Year: 2007
Type: article
Abstract: The growing imbalance between need and resources for diabetes careThe number of people living with diabetes continues to rise at an astounding rate (1).Moreover, the epidemic of childhood obesity, coupled with widespread intake of high-fat, low-fiber diets, suggests that this problem will not abate in the foreseeable future (2).Even if the number of diabetic patients miraculously held constant, the need for diabetes medical management and self-care support would continue to trend upward.Diabetes treatment and outcomes have improved over recent years (3-5), and, like the population overall, patients are living longer.Meanwhile, expectations for diabetes care are increasing, with clearer standards for what self-care support should include (which is a good thing [6]), as well as increasingly aggressive goals for physiologic targets such as A1C and blood pressure (which has been more controversial [7,8]).Payers for health services are having an increasingly difficult time funding diabetes care.Experts agree that the current Medicare program will be insolvent in less than 20 years (9), and mounting costs on private insurers have led them to increase cost sharing, limit eligibility and benefits, and even close their doors completely.Insurers pass these financial pressures onto both service providers (through lower payments) and beneficiaries (through higher co-pays and fewer benefits), making out-ofpocket cost one of the major barriers to effective diabetes management (10,11).In short, we now face the untenable situation of a growing demand for diabetes services, coupled with fewer and fewer resources to pay for it.Meeting this challenge requires addressing some of the most complex problems in health care, including how to coordinate diabetes services across providers and how to provide effective support for self-management between outpatient visits.The Chronic Care Model is now accepted worldwide as a blueprint for how a transformed system of care should look (12), and diabetes educators and care managers have been a core resource in the vision for reshaping services so that they prevent, rather than just treat, patients' diabetes-related complications (6 -13).Unfortunately, care management programs and diabetes education services often struggle with staffing shortages, limited funding, and competing time demands (14 -16).Even under the best of circumstances, clinicians cannot provide the day-to-day support that many people with diabetes need to proactively address self-management problems.As a consequence of both resource constraints and acute care-oriented health systems, providers often spend their time only with patients who are either newly diagnosed, in crisis, or the most assertive in advocating on their own behalf.To meet the growing need for diabetes care given these realities, health systems must take a broader approach that views patients' care in the context of their social network, culture, and community (17). Interactive behavior change technology as a partial solution to the looming crisis in diabetes careInteractive behavior change technology (IBCT) is one potential resource for improving the effectiveness of diabetes management programs given the very real limits on funding and staffing time ( 18).IBCTs include the use of hardware and software to promote and sustain behavior changes (18).Examples include the use of PDAs, patient-centered Web sites, automated telephone calls, DVDs, and touchscreen kiosks.In general, these tools 1) assist patients and their clinicians in monitoring changes in health and self-care needs, 2) support patients' efforts to make behavior changes by promoting health and effective self-care, and 3) enhance communication between patients and potential supports for their disease management.Other types of technologies such as physician-targeted clinical decision aids, electronic medical records, and disease registries can also support quality diabetes care, but these tools are usually considered separately from IBCT because they provide information solely to the clinician and represent a more passive repository of data rather than a proactive effort to change behaviors.Some IBCTs are designed to assist patients in being more independent; thus, patients can improve their selfmanagement without assistance from their health care team.For example, resources such as electronic medication reminders, meters that provide longitudinal records of patients' glycemic control, and PDA-based calculators to monitor intake of various nutrients may assist patients with self-regulation and serve as important cues to action.While these tools can be valuable, there are limits to many patients' ability to manage their diabetes on their own, even with technologic supports.Just as the concept of doctor-centered care has given way to a greater emphasis on "self" care, improve-
Source: Diabetes Care
DOI: 10.2337/dc07-1046
Author: John D. Piette
Institution: University of Michigan
Language: English
Subfield: Endocrinology, Diabetes and Metabolism
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2102727205