Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review

Video or In-Clinic Consultation? Selection of Attributes as Preparation for a Discrete Choice Experiment Among Key Stakeholders

INTRODUCTION

Video consultations (VCs) provide increased accessibility of primary care to remote areas and overall improved care for chronic patients. They also contribute to higher patient satisfaction and improved resource management. Despite these benefits, VC integration into the health system is complex and slow. Understanding the VC-related preferences of three key stakeholders-patients, primary care physicians (PCPs) and policy makers (PMs)-is crucial for achieving optimal implementation.

OBJECTIVE

The aim of this study was to select relevant attributes and levels for a discrete choice experiment (DCE) of stakeholders' choice-VC or traditional in-clinic consultation (I-CC) in primary care.

METHODS

Ten semi-structured focus group interviews and 24 semi-structured individual interviews were conducted. Data analysis was performed inductively, using a thematic content analysis method. An attribute-ranking exercise was then conducted based on the results gleaned from the interviews.

RESULTS

The most important attributes when choosing either VC or I-CC, for both patients and PMs, were: (1) time to next available appointment; (2) time in line before consultation; (3) relationship to PCP; and (4) quality of consultation. For PCPs, the most important attributes were: (1) time in line before consultation; (2) patient's self-management ability; (3) consultation purpose; (4) quality of consultation.

CONCLUSIONS

This qualitative study identified attributes and levels for a DCE quantitative stage among three key stakeholder groups. It adds to the literature of examples of developing DCE attributes, and to literature about the stakeholder benefits in the area of telemedicine in healthcare.

Creating an mHealth App for Colorectal Cancer Screening: User-Centered Design Approach

Background

Patients are increasingly using mobile health (mHealth) apps to monitor their health and educate themselves about medical issues. Despite the increasing popularity of such apps, poor design and usability often lead to suboptimal continued use of these apps and subsequently to poor adherence to the behavior changes at which they are aimed. One solution to these design problems is for app developers to use user-centered design (UCD) principles to consider the context and needs of users during the development process.

Objective

This study aimed to present a case study on the design and development process for an mHealth app that uses virtual human technology (VHT) to encourage colorectal cancer (CRC) screening among patients aged 50 years and above.

Methods

We have first provided an overview of the project and discussed its utilization of VHT. We have then reviewed UCD principles and how they can be incorporated into the development of health apps. We have described how we used UCD processes during the app’s development. We have then discussed the unique roles played by communication researchers, computer scientists, clinicians, and community participants in creating an mHealth app that is credible, usable, effective, and accessible to its target audience.

Results

The principles of UCD were woven throughout the project development, with researchers collecting feedback from patients and providers at all stages and using that feedback to improve the credibility, usability, effectiveness, and accessibility of the mHealth app. The app was designed in an iterative process, which encouraged feedback and improvement of the app and allowed teams from different fields to revisit topics and troubleshoot problems.

Conclusions

Implementing a UCD process contributed to the development of an app, which not only reflected cross-disciplinary expertise but also the needs, wants, and concerns of patients.

Power Gaps Among Stakeholders in Israel's Primary Care and the Role of Primary Care Physicians' Relative Power in Their Intention to Use Video-Consultations with Patients

Introduction: Although some correlates of primary care physicians (PCPs) telemedicine adoption have been studied, little is known about whether the intention to use video-consultations (VCs) relates to how PCPs view their power, relative to other stakeholder groups in primary care. The aim of this study was (1) to describe PCPs', patients', and policy makers' (PMs) views of their power and (2) to explore how PCPs views of power are associated with their intention to use VC. Methods: A convergent parallel mixed-methods design was used. Interviews were conducted with five focus groups that comprised 42 patients; five focus groups with 52 PCPs; and 24 individual interviews with PMs. A total of 508 patients, 311 PCPs, and 141 PMs completed the questionnaire, assessing intention to use VC and stakeholders' relative power. The qualitative data were analyzed using the thematic method; survey data were analyzed using quantitative methods. Results: All stakeholder groups rated PCPs' power as significantly lower, relative to that of patients and managers. PCPs' intention to use telemedicine was found to be significantly related to perceived power gaps between them and patients (r = -0.24, p < 0.001) and between them and managers (r = -0.45, p < 0.001). Themes revealed in the analysis describing how PCPs' low power influences their intention to use VC were as follows: PCPs' low-impact telemedicine-related decisions, increased work overload, "big brother" control, and Health Maintenance Organization demands for telemedicine mandatory usage. Conclusions: To successfully adopt VC, efforts should be made to increase PCPs' relative power, by strengthening their involvement in decision-making procedures and by increasing PCPs' control over their work environment.

Importance of the telemedicine network for neurosurgery in Slovenia

The number of invasive procedures in medicine is increasing, as is the employment of new technological achievements. In the era of information-communication technology, one such achievement is also the telemedicine network. In Slovenia, it is known as the Telekap (TeleStroke) network, which was primarily designed for fast and efficient management of stroke patients. In the neurosurgical community, the system is frequently used also for conveying vital information regarding subarachnoid haemorrhage and trauma. Especially in neurosurgical emergencies, this communication system offers thorough information about the extent and location of bleeding and facilitates the preoperative planning of neurosurgical interventions. From our experience so far, the system should be expanded to other neuro-centres as well to all neurosurgery departments in order to facilitate patient management, their acute hospital care, and inter-speciality collaboration.

A process and mechanism of action evaluation of the effect of early and intensive nutrition care, delivered via telephone or mobile application, on quality of life in people with upper gastrointestinal cancer: a study protocol

Background

Cancers of the upper gastrointestinal tract commonly result in malnutrition, which increases morbidity and mortality. Current nutrition best practice lacks a mechanism to provide early and intensive nutrition support to these patients. A 3-arm parallel randomised controlled trial is testing the provision of a tailored, nutritional counselling intervention delivered using a synchronous, telephone-based approach or an asynchronous, mobile application-based approach to address this problem. This protocol outlines the design and methods that will be used to undertake an evaluation of the implementation process, which is imperative for successful replication and dissemination.

Methods

A concurrent triangulation mixed methods comparative analysis will be undertaken. The nutrition intervention will be provided using best practice behaviour change techniques and communicated either via telephone or via mHealth. The implementation outcomes that will be measured are: fidelity to the nutrition intervention protocol and to the delivery approach; engagement; acceptability and contextual factors. Qualitative data from recorded telephone consultations and written messages will be analysed through a coding matrix against the behaviour change techniques outlined in the standard operating procedure, and also thematically to determine barriers and enablers. Negative binomial regression will be used to test for predictive relationships between intervention components with health-related quality of life and nutrition outcomes. Post-intervention interviews with participants and health professionals will be thematically analysed to determine the acceptability of delivery approaches. NVivo 11 Pro software will be used to code for thematic analysis. STATA version 15 will be used to perform quantitative analysis.

Discussion

The findings of this process evaluation will provide evidence of the core active ingredients that enable the implementation of best practice nutrition intervention for people with upper gastrointestinal cancer. Elucidation of the causal pathways of successful implementation and the important relationship to contextual delivery are anticipated. With this information, a strategy for sustained implementation across broader settings will be developed which impact the quality of life and nutritional status of individuals with upper gastrointestinal cancer.

Trial registration

27th January 2017 Australian and New Zealand Clinical Trial Registry (ACTRN12617000152325).

Use of Expectation Disconfirmation Theory to Test Patient Satisfaction with Asynchronous Telemedicine for Diabetic Retinopathy Detection

OBJECTIVE

The purpose of the study is to extend research on patient satisfaction with telemedicine services by employing the theoretical framework of Expectation Disconfirmation Theory (EDT) for diabetic retinopathy screenings focusing on rural patients.

METHOD

Adult subjects (n=220) with diabetes were recruited from a single family practice office in rural Iowa. Subjects completed a "pre" survey concerning their forward-looking perceptions of telemedicine prior to using telemedicine for detection of diabetic retinopathy and a "post" survey after they received recommendations from the distant ophthalmologists.

