Effect of a Multidisciplinary Intensive Targeted Care with Telephone Outreach in Patients with Poor Glycemic Control

Abstract

Background: This research aimed to evaluate the effect of a multidisciplinary intensive targeted care with telephone outreach in patients with poor glycemic control.

Method: A retrospective study was conducted with the total of 122 subjects received multidisciplinary intensive targeted cares during admission and was followed up after being discharged from the hospital by phone using an application line to communicate, educate, evaluate, monitor blood glucose and resolve hypoglycemia or hyperglycemia symptoms. The effect of health behaviors 3E 2S (eating, exercise, emotion, stop smoking and stop drinking), a 9-question Patient Health Questionnaire: PHQ-9, medication adherence scale (MMAS-8) and clinical outcome were assessed at 3 months and 6 months of the follow-ups. The data were analyzed using descriptive statistics, repeated ANOVA and paired t-test.

Results: The results showed that, after completing the program, health behaviors and medication adherence were significantly higher than that before the study (p-value<0.001). Degree of depression was significantly lower than before the study (p-value<0.001). The mean of body mass index, LDL cholesterol, triglycerides cholesterol and blood pressure were significantly lower than that before the study (p-value<0.001). The eGFR was also significantly higher than before the study (p-value=0.003). However, HbA1c decreased slightly with no significant difference (mean difference -10.81±88.88, p-value=0.207).

Conclusion: This study can be used as a tool for continuing diabetes care that can facilitate patients to modify their health behaviors. This telehealth enhances the ability of self-management and improve clinical outcomes. Additional consideration should be paid for patients in aging group that may require caregivers or relatives to collaborate or join the group meetings.