Edith Burns, MD

Medical College of Wisconsin

Milwaukee, WI

T2DM92% of all diabetes10% of adults

20% of adults > 65 years of age

High costTreatment, managementComplications

Optimum management requires patients to take volitional control of a process that is automatic in healthy individualsSelf-regulation/Control processes take place in

“real world” settings- day-to-day life at home, work

Common-sense Models of IllnessLife experience of acute illness teaches us to use symptoms as indicators of sickness-wellness

In most chronic illnesses, symptoms are unreliable as indicators of disease status

Better to utilize objective measures by performing self-monitoring (e.g., SMBG, BP)

• T2DM is a “chaotic” disease

– Multiple factors contribute to acute fluctuations in blood glucose levels

– Individual SMBG measures at any given point in time may provide ambiguous feedback

• Can we teach patients to learn to use SMBG more effectively to become better self managers of a chaotic disease?

Study DesignTest an automated reminder and feedback system (ASMM)Randomized, prospective, “usual care” controlSystem provides reminders AND feedback

Usual Care Intervention

ASMM

Non-vets T2DM

50 50

VA T2DM 50 50

Total of 200 participantsFour in-home visits; intervention begins at visit 2 after 3 months. Exit interview at 15 months.

Qualities Desired in the Assisted-Self-Management Monitor (ASMM)

Physical PropertiesHome-based

Small footprint Limited components Installation

Ease of use Simple docking system “Hidden” technology

Ability to individualizeReminders

PCP & participant-determined schedule Patient “controls” the technology

Qualities Desired in the Assisted-Self-Management Monitor (ASMM), continuedFeedback

Timely – importance of what the results mean at the time Scheduled measures Unscheduled measures

Symptoms? Relationship to management behaviors (timing)

Diet Exercise

Overall control Trend data

Minimizes “catastrophizing” of single readings

NOSymptoms

Can do whatNeed & want To do

Dr. SaysTest ShowsHIGH Blood Sugar

Answer

Okay No Symptoms

Ask Myself How do I feel?

Should I takemeds, diet to control diabetesif I feel Okay?

Act PlanUse the glucometer& computer

Monitor & Appraiseblood sugar readings

If high: Take medication, exercise, etc.

ActPlansTake meds, exercise!

NO

It’s time to testmy blood sugar

Monitor Blood Sugar Readings: Objective Measures

I don’t know my blood sugar level – I can’t feel it

Proper timing and consideration is necessary for this to work- DO THE NUMBERS MAKE SENSE?!!

ASMM Algorithm(Draft 2/8/2008) Version 9

Attach meter to Computer, starting glucose download process.

Multiple meter readings?

Last Glucose<70 or >250?

Hypoglycemia Treatment

Treat hypoglycemia with

15 grams of carbohydrates

every 15 minutes until glucose is

over 90. <70

Hyperglycemia treatment

Your glucose is elevated. Call your health care team if you feel ill. Be sure

to take your medication, eat

wisely, and drink plenty of fluids.

>250

No

Scheduled Time?

Trend analysis Did you eat (time last glucose – 4 hours) ?

After Exercise?Did you eat (time last glucose – 2 hours)?

Improving Trend?-¼ s.d. of mean

Stable Trend?±¼ s.d. of mean

Worsening Trend?+¼ s.d. of mean

Trend SummaryGoal average 90-130Your trend shows: ...

Improving Trend1. At this rate you

will get to goal2. Your current

trend makes you healthier

At Goal1. Keep up the

good work2. All your effort is

keeping right where you need to

be.

Worsening Trend1. Might need

medication adjustment

2. Be sure to be consistent with

exercise3. Be sure

exercise is intense enough

4. If you have question about

ways to improve, contact your health

care team.5. Your current

trend will increase your risks of

complications.

Stable Trend above Goal1. Exercise Moderately

2. Watch you food portion size

3. Make healthy food choices

4. Eat breakfast5. Might need

medication adjustment

Yes No

NoYes

After Exercise1. Goal would be about 90-130 30

mins after exerciseA. Exercise can cause a rise in

your glucose right after exercise.

B. Exercise lowers your long-term glucose trends

C. Exercise improves your

fitnessD. Exercise lowers

your blood pressure

E. Exercise lowers your blood

cholesterol and triglycerides

F. Keep up the good work

Yes

Random Glucose1. Goal is 90-130 if 4 hours since last

food.A. Be sure to be

activeB. Exercise 30

mins, 5 days per week is a good

goalC. Moderate

exercise is an activity that

increases your heart rate up

D. Brisk walk is an example of

moderate exercise

No

Yes

Two hours after eating

1. Goal is 180 or less.

A. use number to adjust portion sizeB. use this number to assess dietary

choices.

Too Soon after Eating

1. Need to wait to soon to assess

glucose. 2. There is no goal established for this

time.

No

Yes

Last glucose < 1 hour ago?

Done for symptoms?Yes or No

Low symptoms?

No

Yes

No

Any Fasting readings?

Yes

Fasting Glucose readings are

important. Please do some.

No

Frequent probems?3 times in 7 days

Frequent ProblemsYou are having frequent

symptoms, consider calling your diabetes health care

team.

Yes

At goal?Yes

No

No

No

Yes

Yes

Yes

Light-blue boxes = computer logicGreen boxes = patient input

Individualized in logic: 1) scheduled glucose reading times, 2) goals for scheduled time for trend summary

Trend summary begins after 10 readingsSD based on 25 readings

System Demonstration

Co-Investigators & Research Team

Jeffrey Whittle, MDPaul Knudson, MDSergei Tarima, PhDBambi Wessel, MSAlexis Dye, MAStephen Flax, PhD

Joan Pleuss, CDE, RDColin Strub, BSKristin Wiescorek, BSHoward Leventhal,

PhD1

1 Center for Health & Behavior, Rutgers University and UMDNJ, New Brunswick, NJ

SUMMARY

Increasing frequency and consistency of SMBG led to improved glycemic control

Higher baseline depression scores had higher baseline HbA1c and showed greater improvement over time

Improvement in HbA1c was not correlated to baseline cognitive function

•Expanded study to rigorously test this system

–Illness cognition, change over time

–Reminder function

–Expanded feedback

•Trends in control

•Unscheduled measures

•Relating measures to diet and activity