Sociodemographic and clinical correlates of key outcomes from a Mobile Insulin Titration Intervention (MITI) for medically underserved patients

Role of digital health communication, sociodemographic factors, and medical conditions on perceived quality of patient-centered communication

OBJECTIVE

To simultaneously explore associations between digital health, sociodemographic factors, and medical conditions on patient-centered communication (PCC). These are under-explored, yet important knowledge gaps to fill because perceived quality PCC may influence health information seeking behaviors and health outcomes.

METHODS

Data from the 2019 Health Information National Trends Survey were analyzed. The primary outcome was PCC, which was the summed score of 7 PCC-related questions. Factors of interest included whether participants used electronic methods to communicate with health professionals, age, gender, race/ethnicity, education, feelings about household income, and history of medical conditions. Descriptive statistics and linear regressions were conducted.

RESULTS

In the multivariate linear regression model, people aged 65-74 years compared with 18-34 year-olds, those with some college compared with college graduates, and those who felt they were living comfortably on their household income compared with all others reported higher PCC scores. People with a history of hypertension compared with those without reported higher PCC scores.

CONCLUSION

Similar to past studies, sociodemographic factors were associated with PCC. A novel finding was that a history hypertension was associated with perceived quality of PCC.

PRACTICE IMPLICATIONS

This research may inform methods to enhance communication between patients and clinicians.

Efficacy of Insulin Titration Driven by SMS in Improving Glycemic Control in People with Type 2 Diabetes

AIM

To evaluate the efficacy of the self-management of insulin titration based on information received by the Short Message Service (SMS).

METHODS

A case-control study including 59 subjects in each arm with 16 weeks of follow-up was performed. The inclusion criteria were: (1) Subjects with type 2 diabetes (T2D) under basal insulin treatment; (2) Suboptimal glycemic control: HbA1c ≥ 7.5% and fasting capillary blood glucose (FCBG) > 140 mg/dL (>3 times per week). Subjects were invited to use an insulin titration service based on SMS feedback aimed at optimizing glycemic control depending on fasting blood glucose levels. Psychological aspects were evaluated in the interventional group by means of validated questionnaires (DDS, HADS and SF-12).

RESULTS

The intervention group achieved a lower mean FCBG (126 mg/dL ± 34 vs. 149 mg/dL ± 46, p = 0.001) and lower HbA1c (7.5% ± 1.3 vs. 7.9% ± 0.9, p = 0.021) than the control group. In addition, the intervention group showed a significant improvement in psychological aspects related to Emotional Burden (p = 0.031), Regimen Distress (p < 0.001), Depression (p = 0.049) and Mental Health (p < 0.01).

CONCLUSIONS

The SMS-guided titration was effective in terms of improving glucometric parameters in comparison with the standard of care and improved significant psychological aspects-mainly, the stress associated with insulin treatment.

Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Background

Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated.

Objective

This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings.

Methods

A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted.

Results

The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low.

Conclusions

Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.

Metabolic and inflammatory risk reduction in response to lipid-lowering and lifestyle modification in the medically underserved individuals

Introduction

Medically underserved (US) populations have an increased level of atherosclerotic cardiovascular disease (ASCVD) risk, however, few studies investigated ASCVD risk reduction in US.

Methods

Of 217 subjects with ApoB ≥120 mg/dL and carotid atherosclerosis (≥15% stenosis by ultrasound) enrolled in the Carotid Plaque Composition by MRI (CPC) study between 2005 and 2011, US (n=33) was defined as those without adequate healthcare insurance, while AS (n=184) included those with adequate healthcare coverage. All subjects received atorvastatin-based lipid therapies and lifestyle intervention for 2 years. Metabolic and inflammatory risk factors were compared between AS and US.

Results

At baseline, compared to AS, US displayed higher levels of metabolic and inflammatory risk including systolic blood pressure (140±27 vs. 131±18 mmHg, p=0.04), fasting glucose (125±59 vs. 102±22 mg/dL, p=0.03) and fasting insulin (39±33 vs. 28±20 µU/dL, p=0.03) which resulted in higher insulin resistance (HOMA-IR 2.2±0.4 vs. 1.3±0.1, p=0.03), and hsCRP (5.6±1.5 vs. 2.8±0.2 mg/L, p=0.03). Over 2 years of intervention, US and AS showed similar reductions in LDL-C (-10.7% vs. -16% per year, p=0.2), triglycerides (-16.7% vs. -15.9% per year, p=0.4), and hsCRP (-0.11% vs. -0.04% per year, p=0.1). However, US continued to show significantly higher levels of fasting blood glucose (115±6.0 vs. 101±2.0 mg/dL, p=0.03) and HOMA-IR (1.9±0.2 vs. 1.5±0.1, p=0.047), and hsCRP (3.9±0.7 vs. 1.9±0.2 mg/L, p<0.001) than AS following 2 years of interventions.