RESULTS

All hypotheses of the EDT model were supported. Patient satisfaction is influenced by both patients' expectations (P<.001) and disconfirmation of expectations (P<.001), and patient satisfaction has a positive impact on patient preference for telemedicine services (P<.001). Overall, patients who received telemedicine services were highly satisfied with telemedicine and developed a favorable disposition towards telemedicine services.

CONCLUSIONS

The EDT model is a viable framework to study patient satisfaction of telemedicine services. While previous feasibility studies have shown that telemedicine for diabetic retinopathy screenings yields diagnostic efficacy, this study applies a theoretical framework to demonstrate the viability of telemedicine for diabetic retinopathy screenings in rural areas.

A randomized controlled pilot trial of a smoking cessation intervention for US women living with HIV: telephone-based video call vs voice call

Background

People living with HIV smoke at a rate three times that of the general population. This randomized controlled pilot trial tested the feasibility and acceptability of a video-call smoking cessation intervention in women living with HIV and its preliminary efficacy compared with a voice-call smoking cessation intervention. The study focused on women due to a paucity of studies among this population, and women are less likely than men to quit smoking when provided with conventional treatment.

Methods

Participants in both arms received an HIV-tailored smoking cessation intervention comprising eight 30-minute weekly counseling sessions in conjunction with active nicotine patches for 8 weeks. The only difference between the two arms was the delivery mode of the intervention: via either telephone-based video or voice call. Survival analysis and a Cox proportional hazard regression model were performed to identify factors predicting 6-month prolonged abstinence from smoking.

Results

A video-call intervention was almost 30% less feasible than a voice-call intervention because women in their 50s and 60s or poorer women living in some southern states did not have access to video-call equipment. However, those who received the video-call intervention were more likely to complete the study than those who had the voice-call intervention. There was no difference in the acceptability of the two interventions. A survival analysis revealed that those in the video arm were significantly more likely to maintain smoking abstinence over the 6-month follow-up period than those in the voice arm (log rank χ²=4.02, P<0.05).

Conclusion

Although a video-call intervention is less feasible than a voice-call intervention, the former seems to outperform the latter in achieving long-term smoking abstinence for women living with HIV, which may offer an advantage over establishing therapeutic alliance and visually monitoring their adherence to nicotine patches.

Clinical trial registration

ClinicalTrials.gov NCT02898597.

Comparative effectiveness of telemonitoring versus usual care for type 2 diabetes: A systematic review and meta-analysis

AIMS

This study evaluated clinical effectiveness of telemonitoring on the management of patients with type 2 diabetes.

METHODS

We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane Library to identify randomized controlled trials that compared telemonitoring and usual care in patients with type 2 diabetes.

RESULTS

Thirty-eight studies (6855 patients) were included. Telemonitoring was associated with a significant decrease in glycated haemoglobin levels compared to usual care (weighted mean difference -0.42%, 95% confidence interval -0.56 to -0.27) but there was evidence of heterogeneity (I²= 96.9%). Telemonitoring was associated with a significant glycated haemoglobin reduction when biological data were transmitted through a web-based device weekly, when voice feedback was performed daily or immediately and when patients were provided with counselling. Telemonitoring also reduced glycated haemoglobin level in studies that monitored patients' medication adherence, provided counselling, education and alarm message. The rate of achieving glycated haemoglobin levels of < 7% was 1.8 times higher in the telemonitoring group compared to the usual care group (risk ratio 1.83, 95% confidence interval 1.35 to 2.47, I²= 0%). There was also significant reduction in systolic blood pressure (weighted mean difference -1.33 mm Hg) and body mass index (weighted mean difference -0.25 kg/m²), but the clinical relevance of these results can be questioned. The data available on patient satisfaction, quality of life, medication adherence, prescription changes, stress and depression were limited.

CONCLUSIONS

Telemonitoring interventions may be a better option than usual care in improving glycated haemoglobin control of patients with type 2 diabetes. Further studies should assess clinical benefit according to specific delivery modes of the intervention and patient-reported outcomes.

Determinants of Successful eHealth Coaching for Consumer Lifestyle Changes: Qualitative Interview Study Among Health Care Professionals

Background

Success with lifestyle change, such as weight loss, tobacco cessation, and increased activity level, using electronic health (eHealth) has been demonstrated in numerous studies short term. However, evidence on how to maintain the effect long-term has not been fully explored, even though there is a pressing need for long-term solutions. Recent studies indicate that weight loss can be achieved and maintained over 12 and 20 months in a primary care setting using a collaborative eHealth tool. The effect of collaborative eHealth in promoting lifestyle changes depends on competent and skilled dieticians, nurses, physiotherapists, and occupational therapists acting as eHealth coaches. How such health care professionals perceive delivering asynchronous eHealth coaching and which determinants they find to be essential to achieving successful long-term lifestyle coaching have only been briefly explored and deserve further exploration.

Objective

The aim of this study is to analyze how health care professionals perceive eHealth coaching and to explore what influences successful long-term lifestyle change for patients undergoing hybrid eHealth coaching using a collaborative eHealth tool.

Methods

A total of 10 health care professionals were recruited by purposive sampling. They were all women aged 36 to 65 years of age with a mean age of 48 years of age. A total of 8/10 (80%) had more than 15 years of experience in their field, and all had more than six months of experience providing eHealth lifestyle coaching using a combination of face-to-face meetings and asynchronous eHealth coaching. They worked in 5 municipalities in the Region of Southern Denmark. We performed individual, qualitative, semistructured, in-depth interviews in their workplace about their experiences with health coaching about lifestyle change, both for their patients and for themselves, and mainly how they perceived using a collaborative eHealth solution as a part of their work.

Results

The health care professionals all found establishing and maintaining an empathic relationship essential and that asynchronous eHealth lifestyle coaching challenged this compared to face-to-face coaching. The primary reason was that unlike typical in-person encounters in health care, they did not receive immediate feedback from the patients. We identified four central themes relevant to the health care professionals in their asynchronous eHealth coaching: (1) establishing an empathic relationship, (2) reflection in asynchronous eHealth coaching, (3) identifying realistic goals based on personal barriers, and (4) staying connected in asynchronous coaching.

Conclusions

Establishing and maintaining an empathic relationship is probably the most crucial factor for successful subsequent eHealth coaching. It was of paramount importance to get to know the patient first, and the asynchronous interaction aspect presented challenges because of the delay in response times (both ways). It also presented opportunities for reflection before answering. The health care professionals found they had to provide both relational communication and goal-oriented coaching when using eHealth solutions. Going forward, the quality of the health care professional–patient interaction will need attention if patients are to benefit from collaborative eHealth coaching fully.

Perceptions of Persons With Type 2 Diabetes Treated in Swedish Primary Health Care: Qualitative Study on Using eHealth Services for Self-Management Support

Background

Digital health services are increasing rapidly worldwide. Strategies to involve patients in self-monitoring of type 2 diabetes (T2D) on a daily basis is of crucial importance, and there is a need to optimize the delivery of care such as self-management support. Digitalized solutions have the potential to modify and personalize the way in which people use primary health services, both by increasing access to information and providing other forms of support at a distance. It is a challenge to integrate core values of person-centered care into digitalized health care services.

Objective

The objective of this study was to describe perceptions of using electronic health (eHealth) services and related technologies for self-management support among people with T2D treated in Swedish primary health care.

Methods

This is a qualitative study based on interviews analyzed using qualitative content analysis conducted among people diagnosed with T2D.

Results

Findings suggest that the participants had mixed feelings regarding the use of digital health services for self-management support. They experienced potentials such as increased involvement, empowerment, and security, as well as concerns such as ambivalence and uncertainty.

Conclusions

Digital health services for self-management are easily accessible and have the potential to reach a wide population. However, targeted training to increase digital skills is required, and personalized devices must be adapted and become more person-centered to improve patients’ involvement in their own care.

