KADIS: model-aided education in type I diabetes. Karlsburg Diabetes Management System

Artificial Intelligence in Decision Support Systems for Type 1 Diabetes

Type 1 diabetes (T1D) is a chronic health condition resulting from pancreatic beta cell dysfunction and insulin depletion. While automated insulin delivery systems are now available, many people choose to manage insulin delivery manually through insulin pumps or through multiple daily injections. Frequent insulin titrations are needed to adequately manage glucose, however, provider adjustments are typically made every several months. Recent automated decision support systems incorporate artificial intelligence algorithms to deliver personalized recommendations regarding insulin doses and daily behaviors. This paper presents a comprehensive review of computational and artificial intelligence-based decision support systems to manage T1D. Articles were obtained from PubMed, IEEE Xplore, and ScienceDirect databases. No time period restrictions were imposed on the search. After removing off-topic articles and duplicates, 562 articles were left to review. Of those articles, we identified 61 articles for comprehensive review based on algorithm evaluation using real-world human data, in silico trials, or clinical studies. We grouped decision support systems into general categories of (1) those which recommend adjustments to insulin and (2) those which predict and help avoid hypoglycemia. We review the artificial intelligence methods used for each type of decision support system, and discuss the performance and potential applications of these systems.

Dynamic Interactive Educational Diabetes Simulations Using the World Wide Web: An Experience of More Than 15 Years with AIDA Online

Background. AIDA is a widely available downloadable educational simulator of glucose-insulin interaction in diabetes. Methods. A web-based version of AIDA was developed that utilises a server-based architecture with HTML FORM commands to submit numerical data from a web-browser client to a remote web server. AIDA online, located on a remote server, passes the received data through Perl scripts which interactively produce 24 hr insulin and glucose simulations. Results. AIDA online allows users to modify the insulin regimen and diet of 40 different prestored "virtual diabetic patients" on the internet or create new "patients" with user-generated regimens. Multiple simulations can be run, with graphical results viewed via a standard web-browser window. To date, over 637,500 diabetes simulations have been run at AIDA online, from all over the world. Conclusions. AIDA online's functionality is similar to the downloadable AIDA program, but the mode of implementation and usage is different. An advantage to utilising a server-based application is the flexibility that can be offered. New modules can be added quickly to the online simulator. This has facilitated the development of refinements to AIDA online, which have instantaneously become available around the world, with no further local downloads or installations being required.

Development of AIDA v4.3b Diabetes Simulator: Technical Upgrade to Support Incorporation of Lispro, Aspart, and Glargine Insulin Analogues

Introduction. AIDA is an interactive educational diabetes simulator available on the Internet without charge since 1996 (accessible at: http://www.2aida.org/). Since the program’s original release, users have developed new requirements, with new operating systems coming into use and more complex insulin management regimens being adopted. The current work has aimed to design a comprehensive diabetes simulation system from both a clinical and information technology perspective.Methods. A collaborative development is taking place with a new generic model of subcutaneous insulin absorption, permitting the simulation of rapidly-acting and very long-acting insulin analogues, as well as insulin injections larger than 40 units. This novel, physiological insulin absorption model has been incorporated into AIDA v4. Technical work has also been undertaken to install and operate the AIDA software within a DOSBox emulator, to ensure compatibility with Windows XP, Vista and 7 operating systems as well as Apple Macintosh computers running Parallels PC emulation software.Results. Plasma insulin simulations are demonstrated following subcutaneous injections of a rapidly-acting insulin analogue, a short-acting insulin preparation, intermediate-acting insulin, and a very long-acting insulin analogue for injected insulin doses up to 60 units of insulin.Discussion.The current work extends the useful life of the existing AIDA v4 program.

The Karlsburg Diabetes Management System: translation from research to eHealth application

BACKGROUND

Several telemedicine-based eHealth programs exist, but patient-focused personalized decision support (PDS) is usually lacking. We evaluated the acceptance, efficiency, and cost-effectiveness of telemedicine-assisted PDS in routine outpatient diabetes care.

