Telehealth--an effective delivery method for diabetes self-management education?

Exploring the Feasibility of Digital Voice Assistants for Delivery of a Home-Based Exercise Intervention in Older Adults With Obesity and Type 2 Diabetes Mellitus: Randomized Controlled Trial

BACKGROUND

Current clinical guidelines for the management of type 2 diabetes mellitus (T2DM) in older adults recommend the use of antihyperglycemic medications, monitoring of blood glucose levels, regular exercise, and a healthy diet to improve glycemic control and reduce associated comorbidities. However, adherence to traditional exercise programs is poor (<35%). Common barriers to adherence include fear of hypoglycemia and the need for blood glucose level monitoring before exercise. Digital health strategies offer great promise for managing T2DM as they facilitate patient-practitioner communication, support self-management, and improve access to health care services for underserved populations. We have developed a novel web-based software program allowing practitioners to create tailored interventions and deliver them to patients via digital voice assistants (DVAs) in their own homes.

OBJECTIVE

We aim to evaluate the feasibility of a 12-week, home-based, personalized lifestyle intervention delivered and monitored by DVAs for older adults with obesity and T2DM.

METHODS

In total, 50 older adults with obesity aged 50-75 years with oral hypoglycemic agent-treated T2DM were randomized to the intervention (DVA, n=25) or a control group (n=25). Participants allocated to the DVA group were prescribed a home-based muscle strengthening exercise program (~20- to 30-min sessions) and healthy eating intervention, delivered via DVAs (Alexa Echo Show 8; Amazon) using newly developed software ("Buddy Link"; Great Australian Pty Ltd). Control group participants received generalized physical activity information via email. Outcomes were feasibility, DVA usability (System Usability Scale), and objectively assessed physical activity and sedentary time (wrist-worn accelerometers).

RESULTS

In total, 45 (90%) out of 50 participants completed this study. Mean adherence to prescribed exercise was 85% (SD 43%) with no intervention-related adverse events. System usability was rated above average (70.4, SD 16.9 out of 100). Compared with controls, the DVA group significantly decreased sedentary time (mean difference -67, SD 23; 95% CI -113 to -21 min/d), which was represented by a medium to large effect size (d=-0.6).

CONCLUSIONS

A home-based lifestyle intervention delivered and monitored by health professionals using DVAs was feasible for reducing sedentary behavior and increasing moderate-intensity activity in older adults with obesity and T2DM.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000307808; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381364&isReview=true.

Health Impact of a Mobile-Delivered Diabetes Intervention to Control Blood Pressure in Older Adults

Introduction

Patient education is an effective modality to reinforce self-care practices for chronic disease management. The purpose of this study was twofold: (1) to assess the health impact of a phone-delivered diabetes intervention and (2) to identify predictors of telehealth message use among adults aged 18-65 years with diabetes in a primary care setting using the Technology Acceptance Model theoretical framework.

Methods

A pretest-posttest experimental study design was employed. Participants were randomized to receive 7 weeks of telehealth self-care messages or to the routine care group. Outcome measures included (1) telehealth use among patients who received weekly telehealth messages, (2) self-care behavior management derived from the Behavior Score Instrument, and (3) clinical outcomes measures.

Results

The study team enrolled 150 patients, and of these, 138 (aged 18-65 years) completed the study. Participants aged 53±9.6 (mean±SD) years were mainly females (n=93; 76%), and the majority received government-sponsored health insurance (n=75; 54%). Age was a strong predictor of telehealth use (p<0.001). Among patients who received telehealth messages, systolic and diastolic blood pressure measures (140/78 mmHg vs 134/74 mmHg) were statistically significant at follow-up (p=0.001 and p=0.007, respectively).

Conclusions

Digital support tools can play a valuable role in supporting lifestyle modification changes and reinforcing good diabetes self-care practices in older adults. Providing accessible tools and resources empowers adults to take an active role in their own health.

Feasibility and Design Factors for Home-Based Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease and Chronic Lung Diseases Based on a People-Object-Environment Framework: Qualitative Interview Study

BACKGROUND

The feasibility of implementing home-based pulmonary rehabilitation (PR) can be assessed from the perspectives of patients with chronic lung disease and health care professionals involved in PR.

OBJECTIVE

Through a qualitative inquiry using interviews and the adoption of the people-object-environment framework, this study aims to understand the influences of interpersonal, environmental, and situational factors on the perceptions and considerations of individuals involved in home-based PR for patients with chronic lung disease.

METHODS

One-on-one interviews were conducted with 20 patients with chronic lung disease and 20 health care professionals for investigating their attitudes and opinions based on their experiences regarding home-based PR as well as for identifying the key factors affecting the benefits and drawbacks of such therapies. This study further evaluates the feasibility of using digital tools for medical diagnosis and treatment by examining the technology usage of both parties.

RESULTS

The 4 key issues that all participants were the most concerned about were as follows: distance to outpatient medical care, medical efficiency, internet connectivity and equipment, and physical space for diagnosis and treatment. Interviews with patients and health care professionals revealed that the use of technology and internet was perceived differently depending on age and area of residence. Most participants reported that digital tools and internet connectivity had many benefits but still could not solve all the problems; moreover, these same digital tools and network transmission could lead to problems such as information security and digital divide concerns. This study also emphasizes the significant impact of human behavior and thinking on shaping the design of health care interventions and technologies. Understanding user perspectives and experiences is crucial for developing effective solutions for unmet needs.

CONCLUSIONS

The results of this study indicate that despite the different perspectives of patients and health care professionals, their considerations of the key issues are very similar. Therefore, the implementation of plans related to telemedicine diagnosis, treatment, or rehabilitation should take the suggestions and considerations of both parties into account as crucial factors for telehealth care design.

