optimizing diabetes pharmacy consultations in the …...9/17/2019 1 optimizing diabetes...

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Optimizing Diabetes Consultations in the Digital Age

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1. Learning objectives

2. Diabetes: a review

3. Prevention and treatment strategies: self-management education (SME) & self-management support (SMS)

4. Case 1: Meet John

5. Features of smart phone mobile apps

6. Case 2: Meet Lucille

7. Benefits of smart phone mobile apps

8. Pharmacist’s role in optimizing diabetes care with technological devices

AGENDA

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Review the 2018 Diabetes Canada Clinical Practice Guidelines to provide practical management of diabetes for self-management education (SME) with self-management support (SMS).

Apply the use of self-management blood glucose (SMBG) devices and mobile applications for diabetes management to facilitate in decision-making, as well as improvements in healthy behaviours and clinical outcomes.

Outline how pharmacists can play a key role in optimizing care for diabetes patients by using technological aids to efficiently manage time during consultations.

Learning objectives

Following participation in this learning activity, pharmacists will be better able to:

Note: References listed at end of presentation.

What is diabetes?

Types of Diabetes (n.d) Retrieved March 10, 2019, from https://medmovie.com/library_id/3255/topic/ahaw_0249i/ Additional reference: (1)

Diabetes complications (n.d) Retrieved March 10, 2019, from https://medmovie.com/library_id/3255/topic/ahaw_0201i/Additional references: (1-4)

Diabetes complications

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https://medmovie.com/library_id/3255/topic/ahaw_0201i/

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In the next 10 years, both prevalence and direct healthcare costs for diabetes are projected to grow by more than 40%.(5)

Prevalence has more than doubled since 2000. (6)

Stigma an issue: 37% of Canadians with type 2 diabetes do not feel comfortable disclosing their condition.(7,8)

57% Canadians unable to follow prescribed treatment due to out-of-pocket costs.(9)

Treatment challenges

Canada At a Glance 2017 2045

Country Prevalence, % 9.6 10.5

Age-adjusted comparative prevalence, % 7.4 7.4

Number of people with diabetes in 1,000s 2,603.2 3,159.1

Number of people with undiagnosed diabetes, in 1, 000s 793.6 963.0

Proportion of undiagnosed cases % 30.5 30.5

Number of deaths due to diabetes in 1,000s 11.3

Proportion of deaths due to diabetes in people under 60 years, % 37.4

Impaired glucose tolerance (20-79 years)

Country prevalence, % 16.1 17.2

Age-adjusted comparative prevalence, % 14.0 14.0

Number of people with impaired glucose tolerance, in 1,000s 4,376.9 5,176.0

Health expenditure due to diabetes (20-79 years)

Total health expenditures, millions USD * 16,970.1 18,273.8

Health expenditures per person with diabetes, USD* 6,519.5 5,784.6

IDF Diabetes Atlas 8th Edition 2017 Country Reports International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium:InternationalDiabetes Federation, 2017.Additional references: (2, 10)

Diabetes in Canada

Global prevalence

Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, Malanda B, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 2018;138: 271 – 281.

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One of the largest global health emergencies of the 21st century(2)

Despite advances in prevention and treatment, many people with diabetes have sub-optimal glycemic control(2)

Global health emergency

Additional reference: (10)

Digital blood glucose monitoring devices can play an important role in primary and secondary prevention strategies

The 2018 Diabetes Canada Clinical Practice Guidelines recommends the use of digital mobile applications along with Self-Management Support (SMS) and Self-Management Education (SME)(15,16)

These guidelines aim to empower patients to be part of the decision-making process and engage in healthy behaviourinterventions.