METHODS

Data are derived from the Diabetiva® program of the German health insurance company BKK TAUNUS. Diabetiva offers telemedicine-based outpatient health care in combination with PDS generated by the Karlsburg Diabetes Management System, KADIS®. This retrospective analysis is based on data from the first year of running KADIS-based PDS in routine diabetes care. Participants were insured persons diagnosed with diabetes and cardiovascular diseases. For final analysis, patients were grouped retrospectively as users or nonusers according to physician acceptance or not (based on questionnaires) of the KADIS-based PDS.

RESULTS

A total of 538 patients participated for more than one year in the Diabetiva program. Of these patients, 289 had complete data sets (two continuous glucose monitoring measurements, two or more hemoglobin A1c (HbA1c) values, and a signed questionnaire) and were included in the final data analysis. Of the physicians, 74% accepted KADIS-based PDS, a rate that was clearly related to HbA1c at the beginning of the observation. If KADIS-based PDS was accepted, HbA1c decreased by 0.4% (7.1% to 6.7%). In contrast, rejection of KADIS-based PDS resulted in an HbA1c increase of 0.5% (6.8% to 7.3%). The insurance company revealed an annual cost reduction of about 900 € per participant in the Diabetiva program.

CONCLUSIONS

KADIS-based PDS in combination with telemedicine has high potential to improve the outcome of routine outpatient diabetes care.

Simulation environment to evaluate closed-loop insulin delivery systems in type 1 diabetes

BACKGROUND

Closed-loop insulin delivery systems linking subcutaneous insulin infusion to real-time continuous glucose monitoring need to be evaluated in humans, but progress can be accelerated with the use of in silico testing. We present a simulation environment designed to support the development and testing of closed-loop insulin delivery systems in type 1 diabetes mellitus (T1DM).

METHODS

The principal components of the simulation environment include a mathematical model of glucose regulation representing a virtual population with T1DM, the glucose measurement model, and the insulin delivery model. The simulation environment is highly flexible. The user can specify an experimental protocol, define a population of virtual subjects, choose glucose measurement and insulin delivery models, and specify outcome measures. The environment provides graphical as well as numerical outputs to enable a comprehensive analysis of in silico study results. The simulation environment is validated by comparing its predictions against a clinical study evaluating overnight closed-loop insulin delivery in young people with T1DM using a model predictive controller.

RESULTS

The simulation model of glucose regulation is described, and population values of 18 synthetic subjects are provided. The validation study demonstrated that the simulation environment was able to reproduce the population results of the clinical study conducted in young people with T1DM.

CONCLUSIONS

Closed-loop trials in humans should be preceded and concurrently guided by highly efficient and resource-saving computer-based simulations. We demonstrate validity of population-based predictions obtained with our simulation environment.

Incorporating a generic model of subcutaneous insulin absorption into the AIDA v4 diabetes simulator. 3. Early plasma insulin determinations

INTRODUCTION

AIDA is an interactive educational diabetes simulator that has been available without charge via the Internet for over 12 years. Recent articles have described the incorporation of a novel generic model of insulin absorption into AIDA as a way of enhancing its capabilities. The basic model components to be integrated have been overviewed, with the aim being to provide simulations of regimens utilizing insulin analogues, as well as insulin doses greater than 40 IU (the current upper limit within the latest release of AIDA [v4.3a]). Some preliminary calculated insulin absorption results have also recently been described.

METHODS

This article presents the first simulated plasma insulin profiles from the integration of the generic subcutaneous insulin absorption model, and the currently implemented model in AIDA for insulin disposition. Insulin absorption has been described by the physiologically based model of Tarín and colleagues. A single compartment modeling approach has been used to specify how absorbed insulin is distributed in, and eliminated from, the human body. To enable a numerical solution of the absorption model, a spherical subcutaneous depot for the injected insulin dose has been assumed and spatially discretized into shell compartments with homogeneous concentrations, having as its center the injection site. The number of these compartments will depend on the dose and type of insulin. Insulin inflow arises as the sum of contributions to the different shells. For this report the first bench testing of plasma insulin determinations has been done.