A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study

Background

Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic.

Methods

This prospective multicenter-cohort pre-/post-intervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period.

Results

Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34-2.85%], p < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81-3.53%), 2.49% (95% CI = 1.92-3.06%), and 2.16% (95% CI = 1.76-2.57%) at centers A, B, and C, respectively (all p < 0.001).

Conclusion

The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.

The Use of Digital Telehealth for the Self-Management of Type 2 Diabetes Patients in Hinds County, Mississippi: A Pilot Study

Self-management is crucial for the management of type 2 diabetes. Remote patient monitoring via telehealth may enhance self-management and control of diabetes. A three-arm randomized controlled trial involving 90 participants randomized into two intervention groups and one control group was conducted. The purpose of this study is to test whether the use of a mobile phone-based app, with or without telehealth counseling, could improve HbA1c level, self-management, and health-related quality of life compared with usual care. The two intervention groups received a mobile phone with a self-management app. One intervention group additionally received telehealth counseling delivered by a diabetes specialist nurse for 6 months. All three groups continued to receive the usual care from their provider. The primary outcome is a reduction in HbA1c level. Secondary outcomes are self-management, health-related quality of life, depressive symptoms, and lifestyle changes. Data were analyzed using univariate and multivariate (descriptive, t-test, MANOVA) methods. There was a significant reduction in the HbA1c levels of participants after 3 and 6 months. There was also a significant difference in HbA1c levels between the control and two intervention groups. Pre- and posteducation surveys for intervention group 2 showed an improvement in the understanding of type 2 diabetes risk factors, diabetes, and self-management. Digital telehealth demonstrated considerable potential for reducing blood sugar levels, enhancing self-management, and improving the quality of life of type 2 diabetic patients. The addition of telehealth education and counseling further improved the positive outcomes.

The experiences of health workers using telehealth services for diabetes-related foot complications: a qualitative exploration

BACKGROUND

Diabetes-related foot disease (DFD) accounts for up to 75% of lower-extremity amputations globally. Rural and remote communities are disproportionately affected by DFD. Telehealth has been advocated as a strategy to improve equity of access to health care in rural and remote communities. Current literature suggests that successful implementation of telehealth requires access to adequate reliable equipment, staff training, and support. A real-time video-based telehealth foot service (TFS) for delivering DFD management has recently been established in a Vascular Surgery and Podiatry clinic within a large South Australian metropolitan hospital. The purpose of this study was to gain insights into the experiences of rural and remote health professionals utilising the TFS, as this could be invaluable in optimising the uptake of telehealth use in DFD.

METHODS

This exploratory, descriptive qualitative study employed one-on-one, semi-structured interviews with health professionals who utilised the service. Thematic analysis using an essentialist inductive approach was employed.

RESULTS

Participants included 14 rural and remote health professionals; 2 general practitioners, 2 nurses, 1 Aboriginal Health Practitioner, and 9 podiatrists. In addition, 2 metropolitan-based TFS staff were interviewed. Five key themes were identified. 'Patients have reduced travel burden' included that telehealth enabled Indigenous patients to stay on country. 'Patients had increased psychosocial support' covered the benefits of having health professionals who knew the patient present in consults. 'Improved access' incorporated how telehealth improved interprofessional relationship building and communication. 'Technological and equipment challenges' highlighted that poor network connectivity and poor access to equipment to conduct telehealth consults in rural areas were barriers. The last theme,'Lack of service communication to rural health professionals', highlighted the need for communication around service details.

CONCLUSION

Telehealth is a valuable tool that can improve access to treatment for rural and remote Indigenous DFD patients. While this has the potential to improve DFD outcomes, empirical data is required to confirm outcomes. Considering the advantages of telehealth and rural staff shortages, there is an urgent need for investment in improved equipment and processes and an understanding of the training needs of the health care workforce to support the use of telehealth in DFD management.

Use of Patient-reported Outcome Measures and Patient-reported Experience Measures within Evaluation Studies of Telemedicine Applications: Systematic Review

Background

With the rise of digital health technologies and telemedicine, the need for evidence-based evaluation is growing. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are recommended as an essential part of the evaluation of telemedicine. For the first time, a systematic review has been conducted to investigate the use of PROMs and PREMs in the evaluation studies of telemedicine covering all application types and medical purposes.

Objective

This study investigates the following research questions: in which scenarios are PROMs and PREMs collected for evaluation purposes, which PROM and PREM outcome domains have been covered and how often, which outcome measurement instruments have been used and how often, does the selection and quantity of PROMs and PREMs differ between study types and application types, and has the use of PROMs and PREMs changed over time.

Methods

We conducted a systematic literature search of the MEDLINE and Embase databases and included studies published from inception until April 2, 2020. We included studies evaluating telemedicine with patients as the main users; these studies reported PROMs and PREMs within randomized controlled trials, controlled trials, noncontrolled trials, and feasibility trials in English and German.

Results

Of the identified 2671 studies, 303 (11.34%) were included; of the 303 studies, 67 (22.1%) were feasibility studies, 70 (23.1%) were noncontrolled trials, 20 (6.6%) were controlled trials, and 146 (48.2%) were randomized controlled trials. Health-related quality of life (n=310; mean 1.02, SD 1.05), emotional function (n=244; mean 0.81, SD 1.18), and adherence (n=103; mean 0.34, SD 0.53) were the most frequently assessed outcome domains. Self-developed PROMs were used in 21.4% (65/303) of the studies, and self-developed PREMs were used in 22.3% (68/303). PROMs (n=884) were assessed more frequently than PREMs (n=234). As the evidence level of the studies increased, the number of PROMs also increased (τ=−0.45), and the number of PREMs decreased (τ=0.35). Since 2000, not only has the number of studies using PROMs and PREMs increased, but the level of evidence and the number of outcome measurement instruments used have also increased, with the number of PREMs permanently remaining at a lower level.

