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Hispanic Health Care International, Vol. 12, No. 2, 2014


Brief report Using Telehealth to Improve Diabetes Management in the Hispanic Population Mirian Zavala, DNS, RN College of Mt. St. Vincent, New York Angie Millan, MSN, RN/NP, CNS, FAAN Children’s Medical Services in the County of Los Angeles Department of Public Health, California



n 2004, the cost of caring for individuals with chronic illness was 78% of all health care spending in the United States (Kaufman et al., 2006). Diabetes, a chronic illness, was the seventh leading cause of death in the United States in 2007 (Centers for Disease Control and Prevention [CDC], 2011). The complications of diabetes may include kidney disease, heart disease, stroke, extremity amputations, and blindness (CDC, 2011; Hogan, Dall, & Nikolov, 2003). The prevalence of diabetes has increased from 12.1 million in 2002 to approximately 25.8 million individuals in 2010 mostly living with type 2 diabetes (Blanchet, 2008; CDC, 2011; Hogan et al., 2003). The economic impact of caring for clients with diabetes was $116 billion for direct medical expenditure, and 287,000 deaths were attributed to diabetes in 2007 (American Diabetes Association [ADA], 2008; CDC, 2011). It is projected that by 2030, the diabetic prevalence rate will rise to 30.3 million in the United States (Wild, Roglic, Green, Sicree, & King, 2004). This data does not account for individuals who are undiagnosed. Urgent efforts are needed to improve diabetes management because of its mortality and morbidity. According to Narayan, Benjamin, Norris, and Engelgau (2004), another factor to consider is that diabetes is a chronic disease being treated in acute health care settings. Diabetes necessitates continuous monitoring because its status fluctuates (Kaufman et al, 2006). One approach to solving the spiraling diabetes prevalence is the use of telehealth, which may improve disease management by providing resources and client motivation (Botsis, Demiris, Pedersen, & Hartvigsen, 2008; Coughlin, Pope, & Leedle, 2006).

The Centers for Medicare and Medicaid Services (2011) defined telehealth as “the transmission of a patient’s medical information from an originating site to the physician or practitioner at the distant site” (p. 404). According to the American Telemedicine Association (2012), telemedicine was defined as the exchange of medical information from one site to another via electronic communications for improving the clients’ health. Examples of telemedicine implementation have been the use of remote monitors to measure vital signs, the provision of patient education, accessing nursing call centers for triaging medical problems, and the transmission of images to be read by medical experts (American Telemedicine Association, 2012). The telehealth/telemedicine technology evolved from the use of the telephone to wireless, multisensorial wearable devices as a response to the lack of access to health care by individuals residing in rural and remote areas (Skiba, Barton, & Nielsen, 2006). This technology will impact health care by transforming the delivery of health care and improve disease end points (Skiba et al., 2006), providing care electronically to clients residing in remote areas and to those clients who are homebound, thus maintaining the link between clients and their health care providers (Kaufman et al., 2006). This intervention encompasses all aspects of health care such as providing patient education, obtaining clients’ vital signs, transmitting images, and accessing nursing call centers for triaging medical issues (American Telemedicine Association, 2012; Loane & Wootton, 2002; Skiba et al., 2006). An outcome of motivating clients to better manage 99

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control group. The VACCHT participants used a messaging device, the telephone, to communicate with their nurse. Based on the nurse’s assessment of the patient, calls for new medication orders appointments were made, appointment reminders were given, and other interventions were administered, such as weekly video conferencing in rare circumstances. Barnett et al. (2006) suggested that the VACCHT program can reduce the avoidable hospitalization use after the implementation of the 24-month program. Outcomes from telehealth use were impressive. One year after implementing telehealth in a program located in Texas with high use of health care by impoverished clients, the study showed that hospital admissions were reduced by 32%, whereas outpatient visits decreased by 49%. One of the major cost savings was the result of reduced usage of acute care services by clients with chronic illnesses (Sorrells-Jones, Tschirch, & Liong, 2006). SorrellJones and colleagues stated that if admissions, emergency room visits, and length of stay can be reduced, less nursing hours will be needed. Telehealth can be a health care workforce multiplier because nurses would be able to provide diabetes management to additional clients and decrease home or office visits (Coughlin et al., 2006). Pressure to contain cost will escalate as coverage expands under health care reform. To sustain the access to universal coverage, the expansion of telemedicine/ telehealth use may be a response for the effective and efficient delivery of health care. The health care reform act requires collaborative care networks, health care institutions being held accountable, and preventive care among other provisions (Patient Protection and Affordable Care Act, 2010).

