Pro-Active Call Center Can Improve Glycemic Control

A Pro-Active call center with nonmedical telephone operators and some software with the help of a diabetes nurse was well received.

Pro-Active Call Center Treatment Support (PACCTS) intervention can improve glycemic control in type 2 diabetes. A second article in the same issue established that this intervention, using trained nonmedical telephone operators supported by specially designed software and a diabetes nurse, was well received by the patients.

"Diabetes educator-led PACCTS for diabetes care is well established as a health care delivery vehicle in the US," write Robert J. Young, MD, from Hope Hospital in Salford, U.K., and colleagues. "It seems to offer service delivery characteristics that might enhance effectiveness, such as continuity, convenience, and risk-stratified intervention. However, it has not been subject to rigorous or large-scale clinical trial assessment of its effectiveness or efficiency."

Of 591 randomly selected individuals with type 2 diabetes,197 individuals were randomized to the usual care (control) group and 394 to the PACCTS (intervention) group. Both groups received lifestyle advice and drug treatment according to local guidelines, but only PACCTS patients were telephoned according to a protocol in which the frequency of calls was proportional to the patients’ last glycated hemoglobin (HbA1c) level. The primary outcome measure was absolute reduction in HbA1c level, and the secondary outcome was the proportion of patients in whom HbA1c level decreased by at least 1%.

The one-year study was completed by 332 patients (84%) in the PACCTS group and 176 patients (89%) in the control group, and final HbA1c values were available in 374 patients (95%) in the PACCTS group and 180 patients (92%) in the usual care group.

Compared with the usual care group, HbA1c level improved by 0.31% overall (95% confidence interval [CI], 0.11-0.52; P = .003) in the PACCTS group. However, for patients with baseline HbA1c level less than 7%, there was no change, and for patients with baseline HbA1c level of more than 7%, improvement increased to 0.49% (95% CI, 0.21-0.77; P < .001). The difference in the proportions of patients achieving at least a 1% reduction in HbA1c level was 10% overall (95% CI, 4-16; P < .001) and 15% (95% CI, 7-24; P < .001) for patients with baseline HbA1c level of more than 7%, favoring the PACCTS intervention.

"In an urban Caucasian trial population with blood glucose HbA1c > 7%, PACCTS facilitated significant improvement in glycemic control," the authors write. "Further research should extend the validity of findings to rural communities and other ethnic groups, as well as to smoking and lipid and blood pressure control."

An accompanying article by Andrew F. Long, MSc, MPhil, and colleagues from the PACCTS Team describes the results of a questionnaire survey designed to examine patients’ views of the acceptability of and satisfaction with PACCTS.

Using the Diabetes Satisfaction and Treatment Questionnaire (DTSQ), the investigators determined satisfaction with care in all 591 patients at baseline and at the end of the study. In addition, 394 intervention patients received an acceptability questionnaire after at least three proactive calls from the call center and at the end of the trial, and a sample of 25 patients participated in in-depth, semistructured interviews.

Response rates were 79% for the DTSQ and 65% for the acceptability questionnaire. Individuals receiving the PACCTS intervention continued to report high levels of satisfaction with their treatment (95% CI, 32.3-33.2 at one year), and more than 90% strongly agreed or agreed that the telecarer approach was acceptable.

Based on qualitative comments, the patients expressed satisfaction with having a personalized service; improved feelings of well-being, such as confidence and self-control; assistance with problem solving; and developing rapport and a strong bond with the telecarers.

"A personalized PACCTS approach is acceptable to patients," the authors conclude. "A service giving priority to the interpersonal dimension leads to increased commitment from patients to improve long-term glycemic control."

"These results suggest that several processes can contribute to a successful patient-centered telephone-supported disease management, [including] listening to and focusing on the concerns of patients, individualized problem solving, and continuity of care over time," the authors conclude. "It may not be the information provision per se that is important (raising awareness and knowledge), but its provision in a context of enablement and support aimed at self-efficacy."

The PACCTS intervention for diabetes management consists primarily of trained telecarer-initiated calls to patients focusing on the domains of knowledge, readiness to change (lifestyle intervention), medication adherence, and blood glucose control.
Compared with usual care, patients with diabetes with a baseline HbA1c level of more than 7% who were offered PACCTS for one year had improved HbA1c control, with a higher proportion showing improvement of at least 1%.

GlaxoSmithKline and British Telecom funded this study, and GlaxoSmithKline indirectly funded some of its authors.
Diabetes Care. 2005;28:278-289