Conclusions

There have been increasingly more studies, particularly high-evidence studies, which use PROMs and PREMs to evaluate telemedicine. PROMs have been used more frequently than PREMs. With the increasing maturity stage of telemedicine applications and higher evidence level, the use of PROMs increased in line with the recommendations of evaluation guidelines. Health-related quality of life and emotional function were measured in almost all the studies. Simultaneously, health literacy as a precondition for using the application adequately, alongside proper training and guidance, has rarely been reported. Further efforts should be pursued to standardize PROM and PREM collection in evaluation studies of telemedicine.

Sauerbruch, STARPAHC, and SARS: Historical Perspectives on Readiness and Barriers in Telemedicine

Aim

Telemedicine is a promising solution to extend traditional health care services. Even though mainly discussed during the past two decades, its roots go back into the past century and even further, considering the use of bonfires to warn other villages of diseases. Insights from historical cases can therefore be useful for the ongoing discussion regarding the successful implementation of telemedicine.

Subject and Methods

We analyzed three historical telemedicine cases (varying regarding time and place) and extracted their success factors and barriers as well as assessed their maturity by using the Telemedicine Community Readiness Model (TCRM). Evidence-based categories of success factors and barriers as well as the TCRM’s dimensions were used as deductive categories to analyze the study material’s content.

Results

The analysis showed that the readiness for telemedicine is higher when the technology is the only option to access health care services. In all three cases, core readiness played a central role. However, the health sector, existing technology, and finance were barriers present at all times, while during pandemics, some barriers are only temporarily removed, for example, by putting legal issues on hold. The analyzed cases were all on lower levels of maturity as they mainly represent pilot tests or exceptional circumstances.

Conclusion

Results indicate the important core functions in telemedicine initiatives as well as the diversity of their circumstances. Insights from such historical meta-perspectives can, for example, help to strengthen the sustainability of the increased use of telemedicine during the COVID-19 pandemic and scale up current telemedicine projects.

Health Information Technology and Diabetes Management: A Review of Motivational and Inhibitory Factors

BACKGROUND

Health information technology helps patients to take better care of themselves and improves health status of patients with chronic diseases, such as diabetes.

OBJECTIVE

This study aimed to identify factors influencing the use of health information technology in diabetes management.

METHODS

This was a review study conducted in 2019. To obtain the related articles, databases, including Scopus, Web of Science, Proquest, and PubMed, were searched and the time frame was between 2010 and 2018. Initially, 1159 articles were retrieved and after screening, 28 articles were selected to be included in the study.

RESULTS

Factors influencing the use of health information technology in diabetes management could be divided into the motivational and inhibitory factors, and each of them could be categorized into five groups of organizational, technical, economic, individual, and ethical/legal factors. The motivational factors included training, system ease of use, economic support, having computer literacy, and maintaining privacy and confidentiality. The inhibitory factors included a lack of long-term planning, technical problems, inadequate financial resources, old age, and concerns over confidentiality issues.

CONCLUSION

Identifying motivational and inhibitory factors can help to make better use of technology for diabetes management. This approach, in turn, can improve the acceptability of the technology and save cost, reduce long-term complications of diabetes, and improve the quality of life in diabetic patients.

Effectiveness of Mobile App-Assisted Self-Care Interventions for Improving Patient Outcomes in Type 2 Diabetes and/or Hypertension: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Mobile app-assisted self-care interventions are emerging promising tools to support self-care of patients with chronic diseases such as type 2 diabetes and hypertension. The effectiveness of such interventions requires further exploration for more supporting evidence.

Objective

A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to examine the effectiveness of mobile app-assisted self-care interventions developed for type 2 diabetes and/or hypertension in improving patient outcomes.

Methods

We followed the Cochrane Collaboration guidelines and searched MEDLINE, Cochrane Library, EMBASE, and CINAHL Plus for relevant studies published between January 2007 and January 2019. Primary outcomes included changes in hemoglobin A_1c (HbA_1c) levels, systolic blood pressure (SBP), and diastolic blood pressure (DBP). Changes in other clinical-, behavioral-, knowledge-, and psychosocial-related outcomes were included as secondary outcomes. Primary outcomes and objective secondary outcomes that were reported in at least two trials were meta-analyzed; otherwise, a narrative synthesis was used for data analysis.

Results

A total of 27 trials were identified and analyzed. For primary outcomes, the use of mobile app-assisted self-care interventions was associated with significant reductions in HbA_1c levels (standardized mean difference [SMD] −0.44, 95% CI −0.59 to −0.29; P<.001), SBP (SMD −0.17, 95% CI −0.31 to −0.03, P=.02), and DBP (SMD −0.17, 95% CI −0.30 to −0.03, P=.02). Subgroup analyses for primary outcomes showed that several intervention features were supportive of self-management, including blood glucose, blood pressure, and medication monitoring, communication with health care providers, automated feedback, personalized goal setting, reminders, education materials, and data visualization. In addition, 8 objective secondary outcomes were meta-analyzed, which showed that the interventions had significant lowering effects on fasting blood glucose levels and waist circumference. A total of 42 secondary outcomes were narratively synthesized, and mixed results were found.

Conclusions

Mobile app-assisted self-care interventions can be effective tools for managing blood glucose and blood pressure, likely because their use facilitates remote management of health issues and data, provision of personalized self-care recommendations, patient–care provider communication, and decision making. More studies are required to further determine which combinations of intervention features are most effective in improving the control of the diseases. Moreover, evidence regarding the effects of these interventions on the behavioral, knowledge, and psychosocial outcomes of patients is still scarce, which warrants further examination.

