Telemedicine in diabetes foot care delivery: health care professionals' experience

Data-driven digital health technologies in the remote clinical care of diabetic foot ulcers: a scoping review

Background

The availability and effectiveness of Digital Health Technologies (DHTs) to support clinicians, empower patients, and generate economic savings for national healthcare systems are growing rapidly. Of particular promise is the capacity of DHTs to autonomously facilitate remote monitoring and treatment. Diabetic Foot Ulcers (DFUs) are characterised by high rates of infection, amputation, mortality, and healthcare costs. With clinical outcomes contingent on activities that can be readily monitored, DFUs present a promising focus for the application of remote DHTs.

Objective

This scoping review has been conducted as a first step toward ascertaining fthe data-related challenges and opportunities for the development of more comprehensive, integrated, and individualised sense/act DHTs. We review the latest developments in the application of DHTs to the remote care of DFUs. We cover the types of DHTs in development and their features, technological readiness, and scope of clinical testing.

Eligibility criteria

Only peer-reviewed original experimental and observational studies, case series and qualitative studies were included in literature searches. All reviews and manuscripts presenting pre-trial prototype technologies were excluded.

Methods

An initial search of three databases (Web of Science, MEDLINE, and Scopus) generated 1,925 English-language papers for screening. 388 papers were assessed as eligible for full-text screening by the review team. 81 manuscripts were found to meet the eligibility criteria.

Results

Only 19% of studies incorporated multiple DHTs. We categorised 56% of studies as 'Treatment-Manual', i.e. studies involving technologies aimed at treatment requiring manual data generation, and 26% as 'Prevention-Autonomous', i.e. studies of technologies generating data autonomously through wearable sensors aimed at ulcer prevention through patient behavioural change. Only 10% of studies involved more ambitious 'Treatment-Autonomous' interventions. We found that studies generally reported high levels of patient adherence and satisfaction.

Conclusions

Our findings point to a major potential role for DHTs in remote personalised medical management of DFUs. However, larger studies are required to assess their impact. Here, we see opportunities for developing much larger, more comprehensive, and integrated monitoring and decision support systems with the potential to address the disease in a more complete context by capturing and integrating data from multiple sources from subjective and objective measurements.

An integrative review on the acceptance of artificial intelligence among healthcare professionals in hospitals

Artificial intelligence (AI) in the domain of healthcare is increasing in prominence. Acceptance is an indispensable prerequisite for the widespread implementation of AI. The aim of this integrative review is to explore barriers and facilitators influencing healthcare professionals' acceptance of AI in the hospital setting. Forty-two articles met the inclusion criteria for this review. Pertinent elements to the study such as the type of AI, factors influencing acceptance, and the participants' profession were extracted from the included studies, and the studies were appraised for their quality. The data extraction and results were presented according to the Unified Theory of Acceptance and Use of Technology (UTAUT) model. The included studies revealed a variety of facilitating and hindering factors for AI acceptance in the hospital setting. Clinical decision support systems (CDSS) were the AI form included in most studies (n = 21). Heterogeneous results with regard to the perceptions of the effects of AI on error occurrence, alert sensitivity and timely resources were reported. In contrast, fear of a loss of (professional) autonomy and difficulties in integrating AI into clinical workflows were unanimously reported to be hindering factors. On the other hand, training for the use of AI facilitated acceptance. Heterogeneous results may be explained by differences in the application and functioning of the different AI systems as well as inter-professional and interdisciplinary disparities. To conclude, in order to facilitate acceptance of AI among healthcare professionals it is advisable to integrate end-users in the early stages of AI development as well as to offer needs-adjusted training for the use of AI in healthcare and providing adequate infrastructure.

A systematic review of telemedicine systems use barriers: primary health care providers' perspective

Purpose

The purpose of this review paper was identifying barriers to the use of telemedicine systems in primary health-care individual level among professionals.

Design/methodology/approach

This study used Scopus and PubMed databases for scientific records identification. A systematic review of the literature structured by PRISMA guidelines was conducted on 37 included papers published between 2009 and 2019. A qualitative approach was used to synthesize insights into using telemedicine by primary care professionals.

Findings

Three barriers were identified and classified: system quality, data quality and service quality barriers. System complexity in terms of usability, system unreliability, security and privacy concerns, lack of integration and inflexibility of systems-in-use are related to system quality. Data quality barriers are data inaccuracy, data timeliness issues, data conciseness concerns and lack of data uniqueness. Finally, service reliability concerns, lack of technical support and lack of user training have been categorized as service quality barriers.

Originality/value

This review identified and mapped emerging themes of barriers to the use of telemedicine systems. This paper also through a new conceptualization of telemedicine use from perspectives of the primary care professionals contributes to informatics literature and system usage practices.

