Nurse-led telecoaching of people with type 2 diabetes in primary care: rationale, design and baseline data of a randomized controlled trial

Clinical and cost-effectiveness of telemedicine among patients with type 2 diabetes in primary care: A systematic review and meta-analysis

AIMS

Telemedicine has been promoted as an effective way of managing type-2 diabetes (T2DM) in primary care. However, the effectiveness of telemedicine is unclear. We investigated the clinical and cost-effectiveness of different telemedicine interventions for people with T2DM, compared to usual care.

METHODS

We searched Medline, Embase, Cochrane, CINHAL, ProQuest and EconLit for randomized controlled trials (RCTs) that examined the effectiveness of telemedicine interventions on clinical outcomes (HbA1c, body mass index [BMI], weight, diastolic blood pressure [DBP], systolic blood pressure [SBP], fasting blood glucose, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, total cholesterol and triglyceride) in adults with T2DM, published in English from inception until 31 December 2022. Meta-analyses were conducted using random-effects models pooling mean differences, heterogeneity was quantified using the I2 statistic. Publication bias was assessed using funnel plots, Egger tests and trim and fill. Subgroup analyses included type of telemedicine intervention, telemedicine mode of delivery and type of healthcare professionals. This study was registered with PROSPERO, CRD 42022375128.

RESULTS

Of the 4093 records identified, 21 RCTs, 10,732 participants from seven regions, were included. Reported interventions included telephone (k = 16 studies), internet-based (k = 2), videoconference (k = 2) and telephone and emails (k = 1). We observed no statistically significant differences between synchronous or asynchronous telemedicine interventions compared to usual care for HbA1c (-0.08% (-0.88 mmol/mol); 95% CI: -0.18, 0.02), BMI (0.51 kg/m2; 95% CI: -0.21, 1.22), SBP (-1.48 mmHg; 95% CI: -3.22, 0.26), DBP (3.23 mmHg; 95% CI: -0.89, 7.34), HDL-cholesterol (0.01 mmol/L; 95% CI: -0.03, 0.05), LDL-cholesterol (0.08 mmol/L; 95% CI: -0.22, 0.37), triglycerides (-0.08 mmol/L, 95% CI: -0.31, -0.15), total cholesterol (-0.10 mmol/L; 95% CI: -0.25, 0.04) and weight (-0.50 kg; 95% CI: -1.21, 0.21).

CONCLUSIONS

Telemedicine was as effective as usual care in improving health outcomes of people with T2DM. They can provide a safe solution in times of rising demands for primary healthcare services, or in extreme events, like a global pandemic. More high-quality RCTs are needed on the cost evaluation of telemedicine.

The effectiveness of a mHealth-based integrated hospital-community-home program for people with type 2 diabetes in transitional care: a protocol for a multicenter pragmatic randomized controlled trial

Background

Diabetes is a progressive condition requiring long-term medical care and self-management. The ineffective transition from hospital to community or home health care may result in poor glycemic control and increase the risk of serious diabetes-related complications. In China, the most common transitional care model is home visits or telephone interventions led by a single healthcare setting, with a lack of cooperation between specialists and primary care, which leads to inadequate service and discontinuous care. Thus, an integrated hospital-community-home (i-HCH) transitional care program was developed to promote hospital and community cooperation and provide comprehensive and continuous medical care for type 2 diabetes mellitus (T2DM) via mobile health (mHealth) technology.

Methods

This protocol is for a multicenter randomized controlled trial in T2DM patients. Hospitalized patients diagnosed with T2DM who meet the eligibility criteria will be recruited. The patients will be randomly allocated to either the intervention or the control group and receive the i-HCH transitional care or usual transitional care intervention. The change in glycated hemoglobin is the primary outcome. Secondary outcome measures are blood pressure, lipids (total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein), body mass index, self-management skills, quality of life, diabetes knowledge, transitional care satisfaction and the rate of readmission. The follow-up period of this study is six months.

Discussion

The study will enhance the cooperation between local hospitals and communities for diabetes transitional care. Research on the effectiveness of diabetes outcomes will have potentially significant implications for chronic disease patients, family members, health caregivers and policymakers.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900023861: June 15, 2019.

