- Email: [email protected]
Protocol for interprofessional cooperation regarding medical telemonitoring of diabetes patients on insulin therapy
European Research in Telemedicine/La Recherche Européenne en Télémédecine (2012) 1, 32—39
Available online at
www.sciencedirect.com
ORIGINAL ARTICLE / REMOTE MONITORING
Protocol for interprofessional cooperation regarding medical telemonitoring of diabetes patients on insulin therapy Protocole de coopération interprofessionnelle pour la télésurveillance médicale du patient diabétique insulinotraité L. Canipel a,∗, H. Laroye a, O. Juy a, S. Mounier a, M.-H. Petit a, S. Franc a,b, G. Charpentier a,b a
CERITD, Bioparc Génopole, Evry Corbeil, Campus 3, bâtiment 5, 1, rue Pierre Fontaine, 91058 Evry cedex, France b CHSF, nouvel hôpital Sud-Francilien, 116, boulevard Jean-Jaurès, 91106 Corbeil Essonnes cedex, France Received 18 December 2011; accepted 3 February 2012
KEYWORDS Co-operation protocol; Specially authorised acts; Nurse; Personalised education programme; Diabetes patient on insulin
∗
Summary The number of doctors in metropolitan France is set to fall by around 20% by 2020, which will necessarily entail longer waiting times to see a specialist. Telemedicine ensures greater proximity between doctors and patients when the latter leave hospital. For this reason, we have created a cooperation protocol for bringing together a multidisciplinary team around an electronic personalised education programme (ePEP) for patient-monitoring using an electronic blood glucose diary. Given changes in the health system, the goal of cooperation under the terms of article 51 of the Hospital, patients, health, territories (HPST) law is to ensure access for patients to high-quality health care throughout the entire national territories. Skills regarding medical activities have been transferred to paramedical actors in numerous countries, in many cases beginning several years ago. The present diabetes treatment protocol involves patient monitoring using telemedicine (submitted on 2 December 2011). The protocol covers remote treatment of patients on insulin therapy by a multidisciplinary team. To this end, we have trained nurses specialised in the management of such patients, who carry an electronic blood glucose diary. These nurses perform medical acts outside their own area of expertise and normally undertaken by doctors; these are known as specially authorised acts. We have taken into consideration the requirements of both the specially authorised acts and of the telemedicine decree. We decided to insert an electronic version of the acts in the ePEP programme. This software, designed for training purposes, serves as a link between the various members of the multidisciplinary team. Doctors and health auxiliaries have access to patient
Corresponding author. E-mail address: [email protected] (L. Canipel).
2212-764X/$ — see front matter © 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurtel.2012.02.004
Protocol for interprofessional cooperation on insulin therapy
33
files at all times. The cooperation protocol is currently undergoing evaluation in the ePEP trial, a multicentre feasibility study that will help define how healthcare is to be reorganised using the personalised education programme by: defining the role of nurses; assessing the benefits perceived by both caregivers and patients; evaluating the impact of ePEP on disease course after 6 months and in the longer term with regard to HbA1c levels, hypoglycaemic episodes, etc. Reorganisation of diabetes care is now well underway. Our management methods are being redesigned and formalised within a protocol in order to improve efficacy without incurring any corresponding increase in costs. We are convinced of the positive role to be played by telemedicine and the involvement of a multidisciplinary team in improving the management of diabetic patients on insulin therapy thanks to more up-to-date organisation of healthcare. We must now discuss the redistribution of costs with the healthcare authorities in order to ensure that such reorganisation is viable! © 2012 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Protocole de coopération ; Actes dérogatoires ; Infirmier ; Plan d’éducation personnalisé ; Diabète insulinotraité
Résumé Le nombre de médecin en France métropolitaine serait amené à baisser d’environ 20 % d’ici à 2020. Des rendez-vous avec un spécialiste dont les délais seront de plus en plus longs. La télémédecine permet d’augmenter la proximité soignant/patient à la sortie de l’hôpital. C’est pourquoi nous avons créé un protocole de coopération réunissant une équipe pluridisciplinaire autour d’un plan d’éducation personnalisé électronique adapté à un suivi par carnet glycémique électronique. Compte tenu des évolutions du système de santé, l’enjeu de la coopération au sens de l’article 51 de la loi Hôpital, patients, santé et territoires (HPST) est de garantir aux patients un accès aux soins de qualité sur tout le territoire national. Le transfert de compétences des activités médicales aux acteurs paramédicaux s’est organisé dans plusieurs pays et souvent depuis de nombreuses années. Ce protocole en diabétologie s’inscrit dans un suivi qui prend appui sur l’acte de télémedecine (déposé le 2 décembre 2011). Au sein de ce protocole, les patients insulino traités sont suivis à distance par une équipe pluridisciplinaire. Pour cela, nous avons formé des infirmiers dédiés à la prise en charge de ces patients, eux mêmes munis de carnet glycémique électronique. Ils exercent des actes ne rentrant pas dans le champ de leur expertise propre mais dans celui du médecin dit actes dérogatoires. Il nous a fallu réfléchir aux exigences à la fois de l’acte de dérogation des actes et à ceux du décret télémédecine. Nous avons donc décidé de reproduire électroniquement tous les actes dans un logiciel appelé ePEP. Le Logiciel ePEP est chargé d’un programme d’éducation. Il est le lien entre tous les acteurs de l’équipe pluridisciplinaire. Le médecin comme l’auxiliaire de santé ont accès à tous moments au dossier patient. Ce protocole de coopération est actuellement en cours d’évaluation dans l’étude ePEP. Cette étude de faisabilité multicentrique contribuera à définir la réorganisation des soins autour du plan d’éducation personnalisé en : définissant le rôle des infirmiers ; évaluant le bénéfice perc ¸u par les soignants et les patients ; évaluant l’impact du plan d’éducation personnalisé sur l’évolution de la maladie après six mois et à long terme : HbA1c, hypoglycémies. . . ; la réorganisation des soins en diabétologie est en marche. Notre prise en charge est repensée, protocolisée afin d’en améliorer l’efficacité sans engendrer de coûts supplémentaires. Nous misons sur la télémédecine et la complémentarité d’une équipe pluridisciplinaire pour améliorer la prise en charge du patient diabétique insulinotraité, au centre d’une nouvelle organisation des soins. Il nous faut penser maintenant avec nos autorités de santé à la redistribution des coûts afin que ces organisations puissent vivre ! © 2012 Elsevier Masson SAS. Tous droits réservés.
