Development and evaluation of a patient-oriented education system for diabetes management

Design, development, and usability evaluation of a smartphone-based application for nutrition management in patients with type II diabetes

Purpose

Information technology (IT)-based interventions, especially mobile health (mHealth), possess a great potential for promoting self-management in patients with chronic diseases, including diabetes type II. The present study was aimed to design and develop a smartphone-based application (app) for nutrition management in patients with type II diabetes and evaluation of its usability.

Methods

In this study, a three-phase research approach was followed; (1) To determine the information content and functionalities of the app, a five-point Likert scale checklist including six parts was developed based on reviews of clinical practice guidelines and specialized databases. The checklist was then given to ten experts in endocrinology and metabolism, internal medicine, and nutrition, and those items with a mean score higher than 3.75 were approved. (2) In Android Studio, the app was designed and developed using Java language. (3) The Questionnaire for User Interaction Satisfaction (QUIS) was used to assess the app's usability by 21 patients with type II diabetes, ten IT experts, and seven endocrinologists, internal medicine practitioners, and nutritionists over one month. Mean scores were divided into three levels: weak (0-3), average (3-6), and good (6-9).

Results

According to experts' view, 17 out of 22 educational content and 17 out of 27 functionalities were approved. The app's most important educational content was the timing of meals for insulin patients and the definition of diabetes and its complications. The designed app had the following functionalities: providing educational information, recording information, performing calculations, representing data graphically, setting reminders, and communicating with physicians. The most important features of the app were the insulin dose calculation, reminders for doctors' appointments, setting times for tests and blood glucose measurements, and also tracking weight, blood glucose levels, and blood pressure. In terms of usability evaluation, the app was rated "good" level by diabetic patients (7.83 ± 0.74), IT experts (8.1 ± 0.66), and physicians (8.03 ± 0.95).

Conclusion

Given the desirable evaluation of the app by patients, physicians, and IT experts, it can be concluded that the developed app has the required functionalities for nutrition management of patients with type II diabetes. Smartphone-based apps appear to be able to improve self-management, the quality of care and health in patients with diabetes, and reduce many of their unnecessary visits to healthcare centers, and costs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01140-x.

Personalized Mobile Health for Elderly Home Care: A Systematic Review of Benefits and Challenges

Mobile health as one of the new technologies can be a proper solution to support care provision for the elderly and provide personalized care for them. This study is aimed at reviewing the benefits and challenges of personalized mobile health (PMH) for elderly home care. With a systematic review methodology, 1895 records were retrieved by searching four databases. After removing duplicates, 1703 articles remained. Following full-text examination, 21 articles that met the inclusion criteria were studied in detail, and the output was presented in different tables. The results indicated that 25% of the challenges were related to privacy, cybersecurity, and data ownership (10%), technology (7.5%), and implementation (7.5%). The most frequent benefits were related to cost-saving (17.5%), nurse engagement improvement (10%), and caregiver stress reduction (7.5%). In general, the number of benefits in this study was slightly higher than the challenges, but in order to use PMH technologies, the challenges presented in this study must be carefully considered and a suitable solution must be adopted. Benefits can also be helpful in persuading individuals and health-care providers. This study shed light on those points that need to be highlighted for further work in order to convert the challenges toward benefits.

Effects of mobile health interventions on health-related outcomes in older adults with type 2 diabetes: A systematic review and meta-analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic metabolic condition that is associated with multiple comorbidities. Apart from pharmacological approaches, patient self-management remains the gold standard of care for diabetes. Improving patients' self-management among the elderly with mobile health (mHealth) interventions is critical, especially in times of the COVID-19 pandemic. However, the extent of mHealth efficacy in managing T2DM in the older population remains unknown. Hence, the present review examined the effectiveness of mHealth interventions on cardiometabolic outcomes in older adults with T2DM.

METHODS

A systematic search from the inception till May 31, 2021, in the MEDLINE, Embase, and PubMed databases was conducted, and 16 randomized controlled trials were included in the analysis.

RESULTS

The results showed significant benefits on glycosylated hemoglobin (HbA1c) (mean difference -0.24%; 95% confidence interval [CI]: -0.44, -0.05; p = 0.01), postprandial blood glucose (-2.91 mmol/L; 95% CI: -4.78, -1.03; p = 0.002), and triglycerides (-0.09 mmol/L; 95% CI: -0.17, -0.02; p = 0.010), but not on low-density lipoprotein cholesterol (-0.06 mmol/L; 95% CI: -0.14, 0.02; p = 0.170), high-density lipoprotein cholesterol (0.05 mmol/L; 95% CI: -0.03, 0.13; p = 0.220), and blood pressure (systolic blood pressure -0.82 mm Hg; 95% CI: -4.65, 3.00; p = 0.670; diastolic blood pressure -1.71 mmHg; 95% CI: -3.71, 0.29; p = 0.090).

CONCLUSIONS

Among older adults with T2DM, mHealth interventions were associated with improved cardiometabolic outcomes versus usual care. Its efficacy can be improved in the future as the current stage of mHealth development is at its infancy. Addressing barriers such as technological frustrations may help strategize approaches to further increase the uptake and efficacy of mHealth interventions among older adults with T2DM.

Cardiovascular diseases and risk factors knowledge and awareness in people with type 2 diabetes mellitus: a global evaluation

AIM

Cardiovascular diseases (CVD) are the leading cause of death in people living with type 2 diabetes mellitus (T2D). The aim of this study was to explore the knowledge and awareness of CVD and related risk factors in people living with T2D, globally.

