Diabetes appointments via webcam in Newham

The traditional model of routine follow-up outpatient care is widely recognised to be inefficient and often ineffective as it fails to reliably provide responsive care when patients need intervention. Diabetes services face rising costs with the rising prevalence of the condition, inadequate self-management and poor clinical outcomes, exemplified by the diabetes outpatient service at Newham, east London.

The aim of this study was to learn if and how web-based consultations could improve patient experience and deliver more effective and efficient diabetes care. Newham has a culturally diverse population of 302 500, in which 9.9% are estimated to have diabetes, with more young people developing type 2 diabetes (four to five times the national average; Diabetes Health Intelligence, 2011; Balasanthiran et al, 2012). A population survey has reported poor attendance, self-management and health outcomes (Newham Ipsos Mori, 2009). Following a proof-of-concept pilot, a literature review and ascertainment that internet access in Newham is high, the group used readily available web-based software to replace routine outpatient care appointments.

Web consultations were offered to all patients from all ages and ethnic groups, where clinically appropriate, under the care of one consultant and one DSN over a 9-month period within the existing clinic, and outcomes were evaluated using quantitative and qualitative methods. The technology available in the participants’ homes was used. A total of 143 (out of 179) patients were considered clinically suitable and 89 patients participated. The main reasons for not participating was a lack of access to the internet (52%). There have been 191 web appointments to date.

Results
Average A&E attendance rates

• Baseline: 0.45 attendances/year/patient (average 5 years each).
• Post-intervention: 0.19 attendances/year/patient (average 7 months each).
• Eleven participants had between one and three A&E admissions in the year prior to the first webcam appointment, whereas only one participant has had an A&E admission since.

Clinic attendance rates
See Table 1 for details on clinic attendance rates.

Outcome measures
Where patients have had more than two webcam appointments, the mean reduction in HbA_1c was 2.9%.

Patient feedback
Patients felt that:

• The appointments were convenient, saving time and money (average saving of 1.8 hours per appointment).
• The quality of care the same as face-to-face.
• They were more in control.

In addition, 15 out of 28 felt more likely to keep webcam appointments and 19 out of 28 preferred webcam appointments.

Conclusions
Although the quantitative data are at present inconclusive, the qualitative data, in accordance with current trends, suggest that web-based consultations provide more effective, person-centred, equitable and timely care. Prolonged follow-up is required to substantiate this.