Effect of Incorporating Computerized Insulin Dose Adjustment Algorithms into a Remote Patient Monitoring Program on HbA1c Levels in Patients with Type 2 Diabetes
Main Article Content
Abstract
Aims: To evaluate the effect of Federal Drug Administration-cleared computerized insulin dose adjustment algorithms (CIDAAs) incorporated into a Remote Patient Monitoring (RPM) program on HbA1c levels.
Material & Methods: Type 2 patients receiving insulin for >6 months with HbA1c levels ≥8.0% enrolled in a Medicare Advantage plan were recruited into 3 arms; Group A (RPM plus CIDAAs, N=40), Group B (RPM but no CIDAAs, N=42), and Group C (usual care with no RPM or CIDAAs, N=33). In Groups A and B, glucose readings of >200 mg/dL and <70 mg/dL triggered alerts and health educators contacted patients for counseling to avoid future episodes.
Results: Baseline HbA1c levels (% ± SD) were not statistically different among Groups A (9.5 ± 1.5), B (9.2 ± 1.1) and C (9.0 ± 0.9). At 6 months, HbA1c levels fell twice as much in Group A (-1.5 ± 1.0) as in Groups B (-0.7 ±1.5) and C (-0.7 ± 1.2) (P <0.001). Alerts >200 mg/dl were significantly less in Group A (N=942) than in B (N=1111) (P = 0.002) but alerts <70 mg/dL were not significantly different (235 vs 209). In Group A, baseline per patient daily insulin doses of 78 units rose 40% to 109 units. Six patients in Group C had emergency room visits for hypoglycemia but none in Groups A and B.
Conclusions: The RPM program lessened clinical hypoglycemic risk but required CIDAAs to markedly increase insulin doses effectively and safely to significantly lower HbA1c levels twice as much as either RPM alone or usual care.
Keywords:
Computerized Insulin Dose Adjustment Algorithms, Remote Patient Monitoring, Remote Glucose Monitoring, Insulin Therapy
Article Details
How to Cite
PULICHARAM, Juvairiya et al.
Effect of Incorporating Computerized Insulin Dose Adjustment Algorithms into a Remote Patient Monitoring Program on HbA1c Levels in Patients with Type 2 Diabetes.
Medical Research Archives, [S.l.], v. 10, n. 12, dec. 2022.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/3396>. Date accessed: 27 dec. 2024.
doi: https://doi.org/10.18103/mra.v10i12.3396.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Centers for Disease Control and Prevention. National Diabetes Statistics Report website. https://www.cdc.gov/diabetes/data/statistics-report/index.html. (Accesssed November 23, 2022).
2. American Diabetes Association. Retinopathy, neuropathy, and foot care: Standards of Medical Care Diabetes -2022. Diabetes Care 2022;45:S185-194.
3. American Diabetes Association. Chronic kidney disease and risk management: Standards of Medical Care Diabetes -2022. Diabetes Care 2022;45:S175-184.
4. Nathan DM, Genuth S, LachinJ, et al. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med 1993;329:977-986.
5. Krolewski AS, Laffel LMB, Krolewski M, et al. Glycosylated hemoglobin and the risk of microalbuminuria in-patients with insulin-dependent diabetes mellitus. N Engl J Med 1995;332:1251-1255.
6. Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study, Diab Res Clin Pract 1995;28:103-117.
7. UK Prospective Diabetes Study (UKPDS) Group. 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;352:837-853.
8. Tanaka Y, Atsumi Y, Matsuoka K, et al. Role of glycemic control and blood pressure in the development and progression of nephropathy in elderly Japanese NIDDM patients. Diabetes Care 1998;21:116-120.
9. Wang L, Li X, Wang Z, et al. Trends in prevalence of diabetes and control of risk factors in diabetes among US Adults, 1999-2018. JAMA 2021;326:704-716.
10. Davidson JA. The increasing role of primary physicians in caring for patients with type 2 diabetes mellitus. Mayo Clin Proc 2010;85(Suppl 12) S3-S4.