Development and Usability Evaluation of a Telemedicine System for Management and Monitoring of Patients with Diabetic Foot

Objectives: The aim of the present study was to develop and evaluate the usability of a telemedicine system for management and monitoring of patients with diabetic foot.Methods: This study was conducted in four phases. In the first phase, the information needs and characteristics required to design the telemedicine system were identified based on a literature review. Then, in a two-stage Delphi survey, 15 experts approved the identified information needs and characteristics. The prototype telemedicine system was then designed. In the third phase, system usability was evaluated through a semi-structured interview. In the fourth phase, users’ satisfaction with the designed system was analyzed.Results: Out of 115 information needs and required characteristics, 95 were considered in the system design. Eight main pages for enabling patient-physician interactions and physician-physician interactions, monitoring the patient and controlling the disease process, providing medical consultation, and prescribing medications were considered. In the third phase, 26 distinct problems were identified. However, 75% of the participants were very satisfied with the system.Conclusions: This study presents an attempt to design and evaluate a telemedicine system for the management and monitoring of patients with diabetic foot. In this system, patients receiving medical services or physicians who encounter rare cases can send the complete medical history, clinical test results, and videos and images related to the foot to specialist physicians. After examining the medical history or images and videos, the physician can provide the necessary medication prescriptions and laboratory tests or other recommendations.

Still engaged – healthcare staff’s engagement when introducing a new eHealth solution for wound management: a qualitative study

Background

eHealth solutions have often been considered favourable for improved effectiveness and quality in healthcare services for wound management. Staff engagement related to organisational changes is a key factor for successful development and implementation of a new eHealth solution, like a digital decision support systems (DDSS). It is essential to understand the engagement process in terms of sustainability, wellbeing in staff and efficiency in a long-term perspective. The aim of this study was to describe healthcare staff’s engagement during a 6-month test of an eHealth solution (DDSS) for wound management.

Methods

A qualitative design, including interviews conducted with healthcare staff working with wound management within primary, community and specialist care (n = 11) on two occasions: at the introduction of the solution and after 6 months, when the test period was over. Data were interpreted with qualitative content analysis.

Results

Healthcare staff’s descriptions from a 6-month test of an eHealth solution for wound management can be summarised as Engaging through meaning, but draining. The analysis revealed a result with three subcategories: Having a shared interest is stimulating, Good but not perfect and Exciting, but sometimes exhausting. The staff described their engagement as sustained through feelings of meaningfulness when using the eHealth solution, but limited by feelings of exhaustion due to heavy workload and lack of support and understanding from others.

Conclusions

The results indicate that the healthcare staff who tested the eHealth solution described themselves as individuals who easily become engaged when an idea and efforts felt meaningful. The staff needed resources to nourish engagement in their new role when implementing eHealth in the clinical everyday work of wound management. Allocating time and support are important to consider when planning for sustainable implementation of eHealth solutions in healthcare organisations.

Toward digital transformation in healthcare: a framework for remote monitoring adoption

Purpose

Digital transformation (DT) is a priority for the healthcare sector. In many countries, it is still considered in the early stages with an underestimation of its benefits and potentiality. Especially in Italy, little is known about the impact of digitalization – particularly of the Internet of Things (IoT) – on the healthcare sector, for example, in terms of clinician's jobs and patient's experience. Drawing from such premises, the paper aims to focus on an overlooked healthcare area related to the chronic heart diseases field and its relationship with DT. The authors aim at exploring and framing the main variables of remote Monitoring (RM) adoption as a specific archetype of healthcare digitalization, both on patients and medical staff level, by shedding some lights on its overall implementation.

Design/methodology/approach

The authors empirically inquiry the RM adoption within the context of the Cardiology Department of the Casilino General Hospital of Rome. To answer our research question, the authors reconstruct the salient information by using induction-type reasoning, direct observation and interviewees with 12 key informants, as well as secondary sources analysis related to the hospital (internal documentation, presentations and technical reports).

Findings

According to a socio-technical framework, the authors build a model composed of five main variables related to medical staff and patients. The authors classify such variables into an input-process-output (I-P-O) model. RM adoption driver represents the input; cultural digital divide, structure flexibility and reaction to change serve the process and finally, RM outcome stands for the output. All these factors, interacting together, contribute to understanding the RM adoption process for chronic disease management.

Research limitations/implications

The authors' research presents two main limitations. The first one is related to using a qualitative method, which is less reliable in terms of replication and the interpretive role of researchers. The second limitation, connected to the first one, is related to the study's scale level, which focuses on a mono-centric consistent level of analysis.

Practical implications

The paper offers a clear understanding of the RM attributes and a comprehensive view for improving the overall quality management of chronic diseases by suggesting that clinicians carefully evaluate both hard and soft variables when undertaking RM adoption decisions.

