Enhancing Self Management of T 2 DM with

Enhancing Self. Management of T 2 DM with In-Home Technology Edith Burns, MD Medical College of Wisconsin Milwaukee, WI

T 2 DM 92% of all diabetes 10% of adults 20% of adults > 65 years of age High cost Treatment, management Complications

Optimum management requires patients to take volitional control of a process that is automatic in healthy individuals Self-regulation/Control processes take place in “real world” settings- day-to-day life at home, work

Common-sense Models of Illness Life 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)

• T 2 DM 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 Design Test an automated reminder and feedback system (ASMM) Randomized, prospective, “usual care” control System provides reminders AND feedback Non-vets T 2 DM VA T 2 DM Usual Care Intervention ASMM 50 50 Total of 200 participants Four 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 Properties Home-based Small footprint Limited components Installation Ease of use Simple docking system “Hidden” technology Ability to individualize Reminders PCP & participant-determined schedule Patient “controls” the technology

Qualities Desired in the Assisted-Self. Management Monitor (ASMM), continued Feedback 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

Monitor Blood Sugar Readings: Objective Measures NO Symptoms Answer Can do what Need & want To do Ask Myself How do I feel? Dr. Says Test Shows HIGH Blood Sugar Act Plans Take meds, exercise! Okay No Symptoms I don’t know my blood sugar level – I can’t feel it If high: Take medication, exercise, etc. Should I take meds, diet to control diabetes if I feel Okay? NO It’s time to test my blood sugar Proper timing and consideration is necessary for this to work- DO THE NUMBERS MAKE SENSE? !! Monitor & Appraise blood sugar readings Act Plan Use the glucometer & computer

Light-blue boxes = computer logic Green boxes = patient input Individualized in logic: 1) scheduled glucose reading times, 2) goals for scheduled time for trend summary Trend summary begins after 10 readings SD based on 25 readings

System Demonstration

Co-Investigators & Research Team Jeffrey Whittle, MD Paul Knudson, MD Sergei Tarima, Ph. D Bambi Wessel, MS Alexis Dye, MA Stephen Flax, Ph. D 1 Joan Pleuss, CDE, RD Colin Strub, BS Kristin Wiescorek, BS Howard Leventhal, Ph. D 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 Hb. A 1 c and showed greater improvement over time Improvement in Hb. A 1 c 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