O R I G I N A L A R T I C L E
TeleHealth Improves Diabetes Self-Management in an Underserved Community
RICHARD M. DAVIS, MD1 ANGELA D. HITCH, MSPH2 MUHAMMAD M. SALAAM, BS2 WILLIAM H. HERMAN, MD3 INGRID E. ZIMMER-GALLER, MD4 ELIZABETH J. MAYER-DAVIS, PHD5 support, home-based interventions, and telemedicine sessions ina clinic setting (6 –9). We conducted a 1-year randomized clinical trial to evaluate a remote comprehensive DSME intervention administered by a dietitian (A.D.H.) and nurse diabetes educator (certiﬁed diabetes educator [CDE]) designed to improve adherence to American Diabetes Association (ADA) guidelines, which included the availability of a remote retinal assessment. Telehealth strategies,including interactive videoconferencing, telephone (both cellular and land lines), fax line, and a telehealth-enabled retinal camera, were used in the setting of a community health center as a means to bridge barriers of access and transportation for ethnically diverse adults with diabetes who reside in rural South Carolina. The primary goal of this clinical trial was to improve glycemic control andcardiovascular risk through improved diabetes self-management. RESEARCH DESIGN AND METHODS — Patients were recruited from three community health centers in northeast South Carolina. The health centers were members of CareSouth Carolina, a federally qualiﬁed health center (FQHC) headquartered in Hartsville, South Carolina. The sites were 100 miles from the University of South Carolina and wereidentiﬁed with assistance from the South Carolina Primary Health Care Association, a consortium of FQHCs across the state. FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing qualityassurance program, and have a governing board of directors (10). A second FQHC was initially included but withdrew early in the recruitment process dueto unspeciﬁed administrative issues. This resulted in a revised ﬁnal sample size (see the “Sample size and statistical analysis” section below). Inclusion criteria were GHb 7%, age 35 years, having been seen within
OBJECTIVE — To conduct a 1-year randomized clinical trial to evaluate a remote comprehensive diabetes self-management education (DSME) intervention,Diabetes TeleCare, administered by a dietitian and nurse/certiﬁed diabetes educator (CDE) in the setting of a federally qualiﬁed health center (FQHC) in rural South Carolina. RESEARCH DESIGN AND METHODS — Participants were recruited from three member health centers of an FQHC and were randomized to either Diabetes TeleCare, a 12-month, 13-session curriculum delivered using telehealth strategies, orusual care. RESULTS — Mixed linear regression model results for repeated measures showed a signiﬁcant reduction in glycated hemoglobin (GHb) in the Diabetes TeleCare group from baseline to 6 and 12 months (9.4 0.3, 8.3 0.3, and 8.2 0.4, respectively) compared with usual care (8.8 0.3, 8.6 0.3, and 8.6 0.3, respectively). LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group comparedwith usual care. Although not part of the original study design, GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group (9.2 0.4, 7.4 0.5, and 7.6 0.5, respectively) compared with usual care (8.7 0.4, 8.1 0.4, and 8.1 0.5, respectively) in a post hoc analysis of a subset of the randomized sample who completed a 24-month follow-up visit. CONCLUSIONS — Telehealtheffectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population. Diabetes Care 33:1712–1717, 2010
he translation of efﬁcacy trials (1,2) that improve metabolic control for adults with type 2 diabetes to communities is of major interest, given the variable...