METHODS

A questionnaire consisting of 17 questions was used to conduct the Taking Diabetes to Heart survey, between September 2017 and May 2018 among people living with T2D. All categorical variables are presented as numbers and percentages. Pearson's chi-square test and Fisher's exact test were used to assess the association between categorical variables.

RESULTS

A total of 12,695 respondents living with T2D in 133 countries completed the questionnaire. Almost half of the respondents (44%) reported having lived with diabetes for more than nine years. Only one in six (17%) considered themselves at high risk of CVD, which was surprising given that almost all the respondents had at least one CVD risk factor and around 28% of respondents had experienced one or more CVD events in the past. Although the majority of the respondents indicated they have had CVD risk factors, one in six (17%) had never discussed their risk with a health professional (HP). Furthermore, one in eleven (9%) did not know about CVD and its associated risk factors.

CONCLUSION

To mitigate the prevalence of CVD in people living with diabetes, it is required to work with HP to increase knowledge and awareness of people with T2D about diabetes complications, in particular CVD.

Mobile Phone-Based Telemedicine Practice in Older Chinese Patients with Type 2 Diabetes Mellitus: Randomized Controlled Trial

BACKGROUND

Previous studies on telemedicine interventions have shown that older diabetic patients experience difficulty in using computers, which is a barrier to remote communication between medical teams and older diabetic patients. However, older people in China tend to find it easy to use mobile phones and personal messaging apps that have a user-friendly interface. Therefore, we designed a mobile health (mHealth) system for older people with diabetes that is based on mobile phones, has a streamlined operation interface, and incorporates maximum automation.

OBJECTIVE

The goal of the research was to investigate the use of mobile phone-based telemedicine apps for management of older Chinese patients with type 2 diabetes mellitus (T2DM). Variables of interest included efficacy and safety.

METHODS

A total of 91 older (aged over 65 years) patients with T2DM who presented to our department were randomly assigned to one of two groups. Patients in the intervention group (n=44) were provided glucometers capable of data transmission and received advice pertaining to medication, diet, and exercise via the mHealth telemedicine system. Patients assigned to the control group (n=47) received routine outpatient care with no additional intervention. Patients in both groups were followed up at regular 3-month intervals.

RESULTS

After 3 months, patients in the intervention group showed significant (P<.05) improvement in postprandial plasma glucose level. After 6 months, patients in the intervention group exhibited a decreasing trend in postprandial plasma glucose and glycated hemoglobin levels compared with the baseline and those in the control group (P<.05).

CONCLUSIONS

Mobile phone-based telemedicine apps help improve glycemic control in older Chinese patients with T2DM.

TRIAL REGISTRATION

China Clinical Trial Registration Center ChiCTR 1800015214; http://www.chictr.org.cn/showprojen.aspx?proj=25949 (Archived by WebCite at http://www.webcitation.org/73wKj1GMq).

A randomized controlled trial of a web-based education intervention for women with gestational diabetes mellitus

OBJECTIVE

This study aimed to investigate changes in maternal body mass index (BMI), blood pressure and glycemic level and infant birthweight using an online educational program compared to standard clinic-based GDM education.

DESIGN

A preliminary randomized controlled trial of the online intervention was conducted in Melbourne, Australia between 2014 and 2015. A total of 110 women were randomized to (1) the control group and received standard clinic-based GDM education; or (2) the intervention group and received standard care plus the web-based education program. Data were collected at two time points: baseline and 12 weeks postpartum. Infant birthweight was also recorded. Chi-squared test, independent t-test and paired t-test were used to compare outcomes.

PARTICIPANTS

Pregnant women with newly diagnosed GDM, in the Western region of Melbourne, Australia.

FINDINGS

Statistically significant differences were reported between intervention and control groups in maternal weight and glycemia post-intervention (p < 0.05). More women in the intervention group than in the control group reported weight loss post-intervention (90.4% vs 48.3%, p < 0.001), and were considered a healthy weight (BMI = 18.5, 24.9kg/m²) at 12 weeks postpartum (44.2% vs 31%). More women in the intervention group had attended for follow up OGTT at 12 weeks postpartum (96.2% vs 70.7%, p < 0.001). Comparing measures pre- and post-intervention in the intervention group, maternal BMI was lower [(28.60 ± 7.93) vs (29.60 ± 8.32); p = 0.000], maternal systolic blood pressure was increased but within normal range [(108.19 ± 11.80) vs (107.29 ± 12.13); p = 0.001], and maternal glycemic level returned to within normal limits [(4.86 ± 0.42) vs (8.80 ± 2.50); p = 0.026]. Most women in both groups gave birth to normal birthweight infants (92.3% and 94.8%). These findings are offset by differences in the groups at baseline.

KEY CONCLUSIONS

Findings suggest that the education intervention had a positive impact on women's postpartum weight and attendance at OGTT by 12 weeks postpartum. No effect was found on maternal blood pressure or infant birthweight. Further studies with matched intervention and control groups are needed to achieve more definitive conclusions.

Type 1 diabetes self-management: developing a web-based telemedicine application

BACKGROUND

Self-management skills are essential for patients with diabetes mellitus to minimise the risks of complications from their condition. The aim of this research was to develop a web-based application for self-management of type 1 diabetes, suitable for use by patients, their carers and physicians.

METHOD

The study was comprised of two phases, the first being analysis of the kind of information and capabilities required by potential users of the system. Based on the results derived from the first phase of the study, the system prototype was designed and then evaluated using the 'think aloud' method and a standard questionnaire. The application was designed for use by patients, their carers and physicians. Patients could enter the level of blood glucose, insulin and activities on a daily basis, and physicians were able to supervise a patient's health status from a distance.

