Design of the e-Vita diabetes mellitus study: effects and use of an interactive online care platform in patients with type 2 diabetes (e-VitaDM-1/ZODIAC-40)

Worldwide a dramatic increase is seen in the prevalence of diabetes. In 2007, the prevalence of diabetes in The Netherlands was estimated to be 740,000, while in a conservative estimate this is expected to rise to over 1,300,000 in 2025, of which more than 90% will have type 2 diabetes mellitus (T2DM) [1, 2]. At the same time, the increase in number of care providers is lagging. This inevitably will result in an actual decrease in available face-to-face time for contacts between patients and care providers. This necessitates development of alternative forms of treatment and support of patients’ needs and self-management abilities beyond current situation and possibilities [2].

One possibility for reducing workload is increasing patients’ participation in their own care by promoting knowledge regarding their chronic disease(s) and insights in their own situation. Improving online access to reliable information through promoting use of an online platform may help to support such goals [3], but may also result in reducing workload for caregivers. Furthermore, by creating patient profiles, more specifically tailored educational and training can be offered. Personal contact through internet between patients and care providers will also add value. Access to credible health information and personal health data may potentially lead to better disease management and improvement of health. Also, collaborative disease tracking may decrease communication barriers between patients and caregivers. This may lead, in turn, to better understanding, more self reliance and promoting taking responsibility [3], with hopefully and eventually lower costs.

Large programs have been started and results have been analysed in the past decades (resulting in decidedly mixed results), such as the Whole System Demonstrator (WSD), to study effects of telehealth and telecare [4] and a study by Kennedy et al. on implementation of self-management support [5]. However, to see some of the positive study results translated into (cost) effective use of e-Health in routine general practice seems to be quite a challenge up to now [6]. In an effort to further explore opportunities and barriers, the current study aims to provide data access and education through an interactive care platform to T2DM patients in primary care in The Netherlands.

The use of this care platform will be offered as part of the e-Vita research program, in which a care platform will be implemented and studies in various regions of The Netherlands. Six sub-studies will be performed, three of which are in patients with different chronic illnesses: T2DM, chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF). The fourth study concentrates on cost-effectiveness of these interventions and will be performed by the Julius Center in Utrecht. The fifth study will assess determinants of platform usage, by using methods developed by the Center for eHealth Research and Disease Management, Department of Psychology, Health and Technology, University of Twente, Enschede. The sixth study is part of the study in T2DM patients and is performed by the Department of Medical Psychology, VU University Medical Center, Amsterdam.

The presented study is performed in T2DM patients in the Netherlands, treated in primary care. Patient empowerment is strived for by offering the possibility to track laboratory results based on the yearly check-ups, as well as offering educational modules to start a self-chosen process of lifestyle intervention through the platform. Even small improvements in lifestyle may on longer term result in moderate to large changes in self-reported dietary and physical activity behaviours that can result in (cost-effective) improvements in health related measurements (adiposity, blood pressure and lipid levels) [7, 8]. Other results may be improvements in patients’ health related quality of life (HRQoL) [9], which in itself is an independent predictor of mortality in patients with T2DM [10, 11]. The earlier mentioned study performed by the VU University Medical Center is a randomized controlled trial nested within the T2DM study, comparing effects of online coaching vs. no coaching of a self-management support module on self-reliance [12].

Offering T2DM patients information, education and insight in health data through internet is not new at all. However, to our knowledge, in The Netherlands there has never been a study of the proposed scale towards feasibility, efficiency and the effects of an interactive care platform as proposed in the e-Vita research program. Furthermore, part of the assessment includes structural measurements of perceived quality of life and care.

At the start of e-VitaDM study the actual content of the care platform is limited to insight in DM-related health data of an individual patient and education. In this ongoing study, new modules will be added especially concentrating on educational content. The development of further educational content is crucial, not only to further enhance active use of the platform, but also to assess the effects of new additions and improvements in a continuous cycle using focus groups in each step. The creation of content, including 2-way communication, e-contact and e-consult, during this study and keeping track of its fit with patients’ needs is not the primary focus in this research, but nevertheless has to be taken into account, not only in striving for the largest possible effect, but also in analyzing the collected data. At the moment, communication between PN’s and patients is limited to automated messages in the electronic patient record when patients allow this in case of completing educational modules. The platform does not provide an extensive 2-way communication tool (e.g. exchange messages) on top of the automated messages, but developments concerning this are already ongoing.

A previous study by the British National Health System proves that unless personal electronic health records align closely with people’s attitude, self management practices, identified information needs and the wider care package (including organizational routines and incentive structures for clinicians), the risk that they will be abandoned or not adopted at all is substantial [33].

The WSD shows that telehealth is associated with lower mortality and emergency admission rates [34], but also that telehealth did not improve quality of life or psychological outcomes for patients with COPD, T2DM or CHF over 12 months [35]. In terms of cost-effectiveness, the WSD shows that the QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with telehealth were higher [6]. However, generalizability of the WSD-study results in terms of diagnosis, relative risks and outcomes to the Dutch situation in uncertain.