Introduction The telemedicine cooperation project, initiated by healthcare professionals at Centre d’études et de recherches pour l’intensification du traitement du diabète (CERITD)/CHSF (centre hospitalier Sud-Francilien), forms part of a general desire among practitioners in France active in the diabetes field to improve the management of diabetic subjects on insulin therapy. The goal is to combat chronic hypoglycaemia, thereby avoiding the associated complications as well as rehospitalisation due to hypoglycaemic and ketoacidosis accidents. WHO forecasts indicate that the number
of diabetes-related deaths will double between 2005 and 2030. In France, the geographical distribution of diabetes specialists is extremely uneven [1]. Working on the hypothesis that there will be no change in the number of doctors being trained, in their choice of specialty, or in the choice of regions in which they set up, and that the rate of retirement will remain constant, a 20% fall in the number of doctors practising in metropolitan France by 2020 seems likely [2], with increasingly long waiting times for patients wishing to see a specialist. Diabetes is a chronic disease in which the onset of complications is entirely dependent upon control of blood
34 glucose levels. Patient motivation is vital to procure adequate and lasting management of effective though complex treatment that inevitably becomes onerous for patients. While regular medical follow-up is the best way of ensuring optimal technical adjustment of the treatment and of providing motivational support for patients, it is hampered in practice by the very limited availability of specialists. Telemedicine ensures greater proximity between doctors and patients when the latter leave hospital. For this reason, we have created a cooperation protocol to bring together a multidisciplinary team around an electronic personalised education programme (ePEP), suitable for patient-monitoring using an electronic blood glucose diary.
Diabetes patients on insulin therapy The estimated number of subjects in France with chronic disease in 2009 was 15 million and this figure is set to double by 2030! The human and financial costs of chronic disease are extremely high; the mean annual reimbursement for a patient with a long-term disease (ALD) is 7068 D [3] and 5431 D [4] for a subject with diabetes. Almost 50% of this sum concerns hospitalisation costs (3411D). Ageing of the population and increasing life expectancy have necessarily engendered an increase in the number of patients with an ALD (mean annual increase of 6.2% for diabetes) [3]; with 180,000 patients with type I diabetes in France, who are now living and will continue to live longer, we will be forced to change our system of healthcare provision. Diabetes is an extremely costly disease in terms of healthcare provision, primarily due to hospitalisation expenses, costs of patient transportation to hospitals and lost workdays due to illness. These costs increase considerably with the onset of complications. The only means available to multidisciplinary teams of limiting such costs is to ensure that mean blood glucose levels, as evaluated by HbA1c, are kept under control and close to normal levels, i.e. around 7%, while avoiding episodes of severe hypoglycaemia. This can only be achieved by close medical follow-up, coupled with education of patients in managing their disease and patient motivation initiatives [5]. In order to improve the efficacy of this team effort, we have created an electronic blood glucose diary to provide assistance with decision-making and the ePEP with sharing of patient information. However this tool, which serves as a means of communication, is still only a tool, and its optimal deployment will always depend upon the way it is used by caregivers.
The role of nurses The French Public Health Code defines a nurse simply as ‘‘any person habitually providing nursing care upon a doctor’s prescription or advice, or in application of the specific role with which they have been entrusted. Nurses are involved in various actions, in particular preventive actions, health education and training, and patient management’’. The World Health Organisation insists that ‘‘the mission of nursing in society is to help individuals, families and groups to determine and achieve their physical, mental and social
L. Canipel et al. potential, and to do so within the challenging context of the environment in which they live and work’’ and independence and initiative are encouraged. The International Council of Nurses states that the key roles of nursing staff comprise: the maintenance and promotion of a healthy environment, research, participation in the creation of health policy, and in the management of health systems and of patients, as well as education.
Transfer of skills The reports for 2002 [6] and 2003 by Prof. Berland concerning the demographics of the healthcare professions and the transfer of responsibility for tasks highlighted the need for increased cooperation between healthcare professionals in order to tackle the challenges facing healthcare system. Article 51 of the French HPST law provides a legal measure open to healthcare professionals enabling them to delegate certain aspects of their medical practice through the transfer of healthcare acts or activities from one medical body to another or through reorganisation of their methods of patient management. Given changes in the health system, the goal of cooperation under the terms of article 51 of the HPST law is to ensure access for patients to high-quality health care throughout the entire national territories. Cooperation between healthcare professionals entails: • patient management based upon effective coordination between the various practitioners in order to optimise treatment; • changes in professional activity and extension of the areas of intervention covered by the paramedical professions, in keeping with changes in professional practice; • time-saving for medical professionals, allowing them to focus on the true areas of their expertise.
Delegation of tasks Skills regarding medical activities have been transferred to paramedical actors in numerous countries, in many cases beginning several years ago. The most extensive experience in this field concerns the United States, Canada and the United Kingdom [6]. In France, there has been no comparable delegation. Article 2 of decree No 2002-194 of 11 February 2002 concerning professional acts and the nursing profession states that nurses may only fulfil medical prescriptions with which they are entrusted. The present diabetes treatment protocol is based on patient monitoring using telemedicine as defined in decree No 2010-1229 of 19 October 2010 concerning telemedicine [7], i.e. as a medical act, and on article 51. The protocol covers remote treatment of patients on insulin therapy by a multidisciplinary team. To this end, we have trained nurses, specialised in the management of such patients, who carry an electronic blood glucose diary. These nurses perform medical acts outside their own area of expertise and normally undertaken by doctors; these are known as specially authorised acts. Each actor has a clearly defined role (Fig. 1):
Protocol for interprofessional cooperation on insulin therapy
35
Figure 1. Telemedicine acts and interfaces included in the protocol. Actes de télémédecine et interfaces dans le protocole.
• teleconsultations: conducted at preset intervals by doctors, limited to the resolution of complex problems (surpassing the special acts delegated to nurses), or general review of the patient’s diabetes. The diabetologist exercises his or her expert role fully. The doctor arranges these teleconsultations and conducts them by telephone, with complete access to the patient’s file and electronic blood glucose diary; • telemonitoring: conducted by the nurse following an initiation-presentation visit. This process comprises telemonitoring (based on alerts) and telephone calls to the patient whose glucose readings (fasting, pre-prandial, post-prandial, evening, bedtime, HbA1c) have fallen too frequently outside the target levels set by the diabetologist. It is also performed on recording of unstable blood glucose levels, with excessively frequent episodes of hypoglycaemia or hyperglycaemia lying outside the previously set limits. The nurse adjusts the prescription and must thus diagnose the causes of the therapeutic imbalance (most commonly, insufficient or excessive insulin dosage, erroneous assessment of prandial carbohydrate intake or inadequate handling of physical effort). He or she then rectifies the insulin prescription and/or provides further patient education. Where patients experience signs of malaise, or they require further motivation or reassurance about a particular concern, they can organise a teleconsultation with their nurse at any time; • medical teleassistance allows the diabetologist provide nurses with remote assistance thanks to a software programme that monitors paramedical acts (ePEP): the shared electronic patient file.