A design and evaluation framework for digital health interventions

Digital health interventions (DHIs) have the potential to help the growing number of chronic disease patients better manage their everyday lives. However, guidelines for the systematic development of DHIs are still scarce. The current work has, therefore, the objective to propose a framework for the design and evaluation of DHIs (DEDHI). The DEDHI framework is meant to support both researchers and practitioners alike from early conceptual DHI models to large-scale implementations of DHIs in the healthcare market.

Improving Diabetes Control Through Remote Glucose Monitoring in a Diabetes Self-Management Program for Employees of a Health System

IN BRIEF This study investigates the combination of diabetes education, telehealth, a wireless enabled meter, and medication algorithms to improve care for a targeted population of employees with type 1 or type 2 diabetes. After more than 2 years of follow-up, mean A1C was reduced by 1.8%, and a reduction was observed in cost of care, along with an increase in visits with the managing physician provider. Thus, this study showed improved diabetes control using new technologies to provide remote monitoring and telehealth augmenting the outreach and education provided in a diabetes self-management program.

A Review of Technology-based Interventions in Improving Type 2 Diabetes Management in Chinese Americans

Health disparities of type 2 diabetes (DM2) in America is an ongoing crisis. Despite this, technology has been helpful in managing DM2 in the non-Hispanic White, Hispanic, and African American populations and has been proven effective. Furthermore, it may be used to supplement health provider DM2 care through telemedicine to lower hemoglobin A1c (A1c), a gold standard DM2 measurement, and other DM2-related outcomes, such as glycated hemoglobin. The purpose of this study was to review current literature on the use of telemedicine in assisting DM2 management in racial ethnic minorities and to discuss how to adjust the telemedicine DM2 management program to be applied to Chinese Americans. In addition, it is worthy to note that the role of nurses makes a substantial difference in the effectiveness of technological management of DM2 from being culturally sensitive and sending catered messages to address specific patient needs.

Mobile App for Improved Self-Management of Type 2 Diabetes: Multicenter Pragmatic Randomized Controlled Trial

Background

As the increasing prevalence of type 2 diabetes mellitus has put pressure on health systems to appropriately manage these patients, there have been a growing number of mobile apps designed to improve the self-management of diabetes. One such app, BlueStar, has been shown to significantly reduce hemoglobin A_1c (HbA_1c) levels in small studies and is the first app in the United States to receive Food and Drug Administration approval as a mobile prescription therapy. However, the impact of the app across real-world population among different clinical sites and health systems remains unclear.

Objective

The primary objective of this study was to conduct a pragmatic randomized controlled trial of the BlueStar mobile app to determine if app usage leads to improved HbA_1c levels among diverse participants in real-life clinical contexts. We hypothesized that this mobile app would improve self-management and HbA_1c levels compared with controls.

Methods

The study consisted of a multicenter pragmatic randomized controlled trial. Overall, 110 participants randomized to the immediate treatment group (ITG) received the intervention for 6 months, and 113 participants randomized to the wait-list control (WLC) group received usual care for the first 3 months and then received the intervention for 3 months. The primary outcome was glucose control measured by HbA_1c levels at 3 months. Secondary outcomes assessed intervention impact on patient self-management, experience of care, and self-reported health utilization using validated scales, including the Problem Areas in Diabetes, the Summary of Diabetes Self-Care Activities, and the EuroQol-5D. Intervention usage data were collected directly from the app.

Results

The results of an analysis of covariance controlling for baseline HbA_1c levels did not show evidence of intervention impact on HbA_1c levels at 3 months (mean difference [ITG−WLC] −0.42, 95% CI −1.05 to 0.21; P=.19). Similarly, there was no intervention effect on secondary outcomes measuring diabetes self-efficacy, quality of life, and health care utilization behaviors. An exploratory analysis of 57 ITG participants investigating the impact of app usage on HbA_1c levels showed that each additional day of app use corresponded with a 0.016-point decrease in participants’ 3-month HbA_1c levels (95% CI −0.03 to −0.003). App usage varied significantly by site, as participants from 1 site logged in to the app a median of 36 days over 14 weeks (interquartile range [IQR] 10.5-124); those at another site used the app significantly less (median 9; IQR 6-51).

Conclusions

The results showed no difference between intervention and control arms for the primary clinical outcome of glycemic control measured by HbA_1c levels. Although there was low usage of the app among participants, results indicate contextual factors, particularly site, had a significant impact on overall usage. Future research into the patient and site-specific factors that increase app utilization are needed.

Trial Registration

Clinicaltrials.gov NCT02813343; https://clinicaltrials.gov/ct2/show/NCT02813343 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT02813343)

Multi-trajectory modeling of home blood pressure telemonitoring utilization among hypertensive patients in China: A latent class growth analysis

BACKGROUND

Home blood pressure telemonitoring (HBPT) has great potential in improving blood pressure (BP) control among patients with hypertension. However, the longitudinal use trajectories of HBPT have not been identified yet. In addition, there has been a lack of understanding of the relationship between developmental trajectories of HBPT and BP control over time. The primary goal of this study was to identify the longitudinal trajectories of using HBPT among hypertensive patients and to explore the relationship between longitudinal trajectories of HBPT use patterns and BP control.

METHODS

A total of 122 hypertensive patients were enrolled consecutively in Xiling, Huayan, Baisha and Xueyuan communities in Yichang City, Hubei Province, China. Each patient was provided with a portable monitoring device which has unlimited data service at the time of enrollment. Socio-demographics (e.g. name, age, sex, marital status) were collected at baseline. Real-time data including systolic and diastolic blood pressure were automatically uploaded to cloud platform through devices. Latent class growth analysis was conducted to determine the latent trajectory of HBPT use. Joint trajectory method was used to correlate the longitudinal trajectories of HBPT utilization and BP control status.