a chronic disease, such as diabetes, is probable because patient self-management is a viable adjunct to improving their disease status (Wagner & Groves, 2002). Better management of diabetes will result in less hospitalization and less long-term complications because this approach is proactive instead of the usual reactive interventions. This will improve the client’s quality of life by using preventive health care services, thereby decreasing cost to insurers. Telehealth devices can be an aggregator of data to be trended by health care providers, thus capturing individual body metrics resulting in individualized client care. Trending of data facilitates early detection of worsening symptoms (Coughlin et al., 2006; Heckinger, Chappell, Downes, & Fitzner, 2006).

comparing telemeDicine/teleHealtH WitH usual care Diabetes has a tremendous mortality, morbidity, and prevalence rates consuming a major portion of health care expenditures, necessitating improvement in care, including using the technique of telemedicine/telehealth (ADA, 2008; Shea et al., 2009). The Informatics for Diabetes Education and Telemedicine Trial (IDEATel) enrolled 1,665 diabetic participants 55 years old and older, who were Medicare beneficiaries residing in a federally designated underserved area. The goal was to determine if telemedicine care would improve their status using the end points of blood pressure, lowdensity lipid (LDL) proteins, cholesterol, and glycosylated hemoglobin (Hgb A1c) compared to usual care. The usual care was the established pattern of care the client has with his or her health care provider. The intervention group was given a home unit containing a computer with web capability, allowing video conferencing with the nurse, glucometer, and blood pressure monitors. The unit transferred the clinical data to the nurse for interventions, guidance, and directions. The usual care group did not receive guidance or directions; they received their usual care from their primary health care providers. Shea et al. (2009) concluded that telemedicine case management resulted in sustained lowering of blood pressure, LDLs, and Hgb A1c compared to the usual care group. The end point results were statistically significant as “HgbA1c, p 5 0.001; LDL, p , 0.001; systolic and diastolic blood pressure, p 5 0.024; p , 0.001” (p. 446). Shea et al. (2009) stated there was no difference in mortality between both groups of participants. Home telehealth technology is used at the Veterans Administration (VA) hospitals as a response to the mortality, morbidity, and financial burden of managing diabetes (Barnett et al., 2006). The Veterans Administration Care Coordination Home Telehealth (VACCHT) group had 319 participants with diabetes who were at high risk for many VA hospital visits and 319 participants in the

Hispanic population WitH Diabetes anD teleHealtH tecHnology According to the U. S. Department of Health and Human Services, Office of Minority Health (2010), Hispanics are 1.5 times more likely to die from diabetes compared to non-Hispanic Whites. Approximately 10.5% of Hispanic population older than the age of 20 years had diabetes in 2006 (Livingston, Minushkin, & Cohn, 2008). Using the VACCHT program, home telehealth technology can reduce the avoidable hospitalizations and the financial stress of managing diabetes (Barnett et al., 2006). This technology may assist the Hispanic population, which suffers disproportionally from diabetes.

conclusion Diabetes has a tremendous mortality, morbidity, and prevalence rates consuming a major portion of health care expenditures. This requires improvement in care, including 100

Telehealth to Improve DM

using the technique of telehealth/telemedicine technology (ADA, 2008; Shea et al., 2009). Statistically significant outcomes were found in the IDEATel trial for HgbA1c, LDL, and systolic and diastolic blood pressure, which showed improvements in those end points of lowering blood pressure, LDL, and HgbA1c and empowering clients to better manage their diabetic health status. This technology would be beneficial to the Hispanic population.