Review of telemedicine tools in the follow-up of diabetic patients on insulin therapy All caregivers are aware of the beneficial effects of a short telephone call made spontaneously to anxious or requesting patients. Are simple follow-up calls such as those made by vocal servers or call centres employing non-medical staff sufficient to replace follow-up using a cooperation protocol? The study by Young RJ sets out to answer this question in the case of type 2 diabetes (call center treatment support [PACCTS] to improve glucose control in type 2 diabetes) [8]; over a period of more than 12 months, 4000 telephone consultations were conducted by a call centre, with a duration of 20 minutes every 12 weeks for patients with baseline HbA1c less than 7%, 20 minutes every 7 weeks for those with HbA1c between 7.1 and 9% and 20 minutes every week for patients with HbA1c greater than 9%, involving a total of 332 patients, comparatively with 176 patients receiving standard follow-up. The results were not significant among patients with the least well-controlled disease (difference of −0.37% in HbA1c compared with patients in the control group, P = 0.33). In patients with HbA1c between 7% and 9%, a significant difference was seen (difference of −0.49% in HbA1c vs. the control group, P < 0.001). We thus concluded that the caregiver/patient relationship in diabetes cannot be replaced by a simple telephone call by non-medical staff using an electronic blood glucose diary. However, the benefits of nursing care with the assistance of telemedicine was evaluated in a study in Vancouver, in which 23 of 46 patients (52% of whom were presenting type
36 1 diabetes) were randomised to receive telephone monitoring based on dose adjustment by a team of specialised nurses. After 6 months, with three 15-minute consultations per week conducted by a nurse educator? focusing the dialogue on dose adjustment, the mean HbA1c level of patients improved significantly (Thompson, insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial)[9], falling from 9.6% to 7.8%, compared with the control group, in which HbA1c remained stationary between 9.4% and 8.9%. Although effective, this follow-up programme was extremely costly in terms of nursing time, involving 17 nursing hours each week, a luxury that no hospital department can currently afford! Another system (T+ system) [10] also evaluated a combination involving the transmission of blood glucose values via mobile phone with automatic generation of analytical curves, with and without a telephone consultation conducted by a nurse. This system was assessed in the UK in 80 patients presenting poorly controlled type I diabetes (HbA1c: 8—11%) who all tested the system before being randomised. Half of the patients had telephone consultations involving commentary by a nurse in addition to the automatically generated analytical graphs, while the other half received only the automatically generated analytical graph of values for the preceding 24 hours. After 9 months, in the group receiving an analytical graph and a telephone call from a nurse, HbA1c had fallen significantly from 9.2% to 8.6% compared with a change from 9.3% to 8.9% in the other group, with no significant difference being seen between the groups. This study demonstrated that the intervention of a nurse acting on blood glucose values alone has little effect.
Anticipated benefits This multidisciplinary extension of tasks should: • reduce the interval between two consecutive medical visits by means of telemonitoring by a nurse; • allow doctors to devote scarce and expensive time to tasks requiring their expertise; • avoid acute events; • limit numbers of patients lost to follow-up through constant support adapted to individual patient requirements; • ensure better balance of blood glucose values by means of improved patient education; • improve sharing among caregivers of information contained in patient files; • improve follow-up of patients in difficulty (the population in which HbA1c greater than 9% is at the highest risk for complications. These so-called patients ‘‘in difficulty’’ require personalised attention with increased remote monitoring by telemedicine being provided by nurses in the multidisciplinary team); • enable alerts to be dealt with in real time, thus providing immediate response to emergency requirements (treatment of hypoglycaemia and hyperglycaemia) so as to avoid rehospitalisation; • reduce transport time and costs; • reduce loss of motivation among patients and abandonment of therapy.
L. Canipel et al.
Computerisation at the service of the cooperation protocol The electronic blood glucose diary All patients on insulin therapy with a smartphone can download a programme to aid decision-making. This electronic blood glucose diary contains a functional insulin therapy programme and algorithms [11] to analyse blood glucose levels, carbohydrate intake and physical activity. It calculates a proposed insulin dose, which the patient is then free to accept or reject.
The electronic personalised education programme software We have taken into consideration the requirements of both the specially authorised acts and of the telemedicine decree. We decided to insert an electronic version of the acts in the so-called ePEP programme (in accordance with decree No 2010-1229 of 19 October 2010). The ePEP software contains a patient education programme. It allows: • traceability of all specially authorised acts (telemonitoring/telephone calls); • organisation of paramedical follow-up; • 24 h/24 h monitoring by doctors of nursing acts and thus the ability to evaluate the delegated services, with training of nurses where necessary; • creation of an electronic patient file shared by doctors and nurses in order to improve management; • tracing of all acts. It serves as the link between all members of the multidisciplinary team.
Respective roles of the actors During a standard visit, the treating diabetologist suggests that the patient should undergo follow-up by telemedicine using an electronic blood glucose diary. The patient is then informed of the methods, and of his role and the nurse’s role, and is asked to provide consent. Patients not wishing to undergo this form of treatment will receive standard treatment from their diabetologist. The doctor draws up a patient profile (civil status, treatment type and target glucose values: fasting, postprandial and bedtime) (Fig. 2). He then contacts the nurse to present the patient and to jointly define the personalised mode of management. The nurse makes an appointment for the so-called initiation-presentation visit since telemedicine cannot be conducted without this initial presentation consultation. During this visit, the nurse informs the patient about the modes of the remote followup programme. The patient must sign a consent form (telemedicine, cooperation protocol, sharing of personal health data). The nurse then opens an initiation visit session in the ePEP software and validates the data in the global diabetes management profile at two levels (the patient’s diabetes and treatment). He or she then trains the patient in use of the electronic diary software after assessing their
Protocol for interprofessional cooperation on insulin therapy
37 ◦ number of episodes of fasting hypoglycaemia greater than number set at the patient initiation visit (individual blood glucose targets), ◦ more than seven cases of hyperglycaemia (fasting or post-prandial) greater than 2.20 g/L, ◦ one case of fasting hyperglycaemia greater than 4 g/L, ◦ one case of hypoglycaemia requiring third-party assistance; • in 2 weeks: ◦ no patient synchronisation; • monitoring of HbA1c: ◦ HbA1c greater than 9%, ◦ changing HbA1c for greater than 6 months. The following alert signs trigger an intervention by the doctor: • in 1 week: ◦ one case of fasting hyperglycaemia 4 g/L, ◦ one case of hypoglycaemia requiring third-party assistance.