Telehealth in Primary Health Care: A Scoping Review of the Literature

BACKGROUND

The use of telehealth as a viable mobility to deliver quality services steadily increases in various levels of the health system. Despite the increasing use of telemedicine in secondary and tertiary health care services, there is a long way to go in the use of this technology in public health and primary health care (PHC). This study aimed to explore the features, approaches, and various dimensions of telehealth in PHC.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in three bibliographic databases including PubMed, Web of Sciences, and Scopus and in Google Scholar to collect papers published in November 2018 to 2000. Data were extracted according to a predefined form and check for completeness and accuracy by a second reviewer.

RESULTS

Through reviewing papers, the authors extracted information on the general characteristics and features of telehealth services, kinds of PHC services delivered via telehealth, hardware and software facilities used for providing health care through telehealth services packages, as well as their benefits, outcomes and obstacles.

CONCLUSION

Telehealth can be used for different purposes of PHC through deploying a full range of communication channels available to the public. Due to the opportunistic use of existing devices and platforms, telehealth can provide scalable PHC services nationwide and worldwide. However, implementing telehealth in PHC faces challenges from technical, organizational, and human perspectives. Digital equity (in terms of technology access and e-health literacy) is required to expand telehealth services to the populations in underserved areas.

"Teaching: Individual" to increase adherence to therapeutic regimen in people with hypertension and type-2 diabetes: protocol of the controlled clinical trial ENURSIN

Background

Worldwide, hypertension affects approximately 25% of the adult population and diabetes about 8.5%. Lack of adherence to prescribed treatment regimen remains a problem among patients undergoing long-term treatment, showing high non-adherence rates, at estimated range of between 36 and 93%. In our city, patients with hypertension and diabetes in primary care are looked after mainly by doctors with little nursing support; also, there is no published dataset among Colombian populations on the effect of nursing intervention to increase adherence to therapeutic regimen. The aim of this study was to evaluate the efficacy of nursing intervention "Teaching: Individual" compared with usual care, to increase adherence to therapeutic regimen in people with hypertension and/or type-2 diabetes, and to analyze the impact to glycosylated hemoglobin and systolic blood pressure levels.

Methods

A two-arm, single-blinded, randomized controlled trial, with participants allocated to either intervention group with "Teaching: Individual" provided by two nurses, or control group receiving routine care only. Two Hundred patients attending cardiovascular risk programs of Bucaramanga, Colombia were included. Nursing intervention consisted of six educational sessions about Coping Enhancement; Behavior Modification; Teaching: Disease Process, Prescribed Medication, Prescribed Diet and Prescribed Exercise. The outcomes were Treatment Behavior: Illness or Injury (adherence to treatment), levels of both glycosylated hemoglobin (HbA1c) and systolic blood pressure for 24 h, to be measured at baseline and two follow-up time points. Basic characteristics of the groups were compared through chi-square/Fisher's exact or Students-T/Mann-Whitney U test. Outcomes were evaluated with repeated data methods and investigated changes in the outcomes over time and to compare these changes among treatment groups, and statistical significance with p-value < 0.05 were considered.

Discussion

The nursing intervention "Teaching: Individual" to increase adherence to therapeutic regimen in people with hypertension and/or type-2 diabetes represents an innovative care approach intended for low-income population. The study will advise district health system policy makers and managers as to the efficacy of implementing this intervention. Should this intervention turn out efficacious, it can potentially achieve wide application in cardiovascular risk programs.

Trial registration

ENURSIN was registered in ClinicalTrials.gov (NCT02758275) on April 27, 2016, protocol number 01.

Telemedicine-Based Health Coaching Is Effective for Inducing Weight Loss and Improving Metabolic Markers

BACKGROUND

To assess the efficacy of health coaching (HC) delivered through videoconferencing (VC) to favorably change physical activity (PA), weight, and metabolic markers in adults with high body mass index (BMI).

MATERIALS AND METHODS

Thirty adults (BMI ≥30 kg/m2) were randomly assigned to one of three groups: VC, in-person (IP), or control group (CG). Participants received wireless watches and weight scales to sync with their personal smartphones; recorded data were wirelessly uploaded to a secure database. Participants assigned to VC and IP received individualized HC by a multidisciplinary team (registered dietitian, exercise physiologist, and medical doctor) based on data uploaded over the 12-week intervention. Steps/day and weight loss were analyzed through analyses of covariance.

