Development and evaluation of a patient-oriented education system for diabetes management

doi:10.1016/j.ijmedinf.2006.05.030

International Journal of Medical Informatics

Volume 76, Issue 9, September 2007, Pages 655-663

https://doi.org/10.1016/j.ijmedinf.2006.05.030 Get rights and content

Abstract

Purpose

To develop and evaluate a Web-based, patient-orientated diabetic education management (POEM) system.

Methods

The POEM system has been developed to extend hospital patient education by integrating patients’ medical care data into their education program components and presenting them on the Web. Since most patients are concerned about their medical care data, the POEM system can provide the incentives for patients to continuously and persistently log in and learn the required knowledge and skills, improving their clinical outcomes. A quasi-experimental method that uses control groups and pretests was used to evaluate the outcomes of the system intervention. We recruited patients with type-2 diabetes and alternatively assigned them to intervention and control groups. We compared laboratory test results including fasting blood glucose, HbA1c, total cholesterol, triglyceride (TG), and HDL between the two groups from the first visit through each follow-up visit. The study period progressed from September 2003 to May 2004 at the Metabolism Center of a medical teaching hospital in Taipei.

Results

In this study, we recruited 274 participants: 134 (57% males and 43% females) in the intervention group and 140 (46% males and 54% females) in the control group. The patients’ laboratory test results from the first visit for fasting blood glucose, HbA1c, total cholesterol level, TG, and HDL in the intervention and control groups were respectively 187.54 ± 77.10 and 189.99 ± 73.49 mg/dl, 9.03 ± 2.79% and 8.95 ± 2.23%, 193.29 ± 47.93 and 202.52 ± 58.45 mg/dl, 152.48 ± 70.85 and 157.37 ± 74.88 mg/dl, and 44.97 ± 12.09 and 45.32 ± 12.08 mg/dl. There were three follow-up visits during the study period. We collected laboratory test results of the two groups through each of the following visits and analyzed them using ANCOVA. We discovered a significant difference in fasting blood glucose levels between intervention and control group as early as the first follow-up. At the second follow-up, both fasting blood glucose and HBA1c levels were significantly different between intervention and control group. At the third follow-up, there was a significant difference in fasting blood glucose, HBA1c, and total cholesterol between intervention and control group. We also monitored the number of logins for the patients in the intervention group during the follow-up period. The result showed the patients had consistently logged into the POEM system (about 8.5 ± 3.7 logins per person per month after 3 months enrollment). Thus, the patients in the intervention group had better control of their fasting blood glucose, HbA1c and total cholesterol levels than those in the control group due to the assistance of the system.

Conclusions

The POEM system can help patients control their glucose, HbA1c and total cholesterol levels to manage their diabetes, providing an easy and inexpensive way to extend hospital-based patient education services for community-based continuous patient education.

Introduction

Diabetes is an irreversible disease requiring lifetime care and rehabilitation. Persistent monitoring and control of blood sugar levels are effective treatments [1], [2], [3], [4], whereas consistent patient education to improve their ability in administering self-care is also effective, lowering the risks of developing complications [3], [5], [6], [7], [8], [9], [10]. In Taiwan, traditional patient education as well as follow-ups requires patients to return to the hospitals where they received their medical care. In order to encourage patient participation, most education activities operate in conjunction with follow-up clinics [11], [12], [13].

As the Internet becomes more widespread, the general public is beginning to seek medical information and support online [13], [14], [15], [16]. There are currently many Web sites providing general information on diabetes, its treatments, and knowledge and skills of self-management [17], [18]. However, most patients require more specific information regarding their individual disease conditions. Therefore, it is hardly possible for them to obtain appropriate and adequate education from the Internet without the help of clinical professionals [19], [20], [21].

In recent years, many researchers have used computer programs and Web interfaces [22], [23], [24], [25], [26], [27], [28] to provide frequent and responsive interactions between patients and their physicians online. The online services can motivate patients to utilize the systems more enthusiastically, leading to the better management of their diabetes conditions.

Patient education is usually an important component in routine medical services. After being evaluated and receiving instructions from their doctors at a hospital visit, a patient can receive an individual tutorial along with education materials (such as goals to achieve, and knowledge and skills for self-management) based on the development of their disease conditions. To extend this highly individualized patient education for a lasting effect, such tutorials and education materials should be presented on the Web so patients can easily access the information after having left the hospital.