11. Selvin E, Parrinello CM, Daya N, Bergenstal RM. Trends in insulin use and diabetes control in the U.S.: 1988-1994 and 1999-2012. Diabetes Care 2016;39:e33-e35.
12. Calvert MJ, McManis RJ, Freemantle N. Management of type 2 diabetes with multiple oral hyperglycaemic agents or insulin in primary care retrospective cohort study. Br J Gen Pract 2007;57:455-460.
13. Khunti K, Wolden MI, Thorsted BL, Andersen M, Davies MJ. Clinical inertia in people with type 2 diabetes: a retrospective cohort study of more than 80,000 people. Diabetes Care 2013;36:3411-3417.
14. Harris SB, Kapor J, Lank CN, et al. Clinical inertia in patients with T2DM requiring insulin in family practice. Can Fam Physician 2010;6:e418-e424.
15. Home P, Naggar NE, Khamseh M, et al. An observational non-interventional study of people with diabetes beginning or changed to insulin analogue therapy in non-Western countries: the A1chieve study. Diabetes Res Clin Pract 2011;94:352-363.
16. Mata-Cases M, Franch-Nadal J, Real J, et al. Therapeutic inertia in patients treated with two or more antidiabetics in primary care: factors predicting intensification of treatment. Diabetes Obes Metab 2018;20:103-112.
17. Jeavons D, Hungin APS, Cornford CS. Patients with poorly controlled diabetes in primary care: healthcare clinicians’ beliefs and attitudes. Postgrad Med J 2006;82:347-350.
18. Meece J. Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ 2006;32:1342-1349.
19. Cuddihy RM, Philis-Tsimikas A, Nazeri A. Type 2 diabetes care and insulin intensification: is a more multidisciplinary approach needed? Results from the MODIFY Survey. Diabetes Educ 2011;37:111-123.
20. Patrick AR, Fischer MA, Choudry NK, et al. Trends in insulin initiation and treatment intensification among patients with type 2 diabetes. J Gen Intern Med 2013;29:320-327.
21. Khunti K, Nikolajsen A, Thorsted BL, et al. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes Obes Metab 2016;18:401-409.
22. Ascher-Svanum H, Lage M, Perez-Nieves M, et al. Early discontinuation and restart of insulin in the treatment of type 2 diabetes mellitus. Diabetes Ther 2014;5:225-242.
23. Bonafede M, Chandran A, DiMano S, et al. Medication usage, treatment intensification, and medical cost in patients with type 2 diabetes: a retrospective database study. BMJ Open Diabetes Research and Care 2016:4e000189. doi:10.1136/bmjdrc-2015-00189
24. Ziemer DC, Miller CD, Rhee MK, et al. Clinical inertia contributes to poor diabetes control in a primary care setting. Diabetes Educ 2005;31:564-571.
25. Chen Y, Abbott S, Nguyen M, et al. Glycemic control of insulin treated patients across the U.S.: epidemiologic analysis of a commercially insured population. Diabetes 2013;62(Suppl 1):A704.
26. Davidson MB, Davidson, SJ. Effect of remote glucose monitoring utilizing computerized insulin dose adjustment algorithms: a pilot project. Diabetes Ther 2019;10:523-533.
27. Davidson MB, Davidson SJ. Effective use of computerized insulin dose adjustment algorithms on continuous glucose monitoring results by a clinical pharmacist – proof of concept. J Diabetes 2021;13:439-441.
28. Amante DJ, Harlan DM, Lemon SC, et al. Evaluation of a diabetes remote monitoring program facilitated by connected glucose meters for patients with poorly controlled type 2 diabetes: randomized crossover trial. JMIR Diabetes 2021;6:e25574.
29. Bell KJ, Toschi E, Steil GM, Wolpert HA. Optimized mealtime insulin dosing for fat and protein in type 1 diabetes: application of a model-based approach to derive insulin doses for open-loop diabetes management. Diabetes Care 2016;39:1631-1634.