RESULTS

Users were generally satisfied with the final version of the system. People with a wide range of literacy skills were able to use the system effectively.

CONCLUSION

Patients or their carers could use the web-based application as a log book by entering the level of blood glucose and insulin doses on a regular basis, and as an educational resource to improve self-management skills. Physicians could use the system at any time convenient to them to support patients by giving medical advice. Further research is needed to report the effectiveness of the system in practice.

The efficacy of telehealth delivered educational approaches for patients with chronic diseases: A systematic review

OBJECTIVE

The virtual delivery of patient education and other forms of telehealth have been proposed as alternatives to providing needed care for patients with chronic diseases. The purpose of this systematic review was to compare the efficacy of virtual education delivery on patient outcomes compared with usual care.

METHODS

The review examined citations from 3 databases, MEDLINE, CINAHL, and EMBASE using the search words telehealth, chronic disease, patient education, and related concepts. From 2447 records published between 2006 and 2017, 16 high to moderate quality studies were selected for review. Eligible papers compared virtual education to usual care using designs allowing for assessment of causality.

RESULTS

Telehealth modalities included the web, telephone, videoconference, and television delivered to patients with diabetes, chronic obstructive pulmonary disease, irritable bowel syndrome and heart failure. In 11 of 16 studies, virtually delivered interventions significantly improved outcomes compared to control conditions. In the remaining 5 studies, virtual education showed comparable outcomes to the control conditions.

CONCLUSIONS

Findings demonstrated that virtual education delivered to patients with chronic diseases was comparable, or more effective, than usual care.

RESEARCH IMPLICATIONS

Despite its benefits, there is potential for further research into the individual components which improve effectiveness of virtually delivered interventions.

The diabetes self-management educational programs and their integration in the usual care: A systematic literature review

The increasing prevalence of type 2 diabetes has highlighted the importance of evidence-based guidelines for effective prevention, management and treatment. Diabetes self-management education (SME) produces positive effects on patient behaviours and health status. We analyzed the literature to identify (i) the level of integration between usual care and SME programs and (ii) any possible differences across them in terms of outcomes. Searches were made on three databases - PubMed, Scopus and Web of Science - to identify relevant publications on diabetes SME to 2015, which also describe the provider of usual care. In total, 49 studies met the inclusion criteria. We identified three levels of integration (high, medium and low) between usual care and SME programs based on the level of involvement of usual care professionals within the SME programs. In most cases, the primary care physician was responsible for the diabetes patients. Patient health behaviors and/or outcomes improve in most of the studies, independently from the level of integration. However, findings suggest that when patients/participants could perceive that usual care provider is highly involved in SME delivery, educational programs produced results that appear to be more positive.

Randomised-controlled trial of a web-based dietary intervention for patients with type 2 diabetes: changes in health cognitions and glycemic control

BACKGROUND

Increasing prevalence and disease burden has led to an increasing demand of programs and studies focused on dietary and lifestyle habits, and chronic diseases such as type 2 diabetes mellitus (T2DM). We evaluated the effects of a 6-month web-based dietary intervention on Dietary Knowledge, Attitude and Behaviour (DKAB), Dietary Stages of Change (DSOC), fasting blood glucose (FBG) and glycosylated haemoglobin (HbA1c) in patients with uncontrolled HbA1c (> 7.0%) in a randomised-controlled trial (myDIDeA) in Malaysia.

METHODS

The e-intervention group (n = 62) received a 6-month web-delivered intensive dietary intervention while the control group (n = 66) continued with their standard hospital care. Outcomes (DKAB and DSOC scores, FBG and HbA1c) were compared at baseline, post-intervention and follow-up.

RESULTS

While both study groups showed improvement in total DKAB score, the margin of improvement in mean DKAB score in e-intervention group was larger than the control group at post-intervention (11.1 ± 0.9 vs. 6.5 ± 9.4,p < 0.001) and follow-up (19.8 ± 1.1 vs. 7.6 ± 0.7,p < 0.001), as compared to the baseline. Although there was no significant difference between intervention and control arms with respect to DSOC score and glycaemic control, the e-intervention group showed improved DSOC score (199.7 ± 18.2 vs193.3 ± 14.6,p = 0.046), FBG (7.9 ± 2.5 mmol/L vs. 8.9 ± 3.9 mmol/L,p = 0.015) and HbA1c (8.5 ± 1.8% vs. 9.1 ± 2.0%,p = 0.004) at follow-up compared to the baseline, whereas such improvement was not seen in the control group.

CONCLUSIONS

Most important impact of myDIDeA was on the overall DKAB score. This study is one of the first to demonstrate that an e-intervention can be a feasible method for implementing chronic disease management in developing countries. Concerns such as self-monitoring, length of intervention, intense and individualized intervention, adoption of other domains of Transtheoretical Model and health components, and barriers to change have to be taken into consideration in the development of future intervention programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246687 .

Development of a store-and-forward telescreening system of diabetic retinopathy: lessons learned from Iran

Background

The present study describes the development and identity phases of a teleophthalmology system used for screening of diabetic retinopathy.

Methods

A questionnaire was used to identify the main factors necessary for diagnosis of diabetic retinopathy and the features required for a teleophthalmology system. In the second phase, a web-based prototype of the system was designed using the data collected in the previous phase. In the final phase, the system was optimized based on the users’ ideas and comments; then, it was evaluated through a standard usability testing questionnaire.

