Understanding the patients’ experience in Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme - A Qualitative Study

Abstract

Background Diabetes mellitus related healthcare expenditure is expected to rise drastically as the incidence of diabetes associated comorbidities increase. Hence, it is vital to maintain ideal glycaemia for patients with diabetes to reduce the risk of diabetic complications. Given the strong predictive value for diabetes complications, HbA1c remains the gold standard test to monitor glycaemic control in contemporary clinical practice. HbA1c is recommended to be measured between quarterly to six monthly, depending on the level of patient’s glycaemic control. There is growing positive evidence that supports the use of innovative telemedicine to monitor and manage patients with diabetes. Telemedicine has particularly played a crucial role in efforts against the COVID-19 pandemic. PTEC HAT pilot programme is developed by MOH Office of Healthcare transformation (MOHT) to implement telemonitoring care to low-risk patients with type 2 diabetes mellitus (T2DM) in the community through National Healthcare Group (NHG) Polyclinics collaboration. It is intended to empower low-risk patients to manage their T2DM care independently and maintain their follow-up with the healthcare team by telemonitoring. Through PTEC HAT, eligible patients will be able to replace their three to six monthly interim paired HbA1c test and physical polyclinic visits with home HbA1c tests and teleconsultations, saving them up to three visits to polyclinic per year while getting their glycaemic control telemonitored by the healthcare team. This qualitative study is conducted as part of the evaluation of the pilot implementation of PTEC HAT programme. It aims to explore the experiences of low-risk patients with T2DM who participated in PTEC HAT programme, and to identify the enablers and barriers of using various PTEC HAT components. Methods Patients referred by healthcare team were selected via purposive sampling and invited via telephone. Individual semistructured in-depth interviews were conducted with 12 patients. The interviews were audio-recorded and transcribed verbatim. The results generated from thematic analysis were presented in the form of rich descriptions. The nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability (NASSS) framework was used as the conceptual framework for the topic guide and guided the analysis framework. The emergent results were categorised into the enablers and barriers further grouped into themes. Results The identified enablers and barriers were grouped into themes. For the enablers, patient found the coaching by healthcare team and the access to supporting materials (video tutorial and user guide) useful in encouraging them to complete PTEC HAT programme. Patients accepted PTEC HAT as a suitable telemonitoring programme to maintain care for low-risk T2DM, especially during the pandemic. In term of technology component, patients liked the proactive reminder for home HbA1c testing by the in-app chatbot and the advantage of completing review through teleconsultation. Patients felt rewarded as the reading could be generated instantaneously using the home HbA1c test and the flexibility to perform the home HbA1c test at any preferred time was another great value. The patients also valued the convenience of teleconsultation following home HbA1c test, which saved time and reduced clinic visits. Patient characteristic which enabled successful participation included a reasonable level of digital literacy, prior experience with health monitoring, absence of needle phobia and strong intrinsic motivation. The barriers identified included tedious storage and preparation of the HbA1c self-test kit in addition to the prolonged onboarding process. The three to six months’ gap between onboarding and conducting the actual home HbA1c testing was reported to be challenging for patients to recall the required steps. Other key barriers included issues with syncing the home HbA1c reading to mobile app via the Bluetooth device. The concerns of high cost associated with the PTEC HAT programme had also resulted in a negative impact on patients’ acceptability and lowered their perceived value. Last, low digital literacy, needle phobia and lack of motivation were identified as the barriers at patient level to affect PTEC HAT programme. Conclusion Patients reported that home HbA1c monitoring under PTEC HAT was a useful alternative to routine care. The patients' experience with PTEC HAT varied with their exposure to health monitoring and health literacy. Findings from this study can provide insights to improve the design of other similar telehealth initiatives and enhance widespread adoption, scale-up, spread and sustainability of home HbA1c monitoring.