A Telemedicine system based on Internet and short message service as a new approach in the follow-up of patients with gestational diabetes

User experience and perceived usability of nurse-led telemonitoring among women with gestational diabetes in Dhulikhel, Nepal

Objective

To assess the usability and acceptability of nurse-led telemonitoring in managing gestational diabetes among Nepalese women.

Methods

We conducted a convergent mixed-method study among 91 pregnant women diagnosed with gestational diabetes at Dhulikhel Hospital, Nepal. Participants received glucometers and blood pressure monitors, along with training and instructions to measure and record their blood pressure and glucose levels at home once a week. Starting from the 28th gestational week, the study nurse reviewed measurements obtained at home during the biweekly telemonitoring follow ups, alternating with hospital visits. We used the System Usability Scale (SUS) to assess perceived usability and conducted in-depth interviews to understand participants' experiences with telemonitoring and related technologies, including feasibility, acceptability, satisfaction with treatment, usability, as well as any difficulties or unmet needs. The quantitative analysis included descriptive statistics to summarize participant characteristics and System Usability Scale (SUS) responses, while a framework analysis was applied to examine the qualitative data.

Results

The mean SUS score for telemonitoring services was 72.1 ± 7.6, indicating good usability (a score ≥ 68 indicates good usability). 93% of participants wanted to use the service frequently; 88% found it easy to use; 81% considered it well-integrated with their typical prenatal care. Participants acknowledged the benefits of virtual health visits, such as frequent health monitoring, facilitation of communication with healthcare providers, appointment reminders, added motivation for home monitoring, increased access to health information, and prevention of unnecessary anxiety. Overall, participants expressed satisfaction with the quality and features of the nurse-led telemonitoring for managing gestational diabetes, emphasizing its role in ensuring uninterrupted prenatal care.

Conclusions

Telemonitoring is a feasible and acceptable tool to facilitate close monitoring of pregnant women with gestational diabetes in peri-urban hospital settings in Nepal.

The effects of multifactorial pharmacist-led intervention protocol on medication optimisation and adherence among patients with type 2 diabetes: A randomised control trial

Background

Patient-related factors and limited medication adherence in patients with chronic diseases, are associated with poor clinical outcomes, long-term complications, and increased overall disease costs. Many methods have been tested with mixed results, and innovative approaches are needed to encourage patients to adhere to their prescribed drug regimens.

Methods

This randomised controlled trial examined a new multifactorial pharmacist-led intervention protocol (MPIP), including a medication therapy management (MTM) program with face-to-face counselling, patient-specific medication booklets, and a mobile application, from July 2021 to September 2022 in the Oud Al Touba diagnostic and screening ambulatory centre in 192 patients with type 2 diabetes in the United Arab Emirates. Medication adherence was assessed using the fixed medication possession ratio of medication refills and the medication adherence questionnaire.

Results

At 12 months follow-up, participants in the MPIP showed significant improvement in overall medication adherence with total (composite) medication possession ratio (MPRt) of mean (±SD) 0.95 (±0.09) compared to 0.92 (± 0.09) in the control group with mean difference of 0.03 (95%, CI 0.01-0.06), P =0.02. In addition, improvement trend was evident in the MPIP group for all medication regimens with P value <0.01. Comparable results were noticeable in adherence questionnaire scores at the end of the study, with 66 participants in the intervention group scored zero on the questionnaire, suggesting high adherence to medication compared to the control group (48 participants only). The MTM program performed 41 clinical interventions on drug-related problems, compared to six interventions in the control group, and the use of mobile application and medication booklet have increased to 45.7% compared to 21.4% before study exit.

Conclusions

The pharmacy intervention protocol effectively improved medication adherence and optimised medication regimens in diabetic patients with chronic medication regimens in an ambulatory healthcare centre.

Cultural and Digital Health Literacy Appropriateness of App- and Web-Based Systems Designed for Pregnant Women With Gestational Diabetes Mellitus: Scoping Review

BACKGROUND

The prevalence of women diagnosed with gestational diabetes mellitus (GDM) is increasing dramatically. Mobile technologies to enhance patient self-management offer many advantages for women diagnosed with GDM. However, to our knowledge, although mobile health (mHealth) and telemedicine systems for GDM management exist, evidence on their cultural and digital health literacy appropriateness levels is limited.

OBJECTIVE

This review aimed to search and assess the literature on mHealth and telemedicine systems designed for women diagnosed with GDM. Our assessment of these technologies focused on their cultural and digital health literacy appropriateness as well as the systems' effectiveness in improving glycemic control and maternal and infant outcomes.

METHODS

We conducted a scoping review using a framework adapted from Arksey and O'Malley. Four electronic databases were searched for relevant studies: PubMed, MEDLINE (EBSCO), Web of Science, and Scopus. The databases were searched between January 2010 and January 2022. The inclusion criteria were pregnant women diagnosed with GDM, use of telemedicine for monitoring and management, and vulnerable or disadvantaged patients. We used terms related to mobile apps and telemedicine: GDM, vulnerable populations, periphery, cultural appropriateness, and digital health literacy. Studies were screened and selected independently by 2 authors. We extracted the study data on a Microsoft Excel charting table and categorized them into final themes. The results were categorized according to the cultural and digital health literacy features presented.

RESULTS

We identified 17 studies that reported on 12 telemedicine and mHealth app interventions. We assessed the studies in three domains: cultural appropriateness, digital health literacy, and maternal and infant outcomes. In the literature, we found that existing digital technologies may improve glycemic control and diabetes self-management. However, there is a lack of assessment of cultural and digital health literacy appropriateness for pregnant women diagnosed with GDM. Considerations in app design regarding cultural appropriateness were found in only 12% (2/17) of the studies, and only 25% (3/12) of the interventions scored ≥3 out of 5 in our assessment of digital health literacy.

CONCLUSIONS

mHealth and telemedicine can be an effective platform to improve the clinical management of women with GDM. Although studies published on the use of mHealth and telemedicine systems exist, there is a limited body of knowledge on the digital health literacy and cultural appropriateness of the systems designed for women diagnosed with GDM. In addition, as our study was restricted to the English language, relevant studies may have been excluded. Further research is needed to evaluate, design, and implement better tailored apps regarding cultural and digital literacy appropriateness for enhancing pregnant women's self-management as well as the effectiveness of these apps in improving maternal and infant health outcomes.

Promoting High-Quality Health Communication Between Young Adults With Diabetes and Health Care Providers

Young adults with diabetes assume increasing responsibility for communicating with their health care providers, and engaging in high-quality health communication is an integral component of overall diabetes self-management. This article provides an overview of the main features of health communication, factors that may influence communication quality, interventions to promote communication skills, and practical strategies for clinicians working with young adults with diabetes. The review concludes with a comprehensive summary of future directions for health communication research.

Effects of Telemetric Interventions on Maternal and Fetal or Neonatal Outcomes in Gestational Diabetes: Systematic Meta-Review

Background

In 2019, 1 of 6 births was affected by gestational diabetes mellitus (GDM) globally. GDM results in adverse maternal, fetal, and neonatal outcomes in the short and long term, such as pregnancy and birth complications, type 2 diabetes, metabolic syndrome, and cardiovascular disease. In the context of “transgenerational programming,” diabetes mellitus during pregnancy can contribute to “programming” errors and long-term consequences for the child. Therefore, early therapy strategies are required to improve the clinical management of GDM. The interest in digital therapy approaches, such as telemetry, has increased because they are promising, innovative, and sustainable.

Objective

This study aimed to assess the current evidence regarding the clinical effectiveness of telemetric interventions in the management of GDM, addressing maternal glycemic control, scheduled and unscheduled visits, satisfaction, diabetes self-efficacy, compliance, maternal complications in pregnancy and childbirth, as well as fetal and neonatal outcomes.

Methods

Medline via PubMed, Web of Science Core Collection, Embase, Cochrane Library, and CINAHL databases were systematically searched from January 2008 to April 2020. We included randomized controlled trials, systematic reviews, meta-analyses, and clinical trials in English and German. Study quality was assessed using “A MeaSurement Tool to Assess systematic Reviews” and “Effective Public Health Practice Project.”

Results

Our search identified 1116 unique studies. Finally, we included 11 suitable studies (including a total of 563 patients and 2779 patient cases): 4 systematic reviews or meta-analyses (1 of high quality and 3 of moderate quality), 6 randomized controlled trials (2 of high quality and 4 of moderate quality), and 1 low-quality nonrandomized controlled trial. We classified 4 “asynchronous interventions” and 3 “asynchronous and real-time interventions.” Our findings indicate that telemetric therapy clearly improves glycemic control and effectively reduces glycated hemoglobin A_1c levels. Furthermore, in 1 study, telemetry proved to be a significant predictor for a better glycemic control (hazard ratio=1.71, 95% CI 1.11-2.65; P=.02), significantly fewer insulin titrations were required (P=.04), and glycemic control was achieved earlier. Telemetric therapy significantly reduced scheduled and unscheduled clinic visits effectively, and women were highly satisfied with the treatment (P<.05). From fetal and neonatal short-term outcomes, some improving tendencies in favor of telemetry were determined. No long-term outcomes were detected.