Figure 2. Patient profile. Profil patient.
likelihood of complying with this mode of follow-up. He or she trains the patient in the functional insulin therapy and decision-making parts of the programme. After this initiation visit, the nurse and patient define a telemonitoring programme at the rate required by the disease and suited to the patient’s requirements and degree of acceptance: telemonitoring is prompted by programmed alerts according to level of severity. The following alert signs trigger an intervention by the nurse (Fig. 3): • in 1 week:
Figure 3. Alertes.
Alerts.
Alerts are automatically identified by the software, and patients with alerts are readily identifiable by the nurse, who can act according to the degree of severity: • mild severity: the nurse interprets the blood glucose results and makes a diagnosis: if the ensuing blood glucose results are acceptable, the patient is not contacted. The nurse enters details into the monitoring shared patient file (PEP). The report is available for the doctor; • major severity: on noting a marked abnormality, the nurse phones the patient and proposes corrective measures to bring blood glucose readings back within the target range. He or she then enters details into the monitoring PEP. If there is no subsequent continuing improvement, the nurse notifies the diabetologist;
38
L. Canipel et al.
Figure 5. Procedure. La démarche. Figure 4. Telemonitoring. Télésurveillance.
• extreme severity: in the event of an acute metabolic accident or complex situation beyond the scope of the delegated tasks, the nurse notifies the doctor, who can then personally call the patient to resolve the problem prompting the alert. The nurse enters details into the monitoring PEP.
file (ePEP) at any time and help nurses advance their training and level of expertise by giving them expert advice. Members of the multidisciplinary team meet once weekly. At these meetings, the nurses present the files of patients requiring telephone calls after telemonitoring. The diabetologist consults the patient files at least once every 3 months, either alone or with the nurse. Exchanges between the doctor and nurse are essential for optimisation of protocol, and this combined effort enhances the efficacy and safety of patient therapy.
During telemonitoring (Fig. 4), the nurse makes a diagnosis based on analysis of the blood glucose values (fasting, pre-prandial, post-prandial, evening, bedtime, HbA1c). He or she assesses their level and stability, with identification of any hypoglycaemic and hyperglycaemic incidents or accidents and the possible causes thereof. These diagnoses may then trigger: telephone calls. These may serve several purposes: • adaptation of medical insulin prescription, definition of new target blood glucose values, improved management by patient of special situations (meals, physical activity); • for patients on external insulin pumps, setting with the patient of new basal insulin flow rates for the pump; • in the event of hypoglycaemia, assisting the patient with appropriate sugar intake; • treatment of hypoglycaemia and ketoacidosis by adaptation of insulin doses.
These nurses continue their activity at CERITD, with in-depth training focusing on knowledge of the disease and of available treatments, therapeutic education and the computer programme. At present, it is clear that the level of expertise of these nurses has increased, tending towards specialisation. Such specialisation appears to us vital with regard to the delegation of certain acts, for the patient, for the doctors delegating these acts, and in order to provide nurses with reassurance in the performance of such acts.
The initiation visit and subsequent phone calls involve training the patient in management based on active listening, in three steps (Fig. 5): • educative diagnosis with the patient; • evaluation of the patient’s acceptance of their disease and of the necessary therapeutic equipment; • setting by patients themselves of their own realistic and attainable goals for improvement.
The cooperation protocol is currently undergoing evaluation in the ePEP trial, a multicentre feasibility study that will help define how healthcare is to be reorganised using the personalised education programme by: • defining the role of nurses; • assessing the benefits perceived by both caregivers and patients; • evaluating the impact of ePEP on disease course after 6 months and in the longer term with regard to HbA1c levels, hypoglycaemic episodes, etc.
Doctors and healthcare auxiliaries have access to patient files at all times.
The expert doctor The treating diabetologist retains sole responsibilty for treating the patient. He may consult the shared professional
Increasing specialisation
Conclusion
Reorganisation of diabetes care is now well underway. Our management methods are being redesigned and formalised within a protocol in order to improve efficacy without creating any corresponding increase in costs. We are convinced of the positive role to be played by telemedicine and the involvement of a multidisciplinary team in improving the management of diabetic patients on insulin therapy
Protocol for interprofessional cooperation on insulin therapy thanks to more up-to-date organisation of healthcare. We must now discuss the redistribution of costs with the healthcare authorities in order to ensure that such reorganisation is viable!
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Legmann, M. Atlas de la démographie médicale en France. Situation au 1er janvier 2011. Conseil national de l’Ordre des médecins, 2011. [2] Niel, X. Ministère de l’Emploi et de la Solidarité, La démographie médicale à l’horizon 2020. Une réactualisation des projections à partir de 2002. DREES, 2002. 161 (mars 2002). [3] Vallier N, et al. Coût des trente affections de longue durée pour les bénéficiaires du régime général de l’assurance maladie en 2004. Pratiques et Organisation des Soins 2006;37(4): 267—83.
39 [4] Ricci P, et al., Coût des soins des personnes traitées pour diabète : déterminants et évolution; http://www.invs.sante.fr/entred/. [5] DCCT/EDIC, research group. Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. JAMA 2002;287(19):2563—9. [6] Mission démographie médicale hospitalière. Rapport présenté ¸aise; par le Pr Yvon Berland. Paris: La documentation franc 2002. [7] Décret no 2010-1229 du 19 octobre 2010 relatif à la télémédecine; 2010, Code de la santé publique. [8] Young RJ, et al. Pro-active call center treatment support (PACCTS) to improve glucose control in type 2 diabetes. Diabetes Care 2005;28(2):278—82. [9] Thompson DM, Kozak SE, Sheps S. Insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial. CMAJ 1999;161(8):959—62. [10] Farmer AJ, et al. A randomized controlled trial of the effect of real-time telemedicine support on glycemic control in young adults with type 1 diabetes (ISRCTN 46889446). Diabetes Care 2005;28(11):2697—702. [11] Franc S, et al. Real-life application and validation of flexible intensive insulin-therapy algorithms in type 1 diabetes patients. Diabetes Metab 2009;35(6):463—8.