Conclusions

US displayed higher ASCVD risk than AS at baseline and over 2 years despite similar reductions following the intervention. These findings highlight the unmet needs for improved intervention strategies and implementation methods for ASCVD risk reduction in US.

Clinical Trial Registration

NCT00715273 at ClinicalTrials.gov.

Challenges of conducting a remote behavioral weight loss study: Lessons learned and a practical guide

OBJECTIVES

To describe challenges and lessons learned in conducting a remote behavioral weight loss trial.

METHODS

The Personal Diet Study is an ongoing randomized clinical trial which aims to compare two mobile health (mHealth) weight loss approaches, standardized diet vs. personalized feedback, on glycemic response. Over a six-month period, participants attended dietitian-led group meetings via remote videoconferencing and were encouraged to self-monitor dietary intake using a smartphone app. Descriptive statistics were used to report adherence to counseling sessions and self-monitoring. Challenges were tracked during weekly project meetings.

RESULTS

Challenges in connecting to and engaging in the videoconferencing sessions were noted. To address these issues, we provided a step-by-step user manual and video tutorials regarding use of WebEx, encouraged alternative means to join sessions, and sent reminder emails/texts about the WebEx sessions and asking participants to join sessions early. Self-monitoring app-related issue included inability to find specific foods in the app database. To overcome this, the study team incorporated commonly consumed foods as "favorites" in the app database, provided a manual and video tutorials regarding use of the app and checked the self-monitoring app dashboard weekly to identify nonadherent participants and intervened as appropriate. Among 135 participants included in the analysis, the median attendance rate for the 14 remote sessions was 85.7% (IQR: 64.3%-92.9%).

CONCLUSIONS

Experience and lessons shared in this report may provide critical and timely guidance to other behavioral researchers and interventionists seeking to adapt behavioral counseling programs for remote delivery in the age of COVID-19.

Effectiveness of the Family Portal Function on the Lilly Connected Care Program (LCCP) for Patients With Type 2 Diabetes: Retrospective Cohort Study With Propensity Score Matching

Background

Diabetes is a major health concern worldwide. Family member engagement in diabetes self-management education programs can improve patients’ diabetes management. However, there is limited evidence that the family portal on diabetes management apps is effective in the glycemic control of patients with diabetes.

Objective

We aimed to evaluate the effectiveness of family support through the family portal function on Lilly Connected Care Program (LCCP) platform.

Methods

This retrospective cohort study included patients with type 2 diabetes recruited to the LCCP platform from September 1, 2018, to August 31, 2019. Propensity score matching was used to match family (group A) and non–family (group B) portal use groups with similar baseline characteristics. The patients were followed up with for 12 weeks. The main objectives were differences in mean fasting blood glucose, proportion of patients achieving fasting blood glucose target <7mmol/L, mean postprandial blood glucose, proportion of patients achieving postprandial blood glucose target <10mmol/L, proportion of patients achieving both fasting blood glucose <7mmol/L and postprandial blood glucose <10mmol/L, self-monitoring of blood glucose frequency at week 12 and the number of diabetes education courses patients completed during the 12 weeks. Moreover, logistic regression analysis was used to explore the baseline factors which may be associated with the use of family portal, and odds ratios with 95% confidence intervals were calculated.

Results

A total of 6582 adult patients (aged ≥18 years) with type 2 diabetes who were receiving insulin therapy were enrolled in the study. Overall, 6.1% (402/6582) of the patients chose to engage their family members to use the family portal. Two groups of 394 patients were well-matched regarding baseline characteristics. After matching, mean fasting blood glucose and postprandial blood glucose at week 12 were significantly lower in group A than in group B (fasting blood glucose: 7.12 mmol/L, SD 1.70 vs 7.42 mmol/L, SD 1.88, respectively, P=.02; postprandial blood glucose: 8.56 mmol/L, SD 2.51 vs 9.10 mmol/L, SD 2.69, respectively, P=.002). When comparing group A to group B, the proportion of patients achieving both fasting blood glucose <7mmol and postprandial blood glucose <10mmol/L at week 12 (46.8% vs 39.4%, respectively, P=.04), self-monitoring of blood glucose frequency at week 12 (8.92 times per week, SD 6.77 vs 8.02 times per week, SD 5.97, respectively, P=.05) and number of diabetes education courses completed in 12 weeks (23.00, IQR9.00-38.00 vs 15.00, IQR 4.00-36.00, respectively, P<.001) was higher. Additionally, multivariate logistic regression analysis showed that higher age (OR=0.987, 95% CI 0.978-0.996, P=.006) and higher baseline fasting blood glucose (OR=0.914, 95% CI 0.859-0.972, P=.004) were correlated with less use of the family portal function, while increased baseline self-monitoring of blood glucose frequency (OR=1.022, 95% CI 1.012-1.032], P<.001) as well as increased education courses (OR=1.026, 95% CI 1.015-1.036, P<.001) were associated with more use of the family portal function.

Conclusions

Family support through the LCCP family portal is effective for glycemic control and self-management behavior improvement in type 2 diabetes patients.