Using Skype to Improve Diabetes Outcomes in Youth
Using Skype to Improve Diabetes Outcomes in Youth
Objective The objective of this study was to compare the relative effectiveness of two modes of delivering Behavioral Family Systems Therapy for Diabetes (BFST-D) to improve adherence and glycemic control among adolescents with type 1 diabetes with suboptimal glycemic control (HbA1c ≥9.0% [≥74.9 mmol/mol]): face to face in clinic (Clinic) and Internet videoconferencing (Skype) conditions.
Research Design and Methods Adolescents aged 12 to 18 years and at least one adult caregiver were randomized to receive BFST-D via the Clinic or Skype condition. Participants completed up to 10 therapy sessions within a 12-week period. Changes in youth- and parent-reported adherence and glycemic control were compared before and after the intervention and at follow-up assessment.
Results Using an intent-to-treat analytic approach, no significant between-group differences were identified between the before, after, and follow-up assessments. Groups were collapsed to examine the overall effects of BFST-D on adherence and glycemic control. Results identified that statistically significant improvements in adherence and glycemic control occurred from before to after the intervention; improvements were maintained at 3-month follow-up.
Conclusions Delivery of BFST-D via Internet-based videoconferencing is viable for addressing nonadherence and suboptimal glycemic control in adolescents with type 1 diabetes, potentially reducing important barriers to care for youth and families.
The intensive management of type 1 diabetes has been well established as critical to optimizing long-term health outcomes. Modern diabetes care is difficult to accomplish, however, because it is often complex and demanding for youth and families. Achieving optimal management of type 1 diabetes is difficult at any age but particularly during adolescence, as youth assume increasing responsibility for their care. While numerous factors likely contribute to adherence difficulties during this critical developmental period, family functioning is an important predictor of adherence and glycemic control. Specifically, family conflict, parent–adolescent communication, and family problem-solving have been associated with diabetes outcomes during adolescence.
Given the role of family interactions, interventions to address family functioning during this developmental period have been well tested. Behavioral Family Systems Therapy (BFST) is a well-supported intervention designed to improve family functioning and adherence in youth with diabetes. BFST is a structured, manualized intervention that includes four primary components: problem-solving, communication skills, cognitive restructuring, and family systems interventions. BFST improves family communication and problem-solving when compared with standard medical care. A modified version, BFST for Diabetes (BFST-D), which specifically targets optimizing diabetes care, significantly improves glycemic control, treatment adherence, and diabetes-related family conflict among adolescents with type 1 diabetes. Further, a home-based version of BFST-D has resulted in statistically and clinically meaningful improvements in family functioning and glycemic control, thus demonstrating that modified delivery methods can be used to improve access to care.
While growing evidence supports the benefits of interventions such as BFST-D to assist with adherence in pediatric chronic health conditions, access to well-trained providers remains a barrier to implementation. Specialty behavioral health care often is concentrated in large urban areas and associated with university clinics and/or academic medical health centers. Rural settings present particular challenges to accessing behavioral health services because of shortages of providers. While primary care providers in rural settings often attempt to address their patients' behavioral health needs, limitations in time, expertise, and reimbursement for such services are barriers to addressing the often complex behavioral health and family dynamic needs of youth with poorly controlled diabetes. Accessibility limitations in rural and underserved communities often require families to travel considerable distances to receive services or forgo mental health services altogether.
Although effective, home-based delivery of BFST-D is unlikely to be a practical or sustainable solution to reducing barriers to care, particularly for patients in rural areas. Thus additional methods of delivering evidence-based treatment are needed. The use of technology to delivery behavioral health care is one mechanism for increasing access to services.
Telemental health care, or the delivery of psychological or behavioral health care via communication networks, has been deployed to overcome a shortage of and/or uneven distribution of behavioral health resources and infrastructure. Importantly, recent technological advancements such as the increasing availability and rapid growth in the adoption of household Internet among low-income and rural families has created opportunities to provide services using telemental health. In particular, Internet-based videoconferencing may be an effective method of overcoming obstacles to care by increasing the availability of expert or specialized services to address regional shortages of qualified providers. Use of Internet-based videoconferencing platforms offers several pragmatic advantages, including being available at no or low cost to families, allowing for real-time audio and visual interaction between patients and providers, and facilitating delivery of treatment in the family home, which decrease the direct costs and time associated with treatment.
The use of telemental health is receiving increased attention. Most studies, however, have been preliminary or descriptions of feasibility and usage rather than well-controlled randomized clinical trials. While interventions that use Internet technology are beginning to include youth with diabetes, to date reports have focused exclusively on feasibility and enrollment outcomes. Well-controlled randomized clinical trials examining the effectiveness of behavioral health interventions using teleconferencing technology for youth with poorly controlled diabetes (i.e., HbA1c ≥9.0% [≥74.9 mmol/mol]) are absent in the published literature.
We report the results of a clinical trial comparing the delivery of BFST-D to adolescents with poorly controlled diabetes and their caregiver(s) randomized to receive the intervention via conventional conditions (Clinic) or videoconference (Skype). Because BFST-D has been shown to improve family functioning, adherence, and glycemic control, our primary interest was whether outcomes would differ depending on delivery method. Thus, our first hypothesis was that BFST-D delivered via videoconferencing (Skype) would yield outcomes that were not significantly different than conventional clinic-based delivery. Second, regardless of condition, we hypothesized that BFST-D would significantly improve regimen adherence and glycemic control in youth with poorly controlled type 1 diabetes.