RESULTS

Within- and between-group changes in weight (kg), glucose, insulin, hemoglobin A1c (HbA1c), and Homeostasis Model Assessment estimate of insulin resistance (HOMA-IR) were analyzed through analyses of variance. Weight loss was greater (p < 0.05) for VC (8.23 ± 4.5 kg; 7.7%) than IP (3.2 ± 2.6 kg; 3.4%) and CG (2.9 ± 3.9 kg; 3.3%), respectively. Steps/day were significantly higher in VC than IP at week 4 and VC was significantly higher than the CG at weeks 6, 8, 9, and 11 (p ≤ 0.05). No within- or between-group differences were found for glucose, insulin, or HbA1C. HOMA-IR decreased for VC only (p ≤ 0.05).

CONCLUSIONS

Our innovative, multidisciplinary, telemedicine HC delivered through VC led to more favorable changes in weight loss, PA (steps/day), and HOMA-IR than IP or no HC. VC may be an economical approach to improve health and promote behavior change in obese adults.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT03278951.

Nonpharmacological interventions to improve quality of life in heart failure: an integrative review

Objective:

to identify articles that assessed the effectiveness or efficacy of nonpharmacological interventions to improve quality of life of people with heart failure in the literature.

Method:

an integrative literature review was performed in Lilacs, MedLine and SciELO databases, including randomized or nonrandomized clinical trials and quasi-experimental studies published between 2003 and 2014, in Portuguese, English or Spanish.

Results:

twenty-three studies were included. The categories of nonpharmacological interventions that improved quality of life of people with heart failure were: Remote health monitoring, Instructions on health practices, Physical activity follow-up and Traditional Chinese Medicine practices.

Conclusion:

these results can guide the selection of interventions to be implemented by health professionals that treat people with heart failure. Future systematic reviews with meta-analyses are needed in order to identify the most effective interventions for improving these individuals' quality of life.

Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus

BACKGROUND

Many adults with type 2 diabetes mellitus (T2DM) experience a psychosocial burden and mental health problems associated with the disease. Diabetes-related distress (DRD) has distinct effects on self-care behaviours and disease control. Improving DRD in adults with T2DM could enhance psychological well-being, health-related quality of life, self-care abilities and disease control, also reducing depressive symptoms.

OBJECTIVES

To assess the effects of psychological interventions for diabetes-related distress in adults with T2DM.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, BASE, WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was December 2014 for BASE and 21 September 2016 for all other databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on the effects of psychological interventions for DRD in adults (18 years and older) with T2DM. We included trials if they compared different psychological interventions or compared a psychological intervention with usual care. Primary outcomes were DRD, health-related quality of life (HRQoL) and adverse events. Secondary outcomes were self-efficacy, glycosylated haemoglobin A1c (HbA1c), blood pressure, diabetes-related complications, all-cause mortality and socioeconomic effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified publications for inclusion and extracted data. We classified interventions according to their focus on emotion, cognition or emotion-cognition. We performed random-effects meta-analyses to compute overall estimates.

MAIN RESULTS

We identified 30 RCTs with 9177 participants. Sixteen trials were parallel two-arm RCTs, and seven were three-arm parallel trials. There were also seven cluster-randomised trials: two had four arms, and the remaining five had two arms. The median duration of the intervention was six months (range 1 week to 24 months), and the median follow-up period was 12 months (range 0 to 12 months). The trials included a wide spectrum of interventions and were both individual- and group-based.A meta-analysis of all psychological interventions combined versus usual care showed no firm effect on DRD (standardised mean difference (SMD) -0.07; 95% CI -0.16 to 0.03; P = 0.17; 3315 participants; 12 trials; low-quality evidence), HRQoL (SMD 0.01; 95% CI -0.09 to 0.11; P = 0.87; 1932 participants; 5 trials; low-quality evidence), all-cause mortality (11 per 1000 versus 11 per 1000; risk ratio (RR) 1.01; 95% CI 0.17 to 6.03; P = 0.99; 1376 participants; 3 trials; low-quality evidence) or adverse events (17 per 1000 versus 41 per 1000; RR 2.40; 95% CI 0.78 to 7.39; P = 0.13; 438 participants; 3 trials; low-quality evidence). We saw small beneficial effects on self-efficacy and HbA1c at medium-term follow-up (6 to 12 months): on self-efficacy the SMD was 0.15 (95% CI 0.00 to 0.30; P = 0.05; 2675 participants; 6 trials; low-quality evidence) in favour of psychological interventions; on HbA1c there was a mean difference (MD) of -0.14% (95% CI -0.27 to 0.00; P = 0.05; 3165 participants; 11 trials; low-quality evidence) in favour of psychological interventions. Our included trials did not report diabetes-related complications or socioeconomic effects.Many trials were small and were at high risk of bias for incomplete outcome data as well as possible performance and detection biases in the subjective questionnaire-based outcomes assessment, and some appeared to be at risk of selective reporting. There are four trials awaiting further classification. These are parallel RCTs with cognition-focused and emotion-cognition focused interventions. There are another 18 ongoing trials, likely focusing on emotion-cognition or cognition, assessing interventions such as diabetes self-management support, telephone-based cognitive behavioural therapy, stress management and a web application for problem solving in diabetes management. Most of these trials have a community setting and are based in the USA.