Available online at
www.sciencedirect.com
ORIGINAL ARTICLE / REMOTE MONITORING
Protocol for interprofessional cooperation regarding medical telemonitoring of diabetes patients on insulin therapy Protocole de coopération interprofessionnelle pour la télésurveillance médicale du patient diabétique insulinotraité L. Canipel a,∗, H. Laroye a, O. Juy a, S. Mounier a, M.-H. Petit a, S. Franc a,b, G. Charpentier a,b a
CERITD, Bioparc Génopole, Evry Corbeil, Campus 3, bâtiment 5, 1, rue Pierre Fontaine, 91058 Evry cedex, France b CHSF, nouvel hôpital Sud-Francilien, 116, boulevard Jean-Jaurès, 91106 Corbeil Essonnes cedex, France Received 18 December 2011; accepted 3 February 2012
KEYWORDS Co-operation protocol; Specially authorised acts; Nurse; Personalised education programme; Diabetes patient on insulin
∗
Summary The number of doctors in metropolitan France is set to fall by around 20% by 2020, which will necessarily entail longer waiting times to see a specialist. Telemedicine ensures greater proximity between doctors and patients when the latter leave hospital. For this reason, we have created a cooperation protocol for bringing together a multidisciplinary team around an electronic personalised education programme (ePEP) for patient-monitoring using an electronic blood glucose diary. Given changes in the health system, the goal of cooperation under the terms of article 51 of the Hospital, patients, health, territories (HPST) law is to ensure access for patients to high-quality health care throughout the entire national territories. Skills regarding medical activities have been transferred to paramedical actors in numerous countries, in many cases beginning several years ago. The present diabetes treatment protocol involves patient monitoring using telemedicine (submitted on 2 December 2011). The protocol covers remote treatment of patients on insulin therapy by a multidisciplinary team. To this end, we have trained nurses specialised in the management of such patients, who carry an electronic blood glucose diary. These nurses perform medical acts outside their own area of expertise and normally undertaken by doctors; these are known as specially authorised acts. We have taken into consideration the requirements of both the specially authorised acts and of the telemedicine decree. We decided to insert an electronic version of the acts in the ePEP programme. This software, designed for training purposes, serves as a link between the various members of the multidisciplinary team. Doctors and health auxiliaries have access to patient
Corresponding author. E-mail address: [email protected] (L. Canipel).
2212-764X/$ — see front matter © 2012 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurtel.2012.02.004
Protocol for interprofessional cooperation on insulin therapy
33
files at all times. The cooperation protocol is currently undergoing evaluation in the ePEP trial, a multicentre feasibility study that will help define how healthcare is to be reorganised using the personalised education programme by: defining the role of nurses; assessing the benefits perceived by both caregivers and patients; evaluating the impact of ePEP on disease course after 6 months and in the longer term with regard to HbA1c levels, hypoglycaemic episodes, etc. Reorganisation of diabetes care is now well underway. Our management methods are being redesigned and formalised within a protocol in order to improve efficacy without incurring any corresponding increase in costs. We are convinced of the positive role to be played by telemedicine and the involvement of a multidisciplinary team in improving the management of diabetic patients on insulin therapy thanks to more up-to-date organisation of healthcare. We must now discuss the redistribution of costs with the healthcare authorities in order to ensure that such reorganisation is viable! © 2012 Elsevier Masson SAS. All rights reserved.
MOTS CLÉS Protocole de coopération ; Actes dérogatoires ; Infirmier ; Plan d’éducation personnalisé ; Diabète insulinotraité
Résumé Le nombre de médecin en France métropolitaine serait amené à baisser d’environ 20 % d’ici à 2020. Des rendez-vous avec un spécialiste dont les délais seront de plus en plus longs. La télémédecine permet d’augmenter la proximité soignant/patient à la sortie de l’hôpital. C’est pourquoi nous avons créé un protocole de coopération réunissant une équipe pluridisciplinaire autour d’un plan d’éducation personnalisé électronique adapté à un suivi par carnet glycémique électronique. Compte tenu des évolutions du système de santé, l’enjeu de la coopération au sens de l’article 51 de la loi Hôpital, patients, santé et territoires (HPST) est de garantir aux patients un accès aux soins de qualité sur tout le territoire national. Le transfert de compétences des activités médicales aux acteurs paramédicaux s’est organisé dans plusieurs pays et souvent depuis de nombreuses années. Ce protocole en diabétologie s’inscrit dans un suivi qui prend appui sur l’acte de télémedecine (déposé le 2 décembre 2011). Au sein de ce protocole, les patients insulino traités sont suivis à distance par une équipe pluridisciplinaire. Pour cela, nous avons formé des infirmiers dédiés à la prise en charge de ces patients, eux mêmes munis de carnet glycémique électronique. Ils exercent des actes ne rentrant pas dans le champ de leur expertise propre mais dans celui du médecin dit actes dérogatoires. Il nous a fallu réfléchir aux exigences à la fois de l’acte de dérogation des actes et à ceux du décret télémédecine. Nous avons donc décidé de reproduire électroniquement tous les actes dans un logiciel appelé ePEP. Le Logiciel ePEP est chargé d’un programme d’éducation. Il est le lien entre tous les acteurs de l’équipe pluridisciplinaire. Le médecin comme l’auxiliaire de santé ont accès à tous moments au dossier patient. Ce protocole de coopération est actuellement en cours d’évaluation dans l’étude ePEP. Cette étude de faisabilité multicentrique contribuera à définir la réorganisation des soins autour du plan d’éducation personnalisé en : définissant le rôle des infirmiers ; évaluant le bénéfice perc ¸u par les soignants et les patients ; évaluant l’impact du plan d’éducation personnalisé sur l’évolution de la maladie après six mois et à long terme : HbA1c, hypoglycémies. . . ; la réorganisation des soins en diabétologie est en marche. Notre prise en charge est repensée, protocolisée afin d’en améliorer l’efficacité sans engendrer de coûts supplémentaires. Nous misons sur la télémédecine et la complémentarité d’une équipe pluridisciplinaire pour améliorer la prise en charge du patient diabétique insulinotraité, au centre d’une nouvelle organisation des soins. Il nous faut penser maintenant avec nos autorités de santé à la redistribution des coûts afin que ces organisations puissent vivre ! © 2012 Elsevier Masson SAS. Tous droits réservés.