A high percentage of the population in Taiwan use the Internet (about 61%) [29]; thus, dissemination of health care information through it is becoming increasingly popular. An Internet questionnaire survey on information provided by medical care services most concerned by patients showed that the top two were: completeness of their medical care data and comprehensive explanations for their prescribed medicines [30]. Based on these needs, we have developed a patient-oriented education management (POEM) system for extending the routine patient education service [31].

In the system, we collect diabetic patients’ medical care data along with their education materials at each hospital visit and organize them into educational folders, then present the structured folders on the Web. This paper is organized into six sections presenting: a brief description of the POEM system in Section 2; the method for evaluation of the system in Section 3; the results shown and discussed in Sections 4 Results, 5 Discussion; followed by conclusions in Section 6.

Section snippets

System description

The POEM system, as shown in Fig. 1, consists of the following major components: Web browsers for patients; a patient-oriented medical care data organizer (POMDO) for consolidating an individual's medical care data in a hospital; a Web server as repository and service provider for patients’ medical care information and education materials.

The POMDO is used to retrieve a patient's medical care data from hospital information systems at each visit and organize them into a folder for that visit.

Study design

A quasi-experimental study that uses control groups and pretests was used to evaluate the outcomes of the system intervention. The target population of this study was the patients with type-2 diabetes who visited the Metabolism Center at TMUWFH. In addition, the patients must meet the following conditions:

•
Did not have any severe complications that would affect the patients’ ability to follow physician's orders, for example, blindness, stroke, or amputation;
•
Had a normal level of consciousness

The characteristics of participants

The total number of participants in this study was 274: 134 (57% males and 43% females) in the intervention group and 140 (46% males and 54% females) in the control group. Their characteristics are shown in Table 1. The age and durations of diabetes of the intervention and control group were 61.2 ± 12.7 and 66.0 ± 8.5 years and 5.28 ± 4.70 and 7.01 ± 5.44 years, respectively.

The patients with a college or university degree were the majority: 38.8% in the intervention group and 38.6% in the control

Discussion

Diabetes mellitus is a complex chronic metabolic disease. Without appropriate treatment, complications such as cerebrovascular and coronary heart disease, nephropathy, retinopathy, and gangrenous foot often occur [1], [2]. Persistent and continued patient education can effectively help patients control blood glucose and HbA1c levels and delay the occurrence of associated complications [7], [10], [11], [32]. In our approach we collect and integrate a diabetic patient's medical care data and

Conclusion

We take advantage of Web technology to extend hospital patient education services by integrating patients’ medical care data into their education program components and presenting them on the Web. Since most patients are concerned about their medical care data, the POEM system can provide the incentives to motivate patients to continuously and persistently log in and learn their required knowledge and skills, prolonging the effect of patient education after they have left the hospitals. The

Acknowledgments

This research was partially supported by the grants from the National Science Council (NSC92-2516-S-038-002) and the Taipei Medical University Wan-Fang Hospital (93TMU-WFH-25).

References (37)

C.T. Liu et al.
Development and evaluation of an integrated pharmaceutical education system
Int. J. Med. Inform.
(2004)
P.A. Thakurdesai et al.
Evaluation of the quality and contents of diabetes mellitus patient education on Internet
Patient Educ. Counsel.
(2004)
S. Plougmann et al.
DiasNet—a diabetes advisory system for communication and education via the internet
Int. J. Med. Inform.
(2001)
R.E. Glasgow et al.
The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results
Prev. Med.
(2003)
The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus
N. Engl. J. Med.
(1993)
Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)
Lancet
(1998)
M. Berger et al.
Diabetes care and patient-oriented outcomes
J. Am. Med. Assoc.
(1999)
American Diabetes Association Position Statement
Standards of medical care for patients with diabetes mellitus
Diab. Care
(2003)
N.N. Abourizk et al.
An outpatient model of integrated diabetes treatment and education: functional, metabolic, and knowledge outcomes
Diab. Educ.
(1994)
S. Clement
Diabetes self-management education
Diab. Care
(1995)

R. Deichmann et al.

Improvement in diabetic care as measured by HbA1C after a physician education project

Diab. Care

(1999)

J.D. West et al.

Diabetes self-care knowledge among outpatients at a Veterans Affairs medical center

Am. J. Health Syst. Pharm.

(2002)

K.A. Peterson et al.

Readiness to change and clinical success in a diabetes educational program

J. Am. Board Fam. Pract.

(2002)

Improving quality of life in diabetes education: how effective is education

Patient Educ. Counsel.

(2003)

T.R. Pieber et al.

Evaluation of a structured teaching and treatment programme for type 2 diabetes in general practice in a rural area of Austria

Diab. Med.

(1995)

C.M. Renders et al.