RESULTS

Simulated plasma insulin profiles are provided for currently available insulin preparations, including a rapidly acting insulin analogue (e.g., lispro/Humalog or aspart/Novolog), a short-acting (regular) insulin preparation (e.g., Actrapid), intermediate-acting insulins (both Semilente and neutral protamine Hagedorn types), and a very long-acting insulin analogue (e.g., glargine/Lantus), as well as for insulin doses up to 50 IU.

DISCUSSION

The methodology to be adopted for implementing the generic absorption model within AIDA has been overviewed, and the first plasma insulin profiles based on this approach have been demonstrated. Ideas for future work and development are discussed. It is expected that an updated release of AIDA (v4.5), based on this collaborative approach, will become available for free--in due course--via the www.2aida.org Web site. Readers who wish to be informed when the new software is launched can join the very low volume AIDA announcement list by sending a blank email note to subscribe@2aida.org.

Physical activity into the meal glucose-insulin model of type 1 diabetes: in silico studies

INTRODUCTION

A simulation model of a glucose-insulin system accounting for physical activity is needed to reliably simulate normal life conditions, thus accelerating the development of an artificial pancreas. In fact, exercise causes a transient increase of insulin action and may lead to hypoglycemia. However, physical activity is difficult to model. In the past, it was described indirectly as a rise in insulin. Recently, a new parsimonious model of exercise effect on glucose homeostasis has been proposed that links the change in insulin action and glucose effectiveness to heart rate (HR). The aim of this study was to plug this exercise model into our recently proposed large-scale simulation model of glucose metabolism in type 1 diabetes to better describe normal life conditions.

METHODS

The exercise model describes changes in glucose-insulin dynamics in two phases: a rapid on-and-off change in insulin-independent glucose clearance and a rapid-on/slow-off change in insulin sensitivity. Three candidate models of glucose effectiveness and insulin sensitivity as a function of HR have been considered, both during exercise and recovery after exercise. By incorporating these three models into the type 1 diabetes model, we simulated different levels (from mild to moderate) and duration of exercise (15 and 30 minutes), both in steady-state (e.g., during euglycemic-hyperinsulinemic clamp) and in nonsteady state (e.g., after a meal) conditions.

RESULTS

One candidate exercise model was selected as the most reliable.

CONCLUSIONS

A type 1 diabetes model also describing physical activity is proposed. The model represents a step forward to accurately describe glucose homeostasis in normal life conditions; however, further studies are needed to validate it against data.

Telemedicine-based KADIS combined with CGMS has high potential for improving outpatient diabetes care

BACKGROUND

The Karlsburg Diabetes Management System (KADIS) was developed over almost two decades by modeling physiological glucose-insulin interactions. When combined with the telemedicine-based communication system TeleDIAB and a continuous glucose monitoring system (CGMS), KADIS has the potential to provide effective, evidence-based support to doctors in their daily efforts to optimize glycemic control.

METHODS

To demonstrate the feasibility of improving diabetes control with the KADIS system, an experimental version of a telemedicine-based diabetes care network was established, and an international, multicenter, pilot study of 44 insulin-treated patients with type 1 and 2 diabetes was performed. Patients were recruited from five outpatient settings where they were treated by general practitioners or diabetologists. Each patient underwent CGMS monitoring under daily life conditions by a mobile monitoring team of the Karlsburg diabetes center at baseline and 3 months following participation in the KADIS advisory system and telemedicine-based diabetes care network. The current metabolic status of each patient was estimated in the form of an individualized "metabolic fingerprint." The fingerprint characterized glycemic status by KADIS-supported visualization of relationships between the monitored glucose profile and causal endogenous and exogenous factors and enabled evidence-based identification of "weak points" in glycemic control. Using KADIS-based simulations, physician recommendations were generated in the form of patient-centered decision support that enabled elimination of weak points. The analytical outcome was provided in a KADIS report that could be accessed at any time through TeleDIAB. The outcome of KADIS-based support was evaluated by comparing glycosylated hemoglobin (HbA1c) levels and 24-hour glucose profiles before and after the intervention.

