Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes.

BACKGROUND: Clinical care for type 2 diabetes has improved but remains suboptimal. Collaborative, team-based models that maximize skills of different disciplines may improve care for individuals with diabetes, but few have been tested using rigorous research designs. OBJECTIVE: To investigate the efficacy of a registered dietitian nutritionist-led telemedicine program compared with that of a control group in terms of diabetes optimal care goals. DESIGN: A randomized controlled trial in which participants were assigned to a control or intervention group. PARTICIPANTS/SETTING: One hundred eighteen adults with type 2 diabetes (mean age, 60 years; 45% female) participated in the study between April 2016 and December 2017. Participants were recruited from separate primary care clinics in two rural Minnesota communities. INTERVENTION: For those assigned to the intervention, registered dietitian nutritionists used a treatment protocol to initiate and titrate therapies for blood glucose, hypertension, and lipid levels in addition to providing medical nutrition therapy; telemedicine visits supplemented usual care. MAIN OUTCOME MEASURES: Primary outcomes included composite and individual diabetes optimal care goals: hemoglobin A1c, blood pressure, not using tobacco, and taking a statin and aspirin (as appropriate). Secondary measures included physical activity, breakfast, fruits and vegetables, whole grains, body mass index, low-density lipoprotein, and medication adherence. STATISTICAL ANALYSIS: Mixed-model regression was used to examine outcomes between baseline and 1-year follow-up. RESULTS: A modest but significantly greater improvement in the number of diabetes optimal care measures met at follow-up was found in the intervention group (3.7 vs 3.2 in the control group [P=0.017]). Among individual measures, the intervention group had significantly greater medication use, with 2.5 and 2.2 higher odds (compared with the control group) of taking a statin [95% CI, 1.0 to 6.24]) and aspirin [95% CI, 0.90 to 5.19] as appropriate, respectively. CONCLUSIONS: ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) findings suggest that registered dietitian nutritionists following medication treatment protocols can effectively improve care for adults with type 2 diabetes and can serve an instrumental role as part of the health care team in providing evidence-based, patient-centered care.

Reach and effectiveness of the HeartBeat Connections telemedicine pilot program.

Introduction Innovative care delivery programs that support primary care providers are needed to reduce the burden of cardiovascular disease (CVD). HeartBeat Connections (HBC) is a primary prevention telemedicine program utilizing registered dietitian nutritionists (RDNs) and registered nurses (RNs) to deliver health coaching and medication therapy protocols for dyslipidaemia and hypertension among patients at high risk for developing CVD. Methods This retrospective cohort study documents the reach and six-month effectiveness of the HBC program for improving CVD risk factors. The sample included 1028 high-risk individuals aged 40-79 (without CVD or diabetes) served between 2010 and 2013 (326 participants, 702 eligible non-participants). Mixed-model analyses of variance were used to compare changes in outcome measures between baseline and six-month follow-up for participants and non-participants. Outcomes were also examined for three groups: non-participants, participants with 1-4 encounters, and participants with > 5 encounters. Results Nearly one-third of all eligible patients participated. There were no significant differences over time between HBC participants and non-participants in blood pressure or body mass. A higher proportion of HBC participants quit using tobacco (7.0 vs. 3.2%, p = 0.004) and achieved the low-density lipoprotein (LDL) program goal of < 100 mg/dL (8.9 vs. -1.1%, p = 0.009). Also, more favourable improvements in total and LDL cholesterol were observed among HBC participants with higher program engagement ( p < 0.05). Discussion The HBC telemedicine program resulted in significant improvement in some, but not all, CVD risk factors over six months. HBC reached many high-CVD-risk patients in the target region, which may confer population-level health benefits if this program can be scaled and sustained. Innovative, collaborative care delivery models like HBC can serve as a platform to systematically target and proactively engage at-risk populations, perhaps reducing patients' CVD risk.

HeartBeat Connections: A Rural Community of Solution for Cardiovascular Health.

BACKGROUND: Cardiovascular disease (CVD) continues to be the leading cause of death among Americans. National guidelines emphasize early identification and control of CVD risk factors, but challenges remain in the primary care setting in terms of engaging patients and improving medical therapy adherence. The rapid growth of electronic health records (EHRs) provides a new way to proactively identify populations of high-risk patients and target them with prevention strategies. The HeartBeat Connections (HBC) program was developed as part of a population-based demonstration project aimed at reducing myocardial infarctions. METHODS: HBC uses EHR data to identify residents at high CVD risk in a rural community. Participants receive coaching from a registered dietitian or a registered nurse focused on lifestyle behavior changes and preventive medication initiation/titration. DISCUSSION: HBC provides patients with access to nonprescribing professionals on a more frequent basis than typical office visits, and it is focused specifically on helping patients improve lifestyle behaviors and medication adherence as they relate to the primary prevention of CVD. CONCLUSION: Innovative population health approaches that use EHR data to address common barriers to CVD prevention and engage communities in addressing population health needs are needed to help more patients prevent coronary events.

Telephone counseling and home telemonitoring: the Weigh by Day Trial.

OBJECTIVE: To test the effects of telephone counseling and telemonitoring on weight loss. METHODS: A randomized-controlled trial was conducted over 18 months. Participants were assigned to an immediate or delayed-start group. The intervention included a Thin-Link((R)) home telemonitoring scale and biweekly telephone counseling over 6 months. RESULTS: The immediate group lost significantly more weight relative to the delayed group over the first 6 months (-7.5 versus +1.3 pounds) and at subsequent visits. CONCLUSION: Compared to no treatment, the intervention was effective at producing weight loss. Home telemonitoring may enhance standard weight-loss counseling.

Self-weighing promotes weight loss for obese adults.

BACKGROUND: Frequent self-weighing has been proposed as an adjuvant strategy to promote weight loss. Not all experts agree on its utility, and the literature supporting its effectiveness is somewhat limited by methodologic shortcomings related to the subjective assessment of self-weighing frequency. DESIGN: A prospective cohort design was utilized to examine 100 participants enrolled in a weight-loss trial that encouraged frequent, objectively measured self-weighing at home. Measurements were made at pretreatment and at follow-up visits at 6 and 12 months. SETTING/PARTICIPANTS: Participants were employed, obese adults enrolled in the Weigh By Day trial. Study data were collected between October 2005 and May 2007. INTERVENTION: The intervention consisted of a 6-month behavioral weight-loss program that employed telephone counseling, a written manual, and a home telemonitoring scale. MAIN OUTCOME MEASURES: The primary outcomes of interest were body weight and clinically meaningful weight loss (i.e., > or =5%). Analyses were performed in March 2008. RESULTS: Self-weighing was a significant predictor of body weight over time. Participants lost about 1 extra pound for every 11 days they self-weighed during treatment. In addition, participants who self-weighed at least weekly were 11 times more likely to lose at least 5% of their pretreatment weight after 6 months. Improvements attenuated after 12 months. CONCLUSIONS: Self-weighing may be a strategy to enhance behavioral weight-loss programs. Weekly self-weighing seems to be a reasonable, evidence-supported recommendation for successful weight loss, but more research is warranted to determine the independent contribution of self-weighing to successful weight loss, as well as its potential risk of negative psychological impact.