Community-based tele-health systems for persons with diabetes: development of an outcomes model

Management of postprandial hyperglycaemia and weight gain in women with gestational diabetes mellitus using a novel telemonitoring system

OBJECTIVES

The purpose of this study was to investigate the effect of remotely delivered telemedicine dietary advice on monitoring of blood glucose levels and weight gain of women with gestational diabetes mellitus (GDM).

METHODS

Women with GDM were recruited and randomly allocated into two groups: a Tele-GDM group that received a telemonitoring device, and a control group that was followed-up traditionally. A telemonitoring service calculated the ratio of reaching or exceeding the pregnancy weight gain target (according to pre-pregnancy weight), following Institute of Medicine guidelines for healthy pregnancy weight gain.

RESULTS

The sample comprised 27 women in the Tele-GDM group and 30 in the control group. At the end of pregnancy, the Tele-GDM group showed significantly lower 2-hour postprandial glucose levels than the control group. Most women in the Tele-GDM group reached their recommended range of weight gain at the end of pregnancy. Additionally, the Tele-GDM group showed significantly lower weight gain than the control group.

CONCLUSIONS

Telemonitoring can facilitate close monitoring of women with GDM and motivate patients to adopt a healthy lifestyle.

Effect of telephone-supported ergonomic education on pregnancy-related low back pain

This study investigated the effect of telephone-supported ergonomic education on pregnancy-related low back pain. This study was performed at Trakya University Hospital in Edirne, Turkey between December 15, 2016 and April 4, 2017. One hundred ten pregnant women were included in the study and randomly assigned to one of two groups. Sixty pregnant women received one face-to-face session of ergonomic education followed by three weekly sessions of telephone-supported ergonomic education (intervention group). Fifty pregnant women received only one session of standard face-to-face ergonomic education. Before and after the intervention, low back pain was evaluated using the Visual Analog Scale. Pain-related disability was evaluated with the Oswestry Disability Index, and health-related quality of life was evaluated with the SF-36. Telephone-supported ergonomic education was more effective than standard ergonomic education and can be used as an effective solution for pregnancy-related low back pain.

Telehealth and Occupational Therapy: Integral to the Triple Aim of Health Care Reform

Programs and concepts included in the Patient Protection and Affordable Care Act of 2010 are expected to transform health care in the United States from a volume-based health system to a value-based health system with increased emphasis on prevention and health promotion. The Triple Aim, a framework set forth by the Institute for Healthcare Improvement, focuses on improving the health care experience, the health of populations, and the affordability of care. This article describes telehealth as an integral component in achieving the Triple Aim of health care and discusses implications for occupational therapy practitioners.

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.

Seasonal variation and homes: understanding the social experiences of older adults

There has been limited research on the importance of seasons in the lives of older adults. Previous research has highlighted seasonal fluctuations in physical functioning--including limb strength, range of motion, and cardiac death--the spread of influenza in seasonal migration patterns. In addition, older adults experience isolation for various reasons, such as decline of physical and cognitive ability, lack of transportation, and lack of opportunities for social interaction. There has been much attention paid to the social isolation of older adults, yet little analysis about how the isolation changes throughout the year. Based on findings from an ethnographic study of older adults (n = 81), their family members (n = 49), and supportive professionals (n = 46) as they embark on relocation from their homes, this study analyzes the processes of moving for older adults. It examines the seasonal fluctuations of social isolation because of the effect of the environment on the social experiences of older adults. Isolation occurs because of the difficulty inclement weather causes on social interactions and mobility. The article concludes with discussion of the ways that research and practice can be designed and implemented to account for seasonal variation.

In search of healing between two worlds: the use of traditional and modern health services by older women in rural Bangladesh

The objective of this study is to gain a deeper understanding of the use of traditional and modern medicine among older adult women living in rural Bangladesh. Factors are identified that guide the women's decisions about who to seek help from when they are ill. The findings provide evidence that, in spite of the availability of modern health care, traditional healers--faith-based and herbalists--are widely utilized. Reasons given for their choice of health care providers fall into two categories: belief in the effectiveness of the intervention and service delivery considerations. These data suggest that use of traditional healers persists among women in rural areas of Bangladesh and that health policy should be developed with an acknowledgment of these health practices.

A pilot project for improving paediatric diabetes outcomes using a website: the Pediatric Diabetes Education Portal

We created a website for patients and families that allowed them to review clinic test results, review educational materials related to these results and post questions to their diabetes educator. Fingerstick haemoglobin A(1c) (HbA(1c)) testing and periodic use of a continuous glucose monitoring system (CGMS) were offered to all patients. The HbA(1c) and CGMS results were posted to the website after each clinic visit. A total of 52 patients with type 1 diabetes were enrolled in the study. There were 16 patients with HbA(1c) values within ADA guidelines and 16 with HbA(1c) values above guidelines; 20 patients were excluded for various reasons. Users of the website were defined as families who logged in four or more times over the six-month study period. For patients whose HbA(1c) started above ADA guidelines, the mean HbA(1c) for website users decreased from 10.5% (SD 2.2) at baseline to 9.1% (SD 1.2) after six months. In the non-users, the mean HbA(1c) increased from 9.5% (SD 1.5) at baseline to 10.4% (SD 2.5). However, these changes were not significant. A between groups comparison (users versus non-users) showed a significant improvement in HbA(1c) for website users (P = 0.03). This change in HbA(1c) was clinically relevant. Further studies with more patients are needed to see if these improvements can be sustained over a longer period.

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.