Research Implications for Future Telemedicine Studies and Innovations in Diabetes and Hypertension-A Mixed Methods Study

Evaluation of Telemedicine Consultations Using Health Outcomes and User Attitudes and Experiences: Scoping Review

BACKGROUND

Despite a recent rise in adoption, telemedicine consultations retention remains challenging, and aspects around the associated experiences and outcomes remain unclear. The need to further investigate these aspects was a motivating factor for conducting this scoping review.

OBJECTIVE

With a focus on synchronous telemedicine consultations between patients with nonmalignant chronic illnesses and health care professionals (HCPs), this scoping review aimed to gain insights into (1) the available evidence on telemedicine consultations to improve health outcomes for patients, (2) the associated behaviors and attitudes of patients and HCPs, and (3) how supplemental technology can assist in remote consultations.

METHODS

PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guided the scoping review process. Inclusion criteria were (1) involving adults with nonmalignant, noncommunicable chronic conditions as the study population; (2) focusing on health outcomes and experiences of and attitudes toward synchronous telemedicine consultations between patients and HCPs; and (3) conducting empirical research. A search strategy was applied to PubMed (including MEDLINE), CINAHL Complete, APA PsycNet, Web of Science, IEEE, and ACM Digital. Screening of articles and data extraction from included articles were performed in parallel and independently by 2 researchers, who corroborated their findings and resolved any conflicts.

RESULTS

Overall, 4167 unique articles were identified from the databases searched. Following multilayer filtration, 19 (0.46%) studies fulfilled the inclusion criteria for data extraction. They investigated 6 nonmalignant chronic conditions, namely chronic obstructive pulmonary disease, diabetes, chronic kidney disease, ulcerative colitis, hypertension, and congestive heart failure, and the telemedicine consultation modality varied in each case. Most observed positive health outcomes for patients with chronic conditions using telemedicine consultations. Patients generally favored the modality's convenience, but concerns were highlighted around cost, practical logistics, and thoroughness of clinical examinations. The majority of HCPs were also in favor of the technology, but a minority experienced reduced job satisfaction. Supplemental technological assistance was identified in relation to technical considerations, improved remote workflow, and training in remote care use.

CONCLUSIONS

For patients with noncommunicable chronic conditions, telemedicine consultations are generally associated with positive health outcomes that are either directly or indirectly related to their ailment, but sustained improvements remain unclear. These modalities also indicate the potential to empower such patients to better manage their condition. HCPs and patients tend to be satisfied with remote care experience, and most are receptive to the modality as an option. Assistance from supplemental technologies mostly resides in addressing technical issues, and additional modules could be integrated to address challenges relevant to patients and HCPs. However, positive outcomes and attitudes toward the modality might not apply to all cases, indicating that telemedicine consultations are more appropriate as options rather than replacements of in-person visits.

Patterns of Telemedicine Use and Glycemic Outcomes of Endocrinology Care for Patients With Type 2 Diabetes

Importance

Telemedicine can increase access to endocrinology care for people with type 2 diabetes (T2D), but patterns of use and outcomes of telemedicine specialty care for adults with T2D beyond initial uptake in 2020 are not known.

Objective

To evaluate patterns of telemedicine use and their association with glycemic control among adults with varying clinical complexity receiving endocrinology care for T2D.

Design, Setting, and Participants

Retrospective cohort study in a single large integrated US health system. Participants were adults who had a telemedicine endocrinology visit for T2D from May to October 2020. Data were analyzed from June 2022 to October 2023.

Exposure

Patients were followed up through May 2022 and assigned to telemedicine-only, in-person, or mixed care (both telemedicine and in-person) cohorts according to visit modality.

Main Outcomes and Measures

Multivariable regression models were used to estimate hemoglobin A1c (HbA1c) change at 12 months within each cohort and the association of factors indicating clinical complexity (insulin regimen and cardiovascular and psychological comorbidities) with HbA1c change across cohorts. Subgroup analysis was performed for patients with baseline HbA1c of 8% or higher.

Results

Of 11 498 potentially eligible patients, 3778 were included in the final cohort (81 Asian participants [2%], 300 Black participants [8%], and 3332 White participants [88%]); 1182 used telemedicine only (mean [SD] age 57.4 [12.9] years; 743 female participants [63%]), 1049 used in-person care (mean [SD] age 63.0 [12.2] years; 577 female participants [55%]), and 1547 used mixed care (mean [SD] age 60.7 [12.5] years; 881 female participants [57%]). Among telemedicine-only patients, there was no significant change in adjusted HbA1c at 12 months (-0.06%; 95% CI, -0.26% to 0.14%; P = .55) while in-person and mixed cohorts had improvements of 0.37% (95% CI, 0.15% to 0.59%; P < .001) and 0.22% (95% CI, 0.07% to 0.38%; P = .004), respectively. Patients with a baseline HbA1c of 8% or higher had a similar pattern of glycemic outcomes. For patients prescribed multiple daily injections vs no insulin, the 12-month estimated change in HbA1c was 0.25% higher (95% CI, 0.02% to 0.47%; P = .03) for telemedicine vs in-person care. Comorbidities were not associated with HbA1c change in any cohort.

