Hypertension, Diabetes, Diabetic nephropathy, Chronic kidney disease, Myocardial infarction, Angina pectoris, Stroke, Transient ischemic attack, COPD, Heart failure
Conditions
Interventions
Implementation of disease management programs (acquisition of self-management skills and lifestyle change, 3 month-period) (Attached research: Implementation of AI-based disease management program (1
HF): Self-management education (3 months)
Sponsors
Hiroshima University, The research project management committee for development of AI health education system
Eligibility
Sex/Gender
All
Inclusion criteria
Inclusion criteria: Beneficiaries of national Health insurances or medical care system for elderly in the later stage of life, who live in Hiroshima prefecture, are outpatients of medical facilities, and meet all criteria from 1 to 5 listed below. 1. A patient who falls into one of the two. (1) A patient with any of the following diseases: Hypertension, Diabetes, Diabetic nephropathy, Chronic kidney disease, Myocardial infarction, Angina pectoris, Stroke, Transient ischemic attack (including a patient who quit the treatment) (2) Based on health check-up data, a patient who has Hypertension (Grade 2 hypertension: systolic BP >= 160mmHg or diastolic BP >= 100mmHg), Hyperglycemia (HbA1c >= 7.0% or fasting blood suger >= 130mg/dl), Reduction of kidney function (eGFR < 60 or urine protein >= 2+) 2. A patients was judged by their general physician or physician in charge intended to participate in this study 3. Age >= 20 years old of both sexes 4. Not being participated in another clinical study 5. A patient who agrees with the written consent form. (Attached research) Outpatients of Hiroshima University Hospital aged 20 years and over with the following disease: Diabetes mellitus/diabetic nephropathy (Stage 1-4), CKD (stage G1 to G4), myocardium Infarction/angina, stroke / TIA (up to modify Rankin Scale 3) (Attached research) Beneficiaries of national Health insurances or medical care system for elderly in the later stage of life, who live in Hiroshima prefecture, are outpatients of medical facilities. COPD: GOLD stage 2-4, HF: AHA/ACC stage B & C
Exclusion criteria
Exclusion criteria: 1) A patient was judged by the nurses (who provide the program) as unable to implement the program 2) An inpatient 3) A patient at Renal Replacement Therapy (renal transplantation, treated with dialysis) 4) A patient who has a plan for renal transplantation within 6 months 5) A patient at end stage (be given a year to live) 6) Type 1 diabetes 7) In pregnacy 8) Dementia (HDS-R <= 20/30) 9) Those who have behavioral problems and be considered as difficult to continue the program by his/her primary physician, physician in charge of diabetic care or researcher
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Feasibility evaluation of the system (Attached research: (1) After the nurse provided the health guidance according to the health guidance provided by the AI, did the patient change behavior as planned? (2) The degree of agreement between the risks, health guidance content, and action goals presented by AI and the nurses' thoughts) (Attached research: Change levels of behaviors) | — |
Secondary
| Measure | Time frame |
|---|---|
| 1. Physiological indicators: blood test (HbA1c, BS, CRE, BUN, UA, LDL- C, HDL-C, TC, TG, GOT, GPT, r-GTP, PT-INR, TP, ALB, HGB, K, P), urine test(urine protein, urine albumin), blood pressure, weight, pulse rate, fasting blood glucose(if patient has diabates and measure it) 2. Treatment change: medication, introduction of renal replacement therapy 3. Behavioral indicators: lifestyle, content of meals, presence or absence of smoking/drinking, behavioral goals and achievement (meal, exercise, medication/injection, self-monitoring) 4. Disease, development of disease/complication 5. Regulary visit to a clinic, presence or absence of hospitalization, reason for hospitalization 6. Results of questionnares (self-efficacy, QOL) 7. Records of personal health education, diet records, reports for physicians 8. Records of face-to-face instruction, voice record of telephone instruction | — |
Countries
Japan
Contacts
Public ContactMichiko Moriyama
Hiroshima University Graduate School of Biomedical and Health Sciences
Outcome results
None listed