Social implications

RM technologies could impact on society both in ordinary situations, by preventing patient mobility issues and transport costs, and in extraordinary times (such as a pandemic), where telemedicine contributes to supporting hospitals in swapping in-person visits with remote controls, in order to minimize the risk of coronavirus disease (COVID-19) contagion or the spread of the virus.

Originality/value

The study enriches the knowledge and understanding of RM adoption within the healthcare sector. From a theoretical perspective, the authors contribute to the healthcare DT adoption debate by focusing on the main variables contributing to the DT process by considering both medical staff and patient's role. From a managerial perspective, the authors highlight the main issues for RM of chronic disease management to enable the transition toward its adoption. Such issues range from the need for awareness of the medical staff about RM advantages to the need for adapting the organizational structure and the training and education process of the patients.

Speech-Language Pathology and Audiology in South Africa: Clinical Training and Service in the Era of COVID-19

INTRODUCTION AND PURPOSE

The novel coronavirus (COVID-19) presented new and unanticipated challenges to the provision of clinical services, from student training to the care of patients with speech-language and hearing (SLH) disorders. Prompt changes in information and communication technologies (ICT), were required to ensure that clinical training continued to meet the Health Professions Council of South Africa's regulations and patients received effective clinical care. The purpose of this study was to investigate online clinical training and supervision to inform current and future training and clinical care provision in SLH professions.

METHODOLOGY

A scoping review was conducted using the Arksey and O'Malley (2005) framework. The electronic bibliographic databases Science Direct, PubMed, Scopus, MEDLINE, and ProQuest were searched to identify publications about online clinical training and supervision and their impact on clinical service during COVID-19. Selection and analysis were performed by three independent reviewers using pretested forms.

RESULTS AND CONCLUSIONS

The findings revealed important benefits of teletraining and telepractice with potential application to South African clinical training and service provision. Five themes emerged: (1) practice produces favorable outcomes, (2) appreciation for hybrid models of training and service delivery, (3) cost effectiveness is a "big win" (4) internationalization of remote clinical training and service provision, and (5) comparable modality outcomes. These findings may have significant implications for teletraining and telepractice in low-and-middle income countries (LMICs) in the COVID-19 era and beyond, wherein demand versus capacity challenges (e.g., in human resources) persist. Current findings highlight the need for SLH training programmes to foster a hybrid clinical training model. Few studies were conducted in LMICs, indicating a gap in such research.

Telemedicine for contraceptive counseling: An exploratory survey of US family planning providers following rapid adoption of services during the COVID-19 pandemic

OBJECTIVE

During the COVID-19 pandemic, many clinicians started offering telemedicine services. The objective of this study is to describe the experience of US family planning providers with the rapid adoption of telemedicine for contraceptive counseling during this period.

STUDY DESIGN

This is a cross-sectional web-based survey of family planning providers practicing in the United States.

RESULTS

A total of 172 providers completed the survey (34% response rate). Of these, 156 (91%) provided telemedicine services in the 2 months preceding the survey. Most (78%) were new to telemedicine. About half (54%) referred less than a quarter of contraception patients for in-person visits, and 53% stated that the most common referral reason was long-acting reversible contraceptive (LARC) insertion. A majority of providers strongly agree that telemedicine visits are an effective way to provide contraceptive counseling (80%), and that this service should be expanded after the pandemic (84%). If asked to provide telemedicine visits after the pandemic, 64% of providers would be very happy about it. Many providers used personal phones or smartphones to conduct telemedicine visits but stated that ideal devices would be work-issued computers, tablets, or phones. More than half (59%) of providers prefer video over phone visits.

CONCLUSIONS

Family planning clinicians in the United States reported a positive experience with telemedicine for contraceptive counseling during the early stage of the COVID-19 pandemic and believe that this service should be expanded. Clinicians seem to prefer using work-issued devices and conducting video rather than phone visits.

IMPLICATIONS

Telemedicine is a promising option for providing contraceptive counseling even beyond the COVID-19 pandemic. An investment in hospital or clinic-issued devices that allow for video conferencing may optimize clinicians' telemedicine experience.

Effect of a telemedicine intervention for diabetes-related foot ulcers on health, well-being and quality of life: secondary outcomes from a cluster randomized controlled trial (DiaFOTo)

BACKGROUND

Follow-up care provided via telemedicine (TM) is intended to be a more integrated care pathway to manage diabetes-related foot ulcers (DFU) than traditionally-delivered healthcare. However, knowledge of the effect of TM follow-up on PROMs including self-reported health, well-being and QOL in patients with DFUs is lacking and often neglected in RCT reports in general. Therefore, in this study of secondary outcomes from the DiaFOTo trial, the aim was to compare changes in self-reported health, well-being and QOL between patients with DFUs receiving telemedicine follow-up care in primary healthcare in collaboration with specialist healthcare, and patients receiving standard outpatient care.