Introduction The telemedicine cooperation project, initiated by healthcare professionals at Centre d’études et de recherches pour l’intensification du traitement du diabète (CERITD)/CHSF (centre hospitalier Sud-Francilien), forms part of a general desire among practitioners in France active in the diabetes field to improve the management of diabetic subjects on insulin therapy. The goal is to combat chronic hypoglycaemia, thereby avoiding the associated complications as well as rehospitalisation due to hypoglycaemic and ketoacidosis accidents. WHO forecasts indicate that the number
of diabetes-related deaths will double between 2005 and 2030. In France, the geographical distribution of diabetes specialists is extremely uneven [1]. Working on the hypothesis that there will be no change in the number of doctors being trained, in their choice of specialty, or in the choice of regions in which they set up, and that the rate of retirement will remain constant, a 20% fall in the number of doctors practising in metropolitan France by 2020 seems likely [2], with increasingly long waiting times for patients wishing to see a specialist. Diabetes is a chronic disease in which the onset of complications is entirely dependent upon control of blood
34 glucose levels. Patient motivation is vital to procure adequate and lasting management of effective though complex treatment that inevitably becomes onerous for patients. While regular medical follow-up is the best way of ensuring optimal technical adjustment of the treatment and of providing motivational support for patients, it is hampered in practice by the very limited availability of specialists. Telemedicine ensures greater proximity between doctors and patients when the latter leave hospital. For this reason, we have created a cooperation protocol to bring together a multidisciplinary team around an electronic personalised education programme (ePEP), suitable for patient-monitoring using an electronic blood glucose diary.
Diabetes patients on insulin therapy The estimated number of subjects in France with chronic disease in 2009 was 15 million and this figure is set to double by 2030! The human and financial costs of chronic disease are extremely high; the mean annual reimbursement for a patient with a long-term disease (ALD) is 7068 D [3] and 5431 D [4] for a subject with diabetes. Almost 50% of this sum concerns hospitalisation costs (3411D). Ageing of the population and increasing life expectancy have necessarily engendered an increase in the number of patients with an ALD (mean annual increase of 6.2% for diabetes) [3]; with 180,000 patients with type I diabetes in France, who are now living and will continue to live longer, we will be forced to change our system of healthcare provision. Diabetes is an extremely costly disease in terms of healthcare provision, primarily due to hospitalisation expenses, costs of patient transportation to hospitals and lost workdays due to illness. These costs increase considerably with the onset of complications. The only means available to multidisciplinary teams of limiting such costs is to ensure that mean blood glucose levels, as evaluated by HbA1c, are kept under control and close to normal levels, i.e. around 7%, while avoiding episodes of severe hypoglycaemia. This can only be achieved by close medical follow-up, coupled with education of patients in managing their disease and patient motivation initiatives [5]. In order to improve the efficacy of this team effort, we have created an electronic blood glucose diary to provide assistance with decision-making and the ePEP with sharing of patient information. However this tool, which serves as a means of communication, is still only a tool, and its optimal deployment will always depend upon the way it is used by caregivers.
The role of nurses The French Public Health Code defines a nurse simply as ‘‘any person habitually providing nursing care upon a doctor’s prescription or advice, or in application of the specific role with which they have been entrusted. Nurses are involved in various actions, in particular preventive actions, health education and training, and patient management’’. The World Health Organisation insists that ‘‘the mission of nursing in society is to help individuals, families and groups to determine and achieve their physical, mental and social
L. Canipel et al. potential, and to do so within the challenging context of the environment in which they live and work’’ and independence and initiative are encouraged. The International Council of Nurses states that the key roles of nursing staff comprise: the maintenance and promotion of a healthy environment, research, participation in the creation of health policy, and in the management of health systems and of patients, as well as education.
Transfer of skills The reports for 2002 [6] and 2003 by Prof. Berland concerning the demographics of the healthcare professions and the transfer of responsibility for tasks highlighted the need for increased cooperation between healthcare professionals in order to tackle the challenges facing healthcare system. Article 51 of the French HPST law provides a legal measure open to healthcare professionals enabling them to delegate certain aspects of their medical practice through the transfer of healthcare acts or activities from one medical body to another or through reorganisation of their methods of patient management. Given changes in the health system, the goal of cooperation under the terms of article 51 of the HPST law is to ensure access for patients to high-quality health care throughout the entire national territories. Cooperation between healthcare professionals entails: • patient management based upon effective coordination between the various practitioners in order to optimise treatment; • changes in professional activity and extension of the areas of intervention covered by the paramedical professions, in keeping with changes in professional practice; • time-saving for medical professionals, allowing them to focus on the true areas of their expertise.
Delegation of tasks Skills regarding medical activities have been transferred to paramedical actors in numerous countries, in many cases beginning several years ago. The most extensive experience in this field concerns the United States, Canada and the United Kingdom [6]. In France, there has been no comparable delegation. Article 2 of decree No 2002-194 of 11 February 2002 concerning professional acts and the nursing profession states that nurses may only fulfil medical prescriptions with which they are entrusted. The present diabetes treatment protocol is based on patient monitoring using telemedicine as defined in decree No 2010-1229 of 19 October 2010 concerning telemedicine [7], i.e. as a medical act, and on article 51. The protocol covers remote treatment of patients on insulin therapy by a multidisciplinary team. To this end, we have trained nurses, specialised in the management of such patients, who carry an electronic blood glucose diary. These nurses perform medical acts outside their own area of expertise and normally undertaken by doctors; these are known as specially authorised acts. Each actor has a clearly defined role (Fig. 1):
Protocol for interprofessional cooperation on insulin therapy
35
Figure 1. Telemedicine acts and interfaces included in the protocol. Actes de télémédecine et interfaces dans le protocole.
• teleconsultations: conducted at preset intervals by doctors, limited to the resolution of complex problems (surpassing the special acts delegated to nurses), or general review of the patient’s diabetes. The diabetologist exercises his or her expert role fully. The doctor arranges these teleconsultations and conducts them by telephone, with complete access to the patient’s file and electronic blood glucose diary; • telemonitoring: conducted by the nurse following an initiation-presentation visit. This process comprises telemonitoring (based on alerts) and telephone calls to the patient whose glucose readings (fasting, pre-prandial, post-prandial, evening, bedtime, HbA1c) have fallen too frequently outside the target levels set by the diabetologist. It is also performed on recording of unstable blood glucose levels, with excessively frequent episodes of hypoglycaemia or hyperglycaemia lying outside the previously set limits. The nurse adjusts the prescription and must thus diagnose the causes of the therapeutic imbalance (most commonly, insufficient or excessive insulin dosage, erroneous assessment of prandial carbohydrate intake or inadequate handling of physical effort). He or she then rectifies the insulin prescription and/or provides further patient education. Where patients experience signs of malaise, or they require further motivation or reassurance about a particular concern, they can organise a teleconsultation with their nurse at any time; • medical teleassistance allows the diabetologist provide nurses with remote assistance thanks to a software programme that monitors paramedical acts (ePEP): the shared electronic patient file.
