Web-based guided insulin self-titration in patients with type 2 diabetes: the Di@log study. Design of a cluster randomised controlled trial [TC1316]

Abstract

Background: Many patients with type 2 diabetes (T2DM) are not able to reach the glycaemic target level of HbA1c < 7.0%, and therefore are at increased risk of developing severe complications. Transition to insulin therapy is one of the obstacles in diabetes management, because of barriers of both patient and health care providers. Patient empowerment, a patient-centred approach, is vital for improving diabetes management. We developed a web-based self-management programme for insulin titration in T2DM patients. The aim of our study is to investigate if this internet programme helps to improve glycaemic control more effectively than usual care.

Methods/design: T2DM patients (n = 248), aged 35-75 years, with an HbA1c > or = 7.0%, eligible for treatment with insulin and able to use the internet will be selected from general practices in two different regions in the Netherlands. Cluster randomisation will be performed at the level of general practices. Patients in the intervention group will use a self-developed internet programme to assist them in self-titrating insulin. The control group will receive usual care.Primary outcome is the difference in change in HbA1c between intervention and control group. Secondary outcome measures are quality of life, treatment satisfaction, diabetes self-efficacy and frequency of hypoglycaemic episodes. Results will be analysed according to the intention-to-treat principle.

Discussion: An internet intervention supporting self-titration of insulin therapy in T2DM patients is an innovative patient-centred intervention. The programme provides guided self-monitoring and evaluation of health and self-care behaviours through tailored feedback on input of glucose values. This is expected to result in a better performance of self-titration of insulin and consequently in the improvement of glycaemic control. The patient will be enabled to 'discover and use his or her own ability to gain mastery over his/her diabetes' and therefore patient empowerment will increase. Based on the self-regulation theory of Leventhal, we hypothesize that additional benefits will be achieved in terms of increases in treatment satisfaction, quality of life and self-efficacy.

Trial registration: Dutch Trial Register TC1316.

Figure 1

Flowchart of the study. ¹ The online diary is used for monitoring blood glucose measurements. ² Feedback consistsof 1. a graphic presentation of the input 2. a dose advice for thenext 2 days or coming period 3. compliments/advice. ³ Alerts are generated when there is a medical urgency: hypoglycaemia (< 2.5 mmol/l) or hyperglycaemia (FBG > 20 mmol/l). When the patient gets an alert (feedback and advice), this is also sent to the GP. ⁴ Follow up consists of questionnaires and measurements of physical and clinical characteristics (see text: 'outcome assessment').