Conclusions

Telemetric interventions clearly improved glycemic control, notably glycated hemoglobin A_1c levels, and reduced scheduled and unscheduled clinic visits effectively, which reinforces this digital approach in the treatment of GDM.

Telemedical Approaches to Managing Gestational Diabetes Mellitus During COVID-19: Systematic Review

BACKGROUND

In 2019, a new coronavirus emerged in China, and the disease caused by the virus (COVID-19) was rapidly classified as a pandemic. Pregnant women with gestational diabetes mellitus (GDM) are considered to be at risk for severe COVID-19. In the context of the pandemic, there are serious concerns regarding adverse effects on maternal and neonatal outcomes for women with GDM. Effective treatments for patients with GDM are therefore particularly important. Due to contact restrictions and infection risks, digital approaches such as telemedicine are suitable alternatives.

OBJECTIVE

This systematic review aims to summarize currently available evidence on maternal and offspring outcomes of pregnant women with GDM and COVID-19 and to examine telemedical interventions to improve maternal glycemic control during the COVID-19 pandemic.

METHODS

Publications were systematically identified by searching the Cochrane Library, MEDLINE via PubMed, Web of Science Core Collection, Embase, and CINAHL databases for studies published up to March 2021. We sorted the COVID-19 studies by outcome and divided the telemedical intervention studies into web-based and app-based groups. We analyzed case reports (COVID-19) and both randomized and nonrandomized controlled clinical trials (telemedicine). To determine the change in glycated hemoglobin A_1c (HbA_1c), we pooled appropriate studies and calculated the differences in means, with 95% CIs, for the intervention and control groups at the end of the interventions.

RESULTS

Regarding COVID-19 studies, we identified 11 case reports, 3 letters, 1 case series, and 1 retrospective single-center study. In total, 41 patients with GDM and COVID-19 were analyzed. The maternal and neonatal outcomes were extremely heterogeneous. We identified adverse outcomes for mother and child through the interaction of GDM and COVID-19, such as cesarean deliveries and low Apgar scores. Furthermore, we selected 9 telemedicine-related articles: 6 were randomized controlled trials, 2 were clinical controlled trials, and 1 was a quasi-experimental design. In total, we analyzed 480 patients with GDM in the intervention groups and 494 in the control groups. Regarding the quality of the 9 telemedical studies, 4 were rated as strong, 4 as moderate, and 1 as weak. Telemedical interventions can contribute to favorable impacts on HbA_1c and fasting blood glucose values in the context of the COVID-19 pandemic. Meta-analysis revealed a mean difference in HbA_1c of -0.19% (95% CI 0.34% to 0.03%) for all telemedical interventions, -0.138% (95% CI -0.24% to -0.04%) for the web-based interventions, and -0.305% (96% CI -0.88% to 0.27%) for the app-based interventions.

CONCLUSIONS

Telemedicine is an effective approach in the context of COVID-19 and GDM because it enables social distancing and represents optimal care of patients with GDM, especially with regard to glycemic control, which is very important in view of the identified adverse maternal and neonatal outcomes. Further research is needed.

Integrated substance use and prenatal care delivery in the era of COVID-19

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes: A Systematic Review

Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics.

OBJECTIVE:

To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes.

DATA SOURCES:

We conducted a comprehensive search for primary literature in ClinicalTrials.gov, Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE.

METHODS OF STUDY SELECTION:

Qualifying primary studies had a comparison group, were conducted in countries ranked very high on the United Nations Human Development Index, published in English, and evaluated obstetric and gynecologic health outcomes. Cochrane Collaboration's tool and ROBINS-I tool were used for assessing risk of bias. Summary of evidence tables were created using the United States Preventive Services Task Force Summary of Evidence Table for Evidence Reviews.

TABULATION, INTEGRATION, RESULTS:

Of the 3,926 published abstracts identified, 47 met criteria for inclusion and included 31,967 participants. Telehealth interventions overall improved obstetric outcomes related to smoking cessation and breastfeeding. Telehealth interventions decreased the need for high-risk obstetric monitoring office visits while maintaining maternal and fetal outcomes. One study found reductions in diagnosed preeclampsia among women with gestational hypertension. Telehealth interventions were effective for continuation of oral and injectable contraception; one text-based study found increased oral contraception rates at 6 months. Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Few studies suggested utility for telehealth to improve notification of sexually transmitted infection test results and app-based intervention to improve urinary incontinence symptoms.

CONCLUSION:

Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics. Further well-designed studies are needed to examine these interventions and others to generate evidence that can inform decisions about implementation of newer telehealth technologies into obstetrics and gynecology practice.

Exploring the Use of Telemonitoring for Patients at High Risk for Hypertensive Disorders of Pregnancy in the Antepartum and Postpartum Periods: Scoping Review

BACKGROUND

High blood pressure complicates 2% to 8% of pregnancies, and its complications are present in the antepartum and postpartum periods. Blood pressure during and after pregnancy is routinely monitored during clinic visits. Some guidelines recommend using home blood pressure measurements for the management and treatment of hypertension, with increased frequency of monitoring for high-risk pregnancies. Blood pressure self-monitoring may have a role in identifying those in this high-risk group. Therefore, this high-risk pregnancy group may be well suited for telemonitoring interventions.

OBJECTIVE

The aim of this study was to explore the use of telemonitoring in patients at high risk for hypertensive disorders of pregnancy (HDP) during the antepartum and postpartum periods. This paper aims to answer the following question: What is the current knowledge base related to the use of telemonitoring interventions for the management of patients at high risk for HDP?

METHODS

A literature review following the methodological framework described by Arksey et al and Levac et al was conducted to analyze studies describing the telemonitoring of patients at high risk for HDP. A qualitative study, observational studies, and randomized controlled trials were included in this scoping review.

RESULTS

Of the 3904 articles initially identified, 20 met the inclusion criteria. Most of the studies (13/20, 65%) were published between 2017 and 2018. In total, there were 16 unique interventions described in the 20 articles, all of which provide clinical decision support and 12 of which are also used to facilitate the self-management of HDP. Each intervention's design and process of implementation varied. Overall, telemonitoring interventions for the management of HDP were found to be feasible and convenient, and they were used to facilitate access to health services. Two unique studies reported significant findings for the telemonitoring group, namely, spontaneous deliveries were more likely, and one study, reported in two papers, described inductions as being less likely to occur compared with the control group. However, the small study sample sizes, nonrandomized groups, and short study durations limit the findings from the included articles.

CONCLUSIONS

Although current evidence suggests that telemonitoring could provide benefits for managing patients at high risk for HDP, more research is needed to prove its safety and effectiveness. This review proposes four recommendations for future research: (1) the implementation of large prospective studies to establish the safety and effectiveness of telemonitoring interventions; (2) additional research to determine the context-specific requirements and patient suitability to enhance accessibility to healthcare services for remote regions and underserved populations; (3) the inclusion of privacy and security considerations for telemonitoring interventions to better comply with healthcare information regulations and guidelines; and (4) the implementation of studies to better understand the effective components of telemonitoring interventions.

The Influence of Social Media on Intrapartum Decision Making: A Scoping Review

Social media has been influential in decision making regarding a number of health concerns. However, comparatively little has been examined with regard to its effects on pregnant women. The goal of this scoping review was to examine the literature and identify the role of social media in intrapartum decision making. A scoping review of the literature published between January 1990 and June 2018 was performed using PubMed, CINAHL, EMBASE, PsychINFO, Web of Science, and Cochrane databases. Of the initial 1951 records reviewed, 5 met inclusion criteria. Two of the 5 were quantitative in design, 1 was qualitative, and 2 used mixed methods. Internationally widespread, studies largely took place in developed nations including the United States, the United Kingdom, Canada, Australia, New Zealand, and Finland. Women are using the Internet, including social media, consistently as a source of pregnancy information, for example, 97% of 2400 participates in 1 exploratory study. This knowledge seeking was found to increase women's confidence and self-assurance in making decision during labor and birth. Studies identified issues surrounding women's ability to appraise available information. While it is clear that social media has an influence on women's intrapartum decision making, it is not clear exactly how. Further studies are needed to determine the content of the social media being appraised, the accuracy of the information, and the resulting decision as it affects the intrapartum experience. In addition, efforts should be made to open lines of communication between patients and care providers. This may foster a greater clinical understanding of social media consumption and its influences.