Results

The results showed that the lowest average percentages were related to ethnicity (61%), optometrist’s office address (61%), and consultant physician’s office address (65%). A web-based prototype was designed using the Visual Studio and Dreamweaver programming tools. This system comprised patient identity data, medical history, clinical data, and retinal images of the patient. The mean score of usability testing and user satisfaction including specialists, residents, and optometrist was 7.3, 7.1 and 7.3 (out of a total 9), respectively. The evaluation results revealed that the system was classified as good.

Conclusion

The telescreening system suggested in the current study could be helpful in timely diagnosis. Moreover, it would reduce the treatment costs and complexities. Regardless of the positive points of telemedicine systems, one of the most challenges in this study was the Internet infrastructure to design and apply the system. The future studies, therefore, could focus on the application of cell phone technology for rendering teleophthalmology.

E-healthcare for Diabetes Mellitus Type 2 Patients - A Randomised Controlled Trial in Slovenia

BACKGROUND

Telemonitoring and web-based interventions are increasingly used in primary-care practices in many countries for more effective management of patients with diabetes mellitus (DM). A new approach in treating patients with diabetes mellitus in family practices, based on ICT use and nurse practitioners, has been introduced and evaluated in this study.

METHOD

Fifteen Slovene family practices enrolled 120 DM patients treated only with a diet regime and/or tablets into the study. 58 of them were included into the interventional group, and the other 62 DM patients into the control group, within one-year-long interventional, randomised controlled trial. Patients in the control group had conventional care for DM according to Slovenian professional guidelines, while the patients in the interventional group were using also the eDiabetes application. Patients were randomised through a balanced randomisation process.

RESULTS

Significant reductions of glycated haemoglobin (HbA1c) values were found after 6 and 12 months among patients using this eDiabetes application (p<0.05). Among these patients, a significant correlation was also found between self-monitored blood pressure and the final HbA1c values. Diabetic patients' involvement in web-based intervention had only transient impact on their functional health status.

CONCLUSION

This eDiabetes application was confirmed to be an innovative approach for better self-management of DM type 2 patients not using insulin. Both a significant reduction of HbA1c values and a significant correlation between the average self-measured blood pressure and the final HbA1c values in the interventional group were found. Nurse practitioners - as diabetes care coordinators - could contribute to better adherence in diabetes e-care.

Knowledge of risk factors for diabetes or cardiovascular disease (CVD) is poor among individuals with risk factors for CVD

Background

There is limited evidence on whether having pre-existing cardiovascular disease (CVD) or risk factors for CVD such as diabetes, ensures greater knowledge of risk factors important for motivating preventative behaviours. Our objective was to compare knowledge among the Australian public participating in a health check program and their risk status.

Methods

Data from the Stroke Foundation ‘Know your numbers’ program were used. Staff in community pharmacies provided opportunistic health checks (measurement of blood pressure and diabetes risk assessment) among their customers. Participants were categorised: 1) CVD ± risk of CVD: history of stroke, heart disease or kidney disease, and may have risk factors; 2) risk of CVD only: reported having high blood pressure, high cholesterol, diabetes or atrial fibrillation; and 3) CVD risk free (no CVD or risk of CVD). Multivariable logistic regression analyses were performed including adjustment for age and sex.

Findings

Among 4,647 participants, 12% had CVD (55% male, 85% aged 55+ years), 47% were at risk of CVD (40% male, 72% 55+ years) and 41% were CVD risk free (33% male, 27% 55+ years). Participants with CVD (OR: 0.66; 95% CI: 0.55, 0.80) or risk factors for CVD (OR: 0.65; 95% CI: 0.57, 0.73) had poorer knowledge of the risk factors for diabetes/CVD compared to those who were CVD risk free. After adjustment, only participants with risk factors for CVD (OR: 0.80; 95% CI: 0.69, 0.93) had poorer knowledge. Older participants (55+ years) and men had poorer knowledge of diabetes/CVD risk factors and complications of diabetes.

Conclusions

Participants with poorer knowledge of risk factors were older, more often male or were at risk of developing CVD compared with those who were CVD risk free. Health education in these high risk groups should be a priority, as diabetes and CVD are increasing in prevalence throughout the world.

Diabetes knowledge among Greek Type 2 Diabetes Mellitus patients

BACKGROUND & OBJECTIVE

Diabetes knowledge has been shown to improve glycemic control and associate with several demographic parameters. In Greece, a country with high obesity rates, disease knowledge has never been evaluated in diabetic patients. This cross sectional study aimed to assess diabetes knowledge and its associations between social and demographic parameters, among Greek type 2 diabetes mellitus (T2DM) patients.

METHODS

One hundred fifty nine patients with T2DM were recruited from an urban and a rural clinic in Greece. Diabetes knowledge was assessed with the Brief Diabetes Knowledge Test (DKT). Basic anthropometry was performed. Data regarding glycemic control and sociodemographic characteristics were collected from the patients' medical files.

RESULTS

Greek T2DM patients demonstrated poor disease knowledge (mean DKT score 8.3±2.2/14.0 and mean DKT as a percent of correct answers 59.6±15.8%). No differences were observed between sex, place of residence, or glycemic control, among subjects. Patients with higher education demonstrated greater diabetes knowledge. Simple obesity with concurrent central obesity or suboptimal glycemic control decreased diabetes knowledge among participants. Additionally, waist circumference was inversely correlated to diabetes knowledge.

CONCLUSIONS

Based on the DKT, Greek patients exhibit poor diabetes knowledge. This study provides evidence for the need for better diabetes education in order to ameliorate disease outcome.

Diabetes education for Chinese adults with type 2 diabetes: A systematic review and meta-analysis of the effect on glycemic control

AIMS

The purpose of this study is to systematically review evidence in English and Chinese publications to determine the size of glycemic effect of different diabetes education approaches for Chinese patients.

