John D. Piette

We evaluated the impact of automated telephone disease management (ATDM) calls with telephone nurse follow-up as a strategy for improving outcomes such as mental health, self-efficacy, satisfaction with care, and health-related quality of life (HRQL) among low-income patients with diabetes mellitus. This was a randomized, controlled trial. Two hundred forty-eight primarily English- and Spanish-speaking adults with diabetes enrolled at the time of visits to a county health care system. In addition to usual care, intervention patients received biweekly ATDM calls with telephone follow-up by a diabetes nurse educator. Patients used the ATDM calls to report information about their health and self-care and to access self-care education. The nurse used patients' ATDM reports to allocate her time according to their needs. Patient-centered outcomes were measured at 12 months via telephone interview. Compared with patients receiving usual care, intervention patients at follow-up reported fewer symptoms of depression (P = 0.023), greater self-efficacy to conduct self-care activities (P = 0.006), and fewer days in bed because of illness (P = 0.026). Among English-speaking patients, those receiving the intervention reported greater satisfaction with their health care overall and with the technical quality of the services they received, their choice of providers and continuity of care, their communication with providers, and the quality of their health outcomes (all P <0.042). Intervention and control patients had roughly equivalent scores for established measures of anxiety, diabetes-specific HRQL, and general HRQL. This intervention had several positive effects on patient-centered outcomes of care but no measurable effects on anxiety or HRQL.

OBJECTIVE: We examined whether low-income patients with diabetes were able and willing to use automated telephone disease management (ATDM) calls to provide health status information that could improve the quality of their care. RESEARCH DESIGN AND METHODS: A total of 252 adults with diabetes, 30 of whom spoke Spanish as their primary language, were enrolled at the time of clinic visits in a Department of Veterans Affairs health care system (n = 132) or a county health care system (n = 120). Patients received ATDM calls for 12 months and responded to queries using their touch-tone telephones. We examined 1) whether patients completed ATDM assessments consistently over the year and used the calls to report their self-monitored blood glucose (SMBG) levels, 2) the characteristics of patients most likely to use the system frequently, 3) whether patients responded consistently within ATDM assessments, and 4) whether ATDM assessments differentiated among groups of patients with different clinical profiles at baseline. RESULTS: Half of all patients completed at least 77% of their attempted assessments, and one-fourth completed at least 91%. Half of all patients reported SMBG levels during at least 86% of their assessments. Patients completed assessments and reported glucose levels consistently over the year. Health status indicators were the most important determinants of assessment completion rates, while socioeconomic factors were more strongly associated with patients' likelihood of reporting SMBG data during assessments. Patients' responses within assessments were consistent, and the information they provided during their initial assessments identified groups with poor glycemic control and other health problems. CONCLUSIONS: Most low-income patients with diabetes can and will use ATDM calls as part of their care. The information they provide is reliable and has clinical significance. ATDM calls could improve the information base for diabetes management while relieving some of the pressures of delivering diabetes care under cost constraints.

We compared patient satisfaction among adults with diabetes treated in a Veterans Affairs (VA) health care system with the satisfaction of patients treated in a county-funded health care system. We also examined whether satisfaction differences reflected differences in the process of patient care. Cross-sectional telephone survey of patients recruited from outpatient clinics. Five hundred and thirty eight adults, including 310 patients from 4 VA clinics and 228 patients from 2 county clinics. Overall satisfaction with care and satisfaction with 6 separate dimensions of care were measured using the Employee Health Care Value Survey. VA patients were more satisfied than were county patients overall and with 5 of 6 dimensions of their care. These differences increased when we adjusted for patients' sociodemographic and clinical characteristics. VA patients reported more diabetes counseling and shorter waiting times to see their doctor. Each of these self-reported process measures was positively correlated with satisfaction and, when taken into account, reduced the differences in satisfaction between the two systems. However, even when we controlled both for patient characteristics and the process of care, VA patients still were more satisfied than were county patients with their care overall as well as with their access to care, communication with providers, and the quality of their health outcomes. In this study, VA patients with diabetes were more satisfied with their health care than were county patients. Perceived diabetes-related counseling and shorter waiting times contributed to differences between the systems in patient satisfaction but did not explain them completely.

The purpose of this study is twofold. First, it provides a review of the literature supporting the development of a new service to help patients with diabetes and their providers manage their care. This service, automated voice messaging (A VM) with nurse follow-up, allows for systematic and intensive patient monitoring and diabetes education as well as a means of focusing clinical resources where they are most needed. Second, it provides a description of a prototype AVM-based diabetes management service that has been developed as part of two ongoing, randomized, controlled trials to test the efficacy of AVM care for patients with Type 2 diabetes. Preliminary findings from implementing this service in two large public healthcare systems suggest that AVM-supported care is feasible, desirable by clinicians and patients with diabetes, and may identify serious health problems that otherwise would go unnoted through standard means of clinic-based patient care.

OBJECTIVE: To determine whether automated voice messaging (AVM) systems could be used as an adjunct to primary care for diabetic patients, we examined whether patients were able to respond to AVM queries for clinical information, whether sufficient numbers of problems were identified to warrant the implementation of the service, and whether patients found the system helpful. RESEARCH DESIGN AND METHODS: The AVM system we examined uses specialized computer technology to telephone patients, communicate messages, and collect information. Sixty-five diabetic patients participated. Based on a review of the literature and the input of diabetes clinician-researchers, we developed an AVM monitoring protocol to inquire about patients’ symptoms, glucose monitoring, foot care, diet, and medication adherence. Patients also were given the option to listen to health promotion messages and to report their satisfaction with the calls. Patients responded by using their touch-tone telephone keypads. RESULTS: A total of 216 AVM calls were successfully completed, an average of 3.3 out of four calls per patient. Patients reported a variety of health problems that signaled the need for follow-up. Many patients reported not checking their blood glucose or their feet, and one in four reported problems with medication and diet adherence. Health and self-care problems varied across patient subgroups in ways suggesting that the AVM reports were reliable and valid. Overall, 98% of all patients reported that the calls were helpful, 98% reported that they had no difficulty responding to the calls, and 77% reported that receiving AVM calls would make them more satisfied with their health care. CONCLUSIONS: This study demonstrates that diabetic patients can respond to AVM queries and find the calls helpful. Such calls are a feasible strategy for identifying health and self-care problems that would otherwise go unnoticed by clinicians.