Ethical implications of digital communication for the patient-clinician relationship: analysis of interviews with clinicians and young adults with long term conditions (the LYNC study)

BACKGROUND

Digital communication between a patient and their clinician offers the potential for improved patient care, particularly for young people with long term conditions who are at risk of service disengagement. However, its use raises a number of ethical questions which have not been explored in empirical studies. The objective of this study was to examine, from the patient and clinician perspective, the ethical implications of the use of digital clinical communication in the context of young people living with long-term conditions.

METHODS

A total of 129 semi-structured interviews, 59 with young people and 70 with healthcare professionals, from 20 United Kingdom (UK)-based specialist clinics were conducted as part of the LYNC study. Transcripts from five sites (cancer, liver, renal, cystic fibrosis and mental health) were read by a core team to identify explicit and implicit ethical issues and develop descriptive ethical codes. Our subsequent thematic analysis was developed iteratively with reference to professional and ethical norms.

RESULTS

Clinician participants saw digital clinical communication as potentially increasing patient empowerment and autonomy; improving trust between patient and healthcare professional; and reducing harm because of rapid access to clinical advice. However, they also described ethical challenges, including: difficulty with defining and maintaining boundaries of confidentiality; uncertainty regarding the level of consent required; and blurring of the limits of a clinician's duty of care when unlimited access is possible. Paradoxically, the use of digital clinical communication can create dependence rather than promote autonomy in some patients. Patient participants varied in their understanding of, and concern about, confidentiality in the context of digital communication. An overarching theme emerging from the data was a shifting of the boundaries of the patient-clinician relationship and the professional duty of care in the context of use of clinical digital communication.

CONCLUSIONS

The ethical implications of clinical digital communication are complex and go beyond concerns about confidentiality and consent. Any development of this form of communication should consider its impact on the patient-clinician-relationship, and include appropriate safeguards to ensure that professional ethical obligations are adhered to.

The role of digital communication in patient–clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Background

Young people (aged 16–24 years) with long-term health conditions tend to disengage from health services, resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK NHS clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely.

Objectives

To explore how health-care engagement can be improved using digital clinical communication (DCC); understand effects, impacts, costs and necessary safeguards; and provide critical analysis of its use, monitoring and evaluation.

Design

Observational mixed-methods case studies; systematic scoping literature reviews; assessment of patient-reported outcome measures (PROMs); public and patient involvement; and consensus development through focus groups.

Setting

Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long-term physical or mental health conditions.

Participants

One hundred and sixty-five young people aged 16–24 years living with a long-term health condition; 13 parents; 173 clinical team members; and 16 information governance specialists.

Interventions

Clinical teams and young people variously used mobile phone calls, text messages, e-mail and voice over internet protocol.

Main outcome measures

Empirical work – thematic and ethical analysis of qualitative data; annual direct costs; did not attend, accident and emergency attendance and hospital admission rates plus clinic-specific clinical outcomes. Scoping reviews–patient, health professional and service delivery outcomes and technical problems. PROMs: scale validity, relevance and credibility.

Data sources

Observation, interview, structured survey, routinely collected data, focus groups and peer-reviewed publications.

Results

Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships, but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases and the main cost is staff time. Clinical teams had not evaluated the impact of their intervention and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures, but the Patient Activation Measure and the Physicians’ Humanistic Behaviours Questionnaire are promising. Scoping reviews suggest DCC is acceptable to young people, but with no clear evidence of benefit except for mental health.

Limitations

Qualitative data were mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available.

Conclusions

Timely DCC is perceived as making a difference to health care and health outcomes for young people with long-term conditions, but this is not supported by evidence that measures health outcomes. Such communication is challenging and costly to provide, but valued by young people.

Future work

Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes.

Study registration

Two of the reviews in this study are registered as PROSPERO CRD42016035467 and CRD42016038792.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Telemedicine follow-up facilitates more comprehensive diabetes foot ulcer care: A qualitative study in home-based and specialist health care

AIMS AND OBJECTIVES

To investigate the application of a telemedicine intervention in diabetes foot ulcer care, and its implications for the healthcare professionals in the clinical field.

BACKGROUND

Contextual factors are found to be important when applying technology in health care and applying telemedicine in home-based care has been identified as particularly complex.

DESIGN AND METHODS

We conducted field observations and individual interviews among healthcare professionals in home-based care and specialist health care in a diabetes foot care telemedicine RCT (Clin.Trial.gov: NCT01710774) during 2016. This study was guided by Interpretive Description, an inductive qualitative methodology.

RESULTS

Overall, we identified unequal possibilities for applying telemedicine in diabetes foot ulcer care within the hospital and home care contexts. Different circumstances and possibilities in home-based care made the application of telemedicine as intended more difficult. The healthcare professionals in both care contexts perceived the application of telemedicine to facilitate a more comprehensive approach towards the patients, but with different possibilities to enact it.

CONCLUSIONS

Application of telemedicine in home-based care was more challenging than in the outpatient clinic setting. Introducing more updated equipment and minor structural adjustments in consultation time and resources could make the use of telemedicine in home-based care more robust.

RELEVANCE TO CLINICAL PRACTICE

Application of telemedicine in diabetes foot ulcer follow-up may enhance the nursing staff's ability to conduct comprehensive assessment and care of the foot ulcer as well as the patient's total situation. Access to adequate equipment and time, particularly in home-based care, is necessary to capitalise on this new technology.

The impact of digital health technologies on tuberculosis treatment: a systematic review

Digital technologies are increasingly harnessed to support treatment of persons with tuberculosis (TB). Since in-person directly observed treatment (DOT) can be resource intensive and challenging to implement, these technologies may have the potential to improve adherence and clinical outcomes. We reviewed the effect of these technologies on TB treatment adherence and patient outcomes.We searched several bibliographical databases for studies reporting the effect of digital interventions, including short message service (SMS), video-observed therapy (VOT) and medication monitors (MMs), to support treatment for active TB. Only studies with a control group and which reported effect estimates were included.Four trials showed no statistically significant effect on treatment completion when SMS was added to standard care. Two observational studies of VOT reported comparable treatment completion rates when compared with in-person DOT. MMs increased the probability of cure (RR 2.3, 95% CI 1.6-3.4) in one observational study, and one trial reported a statistically significant reduction in missed treatment doses relative to standard care (adjusted means ratio 0.58, 95% CI 0.42-0.79).Evidence of the effect of digital technologies to improve TB care remains limited. More studies of better quality are needed to determine how such technologies can enhance programme performance.

The Effect of Telemedicine Follow-up Care on Diabetes-Related Foot Ulcers: A Cluster-Randomized Controlled Noninferiority Trial

OBJECTIVE

To evaluate whether telemedicine (TM) follow-up of patients with diabetes-related foot ulcers (DFUs) in primary health care in collaboration with specialist health care was noninferior to standard outpatient care (SOC) for ulcer healing time. Further, we sought to evaluate whether the proportion of amputations, deaths, number of consultations per month, and patient satisfaction differed between the two groups.

RESEARCH DESIGN AND METHODS

Patients with DFUs were recruited from three clinical sites in western Norway (2012-2016). The cluster-randomized controlled noninferiority trial included 182 adults (94/88 in the TM/SOC groups) in 42 municipalities/districts. The intervention group received TM follow-up care in the community; the control group received SOC. The primary end point was healing time. Secondary end points were amputation, death, number of consultations per month, and patient satisfaction.

RESULTS

Using mixed-effects regression analysis, we found that TM was noninferior to SOC regarding healing time (mean difference -0.43 months, 95% CI -1.50, 0.65). When competing risk from death and amputation were taken into account, there was no significant difference in healing time between the groups (subhazard ratio 1.16, 95% CI 0.85, 1.59). The TM group had a significantly lower proportion of amputations (mean difference -8.3%, 95% CI -16.3%, -0.5%), and there were no significant differences in the proportion of deaths, number of consultations, or patient satisfaction between groups, although the direction of the effect estimates for these clinical outcomes favored the TM group.

