Results of the pilot study of DIADEM: a comprehensive disease management programme for type 2 diabetes

Users' acceptance of electronic patient portals in Lebanon

Background

Acceptance of Electronic patient portal (EPP) is instrumental for its success. Studies on users’ acceptance in the Middle East region are scarce. This study aims to use the TAM as a framework to quantitatively describe potential users, diabetic and chronic high blood pressure patients and their providers, intention to use and factors influencing the intention to use EPP at AUBMC-FMC We concurrently test the internal construct validity and the reliability of the TAM.

Methods

A cross-sectional survey design and the vignette approach were used. For validation, we needed a minimum of 180 patients; all 35 attending physicians and 11 registered nurses were targeted. We used descriptive statistics to calculate the intention to use EPP and its determinants based on the TAM constructs. Exploratory factor analysis (EFA) and structural equation modeling (SEM) were employed to estimate significant path coefficients for patients only as the sample size of providers was too small.

Results

We had 199 patients, half intended to use EPP; 73% of providers (N = 17) intended to use EPP. Perceived ease of use and privacy concerns were significantly higher among providers than patients (Mean (M) = 0.77 vs M = 0.42 (CI: − 0.623; − 0.081)) and (M = 3.67 vs M = 2.13, CI: − 2.16; − 0.91) respectively; other constructs were not significantly different. Reliability of TAM revealed a Cronbach Alpha of α=.91. EFA showed that three components explained 73.48% of the variance: Behavioral Intention of Use (14.9%), Perceived Ease of Use (50.74%), Perceived Usefulness (7.84%). SEM found that perceived ease of use increased perceived usefulness (standardized regression weight = 0.49); perceived usefulness (0.51) had more predictive value than perceived ease of use (0.27) to explain the behavioral intention of use of the EPP.

Conclusions

We found that providers valued the usefulness of EPP and were mostly intending to use it. This finding has yet to be tested in future studies testing actual use as intention and actual use may not be concordant. The intention to use among patients was lower than those reported in developed countries. We identified two factors that we need to address to increase use, namely perceived ease and usefulness, and proposed practical implications to address them; future research directions were also discussed.

Self-monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes (The SMBG Study): study protocol for a randomised controlled trial

BACKGROUND

The benefit of Self-monitoring of Blood Glucose (SMBG) in people with non-insulin treated type 2 diabetes remains unclear with inconsistent evidence from randomised controlled trials fuelling the continued debate. Lack of a consistent finding has been attributed to variations in study population and design, including the SMBG intervention. There is a growing consensus that structured SMBG, whereby the person with diabetes and health care provider are educated to detect patterns of glycaemic abnormality and take appropriate action according to the blood glucose profiles, can prove beneficial in terms of lowering HbA1c and improving overall well-being. Despite this, many national health agencies continue to issue guidelines restricting the use of SMBG in non-insulin treated type 2 diabetes.

METHODS

The SMBG Study is a 12 month, multi-centre, randomised controlled trial in people with type 2 diabetes not on insulin therapy who have poor glycaemic control (HbA1c ≥58 mmol/mol / 7.5%). The participants will be randomised into three comparative groups: Group 1 will act as a control group and receive their usual diabetes care; Group 2 will undertake structured SMBG with clinical review every 3 months; Group 3 will undertake structured SMBG with additional monthly telecare support from a trained study nurse. A total of 450 participants will be recruited from 16 primary and secondary care sites across Wales and England. The primary outcome measure will be HbA1c at 12 months with secondary measures to include weight, BMI, total cholesterol and HbA1c levels at 3, 6, 9 and 12 months. Participant well-being and attitude towards SMBG will be monitored throughout the course of the study. Recruitment began in December 2012 with the last participant visit due in September 2016.

DISCUSSION

This study will attempt to answer the question of whether structured SMBG provides any benefits to people with poorly controlled type 2 diabetes who are not being treated with insulin. The data will also clarify whether the telecare support provides additional value. The overall acceptability of SMBG as a tool for self-management will be assessed.

TRIAL REGISTRATION

UKCRN 12038 (Registered March 2012). ISRCTN21390608 (Retrospectively registered 15^th May 2014).

Home telehealth for chronic disease management: selected findings of a narrative synthesis

BACKGROUND

Chronic disease has become an increasingly important issue for individuals and healthcare organizations across Canada. Home telehealth may have the potential to alleviate the economic and social challenges associated with rising rates of chronic disease. An aim of this review was to gather and synthesize the evidence on the effectiveness of home telehealth in chronic disease management.

MATERIALS AND METHODS

We searched the Medline, EMBASE, Web of Science, CINAHL, and PAIS databases for studies published in English from January 1, 2005, and December 31, 2010. Academic publications, white papers, and gray literature were all considered eligible for inclusion, provided an original research element was present. Articles were screened for relevance.

RESULTS

One hundred one articles on quantitative or mixed-methods studies reported the effects of home telehealth on disease state, symptoms, and quality of life in chronic disease patients. Studies were consistent in finding that home telehealth was equivalent or superior to usual care.

CONCLUSIONS

The literature strongly supports the use of home telehealth as an equally effective alternative to usual care. The circumstances under which home telehealth emerges as significantly better than usual care have not been extensively researched. Further research into factors affecting the effectiveness of home telehealth would support more widespread realization of telehealth's potential benefits.

Patient and provider attitudes toward the use of patient portals for the management of chronic disease: a systematic review

Background

Patient portals provide patients with the tools to better manage and understand their health status. However, widespread adoption of patient portals faces resistance from patients and providers for a number of reasons, and there is limited evidence evaluating the characteristics of patient portals that received positive remarks from patients and providers.