AUTHORS' CONCLUSIONS

Low-quality evidence showed that none of the psychological interventions would improve DRD more than usual care. Low-quality evidence is available for improved self-efficacy and HbA1c after psychological interventions. This means that we are uncertain about the effects of psychological interventions on these outcomes. However, psychological interventions probably have no substantial adverse events compared to usual care. More high-quality research with emotion-focused programmes, in non-US and non-European settings and in low- and middle-income countries, is needed.

Nursing appointment and cardiometabolic control of diabetics: a randomized clinical trial

ABSTRACT Objective: to verify the effect of nursing appointment on cardiometabolic profile of people with Diabetes Mellitus type 2. Method: randomized controlled trial, developed with 134 individuals chosen for two groups: intervention and control. The intervention consisted of three nursing appointments alternated bimonthly, with two phone calls, over five months. The control group received usual care offered by the Health Unit. Data were collected through semi-structured interviews before and after the intervention, in addition to conducting laboratory tests. Results: after the intervention, a significant difference was shown in the amount of glycated hemoglobin (p = 0.006) and in the systolic blood pressure (p = 0.031), which were higher in the control group. Conclusion: besides being low-cost and easy to develop on the monitoring routine of people with diabetes, the intervention performed influenced positively the biochemical profile.

Effectiveness of individual and group interventions for people with type 2 diabetes

OBJECTIVE:

to compare the effectiveness of two educational interventions used by a healthcare provider in the monitoring of individuals with type 2 diabetes mellitus (T2DM), regarding knowledge of the disease, impact on quality of life and adoption of self-care actions.

METHODS:

comparative, longitudinal, prospective study performed with 150 subjects with type 2 diabetes, analyzed according to the type of participation in the program (individual and/or group). Participants of the individual intervention (II) received nursing consultations every six months and those of the group intervention (GI) took part in weekly meetings for three months. Data were collected through four questionnaires: Identification questionnaire, Problem Areas in Diabetes Questionnaire (PAID), Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) and the Diabetes Knowledge Scale (DKN-A). Data were analyzed using the Friedman and Mann Whitney tests, considering a statistical significance of p ≤ 0.05.

RESULTS:

there was an increase in knowledge about the disease in the II (p<0.003) and GI (p<0.007), with reduction of the impact on the quality of life in the II (p<0.007) and improvement in self-care actions in the GI (p<0.001).

CONCLUSION:

in both intervention models improvements were observed in the indicators, over the six month monitoring period.

Does Telephone Follow-Up and Education Affect Self-Care and Metabolic Control in Diabetic Patients?