RESULTS

Application of KADIS-based decision support reduced HbA1c by 0.62% within 3 months. The reduction was strongly related to the level of baseline HbA1c, diabetes type, and outpatient treatment setting. The greatest benefit was obtained in the group with baseline HbA1c levels >9% (1.22% reduction), and the smallest benefit was obtained in the group with baseline HbA1c levels of 6-7% (0.13% reduction). KADIS was more beneficial for patients with type 1 diabetes (0.79% vs 0.48% reduction) and patients treated by general practitioners (1.02% vs 0.26% reduction). Changes in HbA1c levels were paralleled by changes in mean daily 24-hour glucose profiles and fluctuations in daily glucose.

CONCLUSION

Application of KADIS in combination with CGMS and the telemedicine-based communication system TeleDIAB successfully improved outpatient diabetes care and management.

Outpatient assessment of Karlsburg Diabetes Management System-based decision support

OBJECTIVE

We sought to assess the benefit of the Karlsburg Diabetes Management System (KADIS) in conjunction with the continuous glucose monitoring system (CGMS) in an outpatient setting.

RESEARCH DESIGN AND METHODS

A multicentric trial was performed in insulin-treated outpatients (n = 49), aged 21-70 years, with a mean diabetes duration of 14.2 years. Subjects were recruited from five outpatient centers and randomized for CGMS- or CGMS/KADIS-based decision support and followed up for 3 months. After two CGMS monitorings, the outcome parameters A1C (%), mean sensor glucose of the CGMS profile (MSG) (mmol/l), and duration of hyperglycemia (h/day) were evaluated.

RESULTS

In contrast with the CGMS group (0.27 +/- 0.67%), mean change in A1C decreased in the CGMS/KADIS group during the follow-up (-0.34 +/- 0.49%; P < 0.01). MSG levels were not affected in the CGMS group (7.75 +/- 1.33 vs. 8.45 +/- 2.46 mmol/l) but declined in the CGMS/KADIS group (8.43 +/- 1.33 vs. 7.59 +/- 1.47 mmol/l; P < 0.05). Net KADIS effect (-0.60 [95% CI -0.96 to - 0.25%]; P < 0.01) was associated with reduced duration of hyperglycemia (4.6 vs. 1.0 h/day; P < 0.01) without increasing hypoglycemia. Multiple regression revealed that the A1C outcome was dependent on KADIS-based decision support. Age, sex, physician's specialty, diabetes type, and BMI had no measurable effect.

CONCLUSIONS

If physicians were supported by CGMS/KADIS in therapeutic decisions, they achieved better glycemic control for their patients compared with support by CGMS alone. KADIS is a suitable decision support tool for physicians in outpatient diabetes care and has the potential to improve evidence-based management of diabetes.

Retrospective pilot feedback survey of 200 users of the AIDA Version 4 Educational Diabetes Program. 1--Quantitative Survey Data

This column reports a detailed, questionnaire-based, post-release feedback survey of 200 users of the AIDA version 4 educational diabetes simulator. AIDA is a freeware computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, self-learning, and research purposes. Since its Internet launch in 1996 over 700,000 visits have been logged to the AIDA Websites-including www.2aida.org-and over 200,000 program copies have been downloaded free-of-charge. The main goals of the current study were: (1) to establish what people have thought about the AIDA program, (2) to assess the utility of the software, and (3) to ascertain how much people have actually used it. An analysis was therefore undertaken of the first 200 feedback forms that were returned by AIDA users. The questionnaire-based survey methodology was found to be robust and reliable. Feedback forms were received from participants in 21 countries. One hundred six of 209 responses (50.7%) were received from people with diabetes, and 36 of 209 (17.2%) from relatives of patients, with lesser numbers from doctors, students, diabetes educators, nurses, pharmacists, and other end users. Please note some respondents fulfilled more than one end-user category, hence the denominator <200; for example, someone with diabetes who was also a doctor. This study has established the feasibility of using a simple feedback form to survey a substantial number of diabetes software users. In addition, it has yielded interesting data in terms of who are the main users of the AIDA program, and has also provided technical (computer) information that has aided the release of a freeware upgrade to the software. In general, users reported finding the program to be of educational value. The majority also felt it would be of interest to diabetes educators and people with diabetes. Most were clear about its limitations as a simulator-based learning tool. The implications of these findings will be discussed.

