Evaluation of Social Platform-Based Continuity of Care in Improving Cognitive and Prognostic Effects of Young Patients with Diabetic Retinopathy

Introduction

Diabetic retinopathy (DR) is one of the most common and serious complications in diabetic patients.¹ In recent years, the incidence of DR in younger age groups is increasing as the standard of living of Chinese people continues to improve.² While the pathogenesis of DR are complicated and people do not know it well, the evidence indicated that hypoxia plays an important part in its development and progression.³ Diabetes linked to insufficient oxygen delivery to retina. Retinal hypoxia may be evident even before clinically detectable microvascular damage develops.⁴ Complete clinical control of DR is currently unattainable. It has been shown in clinical research⁵ that patients with diabetic disease often suffer from severe vision loss or DR due to factors such as poorly controlled blood sugar levels and vitreous blood accumulation caused by retinal detachment. Moreover, a study⁶ indicated that the majority of diabetic patients discharged from the hospital lack knowledge of relevant treatment and awareness of regular checkups, resulting in lower compliance and risks of poor glycemic control and DR. Early and effective nursing interventions, symptomatic treatment and glycemic control can significantly delay the development of DR in patients. Therefore, effective continuity of care is essential to improve patient prognosis.⁷

Wewer Albrechtsen et al⁸ found that massive Open Online Courses (MOOCs) are educational tools for institutions to teach and share their research around the world. The medical education based on MOOCs can provide accessible and free research-based education for health professionals who live in the developing and developed countries. This project looks promising. Christensen et al⁹ suggested that successful weight loss maintenance was related to an interplay between behavioral, affective and contextual changes. “Instrumentalization of eating behavior” seems to be an necessary part in long-term weight maintenance.

WeChat-based continuity of care is a new model of care with the integration of the continuity of care and WeChat.⁶ The WeChat-based continuity of care model is more coordinated, collaborative, continuous, and comprehensive than conventional continuity of care, allowing patients to return to families and society with good physical and psychological functions.⁷ The WeChat-based continuity of care model has been frequently adopted in several clinical studies of chronic diseases⁸ and produces excellent clinical outcomes. This research was undertaken to evaluate the validity of WeChat-based continuity of care in improving cognitive and prognostic effects of patients with diabetes without DR.

Materials and Methods

Participants

A total of 88 young age diabetic patients admitted to the outpatient clinic of First Affiliated Hospital of Soochow University (Endocrine and Ophthalmology Outpatient) from January 2021 to May 2022 were solicited and appointed via random number table method to receive either routine follow-up care (routine group) or WeChat-based continuity of care (WeChat group), with 44 patients in each group. The study was approved by the ethics committee of the hospital.

Inclusion and Exclusion Criteria

Inclusion criteria: 1) patients were diagnosed with diabetes by clinically relevant test results; 2) aged 18–40 years; 3) patients undergoing treatment; 4) with good visual function with a baseline BCVA letter score (approximate Snellen equivalent) of 23 (20/400); 5) who were able to use smartphones; 6) patients and their families were informed about the research and voluntarily signed the relative informed consent forms; 7) patients who were from inpatient to the outpatient clinic, and whose main compliant was diabetes acute complication.

Exclusion criteria: 1) patients with co-morbid psychiatric disorders or communication disorders; 2) Have a serious pre-existing medical condition like cardiovascular, liver or kidney disease or mental illness; 3) with other ocular complications, like glaucoma, severe cataracts, poor vision, retinal detachment, ophthalmic nerve disease, uveitis and retinopathy not linked to DM; 4) patients and family members who could not fully cooperate with the study.

Treatment Methods

(1) Patients in the routine group received routine follow-up care. These patients were given discharge instructions 1 week before discharge and were instructed to receive regular home health education and develop good lifestyle habits. Patients were informed to perform regular reviews and seek medical attention for any abnormalities. The frequency of follow-up by telephone was once every 2 weeks.