RESULTS

Five trajectories were identified which are persistently low (47.1%), moderate with decreasing (23.9%), sharply decreasing (11.2%), high with decreasing (11.3%) and persistently high with increasing (6.6%). There was no statistically significant difference among 5 trajectories in the baseline survey in terms of age, marital status, BP (both SBP and DBP) and BP control status. However, there was a strong positive correlation between the HBPT utilization pattern and BP control status over time.

CONCLUSIONS

The latent trajectories of HBPT utilization were identified in our study. However, no predictors of trajectory membership were identified. Nevertheless, we have demonstrated that HBPT was to some extent positively correlated with improved BP control, and this correlation still needs to be further proved.

Mobile Diabetes Intervention Study of Patient Engagement and Impact on Blood Glucose: Mixed Methods Analysis

BACKGROUND

Successful treatment of diabetes includes patient self-management behaviors to prevent or delay complications and comorbid diseases. On the basis of findings from large clinical trials and professional guidelines, diabetes education programs and health providers prescribe daily regimens of glucose monitoring, healthy eating, stress management, medication adherence, and physical activity. Consistent, long-term commitment to regimens is challenging. Mobile health is increasingly being used to assist patients with lifestyle changes and self-management behaviors between provider visits. The effectiveness of mobile health to improve diabetes outcomes depends on patient engagement with a technology, content, or interactions with providers.

OBJECTIVES

In the current analysis, we aimed to identify patient engagement themes in diabetes messaging with diabetes providers and determine if differences in engagement in the Mobile Diabetes Intervention Study (MDIS) influenced changes in glycated hemoglobin A1c (HbA1c) over a 1-year treatment period (1.9% absolute decrease in the parent study).

METHODS

In the primary MDIS study, 163 patients were enrolled into 1 of 3 mobile intervention groups or a usual care control group based on their physician cluster randomization assignment. The control group received care from their physicians as usual. Participants in each intervention group had access to a patient portal where they could record monitoring values for blood glucose, blood pressure, medication changes, or other self-management information while also assigned to varying levels of physician access to patient data. Intervention participants could choose to send and receive messages to assigned certified diabetes educators with questions or updates through the secure Web portal. For this secondary analysis, patient engagement was measured using qualitative methods to identify self-care themes in 4109 patient messages. Mixed methods were used to determine the impact of patient engagement on change in HbA1c over 1 year.

RESULTS

Self-care behavior themes that received the highest engagement for participants were glucose monitoring (75/107, 70.1%), medication management (71/107, 66.4%), and reducing risks (71/107, 66.4%). The average number of messages sent per patient were highest for glucose monitoring (9.2, SD 14.0) and healthy eating (6.9, SD 13.2). Compared to sending no messages, sending any messages about glucose monitoring (P=.03) or medication (P=.01) led to a decrease in HbA1c of 0.62 and 0.72 percentage points, respectively. Sending any messages about healthy eating, glucose monitoring, or medication combined led to a decrease in HbA1c of 0.54 percentage points compared to not sending messages in these themes (P=.045).

CONCLUSIONS

The findings from this study help validate the efficacy of the mobile diabetes intervention. The next step is to determine differences between patients who engage in mobile interventions and those who do not engage and identify methods to enhance patient engagement.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by WebCite at http://www.webcitation.org/6wh4ekP4R).

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

Background

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

Objectives

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

Design

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

Setting

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

Participants

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

Interventions

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

Main outcome measures

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

Data sources

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

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

Funding

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

Comparative analysis of diabetes self-management education programs in the European Union Member States

Diabetes self-management education (DSME) is generally considered as an integral part of diabetes care. The availability of different types of self-management in the European Union Member States (EUMS) remains uncertain. The aim of this study is to perform a comparative analysis of existing DSME programs (DSMEP) implemented in EUMS. Unpublished data regarding DSME in the EUMS was assessed with Diabetes Literacy Survey using wiki tool (WT) targeting patients and different stakeholders. An additional literature review (LR) was performed in PubMed to identify published studies regarding DSMEP in the EUMS from 2004 to 2014. A total of 102 DSMEP implemented in EUMS were reported in the WT and 154 programs were identified from the LR. Comparative analysis of the data indicated that a majority of programs are aimed at adults and only a minority at children and elderly. Only a small percentage of the programs utilize information technology for teaching and learning, and only one out of five programs pay attention to depression. The identified DSMEP aimed primarily to empower patients through increasing knowledge and changing attitudes and beliefs towards diabetes. This study provides an overview of the present state-of-the-art on diabetes self-management education programs in the 28 EUMS. To increase participation, existing DSMEP should be made more accessible to the patients as well as tailored to specific patient groups.

Adopting Telemedicine for the Self-Management of Hypertension: Systematic Review

BACKGROUND

Hypertension is a chronic condition that affects adults of all ages. In the United States, 1 in 3 adults has hypertension, and about half of the hypertensive population is adequately controlled. This costs the nation US $46 billion each year in health care services and medications required for treatment and missed workdays. Finding easier ways of managing this condition is key to successful treatment.

OBJECTIVE

A solution to reduce visits to physicians for chronic conditions is to utilize telemedicine. Research is limited on the effects of utilizing telemedicine in health care facilities. There are potential benefits for implementing telemedicine programs with patients dealing with chronic conditions. The purpose of this review was to weigh the facilitators against the barriers for implementing telemedicine.