Conclusions and Relevance

In this cohort study of adults with T2D receiving endocrinology care, patients using telemedicine alone had inferior glycemic outcomes compared with patients who used in-person or mixed care. Additional strategies may be needed to support adults with T2D who rely on telemedicine alone to access endocrinology care, especially for those with complex treatment or elevated HbA1c.

Acupuncture for brain diseases: Conception, application, and exploration

The brain is probably the most complex organ in the human body. It has been the hot spot and direction of brain science research all over the world to deeply study the pathogenesis of various kinds of brain diseases and find effective treatment methods. Acupuncture is a nonpharmacological therapy of traditional Chinese medicine originating from ancient clinical practice. The research on the treatment of brain diseases by acupuncture has been constantly enriched and updated with the promotion of interdisciplinary research. In order to account for the current achievements in the field of acupuncture for brain diseases, this article reviews it in terms of conception, application, and exploration. Based on the literature review, we found that in the past decades, acupuncture has received widespread attention worldwide and many literatures have reported the clinical efficacy and underlying mechanisms of acupuncture in the treatment of brain diseases. Presently, the conception, application, and exploration of acupuncture in the treatment of brain diseases have evolved from empirical medicine to evidence-based medicine and precision medicine, and are experiencing a deeper understanding of the information about acupuncture regulating the brain function based on interdisciplinary research.

[Developing, Evaluating and Implementing Digital Health Interventions Part II - Discussion Paper of the Digital Health Working Group of the German Network for Health Services Research (DNVF)]

The methodological challenges of evaluating digital interventions (DI) for health services research are omnipresent. The Digital Health Working Group of the German Network for Health Services Research (DNVF) presented and discussed these challenges in a two-part discussion paper. The first part addressed challenges in definition, development and evaluation of DI. In this paper, which represents the second part, the definition of outcomes, reporting of results, synthesis of evidence, and implementation are addressed as methodological challenges of DI. Potential solutions are presented and the need to address these challenges in future research are discussed.

A cross-sector systematic review and synthesis of knowledge on telemedicine interventions in chronic wound management-Implications from a system perspective

Based on initially identified needs for further telemedicine (TM) and chronic wound management research, the objective of this article is twofold: to conduct a systematic review of existing knowledge on TM interventions in chronic wound management-including barriers and opportunities-across the specialist and primary care sectors, and to incorporate the review findings into a system framework that can be further developed and validated through empirical data. We conclude that there is a pressing need for broader and more comprehensive empirical explorations into quality improvement and integration of TM in chronic wound management, including using system frameworks that can capture cross-sector system perspectives and associated implications. Of practical consideration, we suggest that the design and execution of TM improvement interventions and associated research projects should be conducted in close cooperation with managers and practitioners knowledgeable about barriers and opportunities that can influence the implementation of important interventions within chronic wound management.

Effectiveness of Digital Counseling Environments on Anxiety, Depression, and Adherence to Treatment Among Patients Who Are Chronically Ill: Systematic Review

Background

Patients who are chronically ill need novel patient counseling methods to support their self-care at different stages of the disease. At present, knowledge of how effective digital counseling is at managing patients’ anxiety, depression, and adherence to treatment seems to be fragmented, and the development of digital counseling will require a more comprehensive view of this subset of interventions.

Objective

This study aims to identify and synthesize the best available evidence on the effectiveness of digital counseling environments at improving anxiety, depression, and adherence to treatment among patients who are chronically ill.

Methods

Systematic searches of the EBSCO (CINAHL), PubMed, Scopus, and Web of Science databases were conducted in May 2019 and complemented in October 2020. The review considered studies that included adult patients aged ≥18 years with chronic diseases; interventions evaluating digital (mobile, web-based, and ubiquitous) counseling interventions; and anxiety, depression, and adherence to treatment, including clinical indicators related to adherence to treatment, as outcomes. Methodological quality was assessed using the standardized Joanna Briggs Institute critical appraisal tool for randomized controlled trials or quasi-experimental studies. As a meta-analysis could not be conducted because of considerable heterogeneity in the reported outcomes, narrative synthesis was used to synthesize the results.

Results

Of the 2056 records screened, 20 (0.97%) randomized controlled trials, 4 (0.19%) pilot randomized controlled trials, and 2 (0.09%) quasi-experimental studies were included. Among the 26 included studies, 10 (38%) digital, web-based interventions yielded significantly positive effects on anxiety, depression, adherence to treatment, and the clinical indicators related to adherence to treatment, and another 18 (69%) studies reported positive, albeit statistically nonsignificant, changes among patients who were chronically ill. The results indicate that an effective digital counseling environment comprises high-quality educational materials that are enriched with multimedia elements and activities that engage the participant in self-care. Because of the methodological heterogeneity of the included studies, it is impossible to determine which type of digital intervention is the most effective for managing anxiety, depression, and adherence to treatment.