Review of telemedicine tools in the follow-up of diabetic patients on insulin therapy All caregivers are aware of the beneficial effects of a short telephone call made spontaneously to anxious or requesting patients. Are simple follow-up calls such as those made by vocal servers or call centres employing non-medical staff sufficient to replace follow-up using a cooperation protocol? The study by Young RJ sets out to answer this question in the case of type 2 diabetes (call center treatment support [PACCTS] to improve glucose control in type 2 diabetes) [8]; over a period of more than 12 months, 4000 telephone consultations were conducted by a call centre, with a duration of 20 minutes every 12 weeks for patients with baseline HbA1c less than 7%, 20 minutes every 7 weeks for those with HbA1c between 7.1 and 9% and 20 minutes every week for patients with HbA1c greater than 9%, involving a total of 332 patients, comparatively with 176 patients receiving standard follow-up. The results were not significant among patients with the least well-controlled disease (difference of −0.37% in HbA1c compared with patients in the control group, P = 0.33). In patients with HbA1c between 7% and 9%, a significant difference was seen (difference of −0.49% in HbA1c vs. the control group, P < 0.001). We thus concluded that the caregiver/patient relationship in diabetes cannot be replaced by a simple telephone call by non-medical staff using an electronic blood glucose diary. However, the benefits of nursing care with the assistance of telemedicine was evaluated in a study in Vancouver, in which 23 of 46 patients (52% of whom were presenting type
36 1 diabetes) were randomised to receive telephone monitoring based on dose adjustment by a team of specialised nurses. After 6 months, with three 15-minute consultations per week conducted by a nurse educator? focusing the dialogue on dose adjustment, the mean HbA1c level of patients improved significantly (Thompson, insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial)[9], falling from 9.6% to 7.8%, compared with the control group, in which HbA1c remained stationary between 9.4% and 8.9%. Although effective, this follow-up programme was extremely costly in terms of nursing time, involving 17 nursing hours each week, a luxury that no hospital department can currently afford! Another system (T+ system) [10] also evaluated a combination involving the transmission of blood glucose values via mobile phone with automatic generation of analytical curves, with and without a telephone consultation conducted by a nurse. This system was assessed in the UK in 80 patients presenting poorly controlled type I diabetes (HbA1c: 8—11%) who all tested the system before being randomised. Half of the patients had telephone consultations involving commentary by a nurse in addition to the automatically generated analytical graphs, while the other half received only the automatically generated analytical graph of values for the preceding 24 hours. After 9 months, in the group receiving an analytical graph and a telephone call from a nurse, HbA1c had fallen significantly from 9.2% to 8.6% compared with a change from 9.3% to 8.9% in the other group, with no significant difference being seen between the groups. This study demonstrated that the intervention of a nurse acting on blood glucose values alone has little effect.
Anticipated benefits This multidisciplinary extension of tasks should: • reduce the interval between two consecutive medical visits by means of telemonitoring by a nurse; • allow doctors to devote scarce and expensive time to tasks requiring their expertise; • avoid acute events; • limit numbers of patients lost to follow-up through constant support adapted to individual patient requirements; • ensure better balance of blood glucose values by means of improved patient education; • improve sharing among caregivers of information contained in patient files; • improve follow-up of patients in difficulty (the population in which HbA1c greater than 9% is at the highest risk for complications. These so-called patients ‘‘in difficulty’’ require personalised attention with increased remote monitoring by telemedicine being provided by nurses in the multidisciplinary team); • enable alerts to be dealt with in real time, thus providing immediate response to emergency requirements (treatment of hypoglycaemia and hyperglycaemia) so as to avoid rehospitalisation; • reduce transport time and costs; • reduce loss of motivation among patients and abandonment of therapy.
L. Canipel et al.
Computerisation at the service of the cooperation protocol The electronic blood glucose diary All patients on insulin therapy with a smartphone can download a programme to aid decision-making. This electronic blood glucose diary contains a functional insulin therapy programme and algorithms [11] to analyse blood glucose levels, carbohydrate intake and physical activity. It calculates a proposed insulin dose, which the patient is then free to accept or reject.
The electronic personalised education programme software We have taken into consideration the requirements of both the specially authorised acts and of the telemedicine decree. We decided to insert an electronic version of the acts in the so-called ePEP programme (in accordance with decree No 2010-1229 of 19 October 2010). The ePEP software contains a patient education programme. It allows: • traceability of all specially authorised acts (telemonitoring/telephone calls); • organisation of paramedical follow-up; • 24 h/24 h monitoring by doctors of nursing acts and thus the ability to evaluate the delegated services, with training of nurses where necessary; • creation of an electronic patient file shared by doctors and nurses in order to improve management; • tracing of all acts. It serves as the link between all members of the multidisciplinary team.
Respective roles of the actors During a standard visit, the treating diabetologist suggests that the patient should undergo follow-up by telemedicine using an electronic blood glucose diary. The patient is then informed of the methods, and of his role and the nurse’s role, and is asked to provide consent. Patients not wishing to undergo this form of treatment will receive standard treatment from their diabetologist. The doctor draws up a patient profile (civil status, treatment type and target glucose values: fasting, postprandial and bedtime) (Fig. 2). He then contacts the nurse to present the patient and to jointly define the personalised mode of management. The nurse makes an appointment for the so-called initiation-presentation visit since telemedicine cannot be conducted without this initial presentation consultation. During this visit, the nurse informs the patient about the modes of the remote followup programme. The patient must sign a consent form (telemedicine, cooperation protocol, sharing of personal health data). The nurse then opens an initiation visit session in the ePEP software and validates the data in the global diabetes management profile at two levels (the patient’s diabetes and treatment). He or she then trains the patient in use of the electronic diary software after assessing their
Protocol for interprofessional cooperation on insulin therapy
37 ◦ number of episodes of fasting hypoglycaemia greater than number set at the patient initiation visit (individual blood glucose targets), ◦ more than seven cases of hyperglycaemia (fasting or post-prandial) greater than 2.20 g/L, ◦ one case of fasting hyperglycaemia greater than 4 g/L, ◦ one case of hypoglycaemia requiring third-party assistance; • in 2 weeks: ◦ no patient synchronisation; • monitoring of HbA1c: ◦ HbA1c greater than 9%, ◦ changing HbA1c for greater than 6 months. The following alert signs trigger an intervention by the doctor: • in 1 week: ◦ one case of fasting hyperglycaemia 4 g/L, ◦ one case of hypoglycaemia requiring third-party assistance.