METHODS

CINAHL Plus, Embase, Ovid Medline, Scopus and the China National Knowledge Infrastructure database were searched. Studies were included if they were randomised controlled trials with a detailed description of education approach, with more than 50 Chinese-adult participants, reporting actual glycemic outcome and with at least 3-month follow-up. Data was systematically extracted and cross-checked by the authors. Methodological quality was assessed.

RESULTS

Fifty-three studies, including five English and 48 Chinese publications, were included. The overall weighted mean difference (WMD) in glycated haemoglobin (HbA1c) was -1.19% (-13mmol/mol). Ongoing regular education was most-commonly employed, with a reported WMD of -2.02% (-22mmol/mol). Glycemic control was further enhanced in studies using information reinforcement strategies.

CONCLUSIONS

Diabetes education in any format generates glycemic improvement for Chinese patients, but is particularly effective when an ongoing regular education is employed. Innovative strategies aligned with cultural concepts, such as employing patient examination to reinforce diabetes management knowledge and/or involving family in patient care deserve further trial to determine whether they enhance glycemic control in this group.

The Impact of Information Technology on Patient Engagement and Health Behavior Change: A Systematic Review of the Literature

Background

Advancements in information technology (IT) and its increasingly ubiquitous nature expand the ability to engage patients in the health care process and motivate health behavior change.

Objective

Our aim was to systematically review the (1) impact of IT platforms used to promote patients’ engagement and to effect change in health behaviors and health outcomes, (2) behavior theories or models applied as bases for developing these interventions and their impact on health outcomes, (3) different ways of measuring health outcomes, (4) usability, feasibility, and acceptability of these technologies among patients, and (5) challenges and research directions for implementing IT platforms to meaningfully impact patient engagement and health outcomes.

Methods

PubMed, Web of Science, PsycINFO, and Google Scholar were searched for studies published from 2000 to December 2014. Two reviewers assessed the quality of the included papers, and potentially relevant studies were retrieved and assessed for eligibility based on predetermined inclusion criteria.

Results

A total of 170 articles met the inclusion criteria and were reviewed in detail. Overall, 88.8% (151/170) of studies showed positive impact on patient behavior and 82.9% (141/170) reported high levels of improvement in patient engagement. Only 47.1% (80/170) referenced specific behavior theories and only 33.5% (57/170) assessed the usability of IT platforms. The majority of studies used indirect ways to measure health outcomes (65.9%, 112/170).

Conclusions

In general, the review has shown that IT platforms can enhance patient engagement and improve health outcomes. Few studies addressed usability of these interventions, and the reason for not using specific behavior theories remains unclear. Further research is needed to clarify these important questions. In addition, an assessment of these types of interventions should be conducted based on a common framework using a large variety of measurements; these measurements should include those related to motivation for health behavior change, long-standing adherence, expenditure, satisfaction, and health outcomes.

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.

A pilot study examining patient attitudes and intentions to adopt assistive technologies into type 2 diabetes self-management

Approximately half of individuals living with type 2 diabetes mellitus (T2DM) have suboptimal self-management, which could be improved by using assistive technologies in self-management regimes. This study examines patient attitudes and intentions to adopt assistive technologies into T2DM self-management. Forty-four participants (M = 58.7 years) with T2DM were recruited from diabetes education classes in the southwestern Ontario, Canada, between February and April 2014. Participants completed a self-reported in-person survey assessing demographic characteristics, current diabetes management, and attitudes toward using assistive technologies in their diabetes self-management. Demographics, disease characteristics, and current technology use and preferences of the cohort were examined, followed by a correlational analysis of descriptive characteristics and attitudes and intentions to use technology in self-management. The majority of (but not all) participants felt that using Internet applications (65%) and smartphone (53.5%) applications for self-management was a good idea. The majority of participants did not currently use an Internet (92.5%) or mobile (96%) application for self-management. Of participants, 77% intended to use an Internet application to manage their diabetes in the future and 58% intended to use mobile applications. Younger age was associated with more positive attitudes (r = -.432, P = .003) and intentions (r = -.425, P = .005) to use assistive technologies in diabetes self-management. Findings suggest that patients, especially those younger in age, are favorable toward adopting assistive technologies into management practice. However, attitudes among older adults are less positive, and few currently make use of such technologies in any age group.

Conventional vs. tablet computer-based patient education following lung transplantation--a randomized controlled trial

BACKGROUND

Accurate immunosuppression is of critical importance in preventing rejection, while avoiding toxicity following lung transplantation. The mainstay immunosuppressants are calcineurin inhibitors, which require regular monitoring due to interactions with other medications and diet. Adherence to immunosuppression and patient knowledge is vital and can be improved through patient education. Education using tablet-computers was investigated.

OBJECTIVE

To compare tablet-PC education and conventional education in improving immunosuppression trough levels in target range 6 months after a single education. Secondary parameters were ratio of immunosuppression level measurements divided by per protocol recommended measurements, time and patient satisfaction regarding education.

DESIGN

Single-centre, open labelled randomised controlled trial.

PARTICIPANTS

Patients >6 months after lung-transplantation with <50% of calcineurin inhibitor trough levels in target range.

INTERVENTION

Tablet-pc education versus personal, nurse-led education.

MEASUREMENTS

Calcineurin inhibitor levels in target range 6 months after education, level variability, interval adherence, knowledge and adherence was studied. As outcome parameter, renal function was measured and adverse events registered.