Abstract and Introduction
Abstract
Objective The objective of this study was to compare the relative effectiveness of two modes of delivering Behavioral Family Systems Therapy for Diabetes (BFST-D) to improve adherence and glycemic control among adolescents with type 1 diabetes with suboptimal glycemic control (HbA1c ≥9.0% [≥74.9 mmol/mol]): face to face in clinic (Clinic) and Internet videoconferencing (Skype) conditions.
Research Design and Methods Adolescents aged 12 to 18 years and at least one adult caregiver were randomized to receive BFST-D via the Clinic or Skype condition. Participants completed up to 10 therapy sessions within a 12-week period. Changes in youth- and parent-reported adherence and glycemic control were compared before and after the intervention and at follow-up assessment.
Results Using an intent-to-treat analytic approach, no significant between-group differences were identified between the before, after, and follow-up assessments. Groups were collapsed to examine the overall effects of BFST-D on adherence and glycemic control. Results identified that statistically significant improvements in adherence and glycemic control occurred from before to after the intervention; improvements were maintained at 3-month follow-up.
Conclusions Delivery of BFST-D via Internet-based videoconferencing is viable for addressing nonadherence and suboptimal glycemic control in adolescents with type 1 diabetes, potentially reducing important barriers to care for youth and families.
Introduction
The intensive management of type 1 diabetes has been well established as critical to optimizing long-term health outcomes. Modern diabetes care is difficult to accomplish, however, because it is often complex and demanding for youth and families. Achieving optimal management of type 1 diabetes is difficult at any age but particularly during adolescence, as youth assume increasing responsibility for their care. While numerous factors likely contribute to adherence difficulties during this critical developmental period, family functioning is an important predictor of adherence and glycemic control. Specifically, family conflict, parent–adolescent communication, and family problem-solving have been associated with diabetes outcomes during adolescence.
Given the role of family interactions, interventions to address family functioning during this developmental period have been well tested. Behavioral Family Systems Therapy (BFST) is a well-supported intervention designed to improve family functioning and adherence in youth with diabetes. BFST is a structured, manualized intervention that includes four primary components: problem-solving, communication skills, cognitive restructuring, and family systems interventions. BFST improves family communication and problem-solving when compared with standard medical care. A modified version, BFST for Diabetes (BFST-D), which specifically targets optimizing diabetes care, significantly improves glycemic control, treatment adherence, and diabetes-related family conflict among adolescents with type 1 diabetes. Further, a home-based version of BFST-D has resulted in statistically and clinically meaningful improvements in family functioning and glycemic control, thus demonstrating that modified delivery methods can be used to improve access to care.
While growing evidence supports the benefits of interventions such as BFST-D to assist with adherence in pediatric chronic health conditions, access to well-trained providers remains a barrier to implementation. Specialty behavioral health care often is concentrated in large urban areas and associated with university clinics and/or academic medical health centers. Rural settings present particular challenges to accessing behavioral health services because of shortages of providers. While primary care providers in rural settings often attempt to address their patients' behavioral health needs, limitations in time, expertise, and reimbursement for such services are barriers to addressing the often complex behavioral health and family dynamic needs of youth with poorly controlled diabetes. Accessibility limitations in rural and underserved communities often require families to travel considerable distances to receive services or forgo mental health services altogether.
Although effective, home-based delivery of BFST-D is unlikely to be a practical or sustainable solution to reducing barriers to care, particularly for patients in rural areas. Thus additional methods of delivering evidence-based treatment are needed. The use of technology to delivery behavioral health care is one mechanism for increasing access to services.
Telemental health care, or the delivery of psychological or behavioral health care via communication networks, has been deployed to overcome a shortage of and/or uneven distribution of behavioral health resources and infrastructure. Importantly, recent technological advancements such as the increasing availability and rapid growth in the adoption of household Internet among low-income and rural families has created opportunities to provide services using telemental health. In particular, Internet-based videoconferencing may be an effective method of overcoming obstacles to care by increasing the availability of expert or specialized services to address regional shortages of qualified providers. Use of Internet-based videoconferencing platforms offers several pragmatic advantages, including being available at no or low cost to families, allowing for real-time audio and visual interaction between patients and providers, and facilitating delivery of treatment in the family home, which decrease the direct costs and time associated with treatment.
The use of telemental health is receiving increased attention. Most studies, however, have been preliminary or descriptions of feasibility and usage rather than well-controlled randomized clinical trials. While interventions that use Internet technology are beginning to include youth with diabetes, to date reports have focused exclusively on feasibility and enrollment outcomes. Well-controlled randomized clinical trials examining the effectiveness of behavioral health interventions using teleconferencing technology for youth with poorly controlled diabetes (i.e., HbA1c ≥9.0% [≥74.9 mmol/mol]) are absent in the published literature.
We report the results of a clinical trial comparing the delivery of BFST-D to adolescents with poorly controlled diabetes and their caregiver(s) randomized to receive the intervention via conventional conditions (Clinic) or videoconference (Skype). Because BFST-D has been shown to improve family functioning, adherence, and glycemic control, our primary interest was whether outcomes would differ depending on delivery method. Thus, our first hypothesis was that BFST-D delivered via videoconferencing (Skype) would yield outcomes that were not significantly different than conventional clinic-based delivery. Second, regardless of condition, we hypothesized that BFST-D would significantly improve regimen adherence and glycemic control in youth with poorly controlled type 1 diabetes.
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