Telehealth as an Alternative to Traditional, In-Person Diabetes Self-Management Support


Greenwood DA, Hankins AI, Parise CA, et al. A comparison of in-person, telephone, and secure messaging for type 2 diabetes self-management support. Diabetes Educ 2014;40:516–25.


Study Overview

Objective. To investigate the feasibility and effectiveness of administering diabetes self-management support (DSMS) via telephone or secure messaging.

Design. Prospective, longitudinal quasi-experimental study.

Setting and participants. Participants (n = 150) who had previously completed diabetes self-management education (DSME) received follow-up DSMS in 1 of 3 self-selected ways: a one-time in-person visit, 3 brief visits by telephone, or via secure messaging via the electronic health record. The (usual care) in-person group (n = 47) received 1 follow-up appointment at the patient’s request with a certified diabetes educator (CDE) within 3 to 6 months of DSME completion. The telephone group (n = 44) was given follow-up phone appointments with a CDE, each lasting approximately 20 minutes, at 3, 6, and 9 months post-DSME. The secure message group (n = 59) received follow-up messages via the patient portal from a CDE at 3, 6, and 9 months post-DSME. At each interval, patients received 3 messages, an initial one followed by 2 structured replies. Motivational interviewing techniques were used in all 3 groups to identify barriers to achieving behavior goals and solutions.

Main outcome measures. Behavior goal measures, feasibility measures, and physiologic measures at 9 months’ post DSME. Behavior goal achievement was measured using a survey that asked patients to rate their achievement regarding the following AADE7 goals: healthy eating, being active, self-monitoring, taking medications, problem solving, reducing risks, and healthy coping. Goals are rated on a scale from 0 to 10, with a rating ≥ 7 considered successful completion. Feasibility to integrate this technology into a DSME platform was assessed by comparing the number of attempts to contact patients with the number of contacts achieved; also calculated was intervention completion, mean time spent with the CDE, and total cost of each visit. Physiologic measures included HbA1C and LDL levels collected through medical record review.

Results. There were no statistically significant differences between groups with respect to any of the primary outcomes. Behavioral goals were achieved by 59% of the in-person group, 73% of the telephone group, and 77% of the secure message group . Mean goal achievement for all 3 groups combined improved from 6.2 ± 2.4 to 7.2 ± 1.8 (P < 0.05). Overall, 70.3% ± 0.46% achieved behavioral goals, with no difference among groups. In terms of feasibility, at 3 months the contact success rate was 39%, 46%, and 29% in the in-person, telephone, and secure message groups, respectively. At 6 months, the contact success rate was 47% in the phone group versus 32% in the secure message group. At 9 months, the contact success rate was 35% in the phone group versus 21% in the secure message group. Sixty-two participants (41%) completed the intervention per protocol: 51% of in-person patients, 47% of phone patients, and 28% of secure message patients (P < 0.02). Visits lasted and cost, on average, 60 minutes and $50.00, 45.3 minutes and $37.75, and 17.8 minutes (P < 0.05) and $14.83 for the in-person, telephone, and secure message groups, respectively. There was no difference in HbA1c among groups. Overall, HbA1c decreased by −0.88% ± 1.63 (P < 0.05) from baseline to 9 months. Change in LDL was not significant, and neither were there statistical differences among groups.

Conclusion. Diabetes follow-up care delivered via telephone and secure messaging is feasible. Using either of these methods results in similar outcomes compared with the traditional in-person visit, while requiring less staff time.



Diabetes mellitus is a growing epidemic in the United States, affecting nearly 10% of American adults [1]. The disease is associated with multiple, potentially fatal complications, including heart disease, stroke, kidney failure, and limb amputation [1]. Studies show that ongoing diabetes self-management education (DSME) can result in lifestyle and behavioral changes that improve glycemic control, ultimately reducing the risk of complications [2,3]. However, traditional follow-up care and education for patients with diabetes requires considerable time on the part of patients and providers, and is both costly and resource-intensive [4]. The use of telehealth to educate and monitor patients with diabetes is a growing phenomenon. Theoretically, telehealth enables providers to reach greater subsets of the population who may not otherwise be able to consult with a doctor or nurse regularly. However, little is known about the overall effectiveness of telehealth compared with regular office visits with respect to diabetes and patient outcomes.

This study investigated the feasibility of using telephone and secure message methods to deliver ongoing DSMS after the completion of an existing DSME program. The results suggest that there is no difference in behavioral goal achievement, feasibility, and clinical outcomes among usual care and intervention groups.

This study had a number of strengths, including a strong scientific background in support of research that examines telehealth options for diabetes management. The inclusion criteria were straightforward and appropriate for the targeted patient population: all participants were over 18 and had previously completed the DSME class; all participants in the phone group were required to have a working telephone line, while the secure message group participants were required to have internet access. However, there were some methodologic weaknesses, most of which were pointed out by the authors. These included (1) lack of randomization, (2) a high attrition rate, and (3) nonspecific outcome measures. In addition, participants were able to self-enroll into a category of their choice. The lack of randomization enabled selection bias and prohibits the authors from inferring a causal effect between DSMS and improved health outcomes. Attrition rates were also problematic in this study. Not only did 59% of enrolled participants fail to complete the intervention, but the overall contact success rates declined over time. Finally, the outcome measure for feasibility is poorly defined because the authors never provide a numerical measure limitation. External validity is limited by a largely Caucasian sample that is predominately female. Due to the weaknesses inherent in the study’s methodology, the findings should be interpreted with some degree of caution.


Applications for Clinical Practice

Given the potential for long-term complications from diabetes, the rising cost of health care services, and the overall shortage of medical and nursing personnel, alternative methods of patient follow-up are needed in the management of diabetes. Telehealth has the potential to reach a significant portion of the population that is receiving little or no care in rural and underserved areas in a convenient and less costly way than traditional care. Investigating which alternatives to usual care are effective for which patient groups will pave the way for resource optimization and cost-effectiveness. Providing DSME follow-up through telehealth methodologies may be an effective alternative to in-person visits. Additional research is needed to support the outcomes of this study and to determine the duration of DSMS that is needed to ensure sufficient diabetes self-management.

—Amy Burchard, BA, and Tina Sadarangani, MSN, ANP-BC, GNP-BC


1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States. Atlanta, GA: US Department of Health and Human Services; 2011.

2. Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 2002;25:1159–71.

3. Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:405–12.

4. Shani M, Sasson N, Lustman A, et al. Structured nursing follow-up: does it help in diabetes care? Isr J Health Policy Res 2014;3:27.

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