Anthropic agency: a multiagent system for physiological processes

Multiagent systems are powerful and flexible tools for modelling and regulating complex phenomena. In fact, a way to manage the complexity of a phenomenon is to decompose it in such a way that each agent embeds the control model for a portion of the phenomenon. In this perspective, the cooperative interaction among the agents results in the controller for the whole phenomenon. Since the portions in which the phenomenon is decomposed may overlap, the actions the single agents undertake to regulate these portions may conflict; hence a balanced negotiation is required. A class of complex phenomena that present several difficulties in their satisfactory modelling and controlling is the class of physiological processes. The purpose of this paper is to introduce a general multiagent architecture, called anthropic agency, for the modelling and the regulation of complex physiological phenomena.

Why people download the freeware AIDA v4.3a diabetes software program: a proof-of-concept semi-automated analysis

AIDA is a diabetes-computing program freely available at www.2aida.org on the Web. The software is intended to serve as an educational support tool and can be used by anyone who has an interest in diabetes, whether they be patients, relatives, health-care professionals, or students. In previous "Diabetes Information Technology & WebWatch" columns various indicators of usage of the AIDA program have been reviewed, and various comments from users of the software have been documented. The purpose of this column is to overview a proof-of-concept semi-automated analysis about why people are downloading the latest version of the AIDA educational diabetes program. AIDA permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, self-learning, and research purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 300,000 visits have been logged at the main AIDA Website-www.2aida.org-and over 60,000 copies of the AIDA program have been downloaded free-of-charge. This column documents the results of a semi-automated analysis of comments left by Website visitors while they were downloading the AIDA software, before they had a chance to use the program. The Internet-based survey methodology and semi-automated analysis were both found to be robust and reliable. Over a 5-month period (from October 3, 2001 to February 28, 2002) 400 responses were received. During the corresponding period 1,770 actual visits were made to the Website survey page-giving a response rate to this proof-of-concept study of 22.6%. Responses were received from participants in over 54 countries-with nearly half of these (n = 194; 48.5%) originating from the United States, United Kingdom, and Canada; 208 responses (52.0%) were received from patients with diabetes, 50 (12.5%) from doctors, 49 (12.3%) from relatives of patients, with fewer responses from students, diabetes educators, nurses, pharmacists, and other end users. The semi-automated analysis adopted for this study has re-affirmed the feasibility of using the Internet to obtain free-text comments, at no real cost, from a substantial number of medical software downloaders/users. The survey has also offered some insight into why members of the public continue to turn to the Internet for medical information. Furthermore it has provided useful information about why people are actually downloading the AIDA v4.3a interactive educational "virtual diabetes patient" simulator.

Who is downloading the free AIDA v4.3a interactive educational diabetes computer software? A 1-year survey of 3864 downloads

AIDA is a free diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, self-learning, and research purposes. To date over 70000 copies of the software have been downloaded from the AIDA Website, www.2aida.org. This column documents a survey of downloaders of the latest release of the program (AIDA v4.3a). The Internet-based survey methodology was confirmed to be robust and reliable. Over a 1-year period (from March 2001 to February 2002) in total 3864 responses were received. During the corresponding period some 8578 actual downloads of the software were independently logged via the same route at the AIDA Website, giving a response rate for this survey of 45%. Responses were received from participants in 66 countries - over half of these (n = 2,137; 55.3%) were from the United States and the United Kingdom. There were 2318 responses (60.0%) received from patients with diabetes and 443 (11.5%) from relatives of patients, with fewer responses from doctors, students, diabetes educators, nurses, pharmacists, and other end users. This study highlights considerable interest amongst patients and their relatives to learn more about balancing insulin and diet in diabetes, as well as possibly to get more involved in self-management of insulin dosages. More computer applications that can cater for this interest in diabetes patient self-care need to be developed and made available. The Internet provides an ideal medium for the distribution of such educational tools.