(2) Patients in the WeChat group received a WeChat-based continuity of care intervention. 1) Establishment of a WeChat education team. The education team consisted of three diabetologists, three ophthalmologists, and four nurses. All members were trained in relevant knowledge as well as intervention and follow-up measures prior to their assignment to ensure uniformity of nursing measures. 2) Details of specific nursing measures: ① The education team leader created and invited all patients into a WeChat group chat. ② The patients were educated by the medical staff through the WeChat group chat between 15:00 and 17:00 every Wednesday and Saturday, such as nutritional matching plan of food or efficacy and contraindication of foods, so as to strengthen the patients’ awareness of reasonable diet, promote the adjustment of their diet structure and improve their consciousness of blood glucose control. ③The patients recorded their daily blood glucose and provided unified feedback at 18:00 every Saturday, and medical staff provided guidance on medication, diet and exercise according to the patient’s blood glucose control. ④ The patients were educated about the contraindications related to exercise to avoid impact on the retina. Patients with good blood sugar control were instructed to carry out appropriate exercises. ⑤ Medical staff regularly post eye care-related articles in the WeChat group to help patients learn proper eye care, and conduct ophthalmologic follow-up weekly for fundus condition review and vision testing. ⑥ The medical staff answered patients and their families’ questions in a timely manner. The medical staff encouraged patients to actively share their personal experiences in the group, thus improving their treatment compliance.

Outcome Measures

Treatment Compliance

The compliance standards were established and defined by the medical staff in our department. Complete compliance: Patients were fully compliant with daily medication and rehabilitation care. Good compliance: Patients were relatively more cooperative with daily medication and rehabilitation care. Poor compliance: Patients were uncooperative with daily dosing and rehabilitation care and frequently showed resistant behaviors.

Cognitive-Behavioral Ability

During outpatient examination and follow-up for 1 year, the cognitive-behavioral ability of the patients was evaluated using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25). The patients would evaluate specific the severity of specific visual symptoms or the difficulty of activities among the twenty-five items which have been listed in the NEI VFQ-25 and presented in Likert scale format. The activities including driving, reading newspapers, etc. There is also a general health subscale generated from the questionnaire besides 11 VRQoL subscales in the below. It is consisted of general vision, eye pain, near range activities, distance range activities, social functioning, mental health, role difficulties, dependency, driving, color vision, and peripheral vision. The overall composite score will be calculated as the average of the 11 visual-related subscales finally. Scores range from 0 to 100, with higher scores showing better cognitive performance.¹⁰

Self-Care Ability

At discharge and 1 year after discharge from hospital, patients’ self-care ability was evaluated using the Exercise of Self-Care Agency (ESCA). The ESCA scale involves 4 dimensions, which means self-concept (9 items, 36 points in all), self-responsibility (8 items, 32 points in all), self-care skills (12 items, 48 points in all), and health knowledge level (14 items, 56 points in all), totaling 43 items. On the basis of the 3-level scoring method, the score was 0–172 points in total. The score status demonstrates the patient’s self-care ability, and the two are directly proportional to each other. Low: 0–57 points; medium: 58–115 points; high: 116–172 points.⁴

Quality of Life

Patients’ life quality was evaluated using the Low Vision Quality of Life Questionnaire (LVQOL). LVQOL was developed by Wolffsohn and Cochrane13 specifically for low vision patients. It includes 25 items in 4 dimensions, eg, distance vision, mobility, and lighting; adjustment; reading and fine work; and activities of daily life. The instrument is adapted to understand the needs of low vision patients in everyday life and to assess whether these requests can be met through low vision rehabilitation. The assessment system requires patients to answer questions on a five-point scale, with 5 being no difficulty and 1 being very difficult. The total score ranges from 0 to 125 points, and the score is directly proportional to the quality of life. It has been shown that LVQOL is a reliable, internally consistent and sensitive measure of life quality in low vision patients.¹¹

All questionnaires were answered by the participants.

Prognosis

A poor prognosis was indicated when patients showed loss of visual acuity or developed DR at follow-up and review. An optokinetic reflex system was applied to discover abnormalities in visual acuity (a measure of percentage (%) head-tracking movement per unit time or optokinetic reflex (OKR). The visual acuity in the left and right eyes is tested and evaluated weekly. Briefly, visual acuity testing was conducted by rotating clockwise and counter-clockwise at an angular speed of 2.61rpm for 2min in each direction, with an interval of 30s between the two rotations.

Sample Size

To achieve an effect size = 0.40 between two groups (conventional nursing and WeChat-based nursing), assuming a type 1 error of 0.2 and 95% confidence level, the total sample size will be 88 participants distributed into 2 groups. The sample calculation was performed in Excel, based on the calculation formula described by Kadam and Bhalerao. Considering a 20% drop-out, 3 extra participants will be inserted into each group, if there is said drop-out this will provide a final sample of participants per group.