Figure 2. Patient profile. Profil patient.
likelihood of complying with this mode of follow-up. He or she trains the patient in the functional insulin therapy and decision-making parts of the programme. After this initiation visit, the nurse and patient define a telemonitoring programme at the rate required by the disease and suited to the patient’s requirements and degree of acceptance: telemonitoring is prompted by programmed alerts according to level of severity. The following alert signs trigger an intervention by the nurse (Fig. 3): • in 1 week:
Figure 3. Alertes.
Alerts.
Alerts are automatically identified by the software, and patients with alerts are readily identifiable by the nurse, who can act according to the degree of severity: • mild severity: the nurse interprets the blood glucose results and makes a diagnosis: if the ensuing blood glucose results are acceptable, the patient is not contacted. The nurse enters details into the monitoring shared patient file (PEP). The report is available for the doctor; • major severity: on noting a marked abnormality, the nurse phones the patient and proposes corrective measures to bring blood glucose readings back within the target range. He or she then enters details into the monitoring PEP. If there is no subsequent continuing improvement, the nurse notifies the diabetologist;
38
L. Canipel et al.
Figure 5. Procedure. La démarche. Figure 4. Telemonitoring. Télésurveillance.
• extreme severity: in the event of an acute metabolic accident or complex situation beyond the scope of the delegated tasks, the nurse notifies the doctor, who can then personally call the patient to resolve the problem prompting the alert. The nurse enters details into the monitoring PEP.
file (ePEP) at any time and help nurses advance their training and level of expertise by giving them expert advice. Members of the multidisciplinary team meet once weekly. At these meetings, the nurses present the files of patients requiring telephone calls after telemonitoring. The diabetologist consults the patient files at least once every 3 months, either alone or with the nurse. Exchanges between the doctor and nurse are essential for optimisation of protocol, and this combined effort enhances the efficacy and safety of patient therapy.
During telemonitoring (Fig. 4), the nurse makes a diagnosis based on analysis of the blood glucose values (fasting, pre-prandial, post-prandial, evening, bedtime, HbA1c). He or she assesses their level and stability, with identification of any hypoglycaemic and hyperglycaemic incidents or accidents and the possible causes thereof. These diagnoses may then trigger: telephone calls. These may serve several purposes: • adaptation of medical insulin prescription, definition of new target blood glucose values, improved management by patient of special situations (meals, physical activity); • for patients on external insulin pumps, setting with the patient of new basal insulin flow rates for the pump; • in the event of hypoglycaemia, assisting the patient with appropriate sugar intake; • treatment of hypoglycaemia and ketoacidosis by adaptation of insulin doses.
These nurses continue their activity at CERITD, with in-depth training focusing on knowledge of the disease and of available treatments, therapeutic education and the computer programme. At present, it is clear that the level of expertise of these nurses has increased, tending towards specialisation. Such specialisation appears to us vital with regard to the delegation of certain acts, for the patient, for the doctors delegating these acts, and in order to provide nurses with reassurance in the performance of such acts.
The initiation visit and subsequent phone calls involve training the patient in management based on active listening, in three steps (Fig. 5): • educative diagnosis with the patient; • evaluation of the patient’s acceptance of their disease and of the necessary therapeutic equipment; • setting by patients themselves of their own realistic and attainable goals for improvement.
The cooperation protocol is currently undergoing evaluation in the ePEP trial, a multicentre feasibility study that will help define how healthcare is to be reorganised using the personalised education programme by: • defining the role of nurses; • assessing the benefits perceived by both caregivers and patients; • evaluating the impact of ePEP on disease course after 6 months and in the longer term with regard to HbA1c levels, hypoglycaemic episodes, etc.
Doctors and healthcare auxiliaries have access to patient files at all times.
The expert doctor The treating diabetologist retains sole responsibilty for treating the patient. He may consult the shared professional
Increasing specialisation
Conclusion
Reorganisation of diabetes care is now well underway. Our management methods are being redesigned and formalised within a protocol in order to improve efficacy without creating any corresponding increase in costs. We are convinced of the positive role to be played by telemedicine and the involvement of a multidisciplinary team in improving the management of diabetic patients on insulin therapy
Protocol for interprofessional cooperation on insulin therapy thanks to more up-to-date organisation of healthcare. We must now discuss the redistribution of costs with the healthcare authorities in order to ensure that such reorganisation is viable!
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Legmann, M. Atlas de la démographie médicale en France. Situation au 1er janvier 2011. Conseil national de l’Ordre des médecins, 2011. [2] Niel, X. Ministère de l’Emploi et de la Solidarité, La démographie médicale à l’horizon 2020. Une réactualisation des projections à partir de 2002. DREES, 2002. 161 (mars 2002). [3] Vallier N, et al. Coût des trente affections de longue durée pour les bénéficiaires du régime général de l’assurance maladie en 2004. Pratiques et Organisation des Soins 2006;37(4): 267—83.
39 [4] Ricci P, et al., Coût des soins des personnes traitées pour diabète : déterminants et évolution; http://www.invs.sante.fr/entred/. [5] DCCT/EDIC, research group. Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. JAMA 2002;287(19):2563—9. [6] Mission démographie médicale hospitalière. Rapport présenté ¸aise; par le Pr Yvon Berland. Paris: La documentation franc 2002. [7] Décret no 2010-1229 du 19 octobre 2010 relatif à la télémédecine; 2010, Code de la santé publique. [8] Young RJ, et al. Pro-active call center treatment support (PACCTS) to improve glucose control in type 2 diabetes. Diabetes Care 2005;28(2):278—82. [9] Thompson DM, Kozak SE, Sheps S. Insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial. CMAJ 1999;161(8):959—62. [10] Farmer AJ, et al. A randomized controlled trial of the effect of real-time telemedicine support on glycemic control in young adults with type 1 diabetes (ISRCTN 46889446). Diabetes Care 2005;28(11):2697—702. [11] Franc S, et al. Real-life application and validation of flexible intensive insulin-therapy algorithms in type 1 diabetes patients. Diabetes Metab 2009;35(6):463—8.