Monash prepares to scale up TLC Diabetes program
Monash University and its partners in the Telephone-Linked Care (TLC) Diabetes program are looking at ways the technology can be offered to the broader community following the publication of successful results from a randomised controlled trial.
The TLC system is an interactive computer-assisted telephone system that has proven successful in several trials, particularly for improving physical activity, nutrition and medication adherence. It has since been adapted by the Monash team to test whether it would be useful for assisting people with type 2 diabetes with better self-management.
Last year, the TLC team – including researchers from Monash's Faculty of Medicine, Nursing and Health Sciences, the University of Queensland, Queensland University of Technology and Boston University in the US – published the results of a randomised-control trial of the technology in people with type 2 diabetes, which found that there was a statistically significant decrease in blood glucose levels as well as an increase in mental health-related quality of life.
The TLC diabetes program uses a mobile phone to send participants' blood glucose results from an Accu-Chek glucometer to the computerised telephone system. Users then phone the system to receive feedback on their blood glucose results, along with feedback and advice on diet, medications and daily exercise.
TLC Diabetes project manager, Dominique Bird, said the technology was nothing really new, having been developed over the years by Robert Friedman, a professor of medicine and public health at Boston University.
However, Dr Bird, a research fellow with the International Public Health Unit in the Department of Epidemiology and Preventive Medicine at Monash who has a position at the School of Nursing at Queensland University of Technology and holds an honorary position at UQ's Centre for Online Health, said that as far as her team was aware, this is one of the first studies in the world to formally evaluate an automated telephone system for diabetes management that involves tailoring to individual needs.
“We first did a pilot study of the TLC system in Australia between 2004 and 2006 for people with a chronic condition, although the technology has been around for longer as it has been used by Boston University over 20 years now,” Dr Bird said.
“They have run a number of trials but not at that stage a diabetes project, so we adapted it to diabetes in the Australian context.”
In a paper published in BioMed Central Public Health last year, the team showed that of the 60 people in the intervention group who made weekly calls for six months, there was a decrease of 0.8 per cent in blood glucose levels from 8.7 per cent to 7.9 per cent after six months, compared with a 0.2 per cent reduction in the control group.
There was also a significant improvement in mental health-related quality of life, with a mean increase of 1.9 in the intervention arm, while the usual care arm decreased by 0.8.
The TLC system is quite easy for the patient to use, Dr Bird said. “We provided people with a kit – a meter, a Bluetooth device and a mobile phone,” she said.
“The app on the mobile was designed to send what we needed to our database, and that was the time, the serial number of the meter and the value. People did that from home as a single press of a button.
“In the TLC server, we had entered at the beginning of the trial – and that could be updated in the trial – the recommended range for that person and that was given to us by the GP or sometimes the endocrinologist. That allowed the TLC system, in the phone call that followed that uploading, to give feedback.”
The phone call goes to an automated system that is able to take the measurements for the past week and compare them with the previous four weeks. It also asks a number of questions about other parameters and provides feedback.
As the serial number of the device is sent to the system, it can identify the patient and opens their individual file. It will also ask preliminary questions such as whether the person is currently in hospital and under medical care, thereby negating the need for the feedback.
“The most crucial feedback is the percentage of this week's blood glucose levels compared to the previous four weeks,” Dr Bird said. “For example, it will say 'this week you only have 20 per cent in the range but in the previous four weeks you were over 75 per cent in the range, so something must has happened'.
“Obviously it can't figure out why, so it asks them if they know why. 'Hopefully it is only temporary and it's easy to fix it, but if you don't know why, I would suggest you speak with your health professional'. It doesn't take over the GP or diabetes educator's role. It is meant to reinforce it.”
After providing feedback on blood glucose levels, the system will then ask questions about medication adherence, physical activity and healthy eating.
In addition to whether the system would show a change in physical condition and improve self-management, the researchers were also interested in studying the acceptability and usability of the system, Dr Bird said.
“We also wanted to know if people who are disadvantaged in access to health services were interested in something that probably to them sounded challenging, because in general people with type 2 diabetes are older than average,” she said.
“The take-up was really good, satisfaction was in the high percentages and overall, all of our key process evaluations were high in satisfaction in terms of ease of use and acceptability.”
Some participants found speaking to a computer rather than a human challenging at first, “but they gave it a go”, she said.
“The positives were that they said it was fantastic to have something or 'someone' to help me stick to my routine, someone that gave me information that I wish I had when I was first diagnosed.”
The team is now investigating the various options for a broader community implementation, Dr Bird said. “Ideally, it would be integrated with other programs. We've always had a very good relationship and we've received a lot of support from Diabetes Australia at a national level and in Queensland, WA and Victoria. They have been working with us looking at future versions and how we can approve our scripts and our model.”
The system can also be easily adapted for other chronic conditions, she said. “This one has feedback on blood glucose but also feedback on the goals that people have set for their physical activity.
“It also did an assessment over eight weeks of the intake of various food groups, as well as medication taking. Those three apply obviously to most chronic conditions – physical activity, food intake and medications – if you think of cardiovascular disease for instance.
“Boston University had done this sort of work when it looked at behaviour change for healthy people with physical activity, for example, or in the context of chronic disease. That is very easily done.”
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