Telemedicine and e-Health.
“We saw that the more a patient used the PDA, the greater the drop in HbA1c,” he said, noting that comparable reductions in blood glucose associated with PDAs or similar technology have been documented by other investigators.
The 18 finishers had an average age of 58 years. The group comprised 56% women, 56% Caucasians, and 38% college graduates. Also, 72% had annual family incomes of $30,000 or more, said Dr. Forjuoh, noting the difficulty of expanding PDA use across a diverse population.
“The majority of patients in this pilot study were at the upper end of computer literacy, and it's apparent that only those who are comfortable using a PDA will benefit,” he said, adding that many patients who could benefit from the technology are strangers to it.
The researchers are about to launch a larger study of 400 patients drawn from 14 Scott and White Health System clinics. The cohort will be assigned to four arms: a PDA-only group, PDA plus chronic disease self-management classes, self-management classes alone, and a usual-care group. In addition, the participants will be representative of the Central Texas population with respect to race, ethnic group, income, location, and insurance status, said coinvestigator Jane N. Bolin, Ph.D.
“We want to see if we can use PDAs to reduce health disparities among the population, and we'll also do a cost analysis that will determine how many health care dollars can be saved for every unit reduction of HbA1c,” said Dr. Bolin, director of the Southwest Rural Health Research Center, a branch of the Texas A&M University System Health Science Center, School of Rural Public Health in College Station.
In the pilot study, it was found that many patients were discouraged by the tedious task of tracking dietary effects on glucose by entering into the PDA all the foods they had eaten. The complaints and potential for further loss of participants led the investigators to relax the rules on data entry. To make data entry easier and help more patients feel comfortable using the PDA, the vendor has been asked to fine-tune the software in time for the upcoming trial, Dr. Forjuoh said.
The cost per participant in the pilot study was $650, but because that included expenses that patients would not normally bear, Dr. Forjuoh estimates the actual cost per patient at around $300; the larger study with comparison groups is expected to settle that point, he said.
The spotty availability of reimbursement for such programs places a cloud over widespread adoption of self-management technology, according to Dr. Forjuoh. “Many states don't require insurance companies to provide reimbursement for nutritional education and diabetes self-management education; that causes patients to become dependent upon clinics, and eventually they end up in the emergency room,” he concluded.