Demonstrated Cost-Effectiveness of a Telehomecare Program for Gestational Diabetes Mellitus Management

Background: Prevalence of gestational diabetes mellitus (GDM) has increased steadily in recent years. Pregnant women with GDM are at risk for obstetrical and neonatal complications and require close multidisciplinary follow-up, which implies a significant use of hospital resources. Methods: A prospective noninferiority and controlled clinical trial was designed. The telehomecare (THCa) initiative is a clinical remote patient management project in women with GDM. The main objective was to evaluate the cost-effectiveness of THCa by assessing the direct costs, including the related reduction in medical visits. Secondary outcomes were to evaluate the impact of THCa on diabetes control, GDM-related complications, and patient satisfaction. Results: A total of 161 women were assigned to either an intervention group provided with a THCa system for transmission and online analysis of capillary glucose data (n = 80) or a control group receiving usual care in the clinic (n = 81). A decrease in medical visits by 56% (P < 0.001) in the THCa group was observed. There was no difference between the two groups in diabetes control or maternal and fetal complications. However, results showed a 10-fold increase in nursing interventions in THCa group (mainly by phone calls and e-mails). Satisfaction with care was high. Direct cost analysis revealed savings of 16% in patients followed by THCa compared with the control group. Conclusion: THCa monitoring significantly decreases medical visits and direct costs in GDM women without compromising pregnancy outcomes, quality of care, or patient satisfaction. THCa was shown to be cost-effective despite placing an additional burden on nursing time.

Web and mobile-based technologies for monitoring high-risk pregnancies

Introduction

High-risk pregnancy is an illness in which there are severe complications and problems that may cause fetal loss and requires continuous care. It seems that using telemedicine technology is helpful to provide wider access to prenatal care. The aim of this study was to compare the feasibility of using web-based and mobile-based technologies in caring for high-risk pregnancy.

Materials and methods

This was a cross-sectional study and the participants included midwives and gynaecologists who worked at teaching hospitals. The data were collected by using two five-point Likert scale questionnaires which were designed based on the literature review. The questionnaires included two main sections: demographic questions and questions related to five aspects of a feasibility study. Face and content validity of the questionnaires were confirmed by the experts and the reliability was checked by using the test-retest method. The data were analysed using descriptive and inferential statistics.

Results

In this study, 79 questionnaires were completed by 50 midwives (63.29%) and 29 gynaecologists (36.71%). Overall, midwives (p=0.001) and gynaecologists (p=0.003) believed that using mobile-based technologies was more feasible than using web-based technologies in caring for high-risk pregnancies.

Conclusion

It seems that planning for the future technological direction and providing mobile-based applications should be taken into account and prioritised to improve the quality of prenatal care and to increase access to healthcare services for high-risk pregnancies.

Understanding the Adoption and Diffusion of a Telemonitoring Solution in Gestational Diabetes Mellitus: Qualitative Study

Background

Women with gestational diabetes mellitus (GDM) require regular follow-ups and overall management to normalize maternal blood glucose and improve pregnancy outcomes. With the advancements made in the digital field, telemedicine is gaining popularity over traditional health care approaches in different medical fields. As for GDM, telemonitoring solutions seem to improve women’s quality of life and enhance self-management.

Objective

The aim of this study is to understand, from patients’ and health care professionals’ (HCPs) perspectives, what drives the adoption and diffusion of a telemonitoring solution (myDiabby) in a context where telemonitoring activities are still not compensated like traditional follow-ups.

Methods

The study was conducted in 12 diabetes services in France using myDiabby for monitoring and managing patients with GDM. A qualitative research approach was adopted for collecting and analyzing data. A total of 20 semistructured interviews were conducted with HCPs working in different health structures in France, and 15 semistructured interviews were conducted with patients who had been using myDiabby. Data were analyzed using a thematic analysis approach.

Results

Different determinants need to be taken into consideration when adopting an innovative health technology. By drawing on the diffusion of innovation theory, a set of factors associated with the technology (the relative advantages, compatibility, ease of use, testability, and observability of the telemedicine platform) has been identified as affecting the adoption and diffusion of telemonitoring solutions in French diabetes services. In addition, data analysis shows a set of environmental factors (the demographic situation of HCPs, the health care access in rural communities, and the economic and political context in France) that also influences the spread and adoption of telemonitoring systems in French hospitals.

Conclusions

Even though telemonitoring activities are still not remunerated as traditional follow-ups, many French HCPs support and encourage the adoption of telemonitoring systems in GDM. As for patients, telemonitoring systems are perceived as a useful and easy way to monitor their GDM. This study contributes to recognizing the value of telemonitoring interventions in managing GDM and considering the expansion of telemonitoring to other chronic conditions.

Cross-sectional study about the use of telemedicine for type 2 diabetes mellitus management in Spain: patient's perspective. The EnREDa2 Study

OBJECTIVES

The usefulness of telemedicine (TM) in type 2 diabetes mellitus (T2DM) has been discussed in recent years. The aim of this study is to describe patients' perceptions about TM and to identify preferences on TM resources, in Spain.

DESIGN

An observational, cross-sectional study was conducted using a structured questionnaire.

PARTICIPANTS

1036 patients with T2DM accepted to participate in the study (response rate: 68%).

RESULTS

Blood glucose values were recorded by 85.9% of the patients while data such as lifestyle habits were only recorded by 14.4% of the patients. Previous experience in TM was reported by 9.8% of the patients, out of which 70.5% were satisfied with its service and 73.5% considered that the use of TM had optimised their T2DM management. However, most of these patients noted aspects to be improved such as user-friendliness (81.4%), interaction with the medical team (78.4%) and time required for recording/transferring data (78.4%). Experienced patients had better perception about TM usefulness than naïve patients for all listed aspects (p<0.05). Among naïve patients, 38.2% expressed their willingness to participate in TM programmes, but only 4.7% were invited to do so. Patients considered that physicians' (77.5%) and pharmacists' (75.5%) encouragement can boost the use of TM.

CONCLUSIONS

In Spain, nearly 10% of patients with T2DM have experience with TM and it is well accepted, especially one based on glucometers. Nevertheless, in order to promote TM use, easier and time-saving programmes for patient-physician interaction should be optimised.

Midwives', Obstetricians', and Recently Delivered Mothers' Perceptions of Remote Monitoring for Prenatal Care: Retrospective Survey

BACKGROUND

The Pregnancy Remote Monitoring (PREMOM) study enrolled pregnant women at increased risk of developing hypertensive disorders of pregnancy and investigated the effect of remote monitoring in addition to their prenatal follow-up.

OBJECTIVE

The objective of this study was to investigate the perceptions and experiences of remote monitoring among mothers, midwives, and obstetricians who participated in the PREMOM study.

METHODS

We developed specific questionnaires for the mothers, midwives, and obstetricians addressing 5 domains: (1) prior knowledge and experience of remote monitoring, (2) reactions to abnormal values, (3) privacy, (4) quality and patient safety, and (5) financial aspects. We also questioned the health care providers about which issues they considered important when implementing remote monitoring. We used a 5-point Likert scale to provide objective scores. It was possible to add free-text feedback at every question.

RESULTS

A total of 91 participants completed the questionnaires. The mothers, midwives, and obstetricians reported positive experiences and perceptions of remote monitoring, although most of them had no or little prior experience with this technology. They supported a further rollout of remote monitoring in Belgium. Nearly three-quarters of the mothers (34/47, 72%) did not report any problems with taking the measurements at the required times. Almost half of the mothers (19/47, 40%) wanted to be contacted within 3 to 12 hours after abnormal measurement values, preferably by telephone.

CONCLUSIONS

Although most of midwives and obstetricians had no or very little experience with remote monitoring before enrolling in the PREMOM study, they reported, based on their one-year experience, that remote monitoring was an important component in the follow-up of high-risk pregnancies and would recommend it to their colleagues and pregnant patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03246737; https://clinicaltrials.gov/ct2/show/NCT03246737 (Archived by WebCite at http://www.webcitation.org/76KVnHSYY).

Effect of Telehealth System on Glycemic Control in Children and Adolescents with Type 1 Diabetes

OBJECTIVE

A close diabetes team-patient relationship is required for establishing satisfactory metabolic control. The purpose of this study was to investigate the effect of a telehealth system on diabetes control.

METHODS

The study was carried out between June 2015 and January 2016 at the Gazi University Faculty of Medicine, Pediatric Endocrinology Department. The telehealth system was developed by the diabetes team. The demographic characteristics, frequency of use and hemoglobin A1c (HbA1c) changes of type 1 diabetic (T1DM) patients using this communication network were analysed.

RESULTS

Eighty two patients [43 (52.4%) females, mean (±standard deviation) age 10.89±4 years] used the telehealth system. Fourteen (17.1%) of the cases were on pump therapy and 59 (72.0%) were counting carbohydrates. The individuals with diabetes or their families preferred WhatsApp communication. Whatsapp provided a means for instant messaging in most instances (57.3%), contact with diabetes education nurse (32.9%) and consultation with the diabetes team about insulin doses and blood glucose regulation (42.7%). HbA1c values after six months were significantly lower in patients/parents calling frequently (p<0.001) compared with HbA1c values recorded at the beginning of the study.

CONCLUSION

Increase in frequency of counselling by the diabetes team led to improved blood glucose control in T1DM patients. A telehealth system is useful for early detection of the need for changes in treatment and for intervention. It also promoted better self care.

Impacting diabetes self-management in women with gestational diabetes mellitus using short messaging reminders

BACKGROUND AND PURPOSE

Gestational diabetes mellitus (GDM) has been associated with multiple complications, including increase risk of gestational hypertension, cesarean delivery, macrosomia, stillbirth, and preeclampsia. The purpose of this study was to determine the acceptability of text messaging in women with GDM and further refine intervention materials and study procedures (recruitment, enrollment, intervention, retention, and data collection).