Why are people downloading the freeware AIDA diabetes computing software program: a pilot study

The purpose of this paper is to report a pilot survey about why people are downloading the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for teaching, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 well over 200,000 visits have been logged at the main AIDA Website--www.2aida.org--and over 40,000 copies of the AIDA program have been downloaded free-of-charge. This article documents a pilot survey of comments left by Website visitors while they were downloading the AIDA software, before they had a chance to actually use the program. The overall paradigm adopted for this study has endeavored to establish why people are resorting to the Internet to obtain diabetes information. Specific intended goals of the study were: (1) to demonstrate ongoing use of the World Wide Web for surveying diabetes software users by obtaining their free-text comments; (2) to identify what sort of things people were planning to do with the AIDA software simulator; and (3) to more generally gain some insight into why people are turning to the Web for healthcare-related information. The Internet-based survey methodology was found to be robust and reliable. Over an 8-month period (from February 2, 2001 to October 1, 2001) 642 responses were received. During the corresponding period 2,248 actual visits were made to the Website survey page--giving a response rate to this pilot study of 28.6%. Responses were received from participants in over 56 countries--although over half of these (n = 343; 53.4%) originated from the United States and United Kingdom. Two hundred forty-four responses (38.0%) were received from patients with diabetes, and 73 (11.4%) from relatives of patients, with fewer responses from doctors, students, diabetes educators, nurses, pharmacists, and other end users. This pilot survey has confirmed the feasibility of using the Internet to obtain free-text comments, at no real cost, from a large number of medical software downloaders/users. The survey has also offered a valuable insight into why members of the public are turning to the Internet for medical information. Furthermore it has provided useful information about why people are actually downloading the AIDA interactive educational "virtual diabetes patient" simulator.

Who is downloading the freeware AIDA v43 interactive educational diabetes simulator? An audit of 2437 downloads

The purpose of this paper is to report an audit of 2437 downloads of the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration, and self-learning purposes. It has been made freely available, without charge, on the Internet as a noncommercial contribution to continuing diabetes education. Since its launch in 1996 over 200000 visits have been logged at the AIDA Website - www.2aida.org - and over 37000 copies of the AIDA program have been downloaded free-of-charge. This report documents an audit of downloaders of the software, with the intended goals of the study being to demonstrate the use of the Internet for auditing and surveying diabetes software users and to confirm the proportion of patients with diabetes and their relatives who are actually making use of the AIDA v4.3 program. The Internet-based survey methodology was confirmed to be robust and reliable. Over a 7(1/2)-month period (from mid-July 2000 to early March 2001) 2437 responses were received. During the corresponding period 4100 actual downloads of the software were independently logged via the same route at the AIDA Website - giving a response rate to this audit of 59.4%. Responses were received from participants in 61 countries - although over half of these (n = 1533; 62.9%) originated from the United States and United Kingdom. Of these responses 1,361 (55.8%) were received from patients with diabetes and 303 (12.4%) from relatives of patients, with fewer responses from doctors, diabetes educators, students, nurses, pharmacists, and other end users. This study has confirmed the feasibility of using the Internet to survey, at no real cost, a large number of medical software downloaders/users. In addition, it has yielded up-to-date and interesting data about who are the main downloaders of the AIDA program.

Further user comments regarding usage of an interactive educational diabetes simulator (AIDA)

This "Diabetes Information Technology & WebWatch" column continues the diabetes simulation theme from previous issues and overviews various user experience with the AIDA v4 interactive educational freeware diabetes simulator. AIDA is a diabetes computer program that permits the interactive simulation of plasma insulin and blood glucose (BG) profiles for educational, demonstration, and self-learning purposes. It has been made freely available, without charge, via the Web as a noncommercial contribution to continuing diabetes education. Since its Internet launch in 1996, over 145,000 visits have been logged at the AIDA Website--www.2aida.org--and over 29,000 copies of the program have been downloaded, free of charge. While these statistics may appear impressive, they do not tell the personal story of how people have been making use of the software, and what they actually think about the program. In this respect, this column documents some of the independent user comments about AIDA sent in spontaneously via electronic mail (email) by patients with diabetes and their relatives, as well as by health-care professionals. Comments posted to diabetes newsgroups and diabetes email lists, as well as a selection of those which have been found at other, linked, diabetes Websites are also highlighted.