Prevention and treatment strategies

Additional references: (2,13,14)

Contour® Next One Meter with the Contour® Diabetes App

Accu-Chek® Aviva Connect Meter with Accu-Chek® Connect Diabetes ManagementOneTouch Verio Reflect™ meter and OneTouch

Verio Flex® meter with the OneTouch Reveal®

app

Self-management blood glucose devices with digital applications

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Monitoring blood sugars

Confirm or detect hypoglycemia unawareness

Manage and treat hypoglycemia symptoms

Determine pre-prandial and post-prandial glycemic levels

Ongoing self-management decisions

Anti-hyperglycemic therapies (insulin, sulfonylureas, meglitinides)

Especially essential in situations where A1C does not accurately reflect glycemia (alcoholism, chronic renal failure, iron deficiency, B12 deficiency, etc.)

References: (17-20)

Factors Increased A1C Decreased A1C Variable Change in A1C

Erythropoiesis Iron deficiencyB12 deficiencyDecreased erythropoiesis

Use of erythropoietin, iron or B12ReticulocytosisChronic liver disease

Altered hemoglobin Fetal HemoglobinHemoglobinopathiesMethemoglobinGenetic determinants

Altered glycation AlcoholismChronic renal failureDecreased erythrocyte PH

Ingestion of aspirin, Vitamin C or Vitamin EHemoglobinopathiesIncreased erythrocyte PH

Erythrocyte destruction Increased erythrocyte lifespan: splenectomy

Decreased erythrocyte lifespan:Chronic renal failureHemoglobinopathiesSplenomegalyRheumatoid arthritisAntiretroviralsRibavirinDapsone

Assays HyperbilirubinemiaCarbamylated hemoglobinAlcoholismLarge dose of aspirinChronic opiate use

Hypertriglyceridemia Hemoglobinopathies

Factors that affect A1C(21)

Adapted from. 2018 Diabetes Clinical Practice Guidelines: Prevention and Management of Diabetes Malekiani CL, Ganesan A, Decker CF. Effect of hemoglobinopathies on hemoglobin A1c measurements. Am J Med 2008;121:e5.

Blood glucose digital technologies give immediate feedback on a patient’s medication compliance, healthy behaviours (dietary choices, stress, physical activity etc.), and effectiveness of pharmacological treatments

Tailoring of treatment by framing a structured educational and therapeutic program

Coaching that encompasses goal setting, knowledge acquisition, individualized care and follow-ups

Sherifali D et al. systematic review found that coaching led to a 0.32% reduction in A1C(25)

Coaching tools for pharmacists

Additional references: (16, 22-24)

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Accu-Chek® Aviva Connect Meter with Accu-Chek®

Connect Diabetes Management

OneTouch Verio Reflect™ and OneTouch Verio Flex® meter with the OneTouch Reveal® app

Smart phone apps

Reference: (20)

Diabetes Canada’s Clinical Practice Guidelines describe SME as a process to involve individuals in decision-making, resulting in improvement in knowledge, attitudes and self-efficacy

In other words, a person adapting to healthy behaviours can result in improved clinical outcomes

Patient empowerment through enhanced knowledge and skills, including problem-solving skills

Pharmacists’ interventions for SME can be guided using glucose digital devices

Self-management education (SME)

References: (7, 16, 26, 27)

SMS strategies augment an individual’s ability to self-manage their diabetes

Significant improvements in A1C seldom continue after three months without additional SMS(17)

Effective communication between individuals and their healthcare providers enhances adherence to patient treatment, leading to positive clinical outcomes.

Self-management support (SMS)

Additional references: (14, 28, 29)

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SME and SMS in Pharmacy Practice

Growing body of research indicates that the combination of SME and SMS is most advantageous for glycemic control, self-efficacy, and self-care behaviours

Technologies such as the internet, web-based education and communities, text messaging, email, automated telephone reminders and telehealth/telephone education are tools to facilitate and enhance SME and SMS(16,20,31-39)

Frequent interactions with text messaging combined with the Internet are associated with improved glycemic control.(17,40-42)

Systematic reviews found that web-based programs effective for increased physical activity and improved diet. (40,43-44)

Additional references: (28, 30)