Statistical Analysis

The data in the present study were organized and analyzed using SPSS 22.0, and GraphPad Prism 8 was used to plot the graphics. The measurement data such as VRQoL and ESCA were expressed as mean ± standard deviation (x ̅ ± s) and examined using a t-test. The count data such as treatment compliance were expressed as the number of cases and tested using the chi-square test. P<0.05 indicates that the difference is statistically significant. If datasets are normally distributed and satisfied with the assumption of variance homogeneity, a multivariate analysis of variance were adopted to evaluate statistical differences among these groups. Bonferroni-corrected post hoc comparisons were applied to figure out discrepancies between the groups. Should the dependent variables exhibit non-normal distributions, the non-parametric Kruskal–Wallis test would be carried out.

Results

Patient Characteristics

Patients in the routine group included 25 males and 19 females, aged 22–39 (30.43±3.82) years, with a disease duration of 2–7 (3.46±1.07) years. There were 17 cases of high school and below and 27 cases of junior college and above in terms of education level. Patients in the WeChat group included 28 males and 16 females, aged 20–40 (30.48±3.79) years, with a disease duration of 1–8 (3.52±1.11) years. There were 20 cases of high school and below and 24 cases of junior college and above in terms of education level. The two groups were well-balanced in terms of patient characteristics (P>0.05) (Table 1).

Table 1 Patient Characteristics

Treatment Compliance

The treatment compliance of the routine group was 77.3% (34/44), in which 12 cases were completely compliant, 22 cases were well compliant, and 10 cases were poorly compliant. The treatment compliance of the WeChat group was 97.7% (43/44), in which 13 cases were complete compliance, 30 cases were good compliance, and 1 case was poor compliance. The WeChat group showed higher treatment compliance than the routine group (P<0.05) (Table 2).

Table 2 Treatment Compliance

Cognitive-Behavioral Ability and Self-Care Ability

The cognitive-behavioral abilities of the routine group at outpatient examination and 1-year follow-up were (69.82±3.31, 76.29±2.34), self-care responsibility scores were (18.23±6.11, 23.25±12.86), self-care skills scores were (16.42±7.73, 22.36±10.25), self-state status scores were (18.33±5.52, 21.28±13.44), and DR knowledge scores were (17.85±6.42, 22.47±11.61). The cognitive behavioral abilities of the WeChat group patients at outpatient examination and 1-year follow-up were (69.74±3.48, 93.21±1.52), self-care responsibility scores were (18.74±5.39, 31.54±10.93), self-care skills scores were (16.34±7.85, 29.39±13.54), self-state status scores were (18.72±5.41, 30.16±12.31), and DR knowledge scores were (17.68±6.33, 31.52±13.99). The difference in cognitive-behavioral ability, self-care responsibility, self-care skills, self-state, and diabetic retinopathy knowledge upon discharge from the hospital between the two groups did not come up to the statistical standard (P>0.05). Patients receiving WeChat-based continuity of care exhibited significantly higher scores of cognitive-behavioral ability, self-care responsibility, self-care skills, self-state, and diabetic retinopathy knowledge during follow-up than those with routine care (P<0.05) (Figure 1).

Figure 1 Cognitive-behavioral ability and self-care ability. Note: *Indicates P<0.05.

Quality of Life

The physical functioning scores at outpatient examination and 1-year follow-up in the routine group were (9.21±1.15, 10.32±1.34), psycho-psychological scores were (7.89±2.05, 11.31±2.14), symptoms and visual function scores were (9.35±1.47, 10.05±1.78), and social activity was (7.82± 1.74, 10.65±1.58). The physical functioning scores outpatient examination and 1-year follow-up in the WeChat group were (9.13±1.17, 11.59±2.06), psycho-psychological scores were (8.04±1.92, 14.72±2.65), symptoms and visual function scores were (9.62±1.52, 11.38±1.85), and social activity scores were (8.03± 1.46, 12.37±2.36). Patients in the WeChat group had a significantly better physical function, mental psychology, symptoms and visual function, and social activity levels than those in the routine group (P<0.05) (Figure 2).

Figure 2 Quality of life (). Note: *Indicates P<0.05.

Prognosis

In the routine group, the incidence of vision loss was 29.5% (13/44) and of diabetic retinopathy was 15.9% (7/44). In the WeChat-based group, the incidence of vision loss was 6.8% (3/44) and of diabetic retinopathy was 2.3% (1/44). WeChat-based continuity of care resulted in a significantly lower incidence of visual acuity loss and diabetic retinopathy during follow-up than routine care (P<0.05) (Table 3).

