NICE recommends using telemedicine, such as Skype, to assist women with diabetes in achieving their blood glucose targets. Skype allows consultations with healthcare professionals over large geographical areas, facilitating discussions related to the achievement of blood glucose levels and related issues. The use of smartphone technology and mobile devices can facilitate a two-way exchange of biochemical information and appropriate advice. The usefulness of Skype technology in facilitating remote consultations with pregnant women diagnosed with gestational diabetes mellitus (GDM) was examined to assess the impact on outcomes and quality of care by the Countess of Chester Hospital NHS Foundation Trust. Outcomes were measured by clinic performance (did-not-attend [DNA] rates versus attendance), patient satisfaction, time to pharmacological therapy with metformin +/- insulin, along with other cost-benefit parameters such as savings in time/pharmacotherapy. The impact of consistent dietetic input on patient outcomes and time to pharmacological treatment was also assessed.
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Skype is not used routinely to manage diabetes in antenatal patients in most Trusts across the country, according to personal communications, networking in meetings and published literature on the internet. However, there was a case study where Skype was offered to young diabetes patients in the Newham area of London, wherein some success was achieved. As most of the consultation with pregnant women diagnosed with gestational diabetes revolves around discussion and recommendations on tight management of glycaemia and does not require a physical appointment for examination, it was agreed that Skype would be feasible, safe and probably effective to use. Pregnant women are a motivated group, willing to engage with health monitoring and advice. Most women of reproductive age usually have an excellent grasp of digital technologies. This is a novel approach to care for pregnant women with diabetes and links to the Trust’s values of being safe, kind and effective by reducing the risk of patient harm, giving patients a good experience and utilising resources effectively.
All newly-diagnosed women with GDM were offered Skype appointments after their first group education sessions. Most were offered weekly and bi-weekly appointments. There was consistent dietetic input in all Skype appointments. In the previous, traditional, non-Skype, appointments, dietetic involvement was only for certain patients. The Trust also wanted to assess the impact of consistent dietetic input on patient outcomes and time to pharmacological treatment. Clinic codes on the electronic booking system were created in order to track appointments, book in and book out patients. A total of 50 patients were enrolled over a six-month period. The project was evaluated using qualitative and quantitative methods. Patient questionnaires were completed before, or immediately after, the final Skype appointments. Case notes, both paper and electronic, were reviewed to assess time to commencement of metformin +/- insulin and this was compared with 50 patients who had had traditional non-Skype appointments.
There was a 98% uptake among the patients offered the appointment. There were 184 episodes over a six-month period; DNA rates were very low (1%). Consistent dietary input was provided to all the Skype patients and better dietetic discipline was observed. This was based on patient feedback, not quantified, as patients’ weights are not measured routinely. A few patients who were pregnant for the second time felt that they gained less weight in the current pregnancy, because of adhering to a better dietetic discipline. Patient engagement was optimal. Face-to-face appointments with the consultants for GMD patients reduced significantly (by 38%) so the consultants could spend more time with the complex Type 1 and Type 2 patients on insulin. More time was available to review data from continuous glucose monitoring (CGM) devices and insulin pumps. The average time to treatment with metformin decreased by 30% and the average time to treatment with insulin (+/-) metformin decreased by 40%.
Sustainability and Spread
The clinic performance (ratio of attendance versus DNAs) was very good (up to 99%). The scale of projected annual savings, the patient satisfaction outcomes, and clear health benefits have encouraged continued use of this technology. The idea is to increase the scope by rolling this out to suitable Type 1 and Type 1 patients in the future. A dietician student is planning to undertake an MSc project to assess the comprehensive impact of the Skype clinic. He has met the Research Committee and is applying for an Integrated Research Application System (IRAS) proportional review of the project. The preliminary service evaluation data will be proposed as a Diabetes UK abstract (or oral presentation) and published in a diabetes journal. It has been presented in the hospital weekly Grand Rounds and will be presented in the annual North West Diabetes in Pregnancy update chaired by the Countess of Chester Hospital NHS Foundation Trust. The GPs are aware of this service and the results of the service evaluation will be shared via the Diabetes Network and Locally Enhanced Services (LES) meetings.
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