Objective

The objectives of this systematic review are to identify the shared characteristics of portals that receive favorable responses from patients and providers and to identify the elements that patients and providers believe need improvement.

Methods

The authors conducted a systematic search of the CINAHL and PubMed databases to gather data about the use of patient portals in the management of chronic disease. Two reviewers analyzed the articles collected in the search process in order remove irrelevant articles. The authors selected 27 articles to use in the literature review.

Results

Results of this systematic review conclude that patient portals show significant improvements in patient self-management of chronic disease and improve the quality of care provided by providers. The most prevalent positive attribute was patient-provider communication, which appeared in 10 of 27 articles (37%). This was noted by both patients and providers. The most prevalent negative perceptions are security (concerns) and user-friendliness, both of which occurred in 11 of 27 articles (41%). The user-friendliness quality was a concern for patients and providers who are not familiar with advanced technology and therefore find it difficult to navigate the patient portal. The high cost of installation and maintenance of a portal system, not surprisingly, deters some providers from implementing such technology into their practice, but this was only mentioned in 3 of the 27 articles (11%). It is possible that the incentives for meaningful use assuage the barrier of cost.

Conclusions

This systematic review revealed mixed attitudes from patients and their providers regarding the use of patient portals to manage their chronic disease. The authors suggest that a standard patient portal design providing patients with the resources to understand and manage their chronic conditions will promote the adoption of patient portals in health care organizations.

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

AIM

A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education.

METHODS

Electronic databases were searched for relevant publications about asynchronous and synchronous tele-consultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard meta-analytical methods.

RESULTS

Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient-caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient-provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (chi(2) = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference -0.10; 95% confidence interval -0.39 to 0.18).

CONCLUSION

The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients' needs.

Integrated primary care in Germany: the road ahead

PROBLEM STATEMENT

Health care delivery in Germany is highly fragmented, resulting in poor vertical and horizontal integration and a system that is focused on curing acute illness or single diseases instead of managing patients with more complex or chronic conditions, or managing the health of determined populations. While it is now widely accepted that a strong primary care system can help improve coordination and responsiveness in health care, primary care has so far not played this role in the German system. Primary care physicians traditionally do not have a gatekeeper function; patients can freely choose and directly access both primary and secondary care providers, making coordination and cooperation within and across sectors difficult.

DESCRIPTION OF POLICY DEVELOPMENT

Since 2000, driven by the political leadership and initiative of the Federal Ministry of Health, the German Bundestag has passed several laws enabling new forms of care aimed to improve care coordination and to strengthen primary care as a key function in the German health care system. These include on the contractual side integrated care contracts, and on the delivery side disease management programmes, medical care centres, gatekeeping and 'community medicine nurses'.

CONCLUSION AND DISCUSSION

Recent policy reforms improved framework conditions for new forms of care. There is a clear commitment by the government and the introduction of selective contracting and financial incentives for stronger cooperation constitute major drivers for change. First evaluations, especially of disease management programmes, indicate that the new forms of care improve coordination and outcomes. Yet the process of strengthening primary care as a lever for better care coordination has only just begun. Future reforms need to address other structural barriers for change such as fragmented funding streams, inadequate payment systems, the lack of standardized IT systems and trans-sectoral education and training of providers.

Influence of diabetic education on patient metabolic control

This study was conducted for the purpose of examining the effect of planned education given to persons with type 2 diabetes mellitus (DM) on their metabolic control. The method of the study was a randomly controlled clinical trial. A sample of 50 individuals participated, of which 25 were in the Experimental group (E), and 25 were in the Control group (C). The educational program consisted of three sessions between the educator and persons with diabetes. Before the education program, there was no statistically important significance between the metabolic control parameters of the E group and the C group. In the analysis of the difference between means of the E and C groups, after the third education program, statistically significant differences were found between fasting blood sugar, postparandial blood sugar, urine glucose, hemoglobin A1c, triglyceride, total cholesterol, and low-density lipoprotein cholesterol levels. In the study, regular and repetitive education provided by the nurses had a positive effect on the metabolic values of persons with DM.

A review of web-assisted interventions for diabetes management: maximizing the potential for improving health outcomes

Current endeavors in diabetes care focus on helping patients and providers deal successfully with the complexities of the disease by improving the system of care, expanding the reach of interventions, and empowering patients to engage in self-care behaviors. Internet technologies that combine the broad reach of mass media with the interactive capabilities of interpersonal media provide a wide range of advantages over standard modes of delivery. The technical affordances of Web delivery enable individualization or tailoring, appropriately timed reinforcement of educational messages, social support, improved feedback, and increased engagement. In turn, these have been significantly correlated with improved health outcomes.This article is a narrative review of Web-based interventions for managing type 2 diabetes published from 2000 to 2007 that utilize Web sites, Web portals, electronic medical records, videoconference, interactive voice response, and short messaging systems. The most effective systems link medical management and self-management. Patient satisfaction is highest when the Web-based system gives them the ability to track blood glucose, receive electronic reminders, schedule physician visits, email their health care team, and interact with other diabetic patients. However, comprehensive medical and self-management programs have not been implemented widely outside of systems funded by government agencies. The cost of developing and maintaining comprehensive systems continues to be a challenge and is seldom measured in efficacy studies. Lack of reimbursement for Web-based treatments is also a major barrier to implementation. These barriers must be overcome for widespread adoption and realization of subsequent cost savings.