METHODS

Searches were methodically conducted in the Cumulative Index to Nursing and Allied Health Literature Complete (CINAHL Complete) via Elton B Stephens Company (EBSCO) and PubMed (which queries MEDLINE) to collect information about self-management of hypertension through the use of telemedicine.

RESULTS

Results identify facilitators and barriers corresponding to the implementation of self-management of hypertension using telemedicine. The most common facilitators include increased access, increase in health and quality, patient knowledge and involvement, technology growth with remote monitoring, cost-effectiveness, and increased convenience/ease. The most prevalent barriers include lack of evidence, self-management difficult to maintain, no long-term results/more areas to address, and long-term added workload commitment.

CONCLUSIONS

This review guides health care professionals in incorporating new practices and identifying the best methods to introduce telemedicine into their practices. Understanding the facilitators and barriers to implementation is important, as is understanding how these factors will impact a successful implementation of telemedicine in the area of self-management of hypertension.

Patient and health care professional perspectives on using telehealth to deliver pulmonary rehabilitation

The objective of this study was to identify the necessary features of pulmonary telerehabilitation (P-TR) from the perspectives of individuals living with chronic lung disease and health care professionals (HCPs) who deliver pulmonary rehabilitation (PR). Focus groups were carried out with patients (n = 26) and HCPs (n = 26) to elicit and explore their opinions about the critical elements of in-person PR and ideas for how these elements could be supported using technology. A questionnaire was used to assess technology use, PR experience, and general health status. Four key elements of PR were identified as critical to P-TR: the social aspect of PR; communicating with HCPs for education and support; using biosensors for monitoring and promoting self-knowledge; and the evolution of support with progress over time. A range of technology-enabled devices and programs were suggested as means to recreate aspects of these integral elements. Consultations with patients and HCPs suggest that users are interested in technology and want to ensure it recreates the important aspects of PR. Patients and HCPs identified similar key elements for P-TR. The opinions and suggestions of patients and HCPs should be the driving force of innovation if P-TR is to succeed in improving health outcomes.

Telemedicine to Promote Patient Safety: Use of Phone-Based Interactive Voice-Response System to Reduce Adverse Safety Events in Pre-dialysis CKD

CKD patients have several features conferring on them a high risk of adverse safety events, which are defined as incidents with unintended harm related to processes of care or medications. These characteristics include impaired kidney function, polypharmacy, and frequent health system encounters. The consequences of such events in CKD can include new or prolonged hospitalization, accelerated kidney function loss, acute kidney injury, ESRD, and death. Health information technology administered via telemedicine presents opportunities for CKD patients to remotely communicate safety-related findings to providers for the purpose of improving their care. However, many CKD patients have limitations that hinder their use of telemedicine and access to the broad capabilities of health information technology. In this review, we summarize previous assessments of the pre-dialysis CKD populations' proficiency in using telemedicine modalities and describe the use of interactive voice-response system to gauge the safety phenotype of the CKD patient. We discuss the potential for expanded interactive voice-response system use in CKD to address the safety threats inherent to this population.

A randomized wait-list control trial to evaluate the impact of a mobile application to improve self-management of individuals with type 2 diabetes: a study protocol

Background

Management of diabetes through improved glycemic control and risk factor modification can help prevent long-term complications. Much diabetes management is self-management, in which healthcare providers play a supporting role. Well-designed e-Health solutions targeting behavior change can improve a range of measures, including glycemic control, perceived health, and a reduction in hospitalizations.

Methods

The primary objective of this study is to evaluate if a mobile application designed to improve self-management among patients with type 2 diabetes (T2DM) improves glycemic control compared to usual care. The secondary objectives are to determine the effects on patient experience and health system costs; evaluate how and why the intervention worked as observed; and gain insight into considerations for system-wide scale-up. This pragmatic, randomized, wait-list-control trial will recruit adult participants from three Diabetes Education Programs in Ontario, Canada. The primary outcome is glycemic control (measured by HbA1c). Secondary outcomes include patient-reported outcomes and patient-reported experience measures, health system utilization, and intervention usability. The primary outcome will be analyzed using an ANCOVA, with continuous secondary outcomes analyzed using Poisson regression. Direct observations will be conducted of the implementation and application-specific training sessions provided to each site. Semi-structured interviews will be conducted with participants, healthcare providers, organizational leaders, and system stakeholders as part of the embedded process evaluation. Thematic analysis will be applied to the qualitative data in order to describe the relationships between (a) key contextual factors, (b) the mechanisms by which they effect the implementation of the intervention, and (c) the impact on the outcomes of the intervention, according to the principles of Realist Evaluation.

Discussion

The use of mobile health and virtual tools is on the rise in health care, but the evidence of their effectiveness is mixed and their evaluation is often lacking key contextual data. Results from this study will provide much needed information about the clinical and cost-effectiveness of a mobile application to improve diabetes self-management. The process evaluation will provide valuable insight into the contextual factors that influence the application effectiveness, which will inform the potential for adoption and scale.

Trial registration

Clinicaltrials.gov NCT02813343. Registered on 24 June 2016 (retrospectively registered).

Trial Sponsor: Ontario Telemedicine Network

Innovative strategies to improve diabetes outcomes in disadvantaged populations

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

Kidney transplant patients' attitudes towards self-management support: A Q-methodological study

OBJECTIVE

Kidney transplant recipients face many self-management challenges. We aimed to identify profiles of attitudes towards self-management support (SMS) shortly after kidney transplantation.

METHODS

Profiles were generated using Q-methodology: In face-to-face interviews participants rank-ordered opinion statements on aspects of SMS according to agreement. Socio-demographic and medical characteristics were assessed using a questionnaire. By-person factor analysis was used to analyze the rankings and qualitative data was used to support choice of profiles. The resulting factors represent clusters of patients with similar attitudes towards SMS.