METHODS

The current study reports secondary endpoints from a cluster randomized controlled trial whose primary endpoint was ulcer healing time. The trial included 182 adults with diabetes-related foot ulcers (94/88 in the telemedicine/standard care groups) in 42 municipalities/districts, recruited from three clinical sites in Western Norway. Mean (SD) diabetes duration for the study population was 20.8 (15.0). The intervention group received care in the community in collaboration with specialist healthcare using an asynchronous telemedicine intervention. The intervention included an interactive web-based ulcer record and a mobile phone enabling counseling and communication between the community nurses and specialist healthcare; the control group received standard outpatient care. In total 156 participants (78/78) reported on secondary endpoints: self-reported health, well-being and quality of life evaluated by generic and disease-specific patient-reported outcome measures (e.g. Euro-QOL, the Hospital Anxiety and Depression Scale (HADS), Problem Areas in Diabetes (PAID), Neuropathy and Foot Ulcer-Specific Quality of Life Instrument (NeuroQOL)). Linear mixed-effects regression was used to investigate possible differences in changes in the scores between the intervention and control group at the end of follow-up.

RESULTS

In intention to treat analyses, differences between treatment groups were small and non-significant for the health and well-being scale scores, as well as for diabetes-related distress and foot ulcer-specific quality of life.

CONCLUSIONS

There were no significant differences in changes in scores for the patient reported outcomes between the intervention and control group, indicating that the intervention did not affect the participants' health, well-being and quality of life.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT01710774 . Registered October 19th, 2012.

Evaluation of the development process and effects of a foot care program with educational tools for nurses and care workers as in-home service providers

Objective

Nurses and care workers who provide in-home services play important roles in assessing and providing care for older people who lack foot self-care abilities. We aimed to evaluate the development process and effects of a foot care program with educational tools for nurses and care workers as in-home service providers. This is a process evaluation with a descriptive mixed-methods study of quantitative and qualitative data conducted from July to October 2019 in Japan.

Results

Foot care education tools were developed to address the issues faced by participants with various work patterns and insufficient foot care education in Japan. The contents of these tools were discussed by a panel and reviewed by experts. Three outcomes were analyzed using descriptive statistics and Pearson’s correlation. Changes in foot care practice scores were significantly correlated with performance scores. The evaluations of five of the eight field nurses suggested that excess information was included in the foot care booklet. Overall, 29 nurses and care workers showed higher than average evaluation scores [3.8–4.1 (standard deviation, 0.62–0.91)] for the motion pictures and PowerPoint presentation. A program according to this conceptual framework must be established and periodically evaluated for refinement.

Trial Registration The trial registration number for the University Hospital Medical Information Network is UMIN000036307. Registration Date—2019/07/25

Facilitators and barriers of using digital technology for the management of diabetic foot ulcers: A qualitative systematic review

The use of digital technology has been shown to be effective in managing chronic conditions. Telemedicine and mobile application are two common applications of digital technology in managing diabetic foot ulcers (DFU). The facilitators and barriers of using it for DFU management are yet to be explored. This is a qualitative systematic review. Five bibliography databases and grey literature sources were searched (2000‐2019). Two reviewers independently screened the citations, extracted the data, assessed the quality of the included studies, and performed thematic synthesis. Three studies on patients and five studies on healthcare practitioners (HCPs) were included. Two studies focused on the use of mobile applications and six on telemedicine. In studies on patients, four analytical themes were generated: the relationships with HCPs; the attitude towards the usage of digital technology; the role of wound image taking; and impact of digital technology on DFU care, encompassing 15 facilitators (eg, enabling community support, improving wound care knowledge) and 12 barriers (eg, lack of technological savviness, difficulty reading on smartphones). Three analytical themes were generated from studies on HCPs: the impact of digital technology on HCPs; the role of digital technology in DFU care; and organisation of DFU care delivery, encompassing 17 facilitators (eg, adequate wound care training, digital technology enables holistic care) and 16 barriers (eg, lack of multidisciplinary approach in caring for DFU, lack of direct contact in care provision). Patients and HCPs reported various barriers and facilitators relating to different aspects of using digital technology in DFU management. Our findings can help inform future research as well as the adoption of digital technology in DFU management.