Interventions to improve the management of diabetes in primary care, output, and community settings

Diab. Care

(2001)

J.J. Cimino et al.

Internet as clinical information system: Application development using the World Wide Web

J. Am. Med. Inform. Assoc.

(1995)

R. Peters et al.

The cardiology beat: an Internet education for patients and health professionals

J. Am. Med. Assoc.

(1997)

Cited by (48)

Cardiovascular diseases and risk factors knowledge and awareness in people with type 2 diabetes mellitus: a global evaluation
2020, Diabetes Research and Clinical Practice
Cardiovascular diseases (CVD) are the leading cause of death in people living with type 2 diabetes mellitus (T2D). The aim of this study was to explore the knowledge and awareness of CVD and related risk factors in people living with T2D, globally.
A questionnaire consisting of 17 questions was used to conduct the Taking Diabetes to Heart survey, between September 2017 and May 2018 among people living with T2D. All categorical variables are presented as numbers and percentages. Pearson’s chi-square test and Fisher’s exact test were used to assess the association between categorical variables.
A total of 12,695 respondents living with T2D in 133 countries completed the questionnaire. Almost half of the respondents (44%) reported having lived with diabetes for more than nine years. Only one in six (17%) considered themselves at high risk of CVD, which was surprising given that almost all the respondents had at least one CVD risk factor and around 28% of respondents had experienced one or more CVD events in the past. Although the majority of the respondents indicated they have had CVD risk factors, one in six (17%) had never discussed their risk with a health professional (HP). Furthermore, one in eleven (9%) did not know about CVD and its associated risk factors.
To mitigate the prevalence of CVD in people living with diabetes, it is required to work with HP to increase knowledge and awareness of people with T2D about diabetes complications, in particular CVD.
A randomized controlled trial of a web-based education intervention for women with gestational diabetes mellitus
2019, Midwifery
Citation Excerpt :
Each of these risks are increased by poorly managed GDM and obesity (Ferrara and Ehrlich, 2011; Rooney and Schauberger, 2002). To date, there have been many studies investigating the utility of web-based interventions to treat type 2 diabetes (Boels et al., 2017; Hansel et al., 2017; Kim and Kang, 2006; Lee et al., 2007) or to prevent the development of type 2 diabetes among women who have recently had GDM (Gadgil et al., 2017; Kim et al., 2012; Pedersen et al., 2017; Tawfik, 2017). Approaches generally include increased physical activity and weight management (Kim et al., 2012; Kim and Kang, 2006; Lee et al., 2007).
This study aimed to investigate changes in maternal body mass index (BMI), blood pressure and glycemic level and infant birthweight using an online educational program compared to standard clinic-based GDM education.
A preliminary randomized controlled trial of the online intervention was conducted in Melbourne, Australia between 2014 and 2015. A total of 110 women were randomized to (1) the control group and received standard clinic-based GDM education; or (2) the intervention group and received standard care plus the web-based education program. Data were collected at two time points: baseline and 12 weeks postpartum. Infant birthweight was also recorded. Chi-squared test, independent t-test and paired t-test were used to compare outcomes.
Pregnant women with newly diagnosed GDM, in the Western region of Melbourne, Australia.
Statistically significant differences were reported between intervention and control groups in maternal weight and glycemia post-intervention (p < 0.05). More women in the intervention group than in the control group reported weight loss post-intervention (90.4% vs 48.3%, p < 0.001), and were considered a healthy weight (BMI = 18.5, 24.9kg/m²) at 12 weeks postpartum (44.2% vs 31%). More women in the intervention group had attended for follow up OGTT at 12 weeks postpartum (96.2% vs 70.7%, p < 0.001). Comparing measures pre- and post-intervention in the intervention group, maternal BMI was lower [(28.60 ± 7.93) vs (29.60 ± 8.32); p = 0.000], maternal systolic blood pressure was increased but within normal range [(108.19 ± 11.80) vs (107.29 ± 12.13); p = 0.001], and maternal glycemic level returned to within normal limits [(4.86 ± 0.42) vs (8.80 ± 2.50); p = 0.026]. Most women in both groups gave birth to normal birthweight infants (92.3% and 94.8%). These findings are offset by differences in the groups at baseline.
Findings suggest that the education intervention had a positive impact on women’s postpartum weight and attendance at OGTT by 12 weeks postpartum. No effect was found on maternal blood pressure or infant birthweight. Further studies with matched intervention and control groups are needed to achieve more definitive conclusions.
The diabetes self-management educational programs and their integration in the usual care: A systematic literature review
2018, Health Policy
Citation Excerpt :
Table 3 describes the levels of integration between usual care and SME programs based on the role of the provider of usual care into the educational programs. In details, providers defined or confirmed patients’ targets [45,48,81,82], changed drugs prescriptions or diet [54,60,61,80,85,86], gave advice or preliminary contents [65,83] (high integration); followed the upgrades of patients through periodical reports produced by programs’ leaders [49,51,67,70,76,78], were available on the web for a consultation [55], was involved in preparing the program’s materials [58] (medium integration). In other studies, health professionals provided those delivering the educational programs with patients’ data [52,64,74,75,90] or referred patients to be enrolled in the program [46,50,56,57,59,66,68,69,71,73–75,78,79,84,87–89] (low level of integration).
The increasing prevalence of type 2 diabetes has highlighted the importance of evidence-based guidelines for effective prevention, management and treatment. Diabetes self-management education (SME) produces positive effects on patient behaviours and health status. We analyzed the literature to identify (i) the level of integration between usual care and SME programs and (ii) any possible differences across them in terms of outcomes.
Searches were made on three databases – PubMed, Scopus and Web of Science - to identify relevant publications on diabetes SME to 2015, which also describe the provider of usual care. In total, 49 studies met the inclusion criteria. We identified three levels of integration (high, medium and low) between usual care and SME programs based on the level of involvement of usual care professionals within the SME programs. In most cases, the primary care physician was responsible for the diabetes patients. Patient health behaviors and/or outcomes improve in most of the studies, independently from the level of integration. However, findings suggest that when patients/participants could perceive that usual care provider is highly involved in SME delivery, educational programs produced results that appear to be more positive.