RESULTS

Forty-three patients (mean age=56; 77% male) participated. Four profiles were identified: (A) transplant-focused and obedient; (B) holistic and collaborative; (C) life-focused and self-determined; and (D) was bipolar. The positive pole (D+) minimalizing and disengaged and the negative pole (D-) coping-focused and needy represent opposing viewpoints within the same profile. Socio-demographic and medical characteristics were not related to profile membership.

DISCUSSION

Each profile represents a specific attitude on post-transplant life, responsibility for health and decision-making, SMS needs, and preferences for SMS.

PRACTICAL IMPLICATIONS

Patients vary in their attitude, needs and preferences for SMS indicating the necessity of providing personalized support after kidney transplantation. Health professionals should explore patients' SMS needs and adapt support accordingly.

eHealth technologies to support nutrition and physical activity behaviors in diabetes self-management

Diabetes is a chronic, complex condition requiring sound knowledge and self-management skills to optimize glycemic control and health outcomes. Dietary intake and physical activity are key diabetes self-management (DSM) behaviors that require tailored education and support. Electronic health (eHealth) technologies have a demonstrated potential for assisting individuals with DSM behaviors. This review provides examples of technologies used to support nutrition and physical activity behaviors in the context of DSM. Technologies covered include those widely used for DSM, such as web-based programs and mobile phone and smartphone applications. In addition, examples of novel tools such as virtual and augmented reality, video games, computer vision for dietary carbohydrate monitoring, and wearable devices are provided. The challenges to, and facilitators for, the use of eHealth technologies in DSM are discussed. Strategies to support the implementation of eHealth technologies within practice and suggestions for future research to enhance nutrition and physical activity behaviors as a part of broader DSM are provided.

Use of a Data Management System to Provide Glycemic Control Instructions to Diabetic Patients Based on Patient Self-Measured Blood Glucose

To make the treatment for diabetes more effective, we assessed the effects of a data management system for glycemic control. This system enables physicians at distant medical institutions to obtain the fluctuations in blood glucose (BG) measured daily by patients themselves at home and then to give instruction for treatment based on the BG. Use of the system for 2 months resulted in decreases in the hemoglobin A1c (HbA1c) level (from 6.8% ± 0.9% to 6.6% ± 0.8% [ M ± SD], p < .05) and the incidences of preprandial hypoglycemia and postprandial hyperglycemia. These effects can be concluded to have resulted from the fact that physicians become able to give patients appropriate instructions quickly. Also, these effects are considered to have resulted from patient awareness of the importance of self-management of BG.

Web-Based Remote Monitoring Systems for Self-Managing Type 2 Diabetes: A Systematic Review

This systematic review aims to evaluate evidence for viability and impact of Web-based telemonitoring for managing type 2 diabetes mellitus. A review protocol included searching Medline, EMBASE, CINAHL, AMED, the Cochrane Library, and PubMed using the following terms: telemonitoring, type 2 diabetes mellitus, self-management, and web-based Internet solutions. The technology used, trial design, quality of life measures, and the glycated hemoglobin (HbA1c) levels were extracted. This review identified 426 publications; of these, 19 met preset inclusion criteria. Ten quasi-experimental research designs were found, of which seven were pre-posttest studies, two were cohort studies, and one was an interrupted time-series study; in addition, there were nine randomized controlled trials. Web-based remote monitoring from home to hospital is a viable approach for healthcare delivery and enhances patients' quality of life. Six of these studies were conducted in South Korea, five in the United States, three in the United Kingdom, two in Taiwan, and one each in Spain, Poland, and India. The duration of the studies varied from 4 weeks to 18 months, and the participants were all adults. Fifteen studies showed positive improvement in HbA1c levels. One study showed high acceptance of the technology among participants. It remains challenging to identify clear evidence of effectiveness in the rapidly changing area of remote monitoring in diabetes care. Both the technology and its implementations are complex. The optimal design of a telemedicine system is still uncertain, and the value of the real-time blood glucose transmissions is still controversial.

Telemedicine in US Army soldiers with type 1 diabetes

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

A Mobile Health Intervention for Self-Management and Lifestyle Change for Persons With Type 2 Diabetes, Part 2: One-Year Results From the Norwegian Randomized Controlled Trial RENEWING HEALTH

Background

Self-management is crucial in the daily management of type 2 diabetes. It has been suggested that mHealth may be an important method for enhancing self-management when delivered in combination with health counseling.

Objective

The objective of this study was to test whether the use of a mobile phone–based self-management system used for 1 year, with or without telephone health counseling by a diabetes specialist nurse for the first 4 months, could improve glycated hemoglobin A_1c (HbA_1c) level, self-management, and health-related quality of life compared with usual care.

Methods

We conducted a 3-arm prospective randomized controlled trial involving 2 intervention groups and 1 control group. Eligible participants were persons with type 2 diabetes with an HbA_1c level ≥7.1% (≥54.1 mmol/mol) and aged ≥18 years. Both intervention groups received the mobile phone–based self-management system Few Touch Application (FTA). The FTA consisted of a blood glucose–measuring system with automatic wireless data transfer, diet manual, physical activity registration, and management of personal goals, all recorded and operated using a diabetes diary app on the mobile phone. In addition, one intervention group received health counseling based on behavior change theory and delivered by a diabetes specialist nurse for the first 4 months after randomization. All groups received usual care by their general practitioner. The primary outcome was HbA_1c level. Secondary outcomes were self-management (heiQ), health-related quality of life (SF-36), depressive symptoms (CES-D), and lifestyle changes (dietary habits and physical activity). Data were analyzed using univariate methods (t test, ANOVA) and multivariate linear and logistic regression.