METHODS

Nineteen women diagnosed with GDM completed a baseline demographic questionnaire followed by 4 weeks of daily text messages that included either a direct reminder to test their blood glucose levels and keep up with their treatment plan or an educational message. A postintervention survey was administered to assess the satisfaction with the messaging program.

CONCLUSION

The use of daily text messages in the treatment plan of patients diagnosed with GDM seems to be acceptable shown by an overall satisfaction with the messages and a willingness to use the messages in future pregnancies. Half of the participants also felt that the messages helped them to eat healthier.

IMPLICATIONS FOR PRACTICE

This study demonstrated a real opportunity for a low-cost intervention in the management plan of GDM.

Prenatal Remote Monitoring of Women With Gestational Hypertensive Diseases: Cost Analysis

Background

Remote monitoring in obstetrics is relatively new; some studies have shown its effectiveness for both mother and child. However, few studies have evaluated the economic impact compared to conventional care, and no cost analysis of a remote monitoring prenatal follow-up program for women diagnosed with gestational hypertensive diseases (GHD) has been published.

Objective

The aim of this study was to assess the costs of remote monitoring versus conventional care relative to reported benefits.

Methods

Patient data from the Pregnancy Remote Monitoring (PREMOM) study were used. Health care costs were calculated from patient-specific hospital bills of Ziekenhuis Oost-Limburg (Genk, Belgium) in 2015. Cost comparison was made from three perspectives: the Belgian national health care system (HCS), the National Institution for Insurance of Disease and Disability (RIZIV), and costs for individual patients. The calculations were made for four major domains: prenatal follow-up, prenatal admission to the hospital, maternal and neonatal care at and after delivery, and total amount of costs. A simulation exercise was made in which it was calculated how much could be demanded of RIZIV for funding the remote monitoring service.

Results

A total of 140 pregnancies were included, of which 43 received remote monitoring (30.7%) and 97 received conventional care (69.2%). From the three perspectives, there were no differences in costs for prenatal follow-up. Compared to conventional care, remote monitoring patients had 34.51% less HCS and 41.72% less RIZIV costs for laboratory test results (HCS: mean €0.00 [SD €55.34] vs mean €38.28 [SD € 44.08], P<.001; RIZIV: mean €21.09 [SD €27.94] vs mean €36.19 [SD €41.36], P<.001) and a reduction of 47.16% in HCS and 48.19% in RIZIV costs for neonatal care (HCS: mean €989.66 [SD €3020.22] vs mean €1872.92 [SD €5058.31], P<.001; RIZIV: mean €872.97 [SD €2761.64] vs mean €1684.86 [SD €4702.20], P<.001). HCS costs for medication were 1.92% lower in remote monitoring than conventional care (mean €209.22 [SD €213.32] vs mean €231.32 [SD 67.09], P=.02), but were 0.69% higher for RIZIV (mean €122.60 [SD €92.02] vs mean €121.78 [SD €20.77], P<.001). Overall HCS costs for remote monitoring were mean €4233.31 (SD €3463.31) per person and mean €4973.69 (SD €5219.00) per person for conventional care (P=.82), a reduction of €740.38 (14.89%) per person, with savings mainly for RIZIV of €848.97 per person (23.18%; mean €2797.42 [SD €2905.18] vs mean €3646.39 [SD €4878.47], P=.19). When an additional fee of €525.07 per month per pregnant woman for funding remote monitoring costs is demanded, remote monitoring is acceptable in their costs for HCS, RIZIV, and individual patients.

Conclusions

In the current organization of Belgian health care, a remote monitoring prenatal follow-up of women with GHD is cost saving for the global health care system, mainly via savings for the insurance institution RIZIV.

Gestational Diabetes Management Using Smart Mobile Telemedicine

Gestational diabetes (GDM) burden has been increasing progressively over the past years. Knowing that intrauterine exposure to maternal diabetes confers high risk for macrosomia as well as for future type 2 diabetes and obesity of the offspring, health care organizations try to provide effective control in spite of the limited resources. Artificial-intelligence-augmented telemedicine has been proposed as a helpful tool to facilitate an efficient widespread medical assistance to GDM. The aim of the study we present was to test the feasibility and acceptance of a mobile decision-support system for GDM, developed in the seventh framework program MobiGuide Project, which includes computer-interpretable clinical practice guidelines, access to data from the electronic health record as well as from glucose, blood pressure, and activity sensors. The results of this pilot study with 20 patients showed that the system is feasible. Compliance of patients with blood glucose monitoring was higher than that observed in a historical group of 247 patients, similar in clinical characteristics, who had been followed up for the 3 years prior to the pilot study. A questionnaire on the use of the telemedicine system showed a high degree of acceptance.

Different methods and settings for glucose monitoring for gestational diabetes during pregnancy

BACKGROUND

Incidence of gestational diabetes mellitus (GDM) is increasing worldwide. Blood glucose monitoring plays a crucial part in maintaining glycaemic control in women with GDM and is generally recommended by healthcare professionals. There are several different methods for monitoring blood glucose which can be carried out in different settings (e.g. at home versus in hospital).

OBJECTIVES

The objective of this review is to compare the effects of different methods and settings for glucose monitoring for women with GDM on maternal and fetal, neonatal, child and adult outcomes, and use and costs of health care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-randomised controlled trials (qRCTs) comparing different methods (such as timings and frequencies) or settings, or both, for blood glucose monitoring for women with GDM.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias, and extracted data. Data were checked for accuracy.We assessed the quality of the evidence for the main comparisons using GRADE, for:- primary outcomes for mothers: that is, hypertensive disorders of pregnancy; caesarean section; type 2 diabetes; and- primary outcomes for children: that is, large-for-gestational age; perinatal mortality; death or serious morbidity composite; childhood/adulthood neurosensory disability;- secondary outcomes for mothers: that is, induction of labour; perineal trauma; postnatal depression; postnatal weight retention or return to pre-pregnancy weight; and- secondary outcomes for children: that is, neonatal hypoglycaemia; childhood/adulthood adiposity; childhood/adulthood type 2 diabetes.

MAIN RESULTS

We included 11 RCTs (10 RCTs; one qRCT) that randomised 1272 women with GDM in upper-middle or high-income countries; we considered these to be at a moderate to high risk of bias. We assessed the RCTs under five comparisons. For outcomes assessed using GRADE, we downgraded for study design limitations, imprecision and inconsistency. Three trials received some support from commercial partners who provided glucose meters or financial support, or both. Main comparisons Telemedicine versus standard care for glucose monitoring (five RCTs): we observed no clear differences between the telemedicine and standard care groups for the mother, for:- pre-eclampsia or pregnancy-induced hypertension (risk ratio (RR) 1.49, 95% confidence interval (CI) 0.69 to 3.20; 275 participants; four RCTs; very low quality evidence);- caesarean section (average RR 1.05, 95% CI 0.72 to 1.53; 478 participants; 5 RCTs; very low quality evidence); and- induction of labour (RR 1.06, 95% CI 0.63 to 1.77; 47 participants; 1 RCT; very low quality evidence);or for the child, for:- large-for-gestational age (RR 1.41, 95% CI 0.76 to 2.64; 228 participants; 3 RCTs; very low quality evidence);- death or serious morbidity composite (RR 1.06, 95% CI 0.68 to 1.66; 57 participants; 1 RCT; very low quality evidence); and- neonatal hypoglycaemia (RR 1.14, 95% CI 0.48 to 2.72; 198 participants; 3 RCTs; very low quality evidence).There were no perinatal deaths in two RCTs (131 participants; very low quality evidence). Self-monitoring versus periodic glucose monitoring (two RCTs): we observed no clear differences between the self-monitoring and periodic glucose monitoring groups for the mother, for:- pre-eclampsia (RR 0.17, 95% CI 0.01 to 3.49; 58 participants; 1 RCT; very low quality evidence); and- caesarean section (average RR 1.18, 95% CI 0.61 to 2.27; 400 participants; 2 RCTs; low quality evidence);or for the child, for:- perinatal mortality (RR 1.54, 95% CI 0.21 to 11.24; 400 participants; 2 RCTs; very low quality evidence);- large-for-gestational age (RR 0.82, 95% CI 0.50 to 1.37; 400 participants; 2 RCTs; low quality evidence); and- neonatal hypoglycaemia (RR 0.64, 95% CI 0.39 to 1.06; 391 participants; 2 RCTs; low quality evidence). Continuous glucose monitoring system (CGMS) versus self-monitoring of glucose (two RCTs): we observed no clear differences between the CGMS and self-monitoring groups for the mother, for:- caesarean section (RR 0.91, 95% CI 0.68 to 1.20; 179 participants; 2 RCTs; very low quality evidence);or for the child, for:- large-for-gestational age (RR 0.67, 95% CI 0.43 to 1.05; 106 participants; 1 RCT; very low quality evidence) and- neonatal hypoglycaemia (RR 0.79, 95% CI 0.35 to 1.78; 179 participants; 2 RCTs; very low quality evidence).There were no perinatal deaths in the two RCTs (179 participants; very low quality evidence). Other comparisons Modem versus telephone transmission for glucose monitoring (one RCT): none of the review's primary outcomes were reported in this trial Postprandial versus preprandial glucose monitoring (one RCT): we observed no clear differences between the postprandial and preprandial glucose monitoring groups for the mother, for:- pre-eclampsia (RR 1.00, 95% CI 0.15 to 6.68; 66 participants; 1 RCT);- caesarean section (RR 0.62, 95% CI 0.29 to 1.29; 66 participants; 1 RCT); and- perineal trauma (RR 0.38, 95% CI 0.11 to 1.29; 66 participants; 1 RCT);or for the child, for:- neonatal hypoglycaemia (RR 0.14, 95% CI 0.02 to 1.10; 66 participants; 1 RCT).There were fewer large-for-gestational-age infants born to mothers in the postprandial compared with the preprandial glucose monitoring group (RR 0.29, 95% CI 0.11 to 0.78; 66 participants; 1 RCT).