30. Paterson MA, Smart CEM, Lopez PE, et al. Increasing the protein quality in a meal results in dose-dependent effects on postmenopausal glucose levels in individuals with type 1 diabetes mellitus. Diabet Med 2017;34:851-854.
31. Evans M, Smart CEM, Paramalingam N, et al. Dietary protein affects both the dose and pattern of insulin delivery required to achieve postprandial euglycemia in thupe1 diabetes: a randomized trial. Diabet Med 2019;36:499-504.
32. Wylie-Rosett J, Hu F. Nutritional strategies for prevention and management of diabetes: consensus and uncertainties. Diabetes Care 2019;42:727-730.
33. Bashan E, Herman WH, Hodish I. Are glucose readings sufficient to adjust insulin dosage? Diabetes Tech Therap 2011;13:85-92.
34. Stone RA, Rao RH, Sevick MA, et al. Active care management supported by home telemonitoring in veterans with type 2 diabetes: the DiaTel randomized controlled trial. Diabetes Care 2010;33:4780484.
35. Tildesley HD, Mazanderani AB, Ross SA. Effect of internet therapeutic intervention on A1C levels in patients with type 2 diabetes treated with insulin. Diabetes Care 2010;33:1738-1740.
36. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-largest-specialties-2019 (Accessed November 23, 2022).
2. American Diabetes Association. Retinopathy, neuropathy, and foot care: Standards of Medical Care Diabetes -2022. Diabetes Care 2022;45:S185-194.
3. American Diabetes Association. Chronic kidney disease and risk management: Standards of Medical Care Diabetes -2022. Diabetes Care 2022;45:S175-184.
4. Nathan DM, Genuth S, LachinJ, et al. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med 1993;329:977-986.
5. Krolewski AS, Laffel LMB, Krolewski M, et al. Glycosylated hemoglobin and the risk of microalbuminuria in-patients with insulin-dependent diabetes mellitus. N Engl J Med 1995;332:1251-1255.
6. Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study, Diab Res Clin Pract 1995;28:103-117.
7. UK Prospective Diabetes Study (UKPDS) Group. 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;352:837-853.
8. Tanaka Y, Atsumi Y, Matsuoka K, et al. Role of glycemic control and blood pressure in the development and progression of nephropathy in elderly Japanese NIDDM patients. Diabetes Care 1998;21:116-120.
9. Wang L, Li X, Wang Z, et al. Trends in prevalence of diabetes and control of risk factors in diabetes among US Adults, 1999-2018. JAMA 2021;326:704-716.
10. Davidson JA. The increasing role of primary physicians in caring for patients with type 2 diabetes mellitus. Mayo Clin Proc 2010;85(Suppl 12) S3-S4.
11. Selvin E, Parrinello CM, Daya N, Bergenstal RM. Trends in insulin use and diabetes control in the U.S.: 1988-1994 and 1999-2012. Diabetes Care 2016;39:e33-e35.
12. Calvert MJ, McManis RJ, Freemantle N. Management of type 2 diabetes with multiple oral hyperglycaemic agents or insulin in primary care retrospective cohort study. Br J Gen Pract 2007;57:455-460.
13. Khunti K, Wolden MI, Thorsted BL, Andersen M, Davies MJ. Clinical inertia in people with type 2 diabetes: a retrospective cohort study of more than 80,000 people. Diabetes Care 2013;36:3411-3417.
14. Harris SB, Kapor J, Lank CN, et al. Clinical inertia in patients with T2DM requiring insulin in family practice. Can Fam Physician 2010;6:e418-e424.
15. Home P, Naggar NE, Khamseh M, et al. An observational non-interventional study of people with diabetes beginning or changed to insulin analogue therapy in non-Western countries: the A1chieve study. Diabetes Res Clin Pract 2011;94:352-363.
16. Mata-Cases M, Franch-Nadal J, Real J, et al. Therapeutic inertia in patients treated with two or more antidiabetics in primary care: factors predicting intensification of treatment. Diabetes Obes Metab 2018;20:103-112.