BP: 125/80 mm Hg

BMI: 31 kg/m2

A1C: 7.9%

Case 1: Meet John

49 years of age, diagnosed with type 2 diabetes five years ago

Recently informed by his physician that his blood sugar numbers are consistently too high

John is aware of his physician’s concerns and wants to have better control over his diabetes

Through consultation, the pharmacist determines blood pressure, body mass index and A1C

Current medications:• Metformin 1000 mg BID• Sitagliptin 100 mg QD• Insulin Glargine U-100: 50 units HS• Olmesartan 40 mg daily• Rosuvastatin 20 mg HS

Photo: vladir_s (iStock)

Case 1: SME Assessment

When the pharmacist discusses SMBG testing, John mentions he has an older meter that he rarely uses.

John saw an advertisement for a meter that connects to his smartphone; he likes the idea of the meter transmitting his results to the phone, as this would simplify the testing process for him.

He asks if this is a suitable option for him.

John is advised on the four different SMBG meter options, each with unique features.

The similarities and unique features of the mobile apps are also briefly described to John, and he selects the most appropriate meter based on his needs and interests.

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Pharmacy technicians or assistants are well suited to walk patients through the various features of blood glucose meters and their respective mobile apps, so that pharmacists can focus their time on the clinical aspects of SME and SMS

Role of the technician

Smart phone app features

Goal-setting and tracking

Bluetooth smart technology

Colour-coding

Instant reports

Blood sugar mentor/ personal diabetes coaching

Photos

Notes

Blood sugar reminders

Estimated HbA1C

Contextual tags

Insulin log

Case 1: Selecting a meter

During his discussion with the technician, John determines he needs a meter that is simple to use and wireless with Bluetooth. He would like colour coding, an alarm reminder, a note section, and an insulin log.

The technician recommends the meter that meets John’s needs, and demonstrates its use.

The pharmacist returns to initiate SME and SMS

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During his discussion with the pharmacist, John agrees that in order to achieve a target of ≤7% he needs to monitor his blood sugar on a regular basis.

Since John uses insulin therapy once a day, the pharmacist discusses the 2018 Diabetes Canada Clinical Guidelines andrecommends that he check his blood sugar level at least once a day.

The pharmacist advises John on when to monitor his blood sugars and what his pre-prandial and post-prandial targets should be.

A follow-up is scheduled in two weeks.

Case 1: Initiation of SME and SMS

How and when to perform self-monitoring

How to record the results in an organized fashion

Understanding of various blood sugar levels and how unhealthy behaviours affects results(15)

People with diabetes should receive instruction on…

To achieve an A1C of ≤7.0%:

Pre-prandial or fasting blood sugar of 4.0 to 7.0 mmol/L and a 2-hour post-prandial target of 5.0 to 10.0 mmol/L.

If A1C of ≤7.0% cannot be achieved:

Pre-prandial or fasting blood sugar levels is lowered to 4.0–5.5 mmol/L and a 2-hour post prandial target to 5.0–8.0 mmol/L.

These targets must be balanced against the risk of hypoglycemia.

2018 Clinical Guidelines recommendations(15)


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Self-monitoring blood glucoserecommendations

Situation SMBG recommendation

Using multiple daily injections of insulin (≥4 times per day)Using an insulin pump

SMBG ≥ 4 times per day

Using insulin <4 times per day SMBG at least as often as insulin in is being given

Pregnant (or planning a pregnancy), whether using insulin r notHospitalized or acutely ill

SMBG individualized and many involve SMBG ≥ 4 times per day

Starting a new medication known to cause hyperglycemia (e.g. steroids)Experiencing an illness known to cause hyperglycemia (e.g. infection)

SMBG individualized and may involve SMBG ≥ 2 times per day

Adapted from Diabetes Canada Clinical Practice Guidelines Expert Committee. Appendix 5. Can J Diabetes. 2018;42 Suppl 1:S312-S313