CONCLUSIONS

The results suggest that use of TM technology can be a relevant alternative and supplement to usual care, at least for patients with more superficial ulcers.

Effects of Face-to-Face and Telephone-Based Family-Oriented Education on Self-Care Behavior and Patient Outcomes in Type 2 Diabetes: A Randomized Controlled Trial

BACKGROUND

Education of patients and their families is the cornerstone of effective diabetes care. The present study aimed to compare the effects of a face-to-face and telephone-based family-oriented educational program on self-care behavior and patient outcomes in type 2 diabetes patients.

METHODS

In the present randomized controlled trial, 90 type 2 diabetes patients were randomly divided into three groups of 30 participants: a face-to-face education group, a telephone-based education group, and a control group. The educational program lasted for 3 months. Outcomes evaluated included self-care, fasting blood sugar, hemoglobin A1c, cholesterol, and triglyceride.

RESULTS

The overall self-care scores in the intervention groups were significantly higher than that in the control group (P = 0.0001). In addition, lipid profiles significantly improved in the interventions compared to the control (P < 0.05). Comparing the two interventions showed better results for the face-to-face group regarding dietary adherence and physical activity, but the latter group had comparable results in blood glucose monitoring, foot care, and cholesterol level.

CONCLUSIONS

This study shows the beneficiary effects of a family-oriented education on self-care and patient outcomes. It also shows the potential value of low-cost telephone technology in delivering effective diabetes care.

Comparative effectiveness of telemedicine strategies on type 2 diabetes management: A systematic review and network meta-analysis

The effects of telemedicine strategies on the management of diabetes is not clear. This study aimed to investigate the impact of different telemedicine strategies on glycaemic control management of type 2 diabetes patients. A search was performed in 6 databases from inception until September 2016 for randomized controlled studies that examined the use of telemedicine in adults with type 2 diabetes. Studies were independently extracted and classified according to the following telemedicine strategies: teleeducation, telemonitoring, telecase-management, telementoring and teleconsultation. Traditional and network meta-analysis were performed to estimate the relative treatment effects. A total of 107 studies involving 20,501 participants were included. Over a median of 6 months follow-up, telemedicine reduced haemoglobin A1c (HbA1c) by a mean of 0.43% (95% CI: −0.64% to −0.21%). Network meta-analysis showed that all telemedicine strategies were effective in reducing HbA1c significantly compared to usual care except for telecase-management and telementoring, with mean difference ranging from 0.37% and 0.71%. Ranking indicated that teleconsultation was the most effective telemedicine strategy, followed by telecase-management plus telemonitoring, and finally teleeducation plus telecase-management. The review indicates that most telemedicine strategies can be useful, either as an adjunct or to replace usual care, leading to clinically meaningful reduction in HbA1c.

Using digital interventions to improve the cardiometabolic health of populations: a meta-review of reporting quality

OBJECTIVES

We conducted a meta-review to determine the reporting quality of user-centered digital interventions for the prevention and management of cardiometabolic conditions.

MATERIALS AND METHODS

Using predetermined inclusion criteria, systematic reviews published between 2010 and 2015 were identified from 3 databases. To assess whether current evidence is sufficient to inform wider uptake and implementation of digital health programs, we assessed the quality of reporting of research findings using (1) endorsement of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, (2) a quality assessment framework (eg, Cochrane risk of bias assessment tool), and (3) 8 parameters of the Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth (CONSORT-eHEALTH) guidelines (developed in 2010).

RESULTS

Of the 33 systematic reviews covering social media, Web-based programs, mobile health programs, and composite modalities, 6 reported using the recommended PRISMA guidelines. Seven did not report using a quality assessment framework. Applying the CONSORT-EHEALTH guidelines, reporting was of mild to moderate strength.

DISCUSSION

To our knowledge, this is the first meta-review to provide a comprehensive analysis of the quality of reporting of research findings for a range of digital health interventions. Our findings suggest that the evidence base and quality of reporting in this rapidly developing field needs significant improvement in order to inform wider implementation and uptake.

CONCLUSION

The inconsistent quality of reporting of digital health interventions for cardiometabolic outcomes may be a critical impediment to real-world implementation.

Video consultations as add-on to standard care among patients with type 2 diabetes not responding to standard regimens: a randomized controlled trial

OBJECTIVE

To examine whether video consultations preceded by measurements of blood glucose, weight and blood pressure as add-on to standard care could contribute to achieving and maintaining good diabetes control among patients with poorly regulated type 2 diabetes (T2D).

DESIGN

Randomized controlled trial.

METHODS

165 patients with T2D were randomized 1:1 to telemedicine intervention as add-on to clinic-based care or control (clinic-based care). The intervention consisted of monthly video conferences with a nurse via a tablet computer and lasted for 32 weeks. Regularly self-monitored measurements of blood sugar, blood pressure and weight were uploaded and visible to patient and nurse. Both groups were followed up six months after the end of the intervention period.

PRIMARY ENDPOINT

HbA1c after eight months.

RESULTS

Video conferences preceded by uploads of measurements as add-on to clinic-based care led to a significant reduction of HbA1c compared to that in standard care (0.69% vs 0.18%, P = 0.022). However, at six-month follow-up, the inter-group difference in HbA1c-reduction was no longer significant. Non-completers had higher HbA1c levels at baseline and a lower degree of education.

CONCLUSION

Video consultations preceded by uploading relevant measurements can lead to clinically and statistically significant improvements in glycemic control among patients who have not responded to standard regimens. However, continuing effort and attention are essential as the effect does not persist when intervention ends. Furthermore, future studies should focus on differentiation as the most vulnerable patients are at greater risk of non-adherence.

Virtual Visits and Patient-Centered Care: Results of a Patient Survey and Observational Study

BACKGROUND

Virtual visits are clinical interactions in health care that do not involve the patient and provider being in the same room at the same time. The use of virtual visits is growing rapidly in health care. Some health systems are integrating virtual visits into primary care as a complement to existing modes of care, in part reflecting a growing focus on patient-centered care. There is, however, limited empirical evidence about how patients view this new form of care and how it affects overall health system use.

OBJECTIVE

Descriptive objectives were to assess users and providers of virtual visits, including the reasons patients give for use. The analytic objective was to assess empirically the influence of virtual visits on overall primary care use and costs, including whether virtual care is with a known or a new primary care physician.

METHODS

The study took place in British Columbia, Canada, where virtual visits have been publicly funded since October 2012. A survey of patients who used virtual visits and an observational study of users and nonusers of virtual visits were conducted. Comparison groups included two groups: (1) all other BC residents, and (2) a group matched (3:1) to the cohort. The first virtual visit was used as the intervention and the main outcome measures were total primary care visits and costs.

RESULTS

During 2013-2014, there were 7286 virtual visit encounters, involving 5441 patients and 144 physicians. Younger patients and physicians were more likely to use and provide virtual visits (P<.001), with no differences by sex. Older and sicker patients were more likely to see a known provider, whereas the lowest socioeconomic groups were the least likely (P<.001). The survey of 399 virtual visit patients indicated that virtual visits were liked by patients, with 372 (93.2%) of respondents saying their virtual visit was of high quality and 364 (91.2%) reporting their virtual visit was "very" or "somewhat" helpful to resolve their health issue. Segmented regression analysis and the corresponding regression parameter estimates suggested virtual visits appear to have the potential to decrease primary care costs by approximately Can $4 per quarter (Can -$3.79, P=.12), but that benefit is most associated with seeing a known provider (Can -$8.68, P<.001).

CONCLUSIONS

Virtual visits may be one means of making the health system more patient-centered, but careful attention needs to be paid to how these services are integrated into existing health care delivery systems.

Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer

Background

Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions.

Objective

The objectives of this metareview were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilization, and (2) identify components of telehealth support and their impact on disease control and the process of self-management. Our goal was to synthesise evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support.