Conclusions

This study provides compelling evidence that digital, web-based counseling environments for patients who are chronically ill are more effective than, or at least comparable to, standard counseling methods; this suggests that digital environments could complement standard counseling.

Reliability of Smartphone Accelerometers for Measuring Gait During Data Collection Over Zoom

This study examined whether gait data could be reliably collected by homebound participants using iPhones under online supervision. Eighteen healthy young adults met with investigators through Zoom and installed an app to record acceleration from their iPhones' accelerometers. Half of the subjects walked normally; the other half walked while spelling words backward. During the gait tasks subjects recorded their anterior-posterior (AP), medial-lateral (ML), and vertical (V) accelerations. Data collection was repeated the following week. Seven maximum and minimum peak accelerations in the AP, ML, and vertical directions associated with events in gait were determined. Significant main effects of week and direction were observed for the first and second vertical acceleration measures. Cronbach alpha values were >0.60 for all acceleration measures, but the maximum and minimum AP accelerations that showed fair to good levels of consistency. The findings suggest gait data collected inside the home setting may be of clinical use.

Long-Term Effects of a Video-Based Smartphone App ("VIDEA Bewegt") to Increase the Physical Activity of German Adults: A Single-Armed Observational Follow-Up Study

As physical inactivity is one of the four leading risk factors for mortality, it should be intensively treated. Therefore, this one-year follow-up study aimed to evaluate the long-term effects of a preventive app to increase physical activity in German adults under real-life circumstances. Data collection took place from July 2019 to July 2021 and included six online questionnaires. Physical activity was studied as the primary outcome based on MET-minutes per week (metabolic equivalent). Secondary outcomes included health-related quality of life based on a mental (MCS) and physical health component summary score (PCS). At the time of publication, 46/65 participants completed the study (median 52 years, 81.5% women). A significant increase of physical activity was observed in people with a low/moderate baseline activity during the first four months of follow-up (median increase by 490 MET-minutes per week, p < 0.001, r = 0.649). Both MCS (median increase by 2.8, p = 0.006, r = 0.344) and PCS (median increase by 2.6, p < 0.001, r = 0.521) significantly increased during the first two months and the BMI significantly decreased during the first six months after the intervention (median decrease by 0.96 kg/m2, p < 0.001, r = 0.465). Thus, this study provides evidence for the medium-term impact of the app, since the effects decreased over time. However, due to the chosen study design and a sizeable loss to follow-up, the validity of these findings is limited.

Tackling the scaling-up problem of digital health applications

Aim

The purpose of this editorial is to provide guidance for the readers concerning the broad realm of approaches towards successful implementation of digital health applications into the health care system. Recent developments due to the challenges posed by the COVID-19 pandemic are used as a current angle.

Subject and Methods

All contributions within the special issue were scanned for their most decisive contribution to the special issue and the field of implementation science, with a focus on digital health. Micro, meso, and macro layers of implementation processes, as well as the technological perspective itself, are used as broad categories for sorting the contributions and structuring the special issue.

Results

The ten contributions to this special issue cover micro (n = 1), technology (n = 1), meso (n = 4) and macro (n = 2) perspectives on the implementation process of digital health applications. Two further contributions also tackle the issue from a wider perspective when aiming to structure telemedicine application types and barriers encountered when implementing digital health.

Conclusion

Considering the wide array of research fields represented in this special issue, an emphasis is put on the importance of interdisciplinary work required for tackling the scale-up problem of digital health. As such, the special issue can assist in leveraging the full potential of digital health, not only when dealing with situations as out-of-the-ordinary as the current pandemic but also well beyond that, for example when dealing with the upcoming challenges of demographic change.

An empirically sound telemedicine taxonomy – applying the CAFE methodology

Aim

Because the field of information systems (IS) research is vast and diverse, structuring it is a necessary precondition for any further analysis of artefacts. To structure research fields, taxonomies are a useful tool. Approaches aiming to develop sound taxonomies exist, but they do not focus on empirical development. We aimed to close this gap by providing the CAFE methodology, which is based on quantitative content analysis.

Subject and methods

Existing taxonomies are used to build a coding scheme, which is then validated on an IS project database. After describing the methodology, it is applied to develop a telemedicine taxonomy.

Results

The CAFE methodology consists of four steps, including applicable methods. It helps in producing quantitative data for statistical analysis to empirically ground any newly developed taxonomy. By applying the methodology, a taxonomy for telemedicine is presented, including, e.g. application types, settings or the technology involved in telemedicine initiatives.

Conclusion

Taxonomies can serve in identifying both components and outcomes to analyse. As such, our empirically sound methodology for deriving those is a contribution not only to evaluation research but also to the development of future successful telemedicine or other digital applications.

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.