Spontaneous comments from users of the AIDA interactive educational diabetes simulator

The user experience with the AIDA simulator demonstrates one of the advantages of making such diabetes software readily available for free via the Internet. The comments collectively provide a picture of some of the many and varied ways in which the simulator has been applied by different users. These comments also demonstrate the potential for empowerment that some people feel can result from the use of the software. The experience with this approach is sufficiently encouraging to warrant formal evaluation studies to quantify the clinical utility of such an interactive educational diabetes simulation program. For this reason, a formal survey of 200 AIDA users (patients, relatives, and healthcare professionals) from at least 15 different countries is currently ongoing, and further formal evaluation studies in the clinic setting are planned.

Computer-based approaches to patient education: a review of the literature

All articles indexed in MEDLINE or CINAHL, related to the use of computer technology in patient education, and published in peer-reviewed journals between 1971 and 1998 were selected for review. Sixty-six articles, including 21 research-based reports, were identified. Forty-five percent of the studies were related to the management of chronic disease. Thirteen studies described an improvement in knowledge scores or clinical outcomes when computer-based patient education was compared with traditional instruction. Additional articles examined patients' computer experience, socioeconomic status, race, and gender and found no significant differences when compared with program outcomes. Sixteen of the 21 research-based studies had effect sizes greater than 0.5, indicating a significant change in the described outcome when the study subjects participated in computer-based patient education. The findings from this review support computer-based education as an effective strategy for transfer of knowledge and skill development for patients. The limited number of research studies (N = 21) points to the need for additional research. Recommendations for new studies include cost-benefit analysis and the impact of these new technologies on health outcomes over time.

Experience with the Internet release of AIDA v4.0--http://www.diabetic.org.uk.aida.htm--an interactive educational diabetes simulator

AIDA v4.0 is a freeware computer program that permits the interactive simulation of plasma insulin and blood glucose profiles for demonstration and teaching purposes. It has been made freely available, without charge, on the World Wide Web as a noncommercial contribution to continuing diabetes education. Since its Internet launch in 1996 over 23,000 people have visited the AIDA Web site (http://www.diabetic.org.uk/aida.htm) and over 7,750 copies of the program have been downloaded gratis. This report overviews the Internet release of AIDA v4.0 and provides examples of the simulator in operation. The concept of a "virtual diabetic patient" is introduced. This provides an electronic representation of a patient with diabetes that can be used for self-learning/teaching/demonstration purposes.

Interactive educational simulators in diabetes care

Since the Diabetes Control and Complications Trial demonstrated the substantial benefits of tight glycaemic control there has been renewed interest in the application of information technology (IT) based techniques for improving the day-to-day care of patients with diabetes mellitus. Computer-based educational approaches have a great deal of potential for patients use, and may offer a means of training more health-care professionals to deliver such improved care. In this article the potential role of IT in diabetes education is reviewed, focusing in particular on the application of compartmental models in both computer-based interactive simulators and educational video games. Close attention is devoted to practical applications-available today-for use by patients, their relatives, students and health-care professionals. The novel features and potential benefits of such methodologies are highlighted and some of the limitations of currently available software are discussed. The need for improved graphical user interfaces, and for further efforts to evaluate such programs and demonstrate an educational benefit from their use are identified as hurdles to their more widespread application. The review concludes with a look to the future and the type of modelling features which should be provided in the next generation of interactive diabetes simulators and educational video games.

Application of computers in diabetes care--a review. II. Computers for decision support and education

This paper concludes a review of the contribution of information technology to diabetes care. The role of decision support tools for planning insulin therapy using various clinical algorithms, knowledge-based approaches and interactive simulations is discussed, and certain telemedicine approaches to therapy are considered. The validation and clinical evaluation of these tools is reviewed, as is the likely impact of the routine clinical application of implantable/non-invasive blood glucose monitoring devices. Finally, the application of computers as teaching tools is considered, and ways in which such educational approaches might be applied for disseminating the benefits of the Diabetes Control and Complications Trial more widely are discussed.