17. Jeavons D, Hungin APS, Cornford CS. Patients with poorly controlled diabetes in primary care: healthcare clinicians’ beliefs and attitudes. Postgrad Med J 2006;82:347-350.
18. Meece J. Dispelling myths and removing barriers about insulin in type 2 diabetes. Diabetes Educ 2006;32:1342-1349.
19. Cuddihy RM, Philis-Tsimikas A, Nazeri A. Type 2 diabetes care and insulin intensification: is a more multidisciplinary approach needed? Results from the MODIFY Survey. Diabetes Educ 2011;37:111-123.
20. Patrick AR, Fischer MA, Choudry NK, et al. Trends in insulin initiation and treatment intensification among patients with type 2 diabetes. J Gen Intern Med 2013;29:320-327.
21. Khunti K, Nikolajsen A, Thorsted BL, et al. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes Obes Metab 2016;18:401-409.
22. Ascher-Svanum H, Lage M, Perez-Nieves M, et al. Early discontinuation and restart of insulin in the treatment of type 2 diabetes mellitus. Diabetes Ther 2014;5:225-242.
23. Bonafede M, Chandran A, DiMano S, et al. Medication usage, treatment intensification, and medical cost in patients with type 2 diabetes: a retrospective database study. BMJ Open Diabetes Research and Care 2016:4e000189. doi:10.1136/bmjdrc-2015-00189
24. Ziemer DC, Miller CD, Rhee MK, et al. Clinical inertia contributes to poor diabetes control in a primary care setting. Diabetes Educ 2005;31:564-571.
25. Chen Y, Abbott S, Nguyen M, et al. Glycemic control of insulin treated patients across the U.S.: epidemiologic analysis of a commercially insured population. Diabetes 2013;62(Suppl 1):A704.
26. Davidson MB, Davidson, SJ. Effect of remote glucose monitoring utilizing computerized insulin dose adjustment algorithms: a pilot project. Diabetes Ther 2019;10:523-533.
27. Davidson MB, Davidson SJ. Effective use of computerized insulin dose adjustment algorithms on continuous glucose monitoring results by a clinical pharmacist – proof of concept. J Diabetes 2021;13:439-441.
28. Amante DJ, Harlan DM, Lemon SC, et al. Evaluation of a diabetes remote monitoring program facilitated by connected glucose meters for patients with poorly controlled type 2 diabetes: randomized crossover trial. JMIR Diabetes 2021;6:e25574.
29. Bell KJ, Toschi E, Steil GM, Wolpert HA. Optimized mealtime insulin dosing for fat and protein in type 1 diabetes: application of a model-based approach to derive insulin doses for open-loop diabetes management. Diabetes Care 2016;39:1631-1634.
30. Paterson MA, Smart CEM, Lopez PE, et al. Increasing the protein quality in a meal results in dose-dependent effects on postmenopausal glucose levels in individuals with type 1 diabetes mellitus. Diabet Med 2017;34:851-854.
31. Evans M, Smart CEM, Paramalingam N, et al. Dietary protein affects both the dose and pattern of insulin delivery required to achieve postprandial euglycemia in thupe1 diabetes: a randomized trial. Diabet Med 2019;36:499-504.
32. Wylie-Rosett J, Hu F. Nutritional strategies for prevention and management of diabetes: consensus and uncertainties. Diabetes Care 2019;42:727-730.
33. Bashan E, Herman WH, Hodish I. Are glucose readings sufficient to adjust insulin dosage? Diabetes Tech Therap 2011;13:85-92.
34. Stone RA, Rao RH, Sevick MA, et al. Active care management supported by home telemonitoring in veterans with type 2 diabetes: the DiaTel randomized controlled trial. Diabetes Care 2010;33:4780484.
35. Tildesley HD, Mazanderani AB, Ross SA. Effect of internet therapeutic intervention on A1C levels in patients with type 2 diabetes treated with insulin. Diabetes Care 2010;33:1738-1740.
36. https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-largest-specialties-2019 (Accessed November 23, 2022).