Whole population management of patients with diabetes

An increasingly aging population is presenting greater prevalence of people with diabetes, co-morbidities and the complications. Moreover, poor management of diabetes increases risk of complications. There is need to monitor these patients more closely to ensure optimum management. However current management is based on simple clinic based blood pressure and HbA1c readings, which prove insensitive to detect problems of lifestyle and habits. We therefore developed a platform that could be deployed to all diabetes patients to take daily blood pressure and blood glucose measurements that were sent automatically to the clinician. Data was reviewed after a two week monitoring period. Those that were deemed well controlled were asked to return the devices, which were cycled to the next patient. Others were asked to make an appointment with the clinician for review. 37% of patients required intervention. When stratified for risk using parameters from the EPR we found the greatest change in HbA1c in the low risk group, with the high risk group having little change. The greatest problem was denial in the recently diagnosed and lapse in others, resulting in poor adherence to medication and lifestyle.