Methods

We performed a metareview (a systematic review of systematic reviews) of randomized controlled trials (RCTs) of telehealth interventions to support self-management in 6 exemplar long-term conditions. We searched 7 databases for reviews published from January 2000 to May 2016 and screened identified studies against eligibility criteria. We weighted reviews by quality (revised A Measurement Tool to Assess Systematic Reviews), size, and relevance. We then combined our results in a narrative synthesis and using harvest plots.

Results

We included 53 systematic reviews, comprising 232 unique RCTs. Reviews concerned diabetes (type 1: n=6; type 2, n=11; mixed, n=19), heart failure (n=9), asthma (n=8), COPD (n=8), and cancer (n=3). Findings varied between and within disease areas. The highest-weighted reviews showed that blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycemic control in type 2, but not type 1, diabetes, and that telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure, but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multifaceted interventions were associated with greater improvements in diabetes, heart failure, and asthma.

Conclusions

While telehealth-mediated self-management was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.

Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People: A Mixed-Methods Study (The LYNC Study)

Background

Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues.

Objective

Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards.

Methods

We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs.

Results

Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches.

Conclusions

As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials

BACKGROUND

Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care. We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care.

METHODS

We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes. Two independent reviewers selected the studies and assessed risk of bias in the studies. The primary outcome was glycated hemoglobin (HbA1C) reported at 3 time points (≤ 3 mo, 4-12 mo and > 12 mo). Other outcomes were quality of life, mortality and episodes of hypoglycemia. Trials were pooled using randomeffects meta-analysis, and heterogeneity was quantified using the I2 statistic.

RESULTS

From 3688 citations, we identified 111 eligible RCTs (n = 23 648). Telemedicine achieved significant but modest reductions in HbA1C in all 3 follow-up periods (difference in mean at ≤ 3 mo: -0.57%, 95% confidence interval [CI] -0.74% to -0.40% [39 trials]; at 4-12 mo: -0.28%, 95% CI -0.37% to -0.20% [87 trials]; and at > 12 mo: -0.26%, 95% CI -0.46% to -0.06% [5 trials]). Quantified heterogeneity (I2 statistic) was 75%, 69% and 58%, respectively. In meta-regression analyses, the effect of telemedicine on HbA1C appeared greatest in trials with higher HbA1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment. Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia.

INTERPRETATION

Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA1C but not other clinically relevant outcomes among patients with diabetes.

Barriers to Remote Health Interventions for Type 2 Diabetes: A Systematic Review and Proposed Classification Scheme

Background

Diabetes self-management involves adherence to healthy daily habits typically involving blood glucose monitoring, medication, exercise, and diet. To support self-management, some providers have begun testing remote interventions for monitoring and assisting patients between clinic visits. Although some studies have shown success, there are barriers to widespread adoption.

Objective

The objective of our study was to identify and classify barriers to adoption of remote health for management of type 2 diabetes.

Methods

The following 6 electronic databases were searched for articles published from 2010 to 2015: MEDLINE (Ovid), Embase (Ovid), CINAHL, Cochrane Central, Northern Light Life Sciences Conference Abstracts, and Scopus (Elsevier). The search identified studies involving remote technologies for type 2 diabetes self-management. Reviewers worked in teams of 2 to review and extract data from identified papers. Information collected included study characteristics, outcomes, dropout rates, technologies used, and barriers identified.

Results

A total of 53 publications on 41 studies met the specified criteria. Lack of data accuracy due to input bias (32%, 13/41), limitations on scalability (24%, 10/41), and technology illiteracy (24%, 10/41) were the most commonly cited barriers. Technology illiteracy was most prominent in low-income populations, whereas limitations on scalability were more prominent in mid-income populations. Barriers identified were applied to a conceptual model of successful remote health, which includes patient engagement, patient technology accessibility, quality of care, system technology cost, and provider productivity. In total, 40.5% (60/148) of identified barrier instances impeded patient engagement, which is manifest in the large dropout rates cited (up to 57%).

Conclusions

The barriers identified represent major challenges in the design of remote health interventions for diabetes. Breakthrough technologies and systems are needed to alleviate the barriers identified so far, particularly those associated with patient engagement. Monitoring devices that provide objective and reliable data streams on medication, exercise, diet, and glucose monitoring will be essential for widespread effectiveness. Additional work is needed to understand root causes of high dropout rates, and new interventions are needed to identify and assist those at the greatest risk of dropout. Finally, future studies must quantify costs and benefits to determine financial sustainability.

Availability of information in Public Health on the Internet: An analysis of national health authorities in the Spanish-speaking Latin American and Caribbean countries

INTRODUCTION

Access to reliable and quality health information and appropriate medical advice can contribute to a dramatic reduction in the mortality figures of countries. The governments of the Americas are faced with the opportunity to continue working on this challenge, and their institutional presence on their websites should play a key role in this task. In a setting where the access to information is essential to both health professionals and citizens, it is relevant to analyze the role of national health authorities. Given that search engines play such a key role in the access to health information, it is important to specifically know - in connection to national health authorities - whether health information offered is easily available to the population, and whether this information is well-ranked in search engines.

METHODS

Quantitative methods were used to gather data on the institutional presence of national health authorities on the web. An exploratory and descriptive research served to analyze and interpret data and information obtained quantitatively from different perspectives, including an analysis by country, and also by leading causes of death. A total of 18 web pages were analyzed. Information on leading causes of death was searched on websites of national health authorities in the week of August 10-14, 2015.

RESULTS

The probability of finding information of national health authorities on the 10 leading causes of death in a country, among the top 10 results on Google, is 6.66%. Additionally, ten out the 18 countries under study (55%) do not have information ranked among the top results in Google when searching for the selected terms. Additionally, a total of 33 websites represent the sources of information with the highest visibility for all the search strategies in each country on Google for the ten leading causes of death in a country. Two websites, the National Library of Medicine and Wikipedia, occur as a result with visibility in the total of eighteen countries of the sample.

CONCLUSIONS

Taking into consideration that providing reliable and quality information on these topics to the population should be one of the priorities of national health authorities, these results suggest that national health authorities need to take measures to try to better position their contents.

Effect of Telehealth Interventions on Hospitalization Indicators: A Systematic Review

BACKGROUND

Telehealth has been defined as the remote delivery of healthcare services using information and communication technology. Where resource-limited health systems face challenges caused by the increasing burden of chronic diseases and an aging global population, telehealth has been advocated as a solution for changing and improving the paradigm of healthcare delivery to cope with these issues. The aim of this systematic review is to investigate the effect of telehealth interventions on two indicators: hospitalization rate and length of stay.

MATERIALS AND METHODS

The reviewers searched the PubMed, ScienceDirect, and Springer electronic databases from January 2005 to November 2013. A search strategy was developed using a combination of the following search keywords: impact, effect, telehealth, telemedicine, telecare, hospitalization, length of stay, and resource utilization. Both randomized controlled trials and observational studies were included in the review. To be included in the review, articles had to be written in English. The results of study were compiled, reviewed, and analyzed on the basis of the review aims.

RESULTS

This systematic review examined 22 existing studies with a total population of 19,086 patients. The effect of telehealth on all-cause hospitalization was statistically significant in 40 percent of the related studies, whereas it was not statistically significant in 60 percent. Similarly, the effect of telehealth on the all-cause length of stay was statistically significant in 36 percent of the studies and nonsignificant in 64 percent.

CONCLUSION

Considering the fact that hospitalization rate and length of stay can be confounded by factors other than telehealth intervention, studies examining the effect of the intervention on these indicators must take into account all other factors influencing them. Otherwise any judgment on the effect of telehealth on these indicators cannot be valid.

Efficacy of Internet-Based Self-Monitoring Interventions on Maternal and Neonatal Outcomes in Perinatal Diabetic Women: A Systematic Review and Meta-Analysis

Background

Self-monitoring using the Internet offers new opportunities to engage perinatal diabetic women in self-management to reduce maternal and neonatal complications.