Situation SMBG recommendation

Newly diagnosed with diabetes (<6 months) SMBG ≥ 1 times per day (at different times of day) to learn the effects of various meals, exercise and or medications on blood glucose

Not meeting glycemic targets SMBG >2 times per day, to assist in lifestyle and/or medication changes until such time as glycemic targets are met

Using drugs known to cause hypoglycemia (e.g. sulfonylureas, meglitinides)

SMBG at times when symptoms of hypoglycemia occur or at times when hypoglycemia has previously occurred

Has an occupation that requires strict avoidance of hypoglycemia

SMBG as often as required by employer

Adapted from Diabetes Canada Clinical Practice Guidelines Expert Committee. Appendix 5. Can J Diabetes. 2018;42 Suppl 1:S312-S313

Increased SMBG frequency

John’s 2-week follow-up

The pharmacist allots 15 minutes for a follow-up

During the first 5 minutes, the pharmacist uses John’s phone to:

1. Collect data and generate a blood sugar report in a logbook pattern format. The simplified format allows the pharmacist to review John’s blood sugar readings quickly.

2. Analyze data using the software’s feature of color-coded blood sugar patterns, to determine if John is experiencing high, in-range or low blood sugar readings. The pharmacist also views the nightly insulin dose administered by John.

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Date Before

Breakfast

2-hrs after

Breakfast

Before

Lunch

2-hrs after

Lunch

Before

Dinner

2-hrs after

Dinner

Bedtime

3/28 4 5

3/27 3.7 9 8

3/25 3.9 6

3/24 3.9 8

3/23 3.7 10

3/22 3 8

3/21 3.5

3/20 3.2 8.5

3/19 5 8

3/18 5.1 7.5

The pharmacist allocates the next 5 minutes to discuss the blood sugar log with John



3. Collaborate: The pharmacist establishes collaboration by congratulating John for making the effort to test his blood sugars more consistently.

Based on their discussion and the colour-coded blood sugar patterns, the pharmacist informs John that he is experiencing nocturnal hypoglycemia events without symptoms, likely due to the glargine U-100.

4. Plan and follow up: The final 5 minutes are dedicated to formulate a plan and schedule additional follow-ups.


The pharmacist recommends another insulin option, degludec, an ultra-long acting insulin that has been associated with lower rates of overall and nocturnal hypoglycemia compared to glargine U-100

The pharmacist speaks with John about the risk, prevention and treatment of hypoglycemia, addressing John’s lifestyle factors regarding food intake and physical activity

The pharmacist also suggests adding a bedtime snack to prevent nocturnal hypoglycemia when bedtime blood sugars are below 7.0 mmol/L.

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Cui M, Wu X, Mao J, Wang X, Nie M (2016) T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis. PLoS ONE 11(11): e0166718. https://doi.org/10.1371/journal.pone.0166718(13)

Efficacy of smart phone apps

Additional references: (12, 20, 32)

BP: 120/80 mm Hg

BMI: 31 kg/m2

A1C: 7.5%

Case 2: Meet Lucille

48-year-old female working mother of three, diagnosed with type 2 diabetes less than 6 months ago.

When filling her new prescription for metformin, Lucille expresses shock and distress about her diagnosis.

Lucille’s physician has provided her with a logbook to record her blood sugar readings.

Lucille indicates she doesn’t know anything about type 2 diabetes, but would like to manage it properly. She feels she can no longer eat anything that contains sugar.

Medications:• Metformin 500 mg with dinner for 5 days then

500 mg twice a day with breakfast and dinner• Perindopril 8 mg daily• Rosuvastatin 10 mg HS

• Cetirizine 20 mg daily as needed for allergiesPhoto: Juanmonino (iStock)

When the pharmacist asks Lucille about self-monitoring blood glucose meters, Lucille states that she was advised by her physician to monitor her blood sugar regularly and keep a daily record.

She doesn’t want her co-workers to know that she has diabetes and therefore doesn’t want to carry her logbook with her at all times.