Telehealth and telemedicine applications for the diabetic foot: A systematic review

The aim of this systematic review is to assess the peer-reviewed literature on the psychometric properties, feasibility, effectiveness, costs, and current limitations of using telehealth and telemedicine approaches for prevention and management of diabetic foot disease. MEDLINE/PubMed was searched for peer-reviewed studies on telehealth and telemedicine approaches for assessing, monitoring, preventing, or treating diabetic foot disease. Four modalities were formulated: dermal thermography, hyperspectral imaging, digital photographic imaging, and audio/video/online communication. Outcome measures were: validity, reliability, feasibility, effectiveness, and costs. Sixty-one studies were eligible for analysis. Three randomized controlled trials showed that handheld infrared dermal thermography as home-monitoring tool is effective in reducing ulcer recurrence risk, while one small trial showed no effect. Hyperspectral imaging has been tested in clinical settings to assess and monitor foot disease and conflicting results on its diagnostic use show that this method is still in an experimental stage. Digital photography is used to assess and monitor foot ulcers and pre-ulcerative lesions and was found to be a valid, reliable, and feasible method for telehealth purposes. Audio/video/online communication is mainly used for foot ulcer monitoring. Two randomized controlled trials show similar healing efficacy compared with regular outpatient clinic visits, but no benefit in costs. In conclusion, several technologies with good psychometric properties are available that may be of benefit in helping to assess, monitor, prevent, or treat diabetic foot disease, but in most cases, feasibility, effectiveness, and cost savings still need to be demonstrated to become accepted and used modalities in diabetic foot care.

Exploring healthcare professionals' understanding and experiences of artificial intelligence technology use in the delivery of healthcare: An integrative review

BACKGROUND

The integration of artificial intelligence (AI) into our digital healthcare system is seen as a significant strategy to contain Australia's rising healthcare costs, support clinical decision making, manage chronic disease burden and support our ageing population. With the increasing roll-out of 'digital hospitals', electronic medical records, new data capture and analysis technologies, as well as a digitally enabled health consumer, the Australian healthcare workforce is required to become digitally literate to manage the significant changes in the healthcare landscape. To ensure that new innovations such as AI are inclusive of clinicians, an understanding of how the technology will impact the healthcare professions is imperative.

METHOD

In order to explore the complex phenomenon of healthcare professionals' understanding and experiences of AI use in the delivery of healthcare, an integrative review inclusive of quantitative and qualitative studies was undertaken in June 2018.

RESULTS

One study met all inclusion criteria. This study was an observational study which used a questionnaire to measure healthcare professional's intrinsic motivation in adoption behaviour when using an artificially intelligent medical diagnosis support system (AIMDSS).

DISCUSSION

The study found that healthcare professionals were less likely to use AI in the delivery of healthcare if they did not trust the technology or understand how it was used to improve patient outcomes or the delivery of care which is specific to the healthcare setting. The perception that AI would replace them in the healthcare setting was not evident. This may be due to the fact that AI is not yet at the forefront of technology use in healthcare setting. More research is needed to examine the experiences and perceptions of healthcare professionals using AI in the delivery of healthcare.

Multidisciplinary diabetic foot care in Sweden - A national survey

AIM

To investigate at a national level the multidisciplinary team (MDT) care of patients with diabetes mellitus and foot complications.

METHODS

A questionnaire was sent to all 75 Swedish hospitals with emergency departments, which were grouped according to size.

RESULTS

The response rate was 92%, 58/69 of the hospitals have a foot team. Most teams have access to an internal medicine specialist/diabetologist, podiatrist and orthotist. Fewer teams reported access to an orthopaedic surgeon and infectious diseases specialist and only half to a vascular surgeon. In joint MDT outpatient evaluations, the majority report the presence of an internal medicine specialist, podiatrist and orthotist, but 50% an infectious disease specialist and orthopaedic surgeon and only a few a vascular surgeon. In hospitalized patients, there is a reduction in the presence of all specialists. The registration of amputation rate and healed foot ulcers is low.

CONCLUSIONS

MDT care is mostly adopted among large and medium-sized hospitals in contrast to small ones, which could reflect unequal health care. Vascular surgeons seldom are present at MDT evaluations and there is a reduced regular input of specialists in the evaluation of hospitalized patients. The hospitals' ability to evaluate their work by potential quality control markers is poor.

REAL-WORLD CLINICAL EVALUATION AND COSTS OF TELEMEDICINE FOR CHRONIC WOUND MANAGEMENT

BACKGROUND

Chronic wounds are frequent, affect quality of life, and increase care costs. Telemedicine provides potential for effective wound care management, especially for the monitoring of complex wounds at home.

OBJECTIVES

The objective of the present study was to determine the clinical effects and costs of telemedicine for the follow-up of complex chronic wounds from the perspective of the public health insurance. The study ran over a period of 9 months.

METHODS

We conducted a prospective, pragmatic, open-label, observational study and carried out a cost-effectiveness analysis. A total of 116 patients with chronic wounds were assigned to their choice of two groups: telemedicine (N = 77) and traditional follow-up (control; N = 39). The primary outcome was the time to healing. Secondary outcomes included percentage of wounds reaching target objective, percentage of wounds healed completely, outpatient care costs, travel costs, and hospitalizations.