AUTHORS' CONCLUSIONS

Evidence from 11 RCTs assessing different methods or settings for glucose monitoring for GDM suggests no clear differences for the primary outcomes or other secondary outcomes assessed in this review.However, current evidence is limited by the small number of RCTs for the comparisons assessed, small sample sizes, and the variable methodological quality of the RCTs. More evidence is needed to assess the effects of different methods and settings for glucose monitoring for GDM on outcomes for mothers and their children, including use and costs of health care. Future RCTs may consider collecting and reporting on the standard outcomes suggested in this review.

Effectiveness of Telemonitoring in Obstetrics: Scoping Review

BACKGROUND

Despite reported positive results of telemonitoring effectiveness in various health care domains, this new technology is rarely used in prenatal care. A few isolated investigations were performed in the past years but with conflicting results.

OBJECTIVE

The aim of this review was to (1) assess whether telemonitoring adds any substantial benefit to this patient population and (2) identify research gaps in this area to suggest goals for future research.

METHODS

This review includes studies exploring the effectiveness of telemonitoring interventions for pregnant women reported in the English language. Due to the paucity of research in this area, all reports including uncontrolled nonrandomized and randomized controlled studies were selected.

RESULTS

Fourteen studies, which performed their data collection from 1988 to 2010, met the inclusion criteria and were published from 1995 to present; four of the 14 published papers were multicenter randomized controlled trials (RCTs), five papers were single-center RCTs, three papers were retrospective studies, one paper was an observational study, and one paper was a qualitative study. Of the 14 papers, nine were available for a risk of bias assessment: three papers were classified as low risk, one as medium risk, and five as high risk. Furthermore, of those 14 papers, 13 focused on telemonitoring for maternal outcomes, and nine of the 14 papers focused on telemonitoring for fetal or neonatal outcomes. The studies reviewed report that telemonitoring can contribute to significant reductions in health care costs, (unscheduled) face-to-face visits, low neonatal birth weight, and admissions to the neonatal intensive care unit (NICU), as well as prolonged gestational age and improved feelings of maternal satisfaction when compared with a control group. When only studies with low risk of bias were taken into account, the added value of telemonitoring became less pronounced: the only added value of telemonitoring is for pregnant women who transmitted their uterine activity by telecommunication. They had significant prolonged pregnancy survivals, and the newborns were less likely to be of low birth weight or to be admitted to the NICU. Following these results, telemonitoring can only be recommended by pregnant women at risk for preterm delivery. It is however important to consider that these studies were published in the mid-90s, which limits their direct applicability given the current technologies and practice.

CONCLUSIONS

This review shows that telemonitoring can be tentatively recommended for pregnant women at risk for preterm delivery. More recent RCTs with a blinded protocol are needed to strengthen the level of evidence around this topic and to have an insight in the added value of the technologies that are available nowadays. In addition, studies investigating patient satisfaction and economic effects in relation to telemonitoring are suggested for future research.

Remote Monitoring of Hypertension Diseases in Pregnancy: A Pilot Study

Background

Although remote monitoring (RM) has proven its added value in various health care domains, little is known about the remote follow-up of pregnant women diagnosed with a gestational hypertensive disorders (GHD).

Objective

The aim of this study was to evaluate the added value of a remote follow-up program for pregnant women diagnosed with GHD.

Methods

A 1-year retrospective study was performed in the outpatient clinic of a 2nd level prenatal center where pregnant women with GHD received RM or conventional care (CC). Primary study endpoints include number of prenatal visits and admissions to the prenatal observation ward. Secondary outcomes include gestational outcome, mode of delivery, neonatal outcome, and admission to neonatal intensive care (NIC). Differences in continuous and categorical variables in maternal demographics and characteristics were tested using Unpaired Student’s two sampled t test or Mann-Whitney U test and the chi-square test. Both a univariate and multivariate analysis were performed for analyzing prenatal follow-up and gestational outcomes. All statistical analyses were done at nominal level, Cronbach alpha=.05.

Results

Of the 166 patients diagnosed with GHD, 53 received RM and 113 CC. After excluding 5 patients in the RM group and 15 in the CC group because of the missing data, 48 patients in RM group and 98 in CC group were taken into final analysis. The RM group had more women diagnosed with gestational hypertension, but less with preeclampsia when compared with CC (81.25% vs 42.86% and 14.58% vs 43.87%). Compared with CC, univariate analysis in RM showed less induction, more spontaneous labors, and less maternal and neonatal hospitalizations (48.98% vs 25.00%; 31.63% vs 60.42%; 74.49% vs 56.25%; and 27.55% vs 10.42%). This was also true in multivariate analysis, except for hospitalizations.

Conclusions

An RM follow-up of women with GHD is a promising tool in the prenatal care. It opens the perspectives to reverse the current evolution of antenatal interventions leading to more interventions and as such to ever increasing medicalized antenatal care.

A web-based clinical decision support system for gestational diabetes: Automatic diet prescription and detection of insulin needs

BACKGROUND

The growth of diabetes prevalence is causing an increasing demand in health care services which affects the clinicians' workload as medical resources do not grow at the same rate as the diabetic population. Decision support tools can help clinicians with the inspection of monitoring data, providing a preliminary analysis to ease their interpretation and reduce the evaluation time per patient. This paper presents Sinedie, a clinical decision support system designed to manage the treatment of patients with gestational diabetes. Sinedie aims to improve access to specialized healthcare assistance, to prevent patients from unnecessary displacements, to reduce the evaluation time per patient and to avoid gestational diabetes adverse outcomes.

METHODS

A web-based telemedicine platform was designed to remotely evaluate patients allowing them to upload their glycaemia data at home directly from their glucose meter, as well as report other monitoring variables like ketonuria and compliance to dietary treatment. Glycaemia values, not tagged by patients, are automatically labelled with their associated meal by a classifier based on the Expectation Maximization clustering algorithm and a C4.5 decision tree learning algorithm. Two finite automata are combined to determine the patient's metabolic condition, which is analysed by a rule-based knowledge base to generate therapy adjustment recommendations. Diet recommendations are automatically prescribed and notified to the patients, whereas recommendations about insulin requirements are notified also to the physicians, who will decide if insulin needs to be prescribed. The system provides clinicians with a view where patients are prioritized according to their metabolic condition. A randomized controlled clinical trial was designed to evaluate the effectiveness and safety of Sinedie interventions versus standard care and its impact in the professionals' workload in terms of the clinician's time required per patient; number of face-to-face visits; frequency and duration of telematics reviews; patients' compliance to self-monitoring; and patients' satisfaction.

RESULTS

Sinedie was clinically evaluated at "Parc Tauli University Hospital" in Spain during 17 months with the participation of 90 patients with gestational diabetes. Sinedie detected all situations that required a therapy adjustment and all the generated recommendations were safe. The time devoted by clinicians to patients' evaluation was reduced by 27.389% and face-to-face visits per patient were reduced by 88.556%. Patients reported to be highly satisfied with the system, considering it useful and trusting in being well controlled. There was no monitoring loss and, in average, patients measured their glycaemia 3.890 times per day and sent their monitoring data every 3.477days.

CONCLUSIONS

Sinedie generates safe advice about therapy adjustments, reduces the clinicians' workload and helps physicians to identify which patients need a more urgent or more exhaustive examination and those who present good metabolic control. Additionally, Sinedie saves patients unnecessary displacements which contributes to medical centres' waiting list reduction.

[Effectiveness and economic impact of a program of integrated care with telemedicine support on insulin-treated type 2 diabetic patients (Study GITDIABE)]

AIM

To evaluate if insulin-treated type 2 diabetic patients with blood glucose self-monitoring (DIA), included in a program of integrated management of diabetes mellitus (DM), achieve a better level of metabolic control with telemedicine support than with conventional support, after 12 months follow-up. The impact on the use and cost of healthcare services, pharmaceutical expenditure, and consumption of test strips for blood glucose, was also assessed.

DESIGN

A prospective parallel cohorts study.

FIELD

Four basic health areas of an integrated healthcare organisation.