Lucille discloses that she has dyslexia and is uncomfortable monitoring her blood sugar readings in case she misinterprets her results.

Lucille doesn’t know which blood sugar machine would be most appropriate.

Case 2: SME assessment

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OneTouch Verio Reflect™ meter with the OneTouch Reveal app

Timing and frequency of SMBG should be determined individually.

SMBG has been demonstrated to be the most effective treatment in persons with Type 2 diabetes within the first 6 months after diagnosis.(46)

People with type 1 diabetes need to test before each meal to know how much insulin to administer.

≥3 self-tests per day are associated with a 1.0% absolute reduction in A1C.(47)

SME and SMS in practice


The pharmacist asks Lucille is she uses a smart phone; Lucille replies yes, and that she always has her smart phone with her

The pharmacist then asks if she’d like an easier way to share results with a health care professional, who can offer support with diabetes management

With a very busy schedule, Lucille would appreciate feedback from her pharmacist on how to manage her blood sugars.

She wants a simple device that gives her instant feedback.

Case 2: SME assessment

Benefits of digital smart phone apps

OneTouch Verio Reflect™ meter and the OneTouch Verio Flex® meter with the OneTouch Reveal® app


Accu-Chek® Aviva Connect Meter with Accu-Chek® Connect


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BLUE represents low blood sugars and IMMEDIATE ACTION is required

GREEN represents blood sugars areWITHIN target range

RED represents blood sugars are ABOVE target range

Contour® Next One Meter

OneTouch Verio Reflect™ meter

Colour range indicator

Ability to set goals collaborativelywith patients

The pharmacist or technician/assistant presents the advantages of a smart phone app over the traditional log book: Instant and immediate confirmation of high or low

blood sugar readings.

Ability to guide patients to treat high or low blood sugar values.

Insight on the effects of diet, exercise, and other factors on blood sugar levels.

Motivates healthy behaviour with features such as photos, notes, and the tracking of daily steps.


versus

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The smart phone also address Lucille’s concerns about misreading results due to her dyslexia.

The pharmacy technician trains Lucille on the glucometer device technique and customizes the device’s blood sugar targets to the recommended CDA blood sugar ranges.

The technician also provides the pharmacy clinic code; when Lucille enters this code into the app, it allows the pharmacist to log in to see her data.


The pharmacist and Lucille mutually agree to achieve target A1C of ≤ 7% in the next 3-6 months.

The pharmacist explains the blood sugar targets as recommended by the 2018 Canadian Diabetes Guidelines blood sugar targets.

Since Lucille is newly diagnosed with diabetes (<6 months), as per 2018 Guidelines Recommendations, the pharmacist suggests that she to monitor her blood sugar at least once a day.


The pharmacist briefly informs Lucille of the impact of carbohydrate, fibre, fat and protein on blood sugar levels, and encourages her not to discontinue eating carbohydrates as this is not sustainable in the long term.

Instead, the pharmacist requests that Lucille monitor her blood sugar twice a day, so that she can understand the effect of food intake on her blood sugar levels.

The pharmacist and Lucille agree to further discuss the effects of both food intake and metformin by phone follow-up in two weeks.

The effect of physical activity will also be discussed during their next follow-up appointment.


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Pharmacist’s role in optimizing diabetes care with technological devices

Digital technology is changing the way patient-centered communication is practiced.

Pharmacists can play a critical role to help improve adherence and clinical outcomes for people living with diabetes.

These technologies and apps provide a quick, reliable way for pharmacists to review detailed analyses of data through automatic reports, which enables pharmacists to augment the patient’s ability to self-manage through coaching and patient support.(49) Photo: Tinpixels (iStock)

Digital technology a tool to help pharmacists fulfill their potential

Meta-analysis: pharmacist interventions resulted in 0.76% decrease in A1C(53,54)

Improvements in blood pressure and cholesterol levels as well.

Digital technologies enable pharmacists to spend more time one-on-one with diabetes patients.

