Post on 25-Dec-2015
Edith Burns, MD
Medical College of Wisconsin
Milwaukee, WI
T2DM92% of all diabetes10% of adults
20% of adults > 65 years of age
High costTreatment, managementComplications
Optimum management requires patients to take volitional control of a process that is automatic in healthy individualsSelf-regulation/Control processes take place in
“real world” settings- day-to-day life at home, work
Common-sense Models of IllnessLife experience of acute illness teaches us to use symptoms as indicators of sickness-wellness
In most chronic illnesses, symptoms are unreliable as indicators of disease status
Better to utilize objective measures by performing self-monitoring (e.g., SMBG, BP)
• T2DM is a “chaotic” disease
– Multiple factors contribute to acute fluctuations in blood glucose levels
– Individual SMBG measures at any given point in time may provide ambiguous feedback
• Can we teach patients to learn to use SMBG more effectively to become better self managers of a chaotic disease?
Study DesignTest an automated reminder and feedback system (ASMM)Randomized, prospective, “usual care” controlSystem provides reminders AND feedback
Usual Care Intervention
ASMM
Non-vets T2DM
50 50
VA T2DM 50 50
Total of 200 participantsFour in-home visits; intervention begins at visit 2 after 3 months. Exit interview at 15 months.
Qualities Desired in the Assisted-Self-Management Monitor (ASMM)
Physical PropertiesHome-based
Small footprint Limited components Installation
Ease of use Simple docking system “Hidden” technology
Ability to individualizeReminders
PCP & participant-determined schedule Patient “controls” the technology
Qualities Desired in the Assisted-Self-Management Monitor (ASMM), continuedFeedback
Timely – importance of what the results mean at the time Scheduled measures Unscheduled measures
Symptoms? Relationship to management behaviors (timing)
Diet Exercise
Overall control Trend data
Minimizes “catastrophizing” of single readings
NOSymptoms
Can do whatNeed & want To do
Dr. SaysTest ShowsHIGH Blood Sugar
Answer
Okay No Symptoms
Ask Myself How do I feel?
Should I takemeds, diet to control diabetesif I feel Okay?
Act PlanUse the glucometer& computer
Monitor & Appraiseblood sugar readings
If high: Take medication, exercise, etc.
ActPlansTake meds, exercise!
NO
It’s time to testmy blood sugar
Monitor Blood Sugar Readings: Objective Measures
I don’t know my blood sugar level – I can’t feel it
Proper timing and consideration is necessary for this to work- DO THE NUMBERS MAKE SENSE?!!
ASMM Algorithm(Draft 2/8/2008) Version 9
Attach meter to Computer, starting glucose download process.
Multiple meter readings?
Last Glucose<70 or >250?
Hypoglycemia Treatment
Treat hypoglycemia with
15 grams of carbohydrates
every 15 minutes until glucose is
over 90. <70
Hyperglycemia treatment
Your glucose is elevated. Call your health care team if you feel ill. Be sure
to take your medication, eat
wisely, and drink plenty of fluids.
>250
No
Scheduled Time?
Trend analysis Did you eat (time last glucose – 4 hours) ?
After Exercise?Did you eat (time last glucose – 2 hours)?
Improving Trend?-¼ s.d. of mean
Stable Trend?±¼ s.d. of mean
Worsening Trend?+¼ s.d. of mean
Trend SummaryGoal average 90-130Your trend shows: ...
Improving Trend1. At this rate you
will get to goal2. Your current
trend makes you healthier
At Goal1. Keep up the
good work2. All your effort is
keeping right where you need to
be.
Worsening Trend1. Might need
medication adjustment
2. Be sure to be consistent with
exercise3. Be sure
exercise is intense enough
4. If you have question about
ways to improve, contact your health
care team.5. Your current
trend will increase your risks of
complications.
Stable Trend above Goal1. Exercise Moderately
2. Watch you food portion size
3. Make healthy food choices
4. Eat breakfast5. Might need
medication adjustment
Yes No
NoYes
After Exercise1. Goal would be about 90-130 30
mins after exerciseA. Exercise can cause a rise in
your glucose right after exercise.
B. Exercise lowers your long-term glucose trends
C. Exercise improves your
fitnessD. Exercise lowers
your blood pressure
E. Exercise lowers your blood
cholesterol and triglycerides
F. Keep up the good work
Yes
Random Glucose1. Goal is 90-130 if 4 hours since last
food.A. Be sure to be
activeB. Exercise 30
mins, 5 days per week is a good
goalC. Moderate
exercise is an activity that
increases your heart rate up
D. Brisk walk is an example of
moderate exercise
No
Yes
Two hours after eating
1. Goal is 180 or less.
A. use number to adjust portion sizeB. use this number to assess dietary
choices.
Too Soon after Eating
1. Need to wait to soon to assess
glucose. 2. There is no goal established for this
time.
No
Yes
Last glucose < 1 hour ago?
Done for symptoms?Yes or No
Low symptoms?
No
Yes
No
Any Fasting readings?
Yes
Fasting Glucose readings are
important. Please do some.
No
Frequent probems?3 times in 7 days
Frequent ProblemsYou are having frequent
symptoms, consider calling your diabetes health care
team.
Yes
At goal?Yes
No
No
No
Yes
Yes
Yes
Light-blue boxes = computer logicGreen boxes = patient input
Individualized in logic: 1) scheduled glucose reading times, 2) goals for scheduled time for trend summary
Trend summary begins after 10 readingsSD based on 25 readings
System Demonstration
Co-Investigators & Research Team
Jeffrey Whittle, MDPaul Knudson, MDSergei Tarima, PhDBambi Wessel, MSAlexis Dye, MAStephen Flax, PhD
Joan Pleuss, CDE, RDColin Strub, BSKristin Wiescorek, BSHoward Leventhal,
PhD1
1 Center for Health & Behavior, Rutgers University and UMDNJ, New Brunswick, NJ
SUMMARY
Increasing frequency and consistency of SMBG led to improved glycemic control
Higher baseline depression scores had higher baseline HbA1c and showed greater improvement over time
Improvement in HbA1c was not correlated to baseline cognitive function
•Expanded study to rigorously test this system
–Illness cognition, change over time
–Reminder function
–Expanded feedback
•Trends in control
•Unscheduled measures
•Relating measures to diet and activity