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Munch L, Bennich BB, Overgaard D, Konradsen H, Middelfart H, Kaarsberg N, Knop FK, Vilsbøll T, Røder ME. Management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care is noninferior to management in a specialized outpatient clinic: a randomized, noninferiority trial. Diabet Med 2019; 36:854-861. [PMID: 30614066 DOI: 10.1111/dme.13896] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2019] [Indexed: 11/26/2022]
Abstract
AIM To evaluate whether management of people with Type 2 diabetes shared between a specialized outpatient clinic and primary health care has noninferior HbA1c outcomes compared with mono-sectorial management in a specialized outpatient clinic. METHODS A randomized controlled, noninferiority study. People with moderate hyperglycaemia, hypertension and/or incipient complications were eligible for the study. All participants had annual comprehensive check-ups at the outpatient clinic. Quarterly check-ups were conducted by general practitioners (GPs) for the shared care group and by endocrinologists at the outpatient clinic for the control group. The primary outcome was the mean difference in HbA1c from baseline to 12 months of follow-up. The noninferiority margin for HbA1c was 4.4 mmol/mol. RESULTS A total of 140 people were randomized [age 65.0 ± 0.9 years, HbA1c 52 ± 0.8 mmol/mol (6.9 ± 0.1%), systolic BP 135.6 ± 1.1 mmHg; all mean ± sem]. Peripheral neuropathy was present in 68% of participants and microalbuminuria in 19%; 15% had history of a previous major cardiovascular event. Among study completers (n = 133), HbA1c increased by 2.3 mmol/mol (0.2%) in the shared care group and by 1.0 mmol/mol (0.1%) in the control group, with a between-group difference of 1.3 mmol/mol [90% confidence interval (CI) -1.3, 3.9] (0.1%, 90% CI -0.1, 0.4). Noninferiority was confirmed in both per protocol and intention to treat analyses. CONCLUSION We found that our shared care programme was noninferior to specialized outpatient management in maintaining glycaemic control in this group of people with Type 2 diabetes. Shared care should be considered for the future diabetes management of Type 2 diabetes.
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Affiliation(s)
- L Munch
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, University of Copenhagen, Gentofte
- Institute of Nursing, University College Copenhagen, Copenhagen, Denmark
| | - B B Bennich
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, University of Copenhagen, Gentofte
- Institute of Nursing, University College Copenhagen, Copenhagen, Denmark
| | - D Overgaard
- Institute of Nursing, University College Copenhagen, