More than 29 million US adults have diabetes and 95 percent of them have Type 2. In this large group are patients with diabetes who do not come into the office regularly. They own equipment to test their blood glucose levels at home, but they don't. They own cell phones which offer many Diabetes apps but are not using them. A return visit is scheduled, but not kept. They find living with diabetes as difficult and too much to add to their complicated life. They may not have the resources or aptitude to reach out to others for support and they feel isolated and discouraged. Dealing with diabetes every day is difficult and time consuming and often causes "burnout". Patients stop taking blood glucose tests, stop medication and stop seeing their provider. This patient population is at high risk for complications of diabetes.
This population would benefit from the A1c Memory Meter. It is a device that reminds patients to check their glycosylated hemoglobin A1c from home every 3 months. It is a simple rubber sleeve that can be put around a pill bottle or insulin box which contains diabetes medication. It has an electronic timer that will give a tone every 3 months reminding the patient to check a blood test on the A1c Memory Meter. The patient completes the test and sends it to the provider electronically. Once the result is received a letter, or text or call goes back to the patient to discuss a treatment plan. The communication could be done by the provider or nurse. The result would allow the staff to do targeted outreach to this patient in an effort to increase engagement and change behavior. It will allow the patient to develop trust and use the support offered to make improvements in their lifestyle. This feedback loop could increase self care, improve blood glucose control and may reduce the rate of complications.
This system may seem below standard because it does not utilize our current technology which includes continuous glucose monitoring (CGM) or home blood glucose testing. It also does not replace the recommended visits a patient with diabetes should make to their medical team to promote good health. It is geared for the patients who are not doing blood glucose tests at home for multiple reasons. Lack of blood glucose testing combined with poor adherence to medications leads to chronic uncontrolled diabetes. A system to help keep these patients feel connected to their provider might make avoidance behavior shorter and improve patients' health today and for the future.
This proposal is relevant to the Triple Aim because it could be easily integrated into clinical workflow at a primary care office. It is practical because there is already a meter able to check a HgA1c at home. There is also technology to share home testing with providers and the two could be combined. It could be piloted in an office setting and scaled up to be used by Medicaid, Medicare and insurance companies who all want patients to maintain their HgA1c < 7. The current cost of the take home kit is about $40 for 5 strips/year. Regular monitoring with a feedback loop for communication could save at least one patient from a hospitalization due to uncontrolled diabetes. This could pay for about 5,000 take home kits making it affordable to stakeholders and available to most patients who need it.
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