RESULTS

Sixty-four patients were 1:1 randomised for either intervention. Levels of immunosuppression 6 months after education were equal (tablet-PC 58% vs. conventional 48%, p = 0.27), both groups improved in achieving a CNI trough level within target range by either education method (delta tablet-PC 29% vs. conventional 20%). In all patients, level variability decreased (-20.4%), whereas interval adherence remained unchanged. Knowledge about immunosuppression improved by 7% and compliance tests demonstrated universal improvements with no significant difference between groups.

CONCLUSION

Education is a simple, effective tool in improving adherence to immunosuppression. Tablet-PC education was non-inferior to conventional education.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01398488 http://clinicaltrials.gov/ct2/show/NCT01398488? term=gottlieb+tablet+pc+education&rank=1.

Evaluating an online pharmaceutical education system for pharmacy interns in critical care settings

Incorporating electronic learning (eLearning) system into professional experimental programs such as pharmacy internships is a challenge. However, none of the current systems can fully support the unique needs of clinical pharmacy internship. In this study we enhanced a commercial eLearning system for clinical pharmacy internship (The Clinical Pharmacy Internship eLearning System, CPIES). The KAP questionnaire was used to evaluate the performance of group A with the traditional teaching model and group B with the CPIES teaching model. The CPIES teaching model showed significant improvement in interns' knowledge and practice (p = 0.002 and 0.031, respectively). The traditional teaching model only demonstrated significant improvement in practice (p = 0.011). Moreover, professionalism, such as attitudes on cooperating with other health professionals, is developed by learning from a good mentor. The on-line teaching and traditional teaching methods should undoubtedly be blended in a complete teaching model in order to improve learners' professional knowledge, facilitate correct attitude, and influence good practice.

Factors associated with knowledge of diabetes in patients with type 2 diabetes using the Diabetes Knowledge Test validated with Rasch analysis

OBJECTIVE

In patients with Type 2 diabetes, to determine the factors associated with diabetes knowledge, derived from Rasch analysis, and compare results with a traditional raw scoring method.

RESEARCH DESIGN & METHODS

Participants in this cross-sectional study underwent a comprehensive clinical and biochemical assessment. Diabetes knowledge (main outcome) was assessed using the Diabetes Knowledge Test (DKT) which was psychometrically validated using Rasch analysis. The relationship between diabetes knowledge and risk factors identified during univariate analyses was examined using multivariable linear regression. The results using raw and Rasch-transformed methods were descriptively compared.

RESULTS

181 patients (mean age±standard deviation = 66.97±9.17 years; 113 (62%) male) were included. Using Rasch-derived DKT scores, those with greater education (β = 1.14; CI: 0.25,2.04, p = 0.013); had seen an ophthalmologist (β = 1.65; CI: 0.63,2.66, p = 0.002), and spoke English at home (β = 1.37; CI: 0.43,2.31, p = 0.005) had significantly better diabetes knowledge than those with less education, had not seen an ophthalmologist and spoke a language other than English, respectively. Patients who were members of the National Diabetes Service Scheme (NDSS) and had seen a diabetes educator also had better diabetes knowledge than their counterparts. Higher HbA1c level was independently associated with worse diabetes knowledge. Using raw measures, access to an ophthalmologist and NDSS membership were not independently associated with diabetes knowledge.

CONCLUSIONS

Sociodemographic, clinical and service use factors were independently associated with diabetes knowledge based on both raw scores and Rasch-derived scores, which supports the implementation of targeted interventions to improve patients' knowledge. Choice of psychometric analytical method can affect study outcomes and should be considered during intervention development.

Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus

BACKGROUND

Diabetes is one of the commonest chronic medical conditions, affecting around 347 million adults worldwide. Structured patient education programmes reduce the risk of diabetes-related complications four-fold. Internet-based self-management programmes have been shown to be effective for a number of long-term conditions, but it is unclear what are the essential or effective components of such programmes. If computer-based self-management interventions improve outcomes in type 2 diabetes, they could potentially provide a cost-effective option for reducing the burdens placed on patients and healthcare systems by this long-term condition.

OBJECTIVES

To assess the effects on health status and health-related quality of life of computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus.

SEARCH METHODS

We searched six electronic bibliographic databases for published articles and conference proceedings and three online databases for theses (all up to November 2011). Reference lists of relevant reports and reviews were also screened.

SELECTION CRITERIA

Randomised controlled trials of computer-based self-management interventions for adults with type 2 diabetes, i.e. computer-based software applications that respond to user input and aim to generate tailored content to improve one or more self-management domains through feedback, tailored advice, reinforcement and rewards, patient decision support, goal setting or reminders.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the abstracts and extracted data. A taxonomy for behaviour change techniques was used to describe the active ingredients of the intervention.

MAIN RESULTS

We identified 16 randomised controlled trials with 3578 participants that fitted our inclusion criteria. These studies included a wide spectrum of interventions covering clinic-based brief interventions, Internet-based interventions that could be used from home and mobile phone-based interventions. The mean age of participants was between 46 to 67 years old and mean time since diagnosis was 6 to 13 years. The duration of the interventions varied between 1 to 12 months. There were three reported deaths out of 3578 participants.Computer-based diabetes self-management interventions currently have limited effectiveness. They appear to have small benefits on glycaemic control (pooled effect on glycosylated haemoglobin A1c (HbA1c): -2.3 mmol/mol or -0.2% (95% confidence interval (CI) -0.4 to -0.1; P = 0.009; 2637 participants; 11 trials). The effect size on HbA1c was larger in the mobile phone subgroup (subgroup analysis: mean difference in HbA1c -5.5 mmol/mol or -0.5% (95% CI -0.7 to -0.3); P < 0.00001; 280 participants; three trials). Current interventions do not show adequate evidence for improving depression, health-related quality of life or weight. Four (out of 10) interventions showed beneficial effects on lipid profile.One participant withdrew because of anxiety but there were no other documented adverse effects. Two studies provided limited cost-effectiveness data - with one study suggesting costs per patient of less than $140 (in 1997) or 105 EURO and another study showed no change in health behaviour and resource utilisation.