RESULTS

Time to healing was shorter in the telemedicine group than in the control group (137 versus 174 days; p .05). Outpatient care and hospitalization costs were not significantly different. The main results in terms of economic savings were medical transport costs reimbursed by the French public health insurance, which were significantly lower in the telemedicine group. Telemedicine costs were found to be €4,583 less per patient compared with standard practice over 9 months.

CONCLUSIONS

This trial suggests that telemedicine saves travel costs and results in a shorter healing time than traditional follow-up.

Impact of Telehealth Interventions on Processes and Quality of Care for Patients With ESRD

Caring for patients with end-stage renal disease (ESRD) requiring dialysis is intensive and expensive. Telehealth may improve the access and efficiency of ESRD care. For this perspective, we systematically reviewed studies that examined the effectiveness of telehealth versus or in addition to usual care for ESRD management. 10 studies were identified, including 7 randomized trials and 3 cohort studies. Study populations, modes of delivery (including telephone, telemetry, or videoconferencing), and the outcomes evaluated varied substantially between studies. Two studies examined telehealth interventions versus standard ESRD care and demonstrated mixed results on processes of care, no differences in laboratory surrogate markers of ESRD care, and reduced or similar rates of hospitalization. Eight studies evaluated the addition of telehealth to usual care and demonstrated no significant improvements in processes of care or surrogate laboratory measures, variable impacts on hospitalization rates, and mixed impacts on some domains of quality of life, including improvement in mental health. Although potential benefits of telehealth in ESRD care have been reported, optimal designs for delivery and elements of care that may be improved through telehealth remain uncertain.

Implementation of telemedicine for knee osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Osteoarthritis (OA) is the most prevalent chronic joint disease, characterized by joint structural deterioration, pain and loss of function among the elders. It is also associated with several extra-articular symptoms (fatigue, sleep disorders, anxiety and depression) and a reduction of life quality. Studies have revealed that patients with OA benefitted from enhanced management via telemedicine. Guangdong Online Hospital (GOH) is the first officially recognized web-based hospital that provides telemedicine service in China. However, the effective implementation of GOH telemedicine (GOHT) to enhance management for patients with OA remains unknown.

METHODS/DESIGN

An assessor-blinded, parallel randomized controlled trial will be performed to study the feasibility and effectiveness of GOHT in the enhanced management of OA. Forty participants with knee OA will be recruited for a 6-month study. Patients meeting the inclusion criteria will be randomly allocated to receive conventional therapy (CT) or conventional therapy plus a brief GOH-based intervention (CT-GOHT). The primary outcome is the feasibility of a full-scale randomized controlled trial. The secondary outcomes include the self-reported total score of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Multidimensional Fatigue Inventory (MFI), the Pittsburgh Sleep Quality Index (PSQI) and the Hospital Anxiety and Depression Scale (HADS). Assessments will be performed at baseline, 2 weeks, 3 months and 6 months later after the initiation of the study.

DISCUSSION

This trial is intended to test the application of GOHT in the chronic management in knee OA. The hypothesis is that OA patients may receive disease management via this network platform conveniently and effectively, especially those in the remote areas of our country. GOHT telemedicine would be an attractive alternative to traditional methods for disease management in knee OA. The results could provide preliminary experiences and guidance for an upcoming full-scale randomized controlled trial (RCT) in disease management via telemedicine.

TRIAL REGISTRATION

ChiCTR: ChiCTR1800014465 . Registered on 16 January 2018.

Telemedicine follow-up facilitates more comprehensive diabetes foot ulcer care: A qualitative study in home-based and specialist health care

AIMS AND OBJECTIVES

To investigate the application of a telemedicine intervention in diabetes foot ulcer care, and its implications for the healthcare professionals in the clinical field.

BACKGROUND

Contextual factors are found to be important when applying technology in health care and applying telemedicine in home-based care has been identified as particularly complex.

DESIGN AND METHODS

We conducted field observations and individual interviews among healthcare professionals in home-based care and specialist health care in a diabetes foot care telemedicine RCT (Clin.Trial.gov: NCT01710774) during 2016. This study was guided by Interpretive Description, an inductive qualitative methodology.

RESULTS

Overall, we identified unequal possibilities for applying telemedicine in diabetes foot ulcer care within the hospital and home care contexts. Different circumstances and possibilities in home-based care made the application of telemedicine as intended more difficult. The healthcare professionals in both care contexts perceived the application of telemedicine to facilitate a more comprehensive approach towards the patients, but with different possibilities to enact it.

