JMIR Publications

ABSTRACT

Background:

Older adults with diabetes are vulnerable due to multimorbidity and difficulty achieving personalized glycemic control. Although insulin is often required, professionals hesitate to intensify therapy, and limited knowledge of geriatric therapeutic goals leads to regimens with high hypoglycemia risk. Simplified approaches such as once-daily basal insulin are recommended, yet titration and incomprehensible regimens remain major barriers in home nursing care. Strengthening nurses through autonomy, decision support, and training is essential, as nurse-led models improve outcomes, reducing hospitalizations. Digital decision support systems such as GlucoTab offer standardized, evidence-based insulin management and workflow integration, enabling safe, person-centered diabetes homecare.

Objective:

This study evaluated the impact of a nurse-led DSS for diabetes management in older adults with type 2 diabetes receiving homecare nursing on diabetes related hospital admissions and glycemic outcomes across pre-, during-, and post-implementation phases.

Methods:

A pre-, during-, and post-implementation proof-of-concept study was conducted using the digital DSS for diabetes management in two homecare nursing sites. Nine adults with type 2 diabetes on insulin therapy were enrolled (five women; mean age 77 ± 10 years; BMI 27.7 ± 4.7 kg/m²; baseline HbA1c 59.5 ± 12.8 mmol/mol). Data were collected six months pre-implementation, three months during implementation, and six months post-implementation. During the intervention, homecare nurses used the digital DSS, which integrates evidence-based diabetes management recommendations adapted to homecare and nursing workflows. Nurses received structured training beforehand. The system guided insulin initiation, titration, and regimen changes and automatically flagged critical situations for physician review.

Results:

In the six months pre-implementation, five diabetes-related emergency admissions led to four hospitalizations, compared with none during implementation and four admissions post-implementation, mostly due to hyperglycemia. The median hospital stay was nine days (pre- and post-implementation). Diabetes management shifted from predominantly mixed insulin therapy at baseline to basal insulin with or without bolus insulin during the intervention. Diabetes-related homecare visits decreased from 1.81 to 1.01 per day (pre- vs. during implementation), and general practitioner contacts for insulin adjustments declined slightly (19 pre-implementation vs. 16 post-implementation). Mean morning blood glucose decreased from 212 ± 72 mg/dl to 162 ± 42 mg/dl, and target range values (70–180 mg/dl) increased from 39.0% to 70.8% (pre- vs. during implementation). No severe hypoglycemia requiring third-party help occurred during implementation. Adherence to DSS recommendations was 94%.

Conclusions:

This study showed that integrating the digital DSS into homecare nursing significantly improved diabetes management. Emergency visits and hospitalizations decreased, no severe hypoglycemia occurred, glycemic control improved, and therapy was simplified. Nursing visits declined, indicating greater efficiency and resource use. High adherence and acceptance by nurses and patients underscore its usability and empowerment potential. These findings align with evidence from hospitalized patients and telemedicine studies, demonstrating clinical efficacy, safety, and potential cost-effectiveness. Clinical Trial: German Clinical Trials Register ID: DRKS00015059, EK.-No. 30-287 ex 17/18, EK.-No. 31-522 ex 18/19