Table 3 Prognosis [n (%)]

Discussion

Diabetes mellitus is a common clinical endocrine disease that causes a substantial impact on the metabolic function of the patient.¹² As the disease progresses, hyperglycemia, hypertension, and urinary microalbumin may lead to peripheral neurological complications in the foot, liver, kidney, and eyes.¹³ Diabetic retinopathy is a metabolic disease caused by insulin abnormalities and is a clinical retinal vascular disease that contributes significantly to blindness in adults.¹⁴ The lack of specific symptoms at the early onset of DR, insufficient attention to the ocular risk, and high cost of regular check-ups in most diabetic patients usually result in untimely treatment.¹⁵ Research¹⁶ indicated that most diabetic patients develop DR due to poor self-management and weak complication awareness, which seriously compromises the patient’s subsequent recovery and prognosis. Christensen et al¹⁷ reviewed the major anti-obesity drugs and the benefit-risk profiles of the long-acting glucagon-like peptide-1 receptor agonists (GLP-1 RAs) liraglutide and semaglutide (a modified version of liraglutide with longer half-life and tripled receptor affinity), and concluded that the safety profiles for both drugs were similar, with transient gastrointestinal disorders being the most commonly reported adverse events. The longest running trial and the most recent trials have not raised any new safety concerns.

Thus, it is of great importance to provide patients with proper out-of-hospital care for their subsequent recovery and to reduce the risk of DR. Continuity of care after patient discharge is an emerging concept of care in recent years.¹⁸ A study¹⁹ has concluded that continuity of care effectively reduced the incidence of adverse reactions in patients at the early stage of discharge, thereby contributing to the improvement of patients’ post-discharge quality of life and consequently lowering the risk of readmission such as disease recurrence. WeChat is an instant chat software that features simple operation and high public acceptance. Thus, the use of WeChat for continuity of care can improve the efficiency of nursing care and the satisfaction and recognition of nursing care by patients and their families to a certain extent.²⁰

The results of the present study showed that patients receiving WeChat-based continuity of care exhibited significantly higher treatment compliance, better cognitive-behavioral ability, self-care responsibility, self-care skills, self-state, and diabetic retinopathy knowledge during follow-up, better physical function, mental psychology, symptoms and visual function, and social activity levels, and a significantly lower incidence of visual acuity loss and diabetic retinopathy than those with routine care. The above results confirm the effectiveness of WeChat-based continuity of care in improving young age diabetic patients’ knowledge of DR and improving their prognosis. The convenience of WeChat allows for easy and rapid communication between doctors and patients, thereby effectively enhancing patients’ understanding of their diseases for better disease control during home care.²¹ In addition, patients can encourage each other through WeChat, significantly improving patient compliance and reducing the risk of complications.²² Furthermore, the integration of WeChat into the continuity of care for patients effectively reduces the cost of patient management.²³ In communication with patients, assistance in improving patients’ knowledge about the disease may be crucial to improve the outcome of care, patients’ self-care ability, and disease awareness.²⁴ No patients in this study were found to be resistant to the continuity of care based on the WeChat social platform. In the patient feedback at the end of the care, all the tested patients gave positive comments about this care modality.²⁵ Through the Wechat-based program, we speculated that (1) patients might learn effective methods to assist patients in recovering to normal life; (2) patients were in close contact with professional nurses in time for any problems during the process of nursing, thus strikingly reducing the risk of adverse responses; (3) the patients could report psychological clinical responses to the experts timely and obtain some effective feedbacks, which might play a potential role in the prevention of anxiety and depression; (4) anxiety and depression are associated with prognosis of DR.

Consistent with the findings of our study, many scholars have drawn similar conclusions. Zhou et al²⁶ found a significant improvement in the health-related quality of life of postoperative women with breast cancer who adopted a WeChat-based multimodal nursing program during early rehabilitation. This demonstrated that the program is effective for postoperative rehabilitation in such patients. Findings of the study will provide evidence for health services in clinical and transitional nursing care. Yan et al²⁷ revealed that WeChat-based remote follow-up management of premature infants after discharge could effectively improve parents’ ability to care and their psychological state and reduce the burden of care. Guo et al²⁸ suggested that WeChat-based mobile health (mHealth) intervention Run4Love significantly reduced depressive symptoms among people living with HIV (PLWH), and the effect was sustained. An app-based mHealth intervention could provide a feasible therapeutic option for many PLWHD in resource-limited settings.

Conclusion

WeChat social platform-based continuity of care effectively improves treatment compliance and diabetic retinopathy awareness among young age diabetic patients, and enhances their self-care ability, thereby improving quality of life and reducing the risk of poor prognosis.