CONCLUSIONS

Application of telemedicine in home-based care was more challenging than in the outpatient clinic setting. Introducing more updated equipment and minor structural adjustments in consultation time and resources could make the use of telemedicine in home-based care more robust.

RELEVANCE TO CLINICAL PRACTICE

Application of telemedicine in diabetes foot ulcer follow-up may enhance the nursing staff's ability to conduct comprehensive assessment and care of the foot ulcer as well as the patient's total situation. Access to adequate equipment and time, particularly in home-based care, is necessary to capitalise on this new technology.

The Effect of Telemedicine Follow-up Care on Diabetes-Related Foot Ulcers: A Cluster-Randomized Controlled Noninferiority Trial

OBJECTIVE

To evaluate whether telemedicine (TM) follow-up of patients with diabetes-related foot ulcers (DFUs) in primary health care in collaboration with specialist health care was noninferior to standard outpatient care (SOC) for ulcer healing time. Further, we sought to evaluate whether the proportion of amputations, deaths, number of consultations per month, and patient satisfaction differed between the two groups.

RESEARCH DESIGN AND METHODS

Patients with DFUs were recruited from three clinical sites in western Norway (2012-2016). The cluster-randomized controlled noninferiority trial included 182 adults (94/88 in the TM/SOC groups) in 42 municipalities/districts. The intervention group received TM follow-up care in the community; the control group received SOC. The primary end point was healing time. Secondary end points were amputation, death, number of consultations per month, and patient satisfaction.

RESULTS

Using mixed-effects regression analysis, we found that TM was noninferior to SOC regarding healing time (mean difference -0.43 months, 95% CI -1.50, 0.65). When competing risk from death and amputation were taken into account, there was no significant difference in healing time between the groups (subhazard ratio 1.16, 95% CI 0.85, 1.59). The TM group had a significantly lower proportion of amputations (mean difference -8.3%, 95% CI -16.3%, -0.5%), and there were no significant differences in the proportion of deaths, number of consultations, or patient satisfaction between groups, although the direction of the effect estimates for these clinical outcomes favored the TM group.

CONCLUSIONS

The results suggest that use of TM technology can be a relevant alternative and supplement to usual care, at least for patients with more superficial ulcers.

Telemedicine in Diabetic Foot Care: A Systematic Literature Review of Interventions and Meta-analysis of Controlled Trials

The care of individuals with diabetic foot ulcers is costly and requires multiple hospital visits. Inadequate care leads to serious complications and a high risk of lower extremity amputation. In this review, we aimed at evaluating whether telemedicine can be effective in diabetic foot patient care. We searched Medline through Embase and PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant studies, published up to April 2017. The studies were summarized and discussed in a narrative method and a meta-analysis of 2 controlled trials was conducted using the fixed-effects model. The main outcomes, assessed in the retrieved studies were the healing rate and satisfaction of patients and health care personnel. Most of the studies showed that implementing telemonitoring programs increased the rate of complete ulcer healing, while the patients were highly satisfied. Two trials providing data on 213 patients on telemedicine and 301 patients on usual care were included for meta-analysis. Subjects in telemedicine, as well as control groups had statistically similar healing time (43 vs 45 days; P = .83), healing time ratio adjusted for age (1 vs 1.4; P = .1), unhealed ulcers or loss to follow-up (3 of 20 vs 7 of 120; P = .13), and amputations (12 of 193 vs 14 of 182; P = .59). Subjects in the telemedicine group experienced a significantly higher mortality rate (8 of 193 vs 1 of 181; P = .0001) due to unexplained factors. No adverse events were attributed to using the telemedicine technology. The odds of complete ulcer healing were statistically similar between the telemedicine group and controls (odds ratio = 0.86; 95% CI = 0.57-1.33; P = .53). Telemedicine care is promising for the management of diabetic foot patients as the results were comparable with usual care. However, further large-scale studies need to be undertaken before it can be implemented widely.

Telemedical strategies for the improvement of secondary prevention in patients with cerebrovascular events—A systematic review and meta-analysis

Background

Data from European countries consistently show that guideline-conform secondary prevention after stroke/transient ischemic attack is being realized in only 50–80% of patients. Use of telemedicine to support long-term secondary prevention has been effective in other cardiovascular diseases.

Aims

We reviewed current evidence for telemedical-supported strategies for the improvement of secondary prevention after stroke/transient ischemic attack. A systematic review was performed in accordance with the PRISMA statement searching MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 18 May 2016. Randomized controlled trials and observational studies were included if they analyzed the effect of a telemedical strategy for supporting secondary prevention after stroke/transient ischemic attack compared to usual care and reported primary (behavior according to guidelines, e.g., medication adherence) or surrogate outcomes (consequences of primary outcome, e.g., blood pressure).