PARTICIPANTS

The study included 126 DIA patients aged 15 or more years, treated with rapid or intermediate Insulin and blood glucose self-monitoring, grouped into 42 cases and 84 controls, matched according to age, sex, level of metabolic control, and morbidity profile.

INTERVENTION

Telematics physician-patient communication and download of blood glucose self-monitoring data through the Emminens eConecta® platform; test strips home delivered according to consumption. Hidden controls with usual follow-up.

MAIN MEASUREMENTS

Glycosylated haemoglobin (%HbA1c); perception of quality of life (EuroQol-5 and EsDQOL); cardiovascular risk; use of healthcare resources; consumption of test strips; pharmaceutical and healthcare expenditure.

RESULTS

Reduction of 0.38% in HbA1c in the cases (95% CI:-0.89% to 0.12%). No significant differences with regard to any of the activities registered, or any significant change in the quality of life.

CONCLUSIONS

The results obtained are similar to other equivalent studies. The profile of the patient is elderly and with multiple morbidities, who still have technological limitations. To surpass these barriers, it would be necessary to devote more time to the training and to the resolution of possible technological problems.

Telemedicine Technologies for Diabetes in Pregnancy: A Systematic Review and Meta-Analysis

Background

Diabetes in pregnancy is a global problem. Technological innovations present exciting opportunities for novel approaches to improve clinical care delivery for gestational and other forms of diabetes in pregnancy.

Objective

To perform an updated and comprehensive systematic review and meta-analysis of the literature to determine whether telemedicine solutions offer any advantages compared with the standard care for women with diabetes in pregnancy.

Methods

The review was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Randomized controlled trials (RCT) in women with diabetes in pregnancy that compared telemedicine blood glucose monitoring with the standard care were identified. Searches were performed in SCOPUS and PubMed, limited to English language publications between January 2000 and January 2016. Trials that met the eligibility criteria were scored for risk of bias using the Cochrane Collaborations Risk of Bias Tool. A meta-analysis was performed using Review Manager software version 5.3 (Nordic Cochrane Centre, Cochrane Collaboration).

Results

A total of 7 trials were identified. Meta-analysis demonstrated a modest but statistically significant improvement in HbA1c associated with the use of a telemedicine technology. The mean HbA1c of women using telemedicine was 5.33% (SD 0.70) compared with 5.45% (SD 0.58) in the standard care group, representing a mean difference of −0.12% (95% CI −0.23% to −0.02%). When this comparison was limited to women with gestational diabetes mellitus (GDM) only, the mean HbA1c of women using telemedicine was 5.22% (SD 0.70) compared with 5.37% (SD 0.61) in the standard care group, mean difference −0.14% (95% CI −0.25% to −0.04%). There were no differences in other maternal and neonatal outcomes reported.

Conclusions

There is currently insufficient evidence that telemedicine technology is superior to standard care for women with diabetes in pregnancy; however, there was no evidence of harm. No trials were identified that assessed patient satisfaction or cost of care delivery, and it may be in these areas where these technologies may be found most valuable.

Efficacy of Internet-Based Self-Monitoring Interventions on Maternal and Neonatal Outcomes in Perinatal Diabetic Women: A Systematic Review and Meta-Analysis

Background

Self-monitoring using the Internet offers new opportunities to engage perinatal diabetic women in self-management to reduce maternal and neonatal complications.

Objective

This review aims to synthesize the best available evidence to evaluate the efficacy of Internet-based self-monitoring interventions in improving maternal and neonatal outcomes among perinatal diabetic women.

Methods

The review was conducted using Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsyINFO, Scopus, and ProQuest Dissertations and Theses to search for English-language research studies without any year limitation. A risk of bias table was used to assess methodological quality. Meta-analysis was performed with RevMan software. Cochran Q and I² tests were used to assess heterogeneity. The overall effect was assessed using z tests at P<.05. Of the 438 studies identified through electronic searches and reference lists, nine experimental studies from 10 publications were selected.

Results

Half of the selected studies showed low risk of bias and comprised 852 perinatal diabetic women in six countries. The meta-analysis revealed that Internet-based self-monitoring interventions significantly decreased the level of maternal glycated hemoglobin A1c (z=2.23, P=.03) compared to usual care among perinatal diabetic women at postintervention. Moreover, Internet-based self-monitoring interventions significantly decreased the cesarean delivery rate (z=2.23, P=.03) compared to usual care among the mixed group at postintervention.

Conclusions

This review shows neonatal or other maternal outcomes are similar between Internet-based self-monitoring interventions and usual diabetes care among perinatal diabetic women. The long-term effects of the intervention must be confirmed in future studies using randomized controlled trials and follow-up data.

Telemedicine for Gestational Diabetes Mellitus (TeleGDM): A Mixed-Method Study Protocol of Effects of a Web-Based GDM Support System on Health Service Utilization, Maternal and Fetal Outcomes, Costs, and User Experience

Background

Women with insulin-treated gestational diabetes mellitus (GDM) require close monitoring and support to manage their diabetes. Recent changes to the diagnostic criteria have implications for service provision stemming from increased prevalence, suggesting an increased burden on health services in the future. Telemedicine may augment usual care and mitigate service burdens without compromising clinical outcomes but evidence in GDM is limited.

Objective

The Telemedicine for Gestational Diabetes Mellitus (TeleGDM) trial aims to explore the use of telemedicine in supporting care and management of women with GDM treated with insulin.

Methods

The TeleGDM is a mixed-methods study comprising an exploratory randomized controlled trial (RCT) and a qualitative evaluation using semistructured interviews. It involves women with insulin-treated GDM who are up to 35 weeks gestation. Participating patients (n=100) are recruited face-to-face in outpatient GDM clinics at an outer metropolitan tertiary hospital with a culturally diverse catchment and a regional tertiary hospital. The second group of participants (n=8) comprises Credentialed Diabetes Educator Registered Nurses involved in routine care of the women with GDM at the participating clinics. The RCT involves use of a Web-based patient-controlled personal health record for GDM data sharing between patients and clinicians compared to usual care. Outcomes include service utilization, maternal and fetal outcomes (eg, glycemic control, 2nd and 3rd trimester fetal size, type of delivery, baby birth weight), diabetes self-efficacy, satisfaction, and costs. Semistructured interviews will be used to examine user experiences and acceptability of telemedicine.

Results

The trial recruitment is currently underway. Results are expected by the end of 2016 and will be reported in a follow-up paper.

Conclusions

Innovative use of technology in supporting usual care delivery in women with GDM may facilitate timely access to GDM monitoring data and mitigate care burdens without compromising maternal and fetal outcomes. The intervention may potentially reduce health service utilization.

Trial Registration

Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614000934640; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366740 (Archived by WebCite® at http://www.webcitation.org/6jRiqzjSv).

Multifactorial intervention in diabetes care using real-time monitoring and tailored feedback in type 2 diabetes

AIMS

In 2011, we demonstrated that an individualized health management system employing advanced medical information technology, designated ubiquitous (u)-healthcare, was helpful in achieving glycemic control without hypoglycemia in patients with diabetes. Following this, we generated a new multidisciplinary u-healthcare system by upgrading our clinical decision support system (CDSS) rule engine and integrating a physical activity-monitoring device and dietary feedback into a comprehensive package.

METHODS

In a randomized, controlled clinical trial, patients with type 2 diabetes aged over 60 years were assigned randomly to a self-monitored blood glucose (SMBG) group (N = 50) or u-healthcare group (N = 50) for 6 months. The primary endpoint was the proportion of patients achieving glycated hemoglobin (HbA1c) <7 % without hypoglycemia. Changes in body composition and lipid profiles were also investigated. The u-healthcare group was educated to use a specially designed glucometer and an activity monitor that automatically transferred test results to a hospital-based server. An automated CDSS rule engine generated and sent patient-specific messages about glucose, diet, and physical activity to their mobile phones and a Web site.

RESULTS

After 6 months of follow-up, the HbA1c level was significantly decreased in the u-healthcare group [8.0 ± 0.7 % (64.2 ± 8.8 mmol/mol) to 7.3 ± 0.9 % (56.7 ± 9.9 mmol/mol)] compared with the SMBG group [8.1 ± 0.8 % (64.9 ± 9.1 mmol/mol) to 7.9 ± 1.2 % (63.2 ± 12.3 mmol/mol)] (P < 0.01). The proportion of patients with HbA1c < 7 % without hypoglycemia was greater in the u-healthcare group (26 %) than in the SMBG group (12 %; P < 0.05). Body fat mass decreased and lipid profiles improved in the u-healthcare group but not in the SMBG group.

CONCLUSION

This u-healthcare service provided effective management for older patients with type 2 diabetes (ClinicalTrial.Gov: NCT01137058).