Objective

This review aims to synthesize the best available evidence to evaluate the efficacy of Internet-based self-monitoring interventions in improving maternal and neonatal outcomes among perinatal diabetic women.

Methods

The review was conducted using Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsyINFO, Scopus, and ProQuest Dissertations and Theses to search for English-language research studies without any year limitation. A risk of bias table was used to assess methodological quality. Meta-analysis was performed with RevMan software. Cochran Q and I² tests were used to assess heterogeneity. The overall effect was assessed using z tests at P<.05. Of the 438 studies identified through electronic searches and reference lists, nine experimental studies from 10 publications were selected.

Results

Half of the selected studies showed low risk of bias and comprised 852 perinatal diabetic women in six countries. The meta-analysis revealed that Internet-based self-monitoring interventions significantly decreased the level of maternal glycated hemoglobin A1c (z=2.23, P=.03) compared to usual care among perinatal diabetic women at postintervention. Moreover, Internet-based self-monitoring interventions significantly decreased the cesarean delivery rate (z=2.23, P=.03) compared to usual care among the mixed group at postintervention.

Conclusions

This review shows neonatal or other maternal outcomes are similar between Internet-based self-monitoring interventions and usual diabetes care among perinatal diabetic women. The long-term effects of the intervention must be confirmed in future studies using randomized controlled trials and follow-up data.

Glycemic control after hospital discharge in insulin-treated type 2 diabetes: a randomized pilot study of daily remote glucose monitoring

OBJECTIVE

Little is known about glycemic control in type 2 diabetes patients treated with insulin in the high-risk period between hospital discharge and follow-up. We sought to assess the impact of remote glucose monitoring on postdischarge glycemic control and insulin titration.

METHODS

We randomly assigned 28 hospitalized type 2 diabetes patients who were discharged home on insulin therapy to routine specialty care (RSC) or RSC with daily remote glucose monitoring (RGM). We compared the primary outcome of mean blood glucose and exploratory outcomes of hypoglycemia/hyperglycemia rates, change in hemoglobin A1c and glycated albumin, and insulin titration frequency between groups.

RESULTS

Mean blood glucose was not significantly different between the treatment arms (144 ± 34 mg/dL in the RSC group and 172 ± 41 mg/dL in the RGM group; not significant), nor were there significant differences in any of the other measures of glycemia during the month after discharge. Hypoglycemia (glucometer reading <60 mg/dL) was common, occurring in 46% of subjects, with no difference between groups. In as-treated analysis, insulin dose adjustments (29% with an increase and 43% with decrease in insulin dose) occurred more frequently in the patients who used RGM (average of 2.8 vs. 1.2 dose adjustments; P = .03).

CONCLUSION

In this pilot trial in insulin-treated type 2 diabetes, RGM did not affect glycemic control after hospital discharge; however, the high rate of hypoglycemia in the postdischarge transition period and the higher frequency of insulin titration in patients who used RGM suggest a safety role for such monitoring in the transition from hospital to home.

Modelling and Predicting eHealth Usage in Europe: A Multidimensional Approach From an Online Survey of 13,000 European Union Internet Users

Background

More advanced methods and models are needed to evaluate the participation of patients and citizens in the shared health care model that eHealth proposes.

Objective

The goal of our study was to design and evaluate a predictive multidimensional model of eHealth usage.

Methods

We used 2011 survey data from a sample of 13,000 European citizens aged 16–74 years who had used the Internet in the previous 3 months. We proposed and tested an eHealth usage composite indicator through 2-stage structural equation modelling with latent variables and measurement errors. Logistic regression (odds ratios, ORs) to model the predictors of eHealth usage was calculated using health status and sociodemographic independent variables.

Results

The dimensions with more explanatory power of eHealth usage were health Internet attitudes, information health Internet usage, empowerment of health Internet users, and the usefulness of health Internet usage. Some 52.39% (6811/13,000) of European Internet users’ eHealth usage was more intensive (greater than the mean). Users with long-term health problems or illnesses (OR 1.20, 95% CI 1.12–1.29) or receiving long-term treatment (OR 1.11, 95% CI 1.03–1.20), having family members with long-term health problems or illnesses (OR 1.44, 95% CI 1.34–1.55), or undertaking care activities for other people (OR 1.58, 95% CI 1.40–1.77) had a high propensity toward intensive eHealth usage. Sociodemographic predictors showed that Internet users who were female (OR 1.23, 95% CI 1.14–1.31), aged 25–54 years (OR 1.12, 95% CI 1.05–1.21), living in larger households (3 members: OR 1.25, 95% CI 1.15–1.36; 5 members: OR 1.13, 95% CI 0.97–1.28; ≥6 members: OR 1.31, 95% CI 1.10–1.57), had more children <16 years of age (1 child: OR 1.29, 95% CI 1.18–1.14; 2 children: OR 1.05, 95% CI 0.94–1.17; 4 children: OR 1.35, 95% CI 0.88–2.08), and had more family members >65 years of age (1 member: OR 1.33, 95% CI 1.18–1.50; ≥4 members: OR 1.82, 95% CI 0.54–6.03) had a greater propensity toward intensive eHealth usage. Likewise, users residing in densely populated areas, such as cities and large towns (OR 1.17, 95% CI 1.09–1.25), also had a greater propensity toward intensive eHealth usage. Educational levels presented an inverted U shape in relation to intensive eHealth usage, with greater propensities among those with a secondary education (OR 1.08, 95% CI 1.01–1.16). Finally, occupational categories and net monthly income data suggest a higher propensity among the employed or self-employed (OR 1.07, 95% CI 0.99–1.15) and among the minimum wage stratum, earning ≤€1000 per month (OR 1.66, 95% CI 1.48–1.87).

Conclusions

We provide new evidence of inequalities that explain intensive eHealth usage. The results highlight the need to develop more specific eHealth practices to address different realities.

Telemedicine Versus Standard Follow-Up Care for Diabetes-Related Foot Ulcers: Protocol for a Cluster Randomized Controlled Noninferiority Trial (DiaFOTo)

Background

This paper presents the protocol for an ongoing study to evaluate a telemedicine follow-up intervention for patients with diabetes-related foot ulcers. Diabetes-related foot ulcers represent challenges for patients and the health services. The large increase in the prevalence of diabetes, combined with the aging population, means that the absolute number of patients with diabetes-related foot ulcers is likely to continue to increase. Health care services therefore need to provide close clinical follow-up care for people with diabetes both in primary and specialist care. Information and communication technologies may enable more integrated treatment and care pathways across organizational boundaries. However, we lack knowledge about the effect of telemedicine follow-up and how such services can be optimally organized.

Objective

To present the design and methods of a study evaluating a telemedicine follow-up intervention for patients with diabetes-related foot ulcers.

Methods

The study is designed as a cluster randomized controlled trial (noninferiority trial) involving municipalities or municipality districts (clusters) belonging to one clinical site in Western Norway. The study includes patients with type 1 and type 2 diabetes presenting with a new foot ulcer at the initial visit to the clinic. Patients in the intervention group receive telemedicine follow-up care in the community. The key ingredient in the intervention is the close integration between health care levels. The intervention is facilitated by the use of an interactive wound platform consisting of a Web-based ulcer record combined with a mobile phone, enabling counseling and communication between nurses in the community and specialist health care. Patients in the control group receive standard hospital outpatient care. The primary endpoint in the trial is healing time; secondary outcomes include amputation and death, patient-reported outcome measures, and follow-up data on the recurrence of foot ulcers. In addition, qualitative substudies are being performed to provide a more comprehensive evaluation of the ongoing processes during the trial with the patients in the intervention and control groups and those health care professionals either working in primary care or in specialist care delivering the intervention.

Results

The project has been funded. The inclusion of patients started in September 2012. Because recruitment goals were not met in the initial period, two more clinical sites have been included to meet sample size requirements. Patient recruitment will continue until June 2016. Data collection in the qualitative substudies has been completed.