The efficacy of telehealth delivered educational approaches for patients with chronic diseases: A systematic review
2018, Patient Education and Counseling
Citation Excerpt :
Heinrich et al. presented information primarily in spoken language, supported by headlines, images, videos, and real patient experiences on different topics [27]. Web-site usage was monitored in several studies [8,27,29,30,34] but there was limited reporting of the use of functionalities and self-management tools. Heinrich et al. [27] reported low use of functionalities, such as searching (41%) or examining additional information (60%).
The virtual delivery of patient education and other forms of telehealth have been proposed as alternatives to providing needed care for patients with chronic diseases. The purpose of this systematic review was to compare the efficacy of virtual education delivery on patient outcomes compared with usual care.
The review examined citations from 3 databases, MEDLINE, CINAHL, and EMBASE using the search words telehealth, chronic disease, patient education, and related concepts. From 2447 records published between 2006 and 2017, 16 high to moderate quality studies were selected for review. Eligible papers compared virtual education to usual care using designs allowing for assessment of causality.
Telehealth modalities included the web, telephone, videoconference, and television delivered to patients with diabetes, chronic obstructive pulmonary disease, irritable bowel syndrome and heart failure. In 11 of 16 studies, virtually delivered interventions significantly improved outcomes compared to control conditions. In the remaining 5 studies, virtual education showed comparable outcomes to the control conditions.
Findings demonstrated that virtual education delivered to patients with chronic diseases was comparable, or more effective, than usual care.
Despite its benefits, there is potential for further research into the individual components which improve effectiveness of virtually delivered interventions
Diabetes knowledge among Greek Type 2 Diabetes Mellitus patients
2016, Endocrinologia y Nutricion
Diabetes knowledge has been shown to improve glycemic control and associate with several demographic parameters. In Greece, a country with high obesity rates, disease knowledge has never been evaluated in diabetic patients. This cross sectional study aimed to assess diabetes knowledge and its associations between social and demographic parameters, among Greek type 2 diabetes mellitus (T2DM) patients.
One hundred fifty nine patients with T2DM were recruited from an urban and a rural clinic in Greece. Diabetes knowledge was assessed with the Brief Diabetes Knowledge Test (DKT). Basic anthropometry was performed. Data regarding glycemic control and sociodemographic characteristics were collected from the patients’ medical files.
Greek T2DM patients demonstrated poor disease knowledge (mean DKT score 8.3 ± 2.2/14.0 and mean DKT as a percent of correct answers 59.6 ± 15.8%). No differences were observed between sex, place of residence, or glycemic control, among subjects. Patients with higher education demonstrated greater diabetes knowledge. Simple obesity with concurrent central obesity or suboptimal glycemic control decreased diabetes knowledge among participants. Additionally, waist circumference was inversely correlated to diabetes knowledge.
Based on the DKT, Greek patients exhibit poor diabetes knowledge. This study provides evidence for the need for better diabetes education in order to ameliorate disease outcome.
Se ha demostrado que el conocimiento de la diabetes mejora el control de la glucemia y se asocia con varias características demográficas. En Grecia, un país con tasas de obesidad elevadas, no se ha evaluado nunca el conocimiento de la diabetes de quienes la sufren. El objetivo de este estudio transversal es valorar el conocimiento de la diabetes y su asociación con parámetros sociales y demográficos en los pacientes griegos con diabetes mellitus tipo 2 (DMT2).
Se reclutaron a 159 pacientes con diabetes mellitus tipo 2 (DMT2) de una consulta urbana y otra rural de Grecia. El conocimiento de la diabetes se valoró mediante el Brief Diabetes Knowledge Test (DKT). Se recogieron datos antropométricos básicos. Los datos sobre el control de la glucemia y las características sociodemográficas se recogieron de los historiales médicos de los pacientes.
Los pacientes griegos con DMT2 mostraron un conocimiento deficiente de la enfermedad (puntuación DKT media de 8,3 ± 2,2/14,0 y DKT media como porcentaje de respuestas correctas 59,6 ± 15,8%). No se observaron diferencias entre los sujetos en función del sexo, del lugar de residencia ni del control de la glucemia. Los pacientes con mayor grado de educación mostraron mayor conocimiento de la diabetes. La obesidad simple con obesidad central o control subóptimo de la glucemia concurrente coincidía con un menor conocimiento de la diabetes por los participantes. Además, había una relación inversa entre el perímetro de la cintura y el conocimiento de la diabetes.
Basándose en el DKT, los pacientes griegos tienen un conocimiento deficiente de la diabetes. Este estudio demuestra la necesidad de una mejor educación sobre la diabetes para mejorar la evolución de la enfermedad.
Diabetes education for Chinese adults with type 2 diabetes: A systematic review and meta-analysis of the effect on glycemic control
2016, Diabetes Research and Clinical Practice
The purpose of this study is to systematically review evidence in English and Chinese publications to determine the size of glycemic effect of different diabetes education approaches for Chinese patients.
CINAHL Plus, Embase, Ovid Medline, Scopus and the China National Knowledge Infrastructure database were searched. Studies were included if they were randomised controlled trials with a detailed description of education approach, with more than 50 Chinese-adult participants, reporting actual glycemic outcome and with at least 3-month follow-up. Data was systematically extracted and cross-checked by the authors. Methodological quality was assessed.
Fifty-three studies, including five English and 48 Chinese publications, were included. The overall weighted mean difference (WMD) in glycated haemoglobin (HbA1c) was −1.19% (−13 mmol/mol). Ongoing regular education was most-commonly employed, with a reported WMD of −2.02% (−22 mmol/mol). Glycemic control was further enhanced in studies using information reinforcement strategies.
Diabetes education in any format generates glycemic improvement for Chinese patients, but is particularly effective when an ongoing regular education is employed. Innovative strategies aligned with cultural concepts, such as employing patient examination to reinforce diabetes management knowledge and/or involving family in patient care deserve further trial to determine whether they enhance glycemic control in this group.