Additional references: (55, 56)

Photo: alvarez (iStock)

Use of blood glucose digital technology as a time-efficient tool for guidance

OneTouch Verio Reflect™ meter with Blood Sugar Mentor™

References: (16, 17, 49)

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Prior to the call, the pharmacists takes about 5 minutes to:

1. Collect data by using the clinic code to access the web-based application and view Lucille’s results

2. Analyze the data, with the following questions in mind:

Is Lucille experiencing any episodes of hypoglycemia?

What is the pattern between Lucille pre- and post- prandial meal times?

Lucille’s 2-week phone follow-up

3. Collaborate: The pharmacist calls Lucille to discuss the results that are out of range.

Lucille shares that she forgets to take the metformin with her dinner meal.

She agrees she has learned the effects of food intake as well as the effect of metformin

She is more mindful of her dietary choices and portions.


Date Before Breakfast

2-hrs after Breakfast

Before Lunch

2-hrs after Lunch

Before Dinner

2-hrs after Dinner

5/11 8 5.4

5/12 8.5 7.9 12

5/13 7.7 6.1

5/14 7 8

5/15 6 14

5/16 7.9 4.8

5/17 7.4 6.6

5/18 7.4 5

5/19 7 8.1

5/20 5 7.4

5/21 8

5/22 7 10

4. Plan of Action and Follow-Up To increase medication adherence, the pharmacist recommends

the extended release formulation of metformin.

Lucille agrees to continue with her efforts on dietary change.

The pharmacist introduces the topic of physical activity, and Lucille agrees to start with walking for 10 minutes a day.

The pharmacist congratulates Lucille for implementing healthy lifestyle choices.

The next phone follow up is scheduled in one month. Lucille agrees to continue with monitoring blood sugar pairings as previously set.


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Diabetes is a progressive disease requiring ongoing training to self-manage symptoms.

Pharmacists can help patients achieve optimal blood glucose levels—and in turn improve their quality of life—through coaching and ongoing support.

SMS and SME interventions offer opportunities for personalized support, customized to an individual’s self-management needs and preferences.

New advances in blood glucose meters provide patients with a better understanding of how to self-manage their disease.

These meters can help pharmacists better understand patients’ needs and desires for self-management, so that pharmacists can further enhance patients’ knowledge, skills and self-efficacy.

Summary

1. Diabetes Canada Clinical Practice Guidelines Expert Committee, Houlden RL. Introduction. Can J Diabetes. 2018; 42 Suppl 1:S1-S5.

2. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva, Switzerland: World Health Organization. 2009. Available from: http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks _report_full.pdf

3. Canadian Institute for Health Information. (2013). Compromised wounds in Canada. Ottawa, Ont.: Canadian Institute for Health Information. https://secure.cihi.ca/free_products/AiB_Compromised_Wounds_EN.pdf

4. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2013). Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes, 37 (suppl 1).

5. Diabetes in Canada: Facts and figures from a public health perspective. Ottawa, ON: Public Health Agency of Canada; 2011. Report No.: HP35-25/2011E. https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffres-eng.pdf

6. Canadian Diabetes Association. 2015 Report on Diabetes: Driving Change. Toronto, ON: CDA; 2015.

7. Garnett, A., Ploeg, J., Markle-Reid, M., & Strachan, P. H. (2018). Self-Management of Multiple Chronic Conditions by Community-Dwelling Older Adults: A Concept Analysis. SAGE Open Nursing. https://doi.org/10.1177/2377960817752471

8. Canadian Diabetes Association. (March 2011). Diabetes: Canada at the tipping point. The public perspective: a national survey. http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/environics-opinion-poll-report-english.pdf

9. Canadian Diabetes Association. (2011). The burden of out-of-pocket costs for Canadians with diabetes. Toronto, Ont.: Canadian Diabetes Association. http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/burden-of-out-of-pocket-costs-for-canadians-with-diabetes.pdf

10. Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, Malanda B, et al. IDF Dia-betes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 2018;138: 271-81.