Conclusions

This telemedicine trial operates in a novel setting and targets patients with diabetes-related foot ulcers during a 12-month follow-up period. The trial addresses whether integrated care using telemedicine between primary and specialist health care can be an equivalent alternative to standard outpatient care.

Trial Registration

ClinicalTrials.gov NCT01710774; https://clinicaltrials.gov/ct2/show/NCT01710774 (Archived by WebCite at http://www.webcitation.org/6im6KfFov).

A randomised, controlled trial of the effects of a mobile telehealth intervention on clinical and patient-reported outcomes in people with poorly controlled diabetes

Objective

The objective of this research is to determine the effects of mobile telehealth (MTH) on glycosylated haemoglobin (HbA1c) and other clinical and patient-reported outcomes in insulin-requiring people with diabetes.

Methods

A nine-month randomised, controlled trial compared standard care to standard care supplemented with MTH (self-monitoring, mobile-phone data transmissions, graphical and nurse-initiated feedback, and educational calls). Clinical (HbA1c, blood pressure, daily insulin dose, diabetes outpatient appointments (DOAs)) and questionnaire data (health-related quality of life, depression, anxiety) were collected. Mean group changes over time were compared using hierarchical linear models and Mann-Whitney tests.

Results

Eighty-one participants with a baseline HbA1c of 8.98% ± 1.82 were randomised to the intervention ( n = 45) and standard care ( n = 36). The Group by Time effect revealed MTH did not significantly influence HbA1c ( p = 0.228), but p values were borderline significant for blood pressure ( p = 0.054) and mental-health related quality of life ( p = 0.057). Examination of effect sizes and 95% confidence intervals for mean group differences at nine months supported the existence of a protective effect of MTH on mental health-related quality of life as well as depression. None of the other measured outcomes were found to be affected by the MTH intervention.

Conclusions

Findings from this study must be interpreted with caution given the small sample size, but they do not support the widespread adoption of MTH to achieve clinically significant changes in HbA1c. MTH may, however, have positive effects on blood pressure and protective effects on some aspects of mental health.

Innovative strategies to improve diabetes outcomes in disadvantaged populations

Diabetes disproportionately affects disadvantaged populations. Eighty percent of deaths directly caused by diabetes occurred in low- and middle-income countries. In high-income countries, there are marked disparities in diabetes control among racial/ethnic minorities and those with low socio-economic status. Innovative, effective and cost-effective strategies are needed to improve diabetes outcomes in these populations. Technological advances, peer educators and community health workers have expanded methodologies to reach, educate and monitor individuals with diabetes. In the present manuscript we review the outcomes of these strategies, and describe the barriers to and facilitators of these approaches for improving diabetes outcomes.

Influences on Technology Use and Efficacy in Type 1 Diabetes

The majority of people with type 1 diabetes have suboptimal glycemic control, increasing their complication risk. Technology to support diabetes self-care has advanced significantly and includes self-monitoring of blood glucose (SMBG), insulin pump therapy (IPT), continuous glucose monitoring (CGM), and sensor-augmented pump therapy (SAPT), which are stepping stones toward the "artificial pancreas" using closed-loop technology. Use of these technologies improves clinical outcomes for patients with the appropriate skills and motivation. This review addresses the psychosocial factors that influence both technology provision and clinical outcome and also how technology impacts on psychological outcomes. Optimal use of the various diabetes self-management technologies is influenced by previous self-care behaviors, demographic and psychological factors. Provision of IPT is also influenced by the same factors. Despite technology increasing the complexity of treatment, the lack of evidence for adverse psychological outcomes is reassuring. Treatment satisfaction is high, and discontinuation rates are low. However, technology will widen the health inequality gap if its use is limited to motivated patients who demonstrate good self-care behaviors. Pivotal to the success of the various technologies is provision of appropriate education at initiation of the technology, regular ongoing contact for treatment adjustments and trouble-shooting device issues plus access to psychological support when required. Additional support strategies may be required to help patients struggling with their diabetes to benefit from the available technology, recognizing that they may have most to gain.

Usability Pitfalls of Diabetes mHealth Apps for the Elderly

Diabetes mellitus has high prevalence in the ageing population and is often accompanied by other comorbidities, such as Alzheimer's disease, and general disabilities, such as poor eyesight. These comorbidities have redefined ways in which patients use mHealth apps, including diabetes apps. The latter have proven benefits for monitoring blood glucose levels and insulin tracking in the general population. In this paper, we analyse a diabetes monitoring app DeStress Assistant (DeSA), which was developed as a part of an EU project and tested in a hospital setting. Due to the increasing number of older adults, we wanted to ensure the app was suitable for that demographic. Based on a number of supervised tests, we show that the app, which was developed with the help of workshops and feedback from tech-savvy patients and clinicians, is difficult to use by elderly users. We demonstrate that with a small number of changes it is possible to raise the usability of the app in a number of categories. We summarise the lessons learned in the discussion. Our findings demonstrate that special care needs to be taken when developing mHealth apps for the elderly population.

Use of Telemedicine to Improve Adherence to American Diabetes Association Standards in Pediatric Type 1 Diabetes

BACKGROUND

The American Diabetes Association (ADA) recommends that children with type 1 diabetes (T1D) see a multidisciplinary team and have hemoglobin A1c (A1C) levels measured every 3 months. Patients in rural areas may not follow guidelines because of limited specialty care access. We hypothesized that videoconferencing would result in equivalent A1C compared with in-person visits and increased compliance with ADA recommendations.

MATERIALS AND METHODS

The Barbara Davis Center (BDC) (Aurora, CO) telemedicine program provides diabetes care to pediatric patients in Casper and Cheyenne, WY, via remote consultation with annual in-person visits. Over 27 months, 70 patients were consented, and 54 patients completed 1 year in the study.

RESULTS

Patients were 70% male, with a mean age of 12.1 ± 4.1 years and T1D duration of 5.4 ± 4.1 years. There was no significant change between baseline and 1-year A1C levels for patients with data at both time points. Patients saw diabetes specialists an average of 2.0 ± 1.3 times per year in the year prior to starting telemedicine and 2.9 ± 1.3 times (P < 0.0001) in the year after starting telemedicine. Patients and families missed significantly less school and work time to attend appointments.

CONCLUSIONS

Our study suggests telemedicine is equivalent to in-person visits to maintain A1C, whereas families increase the number of visits in line with ADA recommendations. Patients and families miss less school and work. Decreased financial burden and increased access may improve overall diabetes care and compliance for rural patients. Further study is needed to detect long-term differences in complications screenings and the financial impact of telemedicine on pediatric diabetes care.

Demographical, Clinical, and Psychological Characteristics of Users and Nonusers of an Online Platform for T2DM Patients (e-VitaDM-3/ZODIAC-44)

BACKGROUND

Online platforms offer opportunities for support in changing lifestyle and taking responsibility for one's health, but engaging patients with type 2 diabetes is challenging. Previous studies have shown that patients interested in platforms were more often male, younger, and higher educated. This study aims to investigate differences in clinical and psychological characteristics between users and nonusers of a newly developed platform.

METHODS

A prospective study started in the Drenthe region of Netherlands. Participants in the study concerning quality of care and quality of life were additionally invited to use the platform.

RESULTS

633 patients were registered after they opted for platform use. Of these patients, 361 (57.0%) never logged on, 184 (29.1%) were labeled "curious" users, and 88 (13.9%) were identified as "active" users. Users had lower HbA1c levels and more often hypertension compared to nonusers, and reported higher quality of life, better well-being, lower diabetes-related distress, and better medication adherence.

DISCUSSION

Platform use was associated with more favorable clinical and psychological characteristics relative to nonuse. Those with greater severity of disease, lower mood, and progression of disease used the platform the least. Other approaches need to be developed to reach these patients. Furthermore, improving the platform could also help to reach them. This trial is registered with Clinicaltrials.gov NCT01570140.

