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Diabetics Have Something to Smile About

Viterbi Professor Shinyi Wu uses technology to improve communication between low-income diabetics and their medical providers.
By: Conrad Wilton
February 28, 2013 —
USC Professor of Industrial Systems Engineering Shinyi Wu

Having diabetes is never easy, but dealing with depression at the same time can make matters unbearable, especially for low-income patients. Just ask Michael Griego, 58, who was diagnosed with type-2 diabetes three years ago during what he expected to be an ordinary visit to his medical clinic.

“I was in shock,” Griego said. “I never thought it would happen to me.” 

Griego is a low-income resident of Alhambra. “I love cookies and I’m a big sweet eater, but I used to run and hike regularly in the mountains near my old house in Altadena.”

Griego’s life changed when he heard his sister was diagnosed with cancer. He soon became dispirited and stopped exercising. When his beauty salon closed, he lost his house and was forced to move.

“I was depressed and in the beginning I didn’t have a lot of motivation to continue my (diabetes) treatment,” Griego said. “But one day I went to my clinic and I heard about a new trial for diabetes patients.”

The Diabetes Depression Care Management Adoption Trial (DCAT) is a government funded research study exploring cost-effective methods to improve communication between diabetics and their medical providers so that patients, especially depressed ones, continue treating their disease. It is the vision of USC Viterbi Assistant Professor of Industrial Systems Engineering Shinyi Wu, who discovered her passion for medical research in Taiwan while caring for her ill grandparents.

“My grandpa had diabetes and a stroke, and my grandma had diabetes too,” Wu said. “In the rural town where I grew up, back then, you couldn’t get care until you were really bad off and were hospitalized. Usually by that time it was too late.”

Wu earned her Ph.D. in industrial engineering at the University of Wisconsin Madison and was an award-winning researcher in the RAND Health Department before coming to USC in 2008. Her strength is employing technology to help medical providers deliver the best possible care to their patients.

DCAT is her most recent endeavor dealing with type-2 diabetics. The study features an automated call system that regularly contacts patients, collects information about their diabetes, and evaluates them for depression. This information is then input into a database that medical providers access and then use to coach each patient through treatment.

Type-2 is the most common type of diabetes. It occurs when the body contains so much sugar that naturally produced insulin cannot remove it from the blood stream. According to the American Diabetes Association (ADA), about 1 in 12 people in the United States have been diagnosed with some form of diabetes. However, it is estimated that seven million Americans live with the disease undiagnosed. This can pose serious health risks, because untreated diabetes often sucks the life out of its patients and makes them more susceptible to depression.  Unsurprisingly, depressed patients are far less motivated to properly manage their disease. All too often their health deteriorates as a result. An estimated 30% of low-income Americans with type-2 diabetes develop depression, Wu said.

Michael Griego

Griego is one of 1,400 participants in Wu's three-year DCAT study. All participants are diabetic, low-income, minority residents of Los Angeles. Every three months, Griego receives an automated phone call from “Amy,” an interactive messaging and speech recognition system, who asks two simple questions about his energy level and outlook on life. If Griego feels blue, Amy calls him once a month asking nine questions to determine the severity of his depression. All information Amy collects about Griego’s depression and diabetes treatment is automatically added to what Wu calls the DMR, or the Disease Management Registry. From there, medical providers can access data for each patient, including medical histories and psychological health. Nurses, social workers and medical assistants can then call the patient, schedule regular visits and coach them through treatment.

DCAT is an inter-disciplinary study featuring collaboration between investigators in the Viterbi School of Engineering, the USC School of Social Work, and the Keck School of Medicine. Wu is the principal investigator of the study and oversees the entire operation. Her duties include designing Amy, training medical providers about team-based depression care and treatment, creating tasks in the DMR to remind providers to contact depressed patients, evaluating the study’s impact on patient health, and assessing patient satisfaction with the study.

Professor Shinyi Wu (center), Professor David Belson (far right) and Fellow DCAT Researchers

Wu’s research team at the LA County Department of Health Services Ambulatory Care Network used Amy in another study called the Heart Failure Automated Remote Monitoring System (HFARMS) in 2010. However, in HFARMS the automated call system was relatively simple, asking only a few questions about a patient’s weight and pulse to determine their risk of heart failure. Wu redesigned Amy for DCAT, equipping her with six different conversation modules and the ability to automatically send tasks to care managers via the DMR. Amy can also speak English and Spanish.

One of Wu’s main objectives was to design the most cost-effective method to contact patients and document vital information about their condition. On average, a call from Amy is much shorter than a call from a medical provider asking the same questions. Amy’s automated call costs about 85 cents, while a similar call from a nurse costs nearly $18, according to Laura Myerchin Sklaroff, the DCAT project coordinator from the Research and Innovation Division of the Los Angeles County Department of Health Services.

“Nurses have other competing responsibilities,” Sklaroff said. “During a call they have to take time to document their notes, but an automated system does this for them and lessons their workload.”

DCAT patients can choose the time of day they receive Amy’s call. If the patient does not pick up, Amy is programmed to call again three times within an hour before finally giving up and waiting until the following day. That means Amy is far more likely to reach a patient than when nurses call, because nurses typically have time to only call a patient once a day.  In addition, Amy is automated so she can talk to several patients at the same time. During HFARMS, in 50 days, Amy successfully recorded vital information from 102 patients. Two nurse practitioners, who also phoned patients asking the same questions, had only 19 successful calls over the same period of time. For patients who prefer people to robots Amy can connect them to a medical provider for a free consultation.

If Amy collects information that flags a patient as potentially suicidal, psychiatrists on call receive a text alert prompting them to contact the patient immediately. Within 48 hours, all patients who are depressed but not suicidal receive a call from medical providers to comfort them.

“It’s the halo effect,” Sklaroff said. “We want patients who are uninsured to know that they can get help from a large system and someone will respond to their needs quickly.

Adriana Cortes-Kanter is a clinical social worker at the Roybal Comprehensive Health Center, one of eight clinics participating in the DCAT study. Every day the DMR sends Kanter a lengthy “task list” with the names of patients she needs to call.

“It’s a lot of work,” she said. “It takes time to adjust, but once we got the hang of it I really appreciate having those tasks because if for some reason I forgot to call or follow up with a patient, (the DMR) would let me know.”

Personalized attention from medical providers has given depressed patients like Griego the care and confidence they need to succeed.

“I don’t feel like a number anymore,” Griego said. “I feel comfortable talking to a real person.”

Griego now visits his clinic every three months for regular check-ups and monitors his blood sugar daily. He also watches what he eats and tries to exercise as much as possible.

“Before we started DCAT, low-income patients would typically see clinicians for their diabetes but would not be screened for depression,” Wu said. “Even if they were screened and diagnosed with depression they’d be given meds and told to go home or referred to mental health clinics.”

In January, Wu testified in front of the California Assembly Health Committee to discuss the positive impact DCAT has made on patients and providers. She hopes DCAT will help revolutionize care for depressed diabetics all across California.

“At the assembly there were lots of people who said California needs better patient-provider communication for chronic illnesses,” Wu said. “I hope this study plays a prominent role in the state so all diabetics can feel more connected with their providers and receive the best care possible.”