Summary of review

The review included 13 of 100 identified studies involving 2672 patients. Telemedical support mainly comprised telephone interventions, predominantly done by nurses. Outcomes were heterogeneous: medication adherence did not differ in one randomized controlled trial (p = 0.089). Mortality was reported in one study and was significantly (p < 0.001) higher in patients non-participating in a web-based intervention. Four studies assessed blood pressure in a comparable way that allowed calculation of a meta-analysis. In that, telemedical intervention had a significant blood-pressure lowering effect compared to the control group (mean difference −6.14 (95% confidence interval −10.41, −1.87), p = 0.005).

Conclusions

Telemedical-supported secondary prevention in cerebrovascular diseases might be effective but larger trials with standardized interventions and outcome measures including clinical endpoints are needed.

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

The effect of telepsychiatric modalities on reduction of readmissions in psychiatric settings: A systematic review

Introduction

Telepsychiatric modalities are used widely in the treatment of many mental illnesses. It has also been proposed that telepsychiatric modalities could be a way to reduce readmissions. The purpose of the study was to conduct a systematic review of the literature on the effects of telepsychiatric modalities on readmissions in psychiatric settings.

Methods

We conducted a systematic literature search in MEDLINE, CINAHL, Embase, Cochrane, PsycINFO and Joanna Briggs databases in October 2015. Inclusion criteria were (a) patients with a psychiatric diagnosis, (b) telepsychiatric interventions and (c) an outcome related to readmission.

Results

The database search identified 218 potential studies, of which eight were eligible for the review. Studies were of varying quality and there was a tendency towards low-quality studies (five studies) which found positive outcomes regarding readmission, whereas the more methodological sound studies (three studies) found no effect of telepsychiatric modalities on readmission rates.

Discussion

Previous studies have proven the effectiveness of telepsychiatric modalities in the treatment of various mental illnesses. However, in the present systematic review we were unable to find an effect of telepsychiatric modalities on the rate of readmission. Some studies found a reduced rate of readmissions, but the poor methodological quality make the findings questionable. At the present time there is no evidence to support the use of telepsychiatry due to heterogeneous interventions, heterogeneous patient groups and lack of high-quality studies.

Telemedicine Versus Standard Follow-Up Care for Diabetes-Related Foot Ulcers: Protocol for a Cluster Randomized Controlled Noninferiority Trial (DiaFOTo)

Background

This paper presents the protocol for an ongoing study to evaluate a telemedicine follow-up intervention for patients with diabetes-related foot ulcers. Diabetes-related foot ulcers represent challenges for patients and the health services. The large increase in the prevalence of diabetes, combined with the aging population, means that the absolute number of patients with diabetes-related foot ulcers is likely to continue to increase. Health care services therefore need to provide close clinical follow-up care for people with diabetes both in primary and specialist care. Information and communication technologies may enable more integrated treatment and care pathways across organizational boundaries. However, we lack knowledge about the effect of telemedicine follow-up and how such services can be optimally organized.

Objective

To present the design and methods of a study evaluating a telemedicine follow-up intervention for patients with diabetes-related foot ulcers.

Methods

The study is designed as a cluster randomized controlled trial (noninferiority trial) involving municipalities or municipality districts (clusters) belonging to one clinical site in Western Norway. The study includes patients with type 1 and type 2 diabetes presenting with a new foot ulcer at the initial visit to the clinic. Patients in the intervention group receive telemedicine follow-up care in the community. The key ingredient in the intervention is the close integration between health care levels. The intervention is facilitated by the use of an interactive wound platform consisting of a Web-based ulcer record combined with a mobile phone, enabling counseling and communication between nurses in the community and specialist health care. Patients in the control group receive standard hospital outpatient care. The primary endpoint in the trial is healing time; secondary outcomes include amputation and death, patient-reported outcome measures, and follow-up data on the recurrence of foot ulcers. In addition, qualitative substudies are being performed to provide a more comprehensive evaluation of the ongoing processes during the trial with the patients in the intervention and control groups and those health care professionals either working in primary care or in specialist care delivering the intervention.

Results

The project has been funded. The inclusion of patients started in September 2012. Because recruitment goals were not met in the initial period, two more clinical sites have been included to meet sample size requirements. Patient recruitment will continue until June 2016. Data collection in the qualitative substudies has been completed.

Conclusions

This telemedicine trial operates in a novel setting and targets patients with diabetes-related foot ulcers during a 12-month follow-up period. The trial addresses whether integrated care using telemedicine between primary and specialist health care can be an equivalent alternative to standard outpatient care.

Trial Registration

ClinicalTrials.gov NCT01710774; https://clinicaltrials.gov/ct2/show/NCT01710774 (Archived by WebCite at http://www.webcitation.org/6im6KfFov).