Tele-Mum: A Feasibility Study for a Randomized Controlled Trial Exploring the Potential for Telemedicine in the Diabetes Care of Those with Gestational Diabetes

BACKGROUND

The incidence of gestational diabetes mellitus (GDM)--hyperglycemia with onset or first recognition during pregnancy--is increasing and will have a significant impact on diabetes services. This study aimed to determine the feasibility and acceptability of using telemedicine in the diabetes care of women with GDM and the possibility of replacing alternate (one in every two) diabetes review appointments with telemedicine.

SUBJECTS AND METHODS

A feasibility study for a randomized controlled trial was conducted across two sites. Fifty women with GDM were randomized to usual care (n = 26) or usual care plus telemedicine (n = 24). Telemedicine entailed weekly blood pressure and weight measurements and transmission of these data, along with blood glucose readings, for review by the healthcare team. Patients were contacted about these results as necessary. Patients completed questionnaires to measure their satisfaction with telemedicine or blood glucose monitoring. The intervention group and healthcare providers also took part in qualitative interviews. Analysis involved descriptive statistics for the satisfaction questionnaires and framework analysis for the qualitative interviews.

RESULTS

Eighty-nine percent of patients were satisfied with telemedicine and would use it again. Both HCPs and patients found the equipment easy to use and were positive about using it to replace alternate diabetes review appointments in the future. If used in this way, healthcare providers felt that protected time in which to perform the telemedicine review would be necessary.

CONCLUSIONS

Telemedicine may help meet the growing demand on diabetes services due to increasing numbers of women being diagnosed with GDM.

Clinical applications of videoconferencing: a scoping review of the literature for the period 2002-2012

We conducted a scoping review of the literature on the clinical applications of videoconferencing. Electronic searches were performed using the PubMed, Embase and CINHAL databases to retrieve papers published from 2002 to 2012 that described clinical applications of videoconferencing. The initial search yielded 4923 records and after removing the duplicates and screening at title/abstract level, 505 articles met the inclusion criteria and were reviewed at full-text level. The countries with the highest number of papers were the US, Australia and Canada. Most studies were non-randomised controlled trials. The discipline with highest number of published studies (39%) was mental health, followed by surgery (7%) and general medicine (6%). The type of care delivered via video comprised acute, sub-acute and chronic care, but in 44% of the papers, the intervention was used for a combination of these purposes. Videoconferencing was used for all age groups but more frequently for adults (20%). Most of the papers (91%) reported using videoconferencing for several clinical purposes including management, diagnosis, counselling and monitoring. The review showed that videoconferencing has been used in a wide range of disciplines and settings for different clinical purposes. The practical value of published papers would be improved by following standard guidelines for reporting research projects and clinical trials.

Validity Study of Video Teleconsultation for the Management of Diabetes: A Pilot Randomized Controlled Trial

BACKGROUND

A large proportion of diabetes patients do not receive a basic minimum of standard care. Telemedicine holds the promise of improving access to health care. However, the validity of remote consultation for diabetes has not been well researched. This pilot randomized control trial was designed to evaluate the agreement on prescription decisions of endocrinologists between two consultation formats: videoconferencing and face-to-face (in-person) consultation.

PATIENTS AND METHODS

Seventy-three patients were randomized to telemedicine (n=36) and reference group (n=37). Each study patient in the telemedicine group received one face-to-face consultation and one video consultation. The reference group received two face-to-face consultations. The paired consultations for each patient were performed by two different endocrinologists. The level of agreement between endocrinologists was evaluated by comparing their recommendations on antidiabetes and cardioprotective medications.

RESULTS

The level of agreement between two endocrinologists on changing antidiabetes drugs was 64% in the telemedicine group and 78% in the reference group. Although the level of agreement was lower when one of the consultations was provided via videoconference, the difference was not significant. The level of agreement on changing cardiovascular drugs was 78% in the telemedicine group and 76% in the reference group, again not significantly different.

CONCLUSIONS

The results of this study demonstrate the preliminary evidence on the validity of recommendations made by endocrinologists via video consultation. Known limitations of videoconferencing for clinical purposes did not have remarkable impact on the outcome of consultation in terms of adjustment of patient's medications. Video teleconsultation can substitute for a considerable proportion of conventional outpatient specialty consultations for people with diabetes.

Using Remote Communication Technology in Insulin Pump Training: A Feasibility Study

PURPOSE

This feasibility study was designed to examine if remote communication technology can be used in the technical training of an insulin pump in adults with diabetes who were familiar with insulin pump therapy.

METHODS

Surveys were emailed to 69 individuals who purchased an insulin pump and had been trained by the manufacturer's diabetes educators. In consultation with providers, participants were given the choice of receiving training in a face-to-face meeting or via remote communication technology. The survey consisted of 27 questions asking participants' characteristics, device proficiency, confidence, and their satisfaction with the insulin pump and the training method. Differences between the 2 groups were examined using bivariate analyses.

RESULTS

There were 17 participants in the remote group and 20 participants in the face-to-face group. Participants had a mean age of 40.9 ± 14.3 years, had diabetes for 24.3 ± 13.8 years, and used an insulin pump for 9.8 ± 4.9 years. The participants in both groups were not statistically different in age, diabetes history, years on insulin pump, device proficiency, confidence, or satisfaction with the training method. The remote group reported less graduate-level education (P < .05) and higher satisfaction scores with the insulin pump training (P < .05).

CONCLUSION

Although this study has limitations associated with the small sample size and self-selection bias, the results suggest that remote communication technology may be an effective tool to provide technical training to adults who are familiar with insulin pump therapy. Additional research is required to determine the effectiveness of the remote insulin pump training.

Telemedicine in care homes in Airedale, Wharfedale and Craven

Purpose

– The purpose of this paper is to observe and analyse the effects of the use of telemedicine in care homes on the use of acute hospital resources.

Design/methodology/approach

– The study was an uncontrolled retrospective observational review of data on emergency hospital admissions and Emergency Department (ED) visits for care home residents in Airedale, Wharfedale and Craven. Acute hospital activity for residents was observed before and after the installation of telemedicine in 27 care homes. Data from a further 21 care homes that did not use telemedicine were used as a control group, using the median date of telemedicine installation for the “before and after” period. Patient outcomes were not considered.

Findings

– Care homes with telemedicine showed a 39 per cent reduction in the costs of emergency admissions and a 45 per cent reduction in ED attendances after telemedicine installation. In the control group reductions were 31 and 31 per cent, respectively. The incremental difference in costs between the two groups of care homes was almost £1.2 million. The cost of telemedicine to care commissioners was £177,000, giving a return on investment over a 20-month period of £6.74 per £1 spent.

Research limitations/implications

– The results should be interpreted carefully. There is inherent bias as telemedicine was deployed in care homes with the highest use of acute hospital resources and there were some methodological limitations due to poor data. Nevertheless, controlling the data as much as possible and adopting a cautious approach to interpretation, it can be concluded that the use of telemedicine in these care homes was cost-effective.

Originality/value

– There are very few telemedicine studies focused on care homes.

Telemedicine in US Army soldiers with type 1 diabetes

A retrospective study of a telemedicine clinic for active duty US Army soldiers with type 1 diabetes was conducted. Fifty-one consecutive patients (mean age 33.9 years) were enrolled into the clinic. All soldiers with known or newly diagnosed type 1 diabetes received three weekly office visits for intensive diabetes education. After this, all communication occurred via a messaging system consisting of texting, web-based download, and/or email to a diabetes management team. For urgent matters, 24/7 direct paging or telephone access was provided. Routine adjustments in insulin dosing were accomplished via email. Soldiers were followed for a mean of 17.1 months. Baseline, three-month, and end of study glycated hemoglobin (A1C) values were 9.8, 7.3, and 6.9, respectively. There were no significant differences in end of study A1C levels between patients with known vs. newly diagnosed type 1 diabetes, nor were there any differences between those patients who received insulin via pump therapy vs. multiple daily injections. Telemedicine was safe and effective in lowering A1C levels in US Army soldiers with type 1 diabetes.