Kaufman, D. R., Pevzner, J., Hilliman, C., Weinstock, R. S., Teresi, J., Shea, S., & Starren, J. (2006). Redesigning a telehealth diabetes management program for a digital divide seniors population. Home Health Care Management & Practice, 18(3), 223–234. Livingston, G., Minushkin, S., & Cohn, D. (2008). Hispanics and health care in the United States. Pew Research Hispanic Center. Retrieved from http://www.pewhispanic.org/2008/08/13/ ii-hispanics-and-chronic-disease-in-the-u-s/ Loane, M., & Wootton, R. (2002). A review of guidelines and standards for telemedicine. Journal of Telemedicine and Telecare, 8(2), 63–71. Narayan, K. M., Benjamin, E., Norris, S. L., & Engelgau, M. M. (2004). Diabetes translation research: Where are we and where do we want to be? Annals of Internal Medicine, 140(11), 956–964. Patient Protection and Affordable Care Act. (2010). Retrieved from http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/ pdf/BILLS-111hr3590enr.pdf Shea, S., Weinstock, R. S., Teresi, J. A., Palmas, W., Starren, J., Cimino, J. J., . . . Eimicke, J. P. (2009). A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study. Journal of American Medical Informatics Association, 16, 446–456. Skiba, D. J., Barton, A. J., & Nielsen, M. M. (2006). Innovations in telehealth. In V. K. Saba, & K. A. McCormick (Eds.), Essentials of nursing informatics. New York, NY: McGraw-Hill. Sorrells-Jones, J., Tschirch, P., & Liong, M. A. S. (2006). Nursing and telehealth: Opportunities for nurse leaders to shape the future. Nurse Leader, 4(5) 42–58. Wagner, E. H., & Groves, T. (2002). Care for chronic diseases. British Medical Journal, 325(7370), 913–914. Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004). Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care, 27, 1047–1053. U. S. Department of Health and Human Services, Office of Minority Health. (2010). Diabetes and Hispanic Americans. Retrieved from http://minorityhealth.hhs.gov/templates/ content.aspx?lvl=2&lvlID=54&ID=3324

RefeRences American Diabetes Association. (2008). Economic costs of diabetes in the U.S. in 2007. Diabetes Care, 31, 596–615. American Telemedicine Association. (2012). What is telemedicine? Retrieved from http://www.americantelemed.org/learn/ what-is-telemedicine Barnett, T. E., Chumbler, N. R., Vogel, W. B., Beyth, R. J., Qin, M., & Kobb, R. (2006). The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up. The American Journal of Managed Care, 12, 467–474. Blanchet, K. D. (2008). Medical connectivity: Telehealth and diabetes monitoring. Telemedicine and E-Health, 14(8), 744–746. Botsis, T., Demiris, G., Pedersen, S., & Hartvigsen, G. (2008). Home telecare technologies for the elderly. Journal of Telemedicine and Telecare, 14, 333–337. Centers for Disease Control and Prevention. (2011). National diabetes fact sheet 2011: Fast facts on diabetes. Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf Centers for Medicare and Medicaid Services. (2011). Authenticated United States government information. Retrieved from http:// www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR2011-title42-vol2-sec410-78.pdf Coughlin, J. F., Pope, J. E., & Leedle, B. R., Jr. (2006). Old age, new technology, and future innovations in disease management and home health care. Home Health Care Management & Practice, 18(3), 196–207. Heckinger, E., Chappell, H., Downes, D., & Fitzner, K. (2006). Disease management: a mid-decade evolution toward patient safety. Home Health Care Management & Practice, 18(3), 178–185. Hogan, P., Dall, T., & Nikolov, P. (2003). Economic costs of diabetes in the U.S. in 2002. Diabetes Care, 26, 917–923.

Correspondence regarding this article should be directed to Mirian Zavala, DNS, RN, College of Mt. St. Vincent, 6301 Riverdale Ave., Founders’ Hall 506, Bronx, NY 10471. E-mail: [email protected]


Using telehealth to improve diabetes management in the Hispanic population.

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