AUTHORS' CONCLUSIONS

Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup. There is no evidence to show benefits in other biological outcomes or any cognitive, behavioural or emotional outcomes.

Results of a randomized controlled trial to assess the effects of a mobile SMS-based intervention on treatment adherence in HIV/AIDS-infected Brazilian women and impressions and satisfaction with respect to incoming messages

OBJECTIVE

To assess whether a warning system based on mobile SMS messages increases the adherence of HIV-infected Brazilian women to antiretroviral drug-based treatment regimens and their impressions and satisfaction with respect to incoming messages.

DESIGN

A randomized controlled trial was conducted from May 2009 to April 2010 with HIV-infected Brazilian women. All participants (n=21) had a monthly multidisciplinary attendance; each participant was followed over a 4-month period, when adherence measures were obtained. Participants in the intervention group (n=8) received SMS messages 30 min before their last scheduled time for a dose of medicine during the day. The messages were sent every Saturday and Sunday and on alternate days during the working week. Participants in the control group (n=13) did not receive messages.

MEASUREMENTS

Self-reported adherence, pill counting, microelectronic monitors (MEMS) and an interview about the impressions and satisfaction with respect to incoming messages.

RESULTS

The HIV Alert System (HIVAS) was developed over 7 months during 2008 and 2009. After the study period, self-reported adherence indicated that 11 participants (84.62%) remained compliant in the control group (adherence exceeding 95%), whereas all 8 participants in the intervention group (100.00%) remained compliant. In contrast, the counting pills method indicated that the number of compliant participants was 5 (38.46%) for the control group and 4 (50.00%) for the intervention group. Microelectronic monitoring indicated that 6 participants in the control group (46.15%) were adherent during the entire 4-month period compared to 6 participants in the intervention group (75.00%). According to the feedback of the 8 participants who completed the research in the intervention group, along with the feedback of 3 patients who received SMS for less than 4 months, that is, did not complete the study, 9 (81.81%) believed that the SMS messages aided them in treatment adherence, and 10 (90.90%) responded that they would like to continue receiving SMS messages.

CONCLUSION

SMS messaging can help Brazilian women living with HIV/AIDS to adhere to antiretroviral therapy for a period of at least 4 months. In general, the results are encouraging because the SMS messages stimulated more participants in the intervention group to be adherent to their treatment, and the patients were satisfied with the messages received, which were seen as reminders, incentives and signs of affection by the health clinic for a marginalized population.

Randomised-controlled trial of a web-based dietary intervention for patients with type 2 diabetes mellitus: study protocol of myDIDeA

Background

The potential of web-based interventions in dietary behaviour modification of the diabetics has not been fully explored. We describe the protocol of a 12-month match-design randomised controlled trial of a web-based dietary intervention for type 2 diabetic patients with primary aim to evaluate the effect of the intervention on their dietary knowledge, attitude and behaviour (KAB). The secondary objective of this study is to improve the participants' dietary practices, physical measurements and biomarkers.

Methods/Design

A minimum total sample of 82 Type 2 diabetics will be randomised, either to the control group, who will receive the standard diabetes care or the e-intervention group, who will participate in a 6-month web-based dietary intervention in addition to the standard care. The dietary recommendations are based on existing guidelines, but personalised according to the patients' Stages of Change (SOC). The participants will be followed up for 6 months post-intervention with data collection scheduled at baseline, 6-month and 12-month.

Discussion

We are aiming for a net improvement in the KAB score in participants of the e-intervention group, besides investigating the impact of the e-intervention on the dietary practices, physical measurements and blood biomarkers of those patients. The successful outcome of this study can be a precursor for policy makers to initiate more rigorous promotion of such web-based programmes in the country.

Trial registration

Clinicaltrials.gov NCT01246687

Behavior matters

Behavior has a broad and central role in health. Behavioral interventions can be effectively used to prevent disease, improve management of existing disease, increase quality of life, and reduce healthcare costs. A summary is presented of evidence for these conclusions in cardiovascular disease/diabetes, cancer, and HIV/AIDS as well as with key risk factors: tobacco use, poor diet, physical inactivity, and excessive alcohol consumption. For each, documentation is made of (1) moderation of genetic and other fundamental biological influences by behaviors and social-environmental factors; (2) impacts of behaviors on health; (3) success of behavioral interventions in prevention; (4) disease management; (5) quality of life, and (6) improvements in the health of populations through behavioral health promotion programs. Evidence indicates the cost effectiveness and value of behavioral interventions, especially relative to other common health services as well as the value they add in terms of quality of life. Pertinent to clinicians and their patients as well as to health policy and population health, the benefits of behavioral interventions extend beyond impacts on a particular disease or risk factor. Rather, they include broad effects and benefits on prevention, disease management, and well-being across the life span. Among priorities for dissemination research, the application of behavioral approaches is challenged by diverse barriers, including socioeconomic barriers linked to health disparities. However, behavioral approaches including those emphasizing community and social influences appear to be useful in addressing such challenges. In sum, behavioral approaches should have a central place in prevention and health care of the 21st century.

