Diabetes Decision Support Technology Making a Difference

sanofi diabetes titrartion app

Decision Support Technology Making a Difference

Would you believe it if I told you that there is a program that can decrease mean HbA1c by 1.9% over 12 months from a baseline HbA1c of 9.4%? Well it’s true and the exciting news is that it utilises technology to do this. Most interestingly, the study was done in 2011, yet sadly it has taken some time to adopt these learning’s and translate them into ‘usual’ care.

Published in Diabetes Care, Quinn and associates from the University of Maryland in Baltimore, published these exciting results[1]. The cluster-randomized controlled trial (RCT) included 163 patients across 26 primary care practices assigned to treatment or control groups (usual care) for one year. Maximal treatment was a mobile and web based self-management patient coaching system, which included provider decision support software. Patients received automated, real-time educational and behavioural messaging in response to individually analysed blood glucose values, diabetes medications, and lifestyle behaviours that was communicated by mobile phone. Those in the maximal treatment arm also had their care providers receive quarterly reports summarising their glycaemic control, diabetes medication management, lifestyle behaviours and evidence-based treatment options and treatment suggestions that were provided through the WellDoc Clinical Decision Support software.

A primary outcome to the success of this program was that these physicians nearly doubled the number of medication changes they made for their patients versus those who provided usual care alone. This one year RCT found that the virtual patient coach portion of the WellDoc solution reduced HbA1c on average by 1.5 % and that when physicians utilised the clinical decision support the A1c was further reduced by approximately 30 percent, or a total of 1.9%. These results were significant in comparison to the 0.7 percent A1c reduction in the control group.

Dr. Quinn stated that “The WellDoc intervention provided a patient-centric care solution that impacted medication therapy management at the provider level, while simultaneously supporting other key aspects of diabetes self-management, such as glucose testing, diet, and exercise.”

This study provides clear evidence that decision support tools are highly valuable in the management of, not only diabetes, but potentially many other chronic conditions. The WellDoc team have gone on to develop another decision support tool for the management of diabetes that is provided on script in the US. This new version, called BlueStar, is an automated expert analytics system that provides real-time motivational, behavioural and educational coaching. In addition, it offers “smart” blood glucose testing, healthy diet and exercise recommendations, medication adherence tools, and information about compliance with quality standards of care for diabetes such as A1c tests, foot exams, and blood pressure and lipid levels.

Although we don’t have WellDoc or BlueStar available in Australia, we do have various decision support tools. Some insulin pumps, blood glucose meters and now some apps offer a level of decision support. As noted in the WellDoc study, treatment to target decision support tools can lead to tangible improvements in patient outcomes.

In review this article we look at an app that provides insulin decision support to health care professionals (HCP’s).

Assisting patients to adjust their own insulin doses can be time consuming, yet the rewards can be great. Self titration can lead to patient empowerment and improved glucose control as a result of timely adjustments and responses to not only trends over time, but the daily variations in readings. However to acquire the level of knowledge and understanding to do this safely and effectively, can be resource intensive, but there is help. Credentialled Diabetes Educators (CDE’S) often play a crucial role in supporting people with diabetes to achieve the required skills, but now there is another resource for all HCP’s toolbox to assist the person with diabetes.

The Sanofi Diabetes Titration App for Smartphones is available for free through the iTunes App Store and Google play. The app requires a code to be entered by the health care professional which is provided by Sanofi representatives.

The app guides the user through:

 Dose optimisation – these guides assist the HCP with starting a person with type 2 diabetes (T2D) on Lantus, starting or optimising Apidra administration for a person with T2D  or the use of premix Lantus that guides the clinician through assisting someone switching from once or twice daily 70/30 premix to Lantus. It is important to note that all the titration charts are for guidance of people with T2D only.

Injection technique – this video guides the patient through appropriate areas and techniques for injection of insulin. This is only available in English

Insulin Pen patient guides – these are step by step guides on how to use the ClikSTAR device for injection of Lantus or Apidra. The guides come in 6 languages and include Arabic, Greek, Italian, Vietnamese and Chinese.

Product information is also available, including PBS information for both Lantus and Apidra.

We have seen other similar apps on the market in Australia designed specifically for the person with diabetes. However Government regulation complexities have viewed these apps as being “devices”, similar to a blood glucose meter, and hence require rigorous testing and surrounded by legal red tape, making these unappealing for companies to offer their consumers. We hope to see the red tape change in the future.

There is growing evidence that technology, and specifically decision support tools, play a valuable role in improving the outcomes in many chronic diseases including diabetes. As health care providers, we should embrace these tools as they offer the opportunity to significantly enhance the clinical contribution we can make to our patients lives.

1 Quinn, C et al, Cluster-Randomized Trial of a Mobile Phone Personalized Behavioral Intervention for Blood Glucose Control Diabetes Care September 2011 34:9 1934-1942;

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