Efficacy of a New Medical Information system, Ubiquitous Healthcare Service with Voice Inception Technique in Elderly Diabetic Patients

We have demonstrated previously that an individualized health management system using advanced medical information technology, named ubiquitous (u)-healthcare, was helpful in achieving better glycemic control than routine care. Recently, we generated a new u-healthcare system using a voice inception technique for elderly diabetic patients to communicate information about their glucose control, physical activity, and diet more easily. In a randomized clinical trial, 70 diabetic patients aged 60–85 years were assigned randomly to a standard care group or u-healthcare group for 6 months. The primary end points were the changes in glycated hemoglobin (HbA_1c) and glucose fluctuation assessed by the mean amplitude glycemic excursion (MAGE). Changes in body weight, lifestyle, and knowledge about diabetes were also investigated. After 6 months, the HbA_1c levels decreased significantly in the u-healthcare group (from 8.6 ± 1.0% to 7.5 ± 0.6%) compared with the standard care group (from 8.7 ± 0.9% to 8.2 ± 1.1%, P < 0.01). The MAGE decreased more in the u-healthcare group than in the standard care group. Systolic blood pressure and body weight decreased and liver functions improved in the u-healthcare group, but not in the standard care group. The u-healthcare system with voice inception technique was effective in achieving glycemic control without hypoglycemia in elderly diabetic patients (Clinicaltrials.gov: NCT01891474).

Telemedicine interventions for gestational diabetes mellitus: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of telemedicine on GDM service and maternal, and foetal outcomes.

METHODS

A systematic review and meta-analysis of randomised controlled trials (RCT) of telemedicine interventions for GDM was conducted. We searched English publications from 01/01/1990 to 31/08/2013, with further new publication tracking to June 2015 on MEDLINE, EMBASE, PUBMED, CINAHL, the Cochrane Central Register of Controlled Trials and the World Health Organization International Clinical Trials Registry electronic databases. Findings are presented as standardised mean difference (SMD) and odds ratios (OR) or narrative and quantitative description of findings where meta-analysis was not possible.

RESULTS

Our search yielded 721 abstracts. Four met the inclusion criteria; two publications arose from the same study, resulting in three studies for review. All studies compared telemedicine to usual care. Telemedicine was associated with significantly fewer unscheduled GDM clinic visits, SMD. Quality of life, glycaemic control (HbA1c, pre and postprandial blood glucose level (BGL)), and caesarean section rate were similar between the telemedicine and usual care groups. None of the studies evaluated costs.

CONCLUSIONS

Telemedicine has the potential to streamline GDM service utilisation without compromising maternal and foetal outcomes. Its advantage may lie in the convenience of reducing face-to-face and unscheduled consultations. Studies are limited and more trials that include cost evaluation are required.

Web-based telemedicine system is useful for monitoring glucose control in pregnant women with diabetes

OBJECTIVE

The aim of this study was to examine the impact of a Web-based telemedicine system for monitoring glucose control in pregnant women with diabetes on healthcare visits, metabolic control, and pregnancy outcomes.

SUBJECTS AND METHODS

A prospective, single-center, interventional study with two parallel groups was performed in Puerto Real University Hospital (Cadiz, Spain). Women were assigned to two different glucose monitoring groups: the control group (CG), which was managed only by follow-ups with the Gestational Diabetes Unit (GDU), and the telemedicine group (TMG), which was monitored by both more spaced GDU visits and a Web-based telemedicine system. The number of healthcare visits, degree of metabolic control, and maternal and neonatal outcomes were evaluated.

RESULTS

One hundred four pregnant women with diabetes (77 with gestational diabetes, 16 with type 1 diabetes, and 11 with type 2 diabetes) were included in the TMG (n=40) or in the CG (n=64). There were no significant differences in mean glycated hemoglobin level during pregnancy or after delivery, despite a significantly lower number of visits to the GDU (3.2±2.3 vs. 5.9±2.3 visits; P<0.001), nurse educator (1.7±1.3 vs. 3.0±1.7 visits; P<0.001), and general practitioner (3.7±2.0 vs. 4.9±2.8 visits; P<0.034) in the TMG. There were no significant differences between groups in maternal or neonatal outcomes.

CONCLUSIONS

A Web-based telemedicine system can be a useful tool facilitating the management of pregnant diabetes patients, as a complement to conventional outpatient clinic visits.

Acceptability and user satisfaction of a smartphone-based, interactive blood glucose management system in women with gestational diabetes mellitus

The increase in gestational diabetes mellitus (GDM) is challenging maternity services. We have developed an interactive, smartphone-based, remote blood glucose (BG) monitoring system, GDm-health. The objective was to determine women's satisfaction with using the GDm-health system and their attitudes toward their diabetes care. In a service development program involving 52 pregnant women (September 2012 to June 2013), BG was monitored using GDm-health from diagnosis until delivery. Following birth, women completed a structured questionnaire assessing (1) general satisfaction, (2) equipment issues, and (3) relationship with the diabetes care team. Responses were scored on a 7-point Likert-type scale. Reliability and validity of the questionnaire were assessed using statistical methods. Of 52 women, 49 completed the questionnaire; 32 had glucose tolerance test confirmed GDM (gestation at recruitment 29 ± 4 weeks (mean ± SD), and 17 women previous GDM recommended for BG monitoring (18 ± 6 weeks). In all, 45 of 49 women agreed their care was satisfactory and the best for them, 47 of 49 and 43 of 49 agreed the equipment was convenient and reliable respectively, 42 of 49 agreed GDm-health fitted into their lifestyle, and 46 of 49 agreed they had a good relationship with their care team. Written comments supported these findings, with very positive reactions from the majority of women. Cronbach's alpha was .89 with factor analysis corresponding with question thematic trends. This pilot demonstrates that GDm-health is acceptable and convenient for a large proportion of women. Effects on clinical and economic outcomes are currently under investigation in a randomized trial (clinicaltrials.gov NCT01916694).

The emerging role of telemedicine in managing glycemic control and psychobehavioral aspects of pregnancy complicated by diabetes

There is a gradual decline in concern of specialists who follow up the care of pregnant women with diabetes. In addition, due to the dwindling economic resources allocated to health services, access to specialized healthcare facilities is becoming more difficult. Telemedicine, or medicine practiced at a distance, is inserted in this context with applications differing for type of interaction (real-time or deferred, i.e., videoconferencing versus store-and-forward data transmission), type of monitoring (automatic versus requesting cooperation from the patient), and type of devices used (web connections and use of mobile phones or smartphones). Telemedicine can cope with the current lack of ability to ensure these patients frequent direct contact with their caregivers. This approach may have an impact not only on the classical maternal-fetal outcome, but also on some underestimated aspects of patients with diabetes in pregnancy, in this case their quality of life, the perception of "diabetes self-efficacy," and the glycemic variability. In this paper, we will analyze the current evidence regarding the use of telemedicine in pregnancies complicated by diabetes, trying to highlight the main limitations of these studies and possible strategies to overcome them in order to improve the effectiveness of future clinical interventions with these medical applications.

Mobile phone-based asthma self-management aid for adolescents (mASMAA): a feasibility study

PURPOSE

Adolescents report high asthma-related morbidity that can be prevented by adequate self-management of the disease. Therefore, there is a need for a developmentally appropriate strategy to promote effective asthma self-management. Mobile phone-based technology is portable, commonly accessible, and well received by adolescents. The purpose of this study was to develop and evaluate the feasibility and acceptability of a comprehensive mobile phone-based asthma self-management aid for adolescents (mASMAA) that was designed to facilitate symptom monitoring, treatment adherence, and adolescent-parent partnership. The system used state-of-the-art natural language-understanding technology that allowed teens to use unconstrained English in their texts, and to self-initiate interactions with the system.

MATERIALS AND METHODS

mASMAA was developed based on an existing natural dialogue system that supports broad coverage of everyday natural conversation in English. Fifteen adolescent-parent dyads participated in a 2-week trial that involved adolescents' daily scheduled and unscheduled interactions with mASMAA and parents responding to daily reports on adolescents' asthma condition automatically generated by mASMAA. Subsequently, four focus groups were conducted to systematically obtain user feedback on the system. Frequency data on the daily usage of mASMAA over the 2-week period were tabulated, and content analysis was conducted for focus group interview data.

RESULTS

Response rates for daily text messages were 81%-97% in adolescents. The average number of self-initiated messages to mASMAA was 19 per adolescent. Symptoms were the most common topic of teen-initiated messages. Participants concurred that use of mASMAA improved awareness of symptoms and triggers, promoted treatment adherence and sense of control, and facilitated adolescent-parent partnerships.

CONCLUSION

This study demonstrates the utility and user acceptability of mASMAA as a potential asthma self-management tool in a selective group of adolescents. Further research is needed to replicate the findings in a large group of adolescents from sociodemographically diverse backgrounds to validate the findings.

Introducing a telemonitoring platform for diabetic patients in primary care: will it increase the socio-digital divide?

AIMS

This study investigates whether diabetes patients visiting a primary care setting are interested in using a telemonitoring platform and if so, whether characteristics of interested users could be distinguished.

METHODS

Three questionnaires were administered by 92 diabetes persons recruited between May and September 2011. Descriptive statistics and logistic regression analysis were performed. Special attention was drawn to include patients with low educational levels.

RESULTS

Patients with middle or high educational levels show quite some interest in the use of a telemonitoring platform, especially for the transmission of glycaemic data or for asking questions. Patients with low educational levels only show a minor interest in using such a platform.

