We developed a Mobile Diabetes Management System (MDMS) to support specialist outpatient diabetes care at the Princess Alexandra Hospital, Brisbane, Australia. The MDMS-enabled model of care incorporates the following elements: (1) targeting of intensive MDMS use to patients with suboptimal glycaemic control; (2) short or long-term remote monitoring of blood glucose level (BGL) and insulin dosage based on clinical need; (3) optional automated tailored text-messaging feedback to patients based on BGL and self-monitoring frequency; (4) periodic patient online self-report; (5) improved clinical data availability for clinicians and (6) deferment or substitution of conventional in-person follow-up consultations with telephone or video consultations.
The MDMS comprises three main interconnected sub-systems: a smartphone App for the person with diabetes that wirelessly connects to a Bluetooth glucose meter, a web application and an online clinician portal . Users receive regular tailored text-message alerts based on the frequency of BGL testing and BGL values. Messages focus on BGL monitoring and key diabetes lifestyle behaviours and include links to Diabetes Australia factsheets. The web application stores data in the cloud, controls access, enables data exchange, runs algorithms and queries, hosts the clinical decision support system, and provides messaging. The clinician portal presents the uploaded data in graphical or tabular formats for credentialled diabetes educators (CDEs) and endocrinologists to monitor and manage a person's condition. It highlights out-of-range BGLs to facilitate monitoring and clinician interventions.
Using the MDMS, the diabetes service model functioned in the study as follows:
After enrolment into the intervention group, each participant was trained to use the MDMS by the CDE. Subsequently, BGLs, insulin dosages, manual note entries and text-message alerts sent to the participant became available on the clinician portal. In advance of each subsequent planned “review” or follow-up appointment , the endocrinologist reviewed participant clinical notes, data on the portal, pathology results and the standardised online participant self-report, and then determined the form of review mode of consultation to recommend: traditional in-person at the clinic; video-conference; telephone; or text only. For example, the text message might suggest deferral to a later clinic because progress has been satisfactory: “Well done, your BGL and most recent lab tests are at target. We can postpone your next clinic visit to xxx. Call the diabetes clinic on xxx if you have any concerns”. When a transition from oral medication to insulin or an adjustment to insulin dosage was required, the CDE managed it using the MDMS, under the supervision of an endocrinologist.
The primary outcome measure was change in HbA1c. Secondary outcome measures were clinical outcomes—percentage of participants achieving target HbA1c, change in blood pressure, lipid profile, body mass index and mean self-reported number of hypoglycaemia events; patient satisfaction; quality-of-life assessed using the AQOL-8D (Assessment of Quality-of-Life) questionnaire. For the participants in the intervention group, patient acceptance was assessed using the Service and User Technology Acceptability Questionnaire (SUTAQ).