11. IDF Diabetes atlas, 7th edn. Brussels, Belgium: International Diabetes Federation (IDF); 2015. Available from: http://www.diabetesatlas.org/resources/2015-atlas.html.

References

12. Diabetes Canada Clinical Practice Guidelines Expert Committee, Punthakee Z, Goldenberg R, Katz P. Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic. Can J Diabetes. 2018; 42 Suppl 1:S10–S15.

13. Cui M, Wu X, Mao J, Wang X, Nie M (2016) T2DM Self-Management via Smartphone Applications: A Systematic Review and Meta-Analysis. PLoS ONE 11(11): e0166718. https://doi.org/10.1371/journal.pone.0166718

14. Chamany S, Walker EA, Schechter CB, et al. Telephone intervention to improve diabetes control: A randomized trial in the New York City A1c Registry. Am J Prev Med 2015;49:832–841.

15. Diabetes Canada Clinical Practice Guidelines Expert Committee, Berard LD, Siemens R, Woo V. Monitoring Glycemic Control. Can J Diabetes. 2018;42 Suppl 1:S47-S53.

16. Diabetes Canada Clinical Practice Guidelines Expert Committee, Sherifali D, Berard LD, Gucciardi E, MacDonald B, MacNeill G. Self-Management Education and Support. Can J Diabetes. 2018;42 Suppl 1:S36-S41.

17. Worswick J, Wayne SC, Bennett R, et al. Improving quality of care for persons with diabetes: An overview of systematic reviews—what does the evidence tell us? Syst Rev 2013;2:26.

18. Klonoff, D. C., Blonde, L., Cembrowski, G., Chacra, A. R., Charpentier, G., Colagiuri, S., Coalition for Clinical Research-Self-Monitoring of Blood Glucose Scientific Board. Consensus report: the current role of self-monitoring of blood glucose in non-insulin-treated type 2 diabetes. Journal of diabetes science and technology. 2011;5(6):1529–48. doi:10.1177/193229681100500630

19. Karter AJ, Parker MM, Moffet HH, et al. Longitudinal study of new and prevalent use of self-monitoring of blood glucose. Diabetes Care. 2006;29:1757-63.

20. Diabetes Canada Clinical Practice Guidelines Expert Committee, Berard LD, Siemens R, Woo V. Monitoring Glycemic Control. Can J Diabetes. 2018;42 Suppl 1:S47-S53.

21. Malekiani CL, Ganesan A, Decker CF. Effect of hemoglobinopathies on hemoglobin A1c measurements. Am J Med 2008;121:e5.

22. Mignerat M, Lapointe L, Vedel I. Using telecare for diabetic patients: A mixed systematic review. Health Policy Technol 2014;3:90–112. http://www.sciencedirect.com/science/article/pii/S2211883714000148.

References

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https://secure.cihi.ca/free_products/AiB_Compromised_Wounds_EN.pdf

https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/pdf/facts-figures-faits-chiffres-eng.pdf

https://doi.org/10.1177/2377960817752471

http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/environics-opinion-poll-report-english.pdf

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23. Marcolino MS, Maia JX, Alkmim MB, et al. Telemedicine application in the care of diabetes patients: Systematic review and meta-analysis. PLoS ONE 2013;8:e79246.

24. Toma T, Athanasiou T, Harling L, et al. Online social networking services in the management of pa-tients with diabetes mellitus: Systematic review and meta-analysis of randomised controlled trials. Diabe-tes Res Clin Pract 2014;106:200–11.

25. Sherifali D, Viscardi V, Bai JW, et al. Evaluating the effect of a diabetes health coach on individuals with type 2 diabetes. Can J Diabetes 2016;40:84–94.

26. Massimi A, De Vito C, Brufola I, Corsaro A, Marzuillo C, Migliara G, et al. (2017) Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis. PLoS ONE 12(3): e0173617. doi:10.1371/journal.pone.0173617

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