The major goal of diabetes control is to assist patients to perform self-care and metabolic control. One possible way to achieve this goal is education and regular monitoring of patients by telephone. Thus, the present study was conducted with the aim of investigating the impact of education and telephone follow-up on self-care and metabolic control in diabetic patients. This experimental study was conducted at a hospital in the Central Anatolia region of Turkey, with 88 diabetic patients including 44 intervention subjects and 44 control subjects. After an initial discussion, patients in the intervention group received education and telephone follow-up for 3 months. Required approvals were obtained before initiation of the study. Data were collected using a questionnaire form and the Diabetes Self-Care Scale. The Diabetes Self-Care Scale scores ranged between 140 and 210, where higher scores indicated increased self-care activities of patients. At the end of the study, the self-care score was found to increase from 61.3 ± 10.9 to 89.9 ± 12.3 in the intervention group (P < .005), but it showed a reduction from 56.5 ± 7.6 to 54.7 ± 9.3 after 3-month period in the control group. Education and telephone follow-up was also found to reduce the values of several variables of metabolic control including hemoglobin A1c, total cholesterol, triglycerides, low-density lipoprotein cholesterol, and systolic blood pressure. In conclusion, education and telephone follow-up of diabetic patients led to increased self-care scores and had a positive impact on metabolic control variables. In light of these findings, we suggest that education and tele-health home monitoring may be provided on a continuous basis to help patients sustain self-care behaviors that they have adopted during the study period.

A guide for the application of analytics on healthcare processes: A dynamic view on patient pathways

OBJECTIVE

The aim of this study is to guide healthcare instances in applying process analytics on healthcare processes. Process analytics techniques can offer new insights in patient pathways, workflow processes, adherence to medical guidelines and compliance with clinical pathways, but also bring along specific challenges which will be examined and addressed in this paper.

METHODS

The following methodology is proposed: log preparation, log inspection, abstraction and selection, clustering, process mining, and validation. It was applied on a case study in the type 2 diabetes mellitus domain.

RESULTS

Several data pre-processing steps are applied and clarify the usefulness of process analytics in a healthcare setting. Healthcare utilization, such as diabetes education, is analyzed and compared with diabetes guidelines. Furthermore, we take a look at the organizational perspective and the central role of the GP. This research addresses four challenges: healthcare processes are often patient and hospital specific which leads to unique traces and unstructured processes; data is not recorded in the right format, with the right level of abstraction and time granularity; an overflow of medical activities may cloud the analysis; and analysts need to deal with data not recorded for this purpose. These challenges complicate the application of process analytics. It is explained how our methodology takes them into account.

CONCLUSION

Process analytics offers new insights into the medical services patients follow, how medical resources relate to each other and whether patients and healthcare processes comply with guidelines and regulations.

Optimizing diabetes control in people with Type 2 diabetes through nurse-led telecoaching

AIMS

To study the effect of a target-driven telecoaching intervention on HbA1c and other modifiable risk factors in people with Type 2 diabetes.

METHODS

We conducted a randomized controlled trial in patients receiving hypoglycaemic agents. The primary outcome was HbA1c level at 6 months in the entire sample and in a subgroup with HbA1c levels ≥ 53 mmol/mol (7%) at baseline. Secondary outcomes were HbA1c at 18 months; total cholesterol, LDL, HDL, triglycerides, blood pressure, BMI and proportion of people who had achieved guideline-recommended targets at 6 and 18 months.

RESULTS

A total of 287 participants were randomized to telecoaching and 287 to usual care. The mean (sd) baseline HbA1c level was 53 (11) mmol/mol [7.0 (1.0)%] overall and 63 (10) mmol/mol [7.9 (0.9)%] in the elevated HbA1c subgroup. At 6 months, the between-group differences in favour of telecoaching were: HbA1c -2 (95% CI -4; -1) mmol/mol [-0.2 (95% CI -0.3;-0.1)%; P=0.003] overall and -4 (95% CI -7; -2) mmol/mol [-0.4 (95% CI -0.7; -0.2)%; P=0.001] in the elevated HbA1c subgroup; BMI -0.4 kg/m(2) (95% CI -0.6; -0.1; P=0.003); total cholesterol -6 mg/dl (95% CI -11; -1, P=0.012). The proportion of participants on target for the composite of HbA1c , LDL and blood pressure increased by 8.9% in the intervention group and decreased by 1.3% in the control group (P=0.011). At 18 months, the difference in HbA1c was: -2 (95% CI -3;-0) mmol/mol [-0.2 (95% CI -0.3; -0.0)%; P=0.046] overall and -4 (-7; -1) mmol/mol [-0.4 (95% CI -0.7; -0.1)%; P=0.023] in the elevated HbA1c subgroup.

CONCLUSION

Nurse-led telecoaching improved glycaemic control, total cholesterol levels and BMI in people with Type 2 diabetes. Twelve months after the intervention completion, there were sustained improvements in glycaemic control.