Results

A total of 151 participants were randomized: 51 to the FTA group, 50 to the FTA-health counseling (FTA-HC) group, and 50 to the control group. Follow-up data after 1 year were available for 120 participants (79%). HbA_1c level decreased in all groups, but did not differ between groups after 1 year. The mean change in the heiQ domain skills and technique acquisition was significantly greater in the FTA-HC group after adjusting for age, gender, and education (P=.04). Other secondary outcomes did not differ between groups after 1 year. In the FTA group, 39% were substantial users of the app; 34% of the FTA-HC group were substantial users. Those aged ≥63 years used the app more than their younger counterparts did (OR 2.7; 95% CI 1.02-7.12; P=.045).

Conclusions

The change in HbA_1c level did not differ between groups after the 1-year intervention. Secondary outcomes did not differ between groups except for an increase in the self-management domain of skill and technique acquisition in the FTA-HC group. Older participants used the app more than the younger participants did.

Are telehealth technologies for hypertension care and self-management effective or simply risky and costly?

Hypertension is a prevalent chronic disease that requires ongoing management and self-care. The disease affects 31% of American adults and contributed to or caused the deaths of 348,000 Americans in 2008, fewer than 50% of whom effectively self-managed the disease. However, self-management is complex, with patients requiring ongoing support and easy access to care. Telehealth may help foster the knowledge and skills necessary for those with hypertension to engage in successful self-management. This paper considers the applicability, efficacy, associated risks, and cost-effectiveness of telehealth for individuals and populations with hypertension. Telehealth is a broad term, encompassing telemedicine and mobile health that is used for physician-patient interactions, diagnostics, care delivery, education, information sharing, monitoring, and reminders. Telemedicine may have considerable utility for people diagnosed with hypertension who have poor access or social barriers that constrain access, but potential risks exist. Telehealth technology is evolving rapidly, even in the absence of fully proven cost-effectiveness and efficacy. Considering the cost of inpatient and emergency department care for patients with hypertension, telehealth is a highly attractive alternative, but there are risks to consider. Incorporating telehealth, which is increasingly characterized by mobile health, can increase both the capacity of health care providers and the reach of patient support, clinical management, and self-care. Telehealth studies need improvement; long-term outcome data on cardiovascular events must be obtained, and robust risk analyses and economic studies are needed to prospectively evaluate the safety and cost savings for hypertension self-management.

Partnering with diabetes educators to improve patient outcomes

Diabetes is a chronic, progressive disease that affects millions worldwide. The paradigm of diabetes management has shifted to focus on empowering the person with diabetes to manage the disease successfully and to improve their quality of life. Diabetes self-management education is a collaborative process through which people with diabetes gain the knowledge and skills needed to modify their behavior and to self-manage successfully the disease and its related conditions. Diabetes educators are health care professionals who apply in-depth knowledge and skills in the biological and social sciences, communication, counseling, and pedagogy to enable patients to manage daily and future challenges. Diabetes educators are integral in providing individualized education and promoting behavior change, using a framework of seven self-care behaviors known as the AADE7 Self-Care Behaviors™, developed by the American Association of Diabetes Educators. The iterative process of promoting behavior change includes assessment, goal setting, planning, implementation, evaluation, and documentation. Diabetes educators work as part of the patient's health care team to engage with the patient in informed, shared decision making. The increasing prevalence of diabetes and the growing focus on its prevention require strategies for providing people with knowledge, skills, and strategies they need and can use. The diabetes educator is the logical facilitator of change. Access to diabetes education is critically important; incorporating diabetes educators into more and varied practice settings will serve to improve clinical and quality of life outcomes for persons with diabetes.

Impact of communicative and critical health literacy on understanding of diabetes care and self-efficacy in diabetes management: a cross-sectional study of primary care in Japan

BACKGROUND

The role of a patient's functional health literacy (HL) has received much attention in the context of diabetes education, but researchers have not fully investigated the roles of communicative and critical HL, especially in primary care. Communicative HL is the skill to extract health information and derive meaning from different forms of communication, and to apply this information to changing circumstances. Critical HL allows the patient to critically analyze information and to use this information to achieve greater control over life events and situations. We examined how HL, particularly communicative and critical HL, is related to the patient's understanding of diabetes care and self-efficacy for diabetes management in primary care settings. We also examined the impact of patient-physician communication factors on these outcomes, taking HL into account.

METHODS

We conducted a cross-sectional observational study of 326 patients with type 2 diabetes who were seen at 17 primary care clinics in Japan. The patients completed a self-administered questionnaire that assessed their HL (functional, communicative, and critical), understanding of diabetes care, and self-efficacy for diabetes management. We also examined the perceived clarity of the physician's explanation to assess patient-physician communication. Multivariate regression analyses were performed to determine whether HL and patient-physician communication were associated with understanding of diabetes care and self-efficacy.

RESULTS

A total of 269 questionnaires were analyzed. Communicative and critical HL were positively associated with understanding of diabetes care (β = 0.558, 0.451, p < 0.001) and self-efficacy (β = 0.365, 0.369, p < 0.001), respectively. The clarity of physician's explanation was associated with understanding of diabetes care (β = 0.272, p < 0.001) and self-efficacy (β = 0.255, p < 0.001). In multivariate regression models, HL and perceived clarity of the physician's explanation were independently associated with understanding of diabetes care and self-efficacy.

CONCLUSIONS

Communicative and critical HL and clear patient-physician communication were independently associated with the patient's understanding of diabetes care and self-efficacy. The potential impact of communicative and critical HL should be considered in communications with, and the education of, patients with diabetes in primary care settings.