View all citing articles on Scopus

View full text

Development and evaluation of a patient-oriented education system for diabetes management

Abstract

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

System description

Study design

The characteristics of participants

Discussion

Conclusion

Acknowledgments

Int. J. Med. Inform.

Patient Educ. Counsel.

Int. J. Med. Inform.

Prev. Med.

The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin-dependent diabetes mellitus

N. Engl. J. Med.

Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)

Lancet

Diabetes care and patient-oriented outcomes

J. Am. Med. Assoc.

Standards of medical care for patients with diabetes mellitus

Diab. Care

An outpatient model of integrated diabetes treatment and education: functional, metabolic, and knowledge outcomes

Diab. Educ.

Diabetes self-management education

Diab. Care

Improvement in diabetic care as measured by HbA1C after a physician education project

Diab. Care

Diabetes self-care knowledge among outpatients at a Veterans Affairs medical center

Am. J. Health Syst. Pharm.

Readiness to change and clinical success in a diabetes educational program

J. Am. Board Fam. Pract.

Improving quality of life in diabetes education: how effective is education

Patient Educ. Counsel.

Evaluation of a structured teaching and treatment programme for type 2 diabetes in general practice in a rural area of Austria

Diab. Med.

Interventions to improve the management of diabetes in primary care, output, and community settings

Diab. Care

Internet as clinical information system: Application development using the World Wide Web

J. Am. Med. Inform. Assoc.

The cardiology beat: an Internet education for patients and health professionals

J. Am. Med. Assoc.