Web-based interventions for the management of type 2 diabetes mellitus: a systematic review of recent evidence

INTRODUCTION

The Internet has emerged as a potentially effective medium for information exchange. The Internet's potential has been recognised and web-based education programmes have been steadily adopted in recent years in preventing and managing chronic diseases such as diabetes mellitus. This review provides a descriptive discussion of web-based behavioural interventions for the management of type 2 diabetes mellitus.

METHOD

Systematic literature searches were performed using MEDLINE, EMBASE, PUBMED, PsycINFO, Web of Science and Cochrane Library to retrieve articles published between 2000 and June 2010 which fulfilled all inclusion criteria. Methodological quality assessment and data synthesis were then performed.

RESULTS

Twenty articles representing 13 different studies were reviewed. None of the studies were ranked as low in the methodological quality. Goal-setting, personalised coaching, interactive feedback and online peer support groups were some of the successful approaches which were applied in e-interventions to manage type 2 diabetes mellitus. Strong theoretical background, use of other technologies and longer duration of intervention were proven to be successful strategies as well.

CONCLUSION

The web-based interventions have demonstrated some level of favourable outcomes, provided they are further enhanced with proper e-research strategies.

Investigation of effect on glycosylated hemoglobin, blood pressure, and body mass index of diabetes intensive education program in patients with type 2 diabetes mellitus

This study investigated the effects of a diabetes intensive education program (DIEP) on glycosylated hemoglobin (HbA(1)c), body mass index (BMI), and arterial blood pressure (BP). An 8-week randomized-controlled trial was conducted in Cumhuriyet University Hospital. Diabetes patients were randomized to control group (CG; n = 25) and intervention group (IG; n = 25) who received DIEP, including the factors affecting metabolic control and implementation of diabetes guidelines. Primary outcomes included HbA(1)c, BP, and BMI. After the 8 weeks, there was a significant decrease in HbA(1)c mean values for the intervention group. Also, BP significantly decreased from 143/87 to 130/80 mmHg in the IG as compared with an increase from 137/82 to 137/86 mmHg in the CG. In addition, the results demonstrated that DIEP improved the number of patients at goal for BP (130/80 mmHg). Baseline BMI did not change significantly in either group during the course of the study. These findings show that the DIEP may be effective in decreasing HbA(1)c levels and improving adherence to BP control.

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.

Evaluation of a remote training approach for teaching seniors to use a telehealth system

OBJECTIVE

There has been a growth of home healthcare technology in rural areas. However, a significant limitation has been the need for costly and repetitive training in order for patients to efficiently use their home telemedicine unit (HTU). This research describes the evaluation of an architecture for remote training of patients in a telemedicine environment. This work examines the viability of a remote training architecture called REmote Patient Education in a Telemedicine Environment (REPETE). REPETE was implemented and evaluated in the context of the IDEATel project, a large-scale telemedicine project, focusing on Medicare beneficiaries with diabetes in New York State.

METHODS

A number of qualitative and quantitative evaluation tools were developed and used to study the effectiveness of the remote training sessions evaluating: (a) task complexity, (b) changes in patient performance and (c) the communication between trainer and patient. Specifically, the effectiveness of the training was evaluated using a measure of web skills competency, a user satisfaction survey, a cognitive task analysis and an interaction analysis.

RESULTS

Patients not only reported that the training was beneficial, but also showed significant improvements in their ability to effectively perform tasks. Our qualitative evaluations scrutinizing the interaction between the trainer and patient showed that while there was a learning curve for both the patient and trainer when negotiating the shared workspace, the mutually visible pointer used in REPETE enhanced the computer-mediated instruction.

CONCLUSIONS

REPETE is an effective remote training tool for older adults in the telemedicine environment. Patients demonstrated significant improvements in their ability to perform tasks on their home telemedicine unit.

Improving doctor-patient communication: examining innovative modalities vis-a-vis effective patient-centric care management technology

This analysis investigates what patients and practitioners can do to improve their interactive communications to achieve optimal patient-centric (PC) care. One goal of this clinical practice approach is to improve patient satisfaction, compliance, and outcomes. The mutual responsibilities required of both the patients and practitioners to attain PC care are discussed. Innovative, information technology techniques in the healthcare environment in general and in care delivery in particular are explored. Practitioner-to-patient encouragement vis-a-vis self education on their conditions is also provided.

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.

Can wireless text messaging improve adherence to preventive activities? Results of a randomised controlled trial

OBJECTIVE

To determine the effectiveness of cell phone wireless text messaging for improving adherence to a healthy behaviour.

DESIGN

A randomised, unblinded, controlled trial was conducted with 102 subjects, 18 years or older, each having a cell phone and willing to take 1 vitamin C pill per day for 1 month for preventive reasons. Intervention group participants received text messaging reminders and were asked to acknowledge receiving their messages after taking the vitamins, whereas control group subjects had no text messaging activity.

MEASUREMENTS

Self-reported adherence and the number of participant text messages acknowledging vitamins taken.

RESULTS

Both groups reported an increased adherence after the trial: by 246% for the intervention group and by 131% for the control group. There was a non-significant difference between the two groups at endpoint: an average difference of 0.8 between the number of pills missed in the last week of the trial (2.5 out of 7 in the intervention and 3.3 out of 7 in the control group) with a power of 0.54. The study revealed a significant correlation (coefficient=-0.352, sig.=0.01) between the average number of text messaging acknowledgements sent by the intervention group participants and the number of pills they reported missed during the last week of the trial.

CONCLUSION

This was a small randomised controlled trial with inconclusive but encouraging results. It suggests a new approach in addressing insufficient adherence in outpatient conditions and shows that the use of information technology tools for compliance warrants further research.