CONCLUSIONS

It is possibly worthwhile to implement a telemonitoring platform in a primary care setting; however this study did not show immediate profit for implementation in a CHC that organises diabetes clinics on regular basis. In primary care settings where it will be implemented, even if there is a social-digital divide today, the use of a telemonitoring platform could possibly reduce inequity in health care as time could become available for those most in need for face-to-face contact with their physician.

The role of telemedicine in the management of the pregnancy complicated by diabetes

The use of technology to deliver health care over a distance has drawn considerable attention and shown dramatic growth over the last decade because of the possibility it has to reduce cost and improve access to modern medical care. Diabetes in pregnancy, which requires tight glycemic control in order to reduce perinatal complications, is a prime telemedicine intervention target. A review of the literature suggests that telemedicine, although not perfect, can potentially play a role in reducing patient visits and could improve quality of life without jeopardizing the outcome.

Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus

BACKGROUND

Health information technology has been proven to be a successful tool for the management of patients with multiple medical conditions. The purpose of this study was to examine the impact of an enhanced telemedicine system on glucose control and pregnancy outcomes in women with gestational diabetes mellitus (GDM).

SUBJECTS AND METHODS

We used an Internet-based telemedicine system to also allow interactive voice response phone communication between patients and providers and to provide automated reminders to transmit data. Women with GDM were randomized to either the telemedicine group (n=40) or the control group (n=40) and asked to monitor their blood glucose levels four times a day. Women in the intervention group transmitted those values via the telemedicine system, whereas women in the control group maintained paper logbooks, which were reviewed at prenatal visits. Primary outcomes were infant birth weight and maternal glucose control. Data collection included blood glucose records, transmission rates for the intervention group, and chart review.

RESULTS

There were no significant differences between the two groups (telemedicine vs. controls) in regard to maternal blood glucose values or infant birth weight. However, adding telephone access and reminders increased transmission rates of data in the intervention group compared with the intervention group in our previous study (35.6±32.3 sets of data vs.17.4±16.9 sets of data; P<0.01).

CONCLUSIONS

Our enhanced telemedicine monitoring system increased system utilization and contact between women with GDM and their healthcare providers but did not impact upon pregnancy outcomes.

A mobile phone short message service improves perceived control of asthma: a randomized controlled trial

OBJECTIVE

Mobile phone short message service (SMS) has been suggested as a potentially powerful tool to improve asthma outcomes, and it can overcome external barriers such as time and distance to participate education programs. We wanted to know whether SMS can help to overcome intrinsic barriers such as perceived control of asthma (PCA).

SUBJECTS AND METHODS

One hundred fifty outpatients with asthma were randomly assigned to the control, traditional, and SMS groups. Patients in all groups received verbal education based on the Global Initiative for Asthma, and patients in the traditional group received additional individualized asthma action plan for self-management with peak expiratory flow monitoring and recording asthma diary, while patients in the SMS group received additional daily SMS reminders on their mobile phone. The six-item PCA Questionnaire (PCAQ-6), Standard Asthma-Specific Quality of Life [AQLQ(S)], spirometry, blood and induced sputum cell count, follow-up compliance rate, medicine compliance rate, and emergency department (ED) visits data were collected at the initial visit and at 12 weeks.

RESULTS

In total, 71 participants completed the trial for analysis. Patients' PCAQ-6 score was significantly increased in the SMS and traditional groups (p<0.001) after 12 weeks, and the change of patients' PCAQ-6 score in the SMS group was higher than in the traditional group (p=0.018). Patients in the SMS group had the highest AQLQ(S) score and follow-up rate after 12 weeks. The change in PCAQ-6 score was associated with change in AQLQ(S) score (r=0.442). Patients in all groups had better forced expiratory volume in 1 s (FEV1%) and fewer ED visits after 12 weeks, but no significant differences were found among the three groups in the changes of FEV1% and blood and induced sputum eosinophil counts and neutrophil counts.

CONCLUSIONS

SMS can improve PCA, and it has a greater advantage in improving follow-up rate and asthma-specific quality of life than traditional programs.

The impact of nurse short message services and telephone follow-ups on diabetic adherence: which one is more effective?

AIM

To compare the effectiveness of two methods of follow-up: short message service and telephone follow-up on type 2 diabetes adherence for three months.

BACKGROUND

Using telemedicine approaches may preserve appropriate blood glucose levels and may improve adherence to diabetes control recommendations in diabetic patients.

DESIGN

A quasi-experimental, two-group, pretest and post-test design was used in this study to evaluate the effectiveness of nurse's follow-up via cellular phones and telephones.

METHODS

The sample consisted of 77 patients with type 2 diabetes that randomly were assigned to two groups: telephone follow-up (n = 39) and short message service (n = 38). Telephone interventions were applied by a researcher for three months; twice a week for the first month and every week for the second and third month. For three successive months, the short message service group that received messages about adherence to therapeutic regimen was examined. The data gathering instrument included data sheets - to record glycosylated haemoglobin - and the questionnaire related to adherence therapeutic regimen. Data gathering was carried out at the beginning of the study and after three and six months. The data were analysed using descriptive and inferential statistic methods with SPSS version 11.5.

RESULTS

Results showed that both interventions had significant mean changes in glycosylated haemoglobin. For the telephone group (p < 0.001), a mean change of -0.93 and for the short message service group (p < 0.001), a mean change of -1.01. There was no significant difference in diet adherence (p = 0.000), physical exercise (p = 0.000) and medication taking (p = 0.000) adherence in either groups.

CONCLUSION

Intervention using short message services of cellular phones and nurse-led-telephone follow-up improved HbA1c levels and adherence to diabetes therapeutic regimen for three months in type 2 diabetic patients.

RELEVANCE TO CLINICAL PRACTICE

Both of follow-up intervention uses in this study can decrease HbA1c levels and escalate adherence to diabetes control recommendations in people with type 2 diabetes for three months.

Improved glycemic control without hypoglycemia in elderly diabetic patients using the ubiquitous healthcare service, a new medical information system

OBJECTIVE

To improve quality and efficiency of care for elderly patients with type 2 diabetes, we introduced elderly-friendly strategies to the clinical decision support system (CDSS)-based ubiquitous healthcare (u-healthcare) service, which is an individualized health management system using advanced medical information technology.

RESEARCH DESIGN AND METHODS

We conducted a 6-month randomized, controlled clinical trial involving 144 patients aged >60 years. Participants were randomly assigned to receive routine care (control, n = 48), to the self-monitored blood glucose (SMBG, n = 47) group, or to the u-healthcare group (n = 49). The primary end point was the proportion of patients achieving A1C <7% without hypoglycemia at 6 months. U-healthcare system refers to an individualized medical service in which medical instructions are given through the patient's mobile phone. Patients receive a glucometer with a public switched telephone network-connected cradle that automatically transfers test results to a hospital-based server. Once the data are transferred to the server, an automated system, the CDSS rule engine, generates and sends patient-specific messages by mobile phone.

RESULTS

After 6 months of follow-up, the mean A1C level was significantly decreased from 7.8 ± 1.3% to 7.4 ± 1.0% (P < 0.001) in the u-healthcare group and from 7.9 ± 1.0% to 7.7 ± 1.0% (P = 0.020) in the SMBG group, compared with 7.9 ± 0.8% to 7.8 ± 1.0% (P = 0.274) in the control group. The proportion of patients with A1C <7% without hypoglycemia was 30.6% in the u-healthcare group, 23.4% in the SMBG group (23.4%), and 14.0% in the control group (P < 0.05).

CONCLUSIONS

The CDSS-based u-healthcare service achieved better glycemic control with less hypoglycemia than SMBG and routine care and may provide effective and safe diabetes management in the elderly diabetic patients.

The outcomes of gestational diabetes mellitus after a telecare approach are not inferior to traditional outpatient clinic visits

Objective. To evaluate the feasibility of a telemedicine system based on Internet and a short message service in pregnancy and its influence on delivery and neonatal outcomes of women with gestational diabetes mellitus (GDM). Methods. 100 women diagnosed of GDM were randomized into two parallel groups, a control group based on traditional face-to-face outpatient clinic visits and an intervention group, which was provided with a Telemedicine system for the transmission of capillary glucose data and short text messages with weekly professional feedback. 97 women completed the study (48/49, resp.). Main Outcomes Measured. The percentage of women achieving HbA1c values <5.8%, normal vaginal delivery and having a large for-gestational-age newborn were evaluated. Results. Despite a significant reduction in outpatient clinic visits in the experimental group, particularly in insulin-treated women (2.4 versus 4.6 hours per insulin-treated woman resp.; P < .001), no significant differences were found between the experimental and traditional groups regarding HbA1c levels (all women had HbA1c <5.8% during pregnancy), normal vaginal delivery (40.8% versus 54.2%, resp.; P > .05) and large-for-gestational-age newborns (6.1% versus 8.3%, resp.; P > .05). Conclusions. The system significantly reduces the need for outpatient clinic visits and achieves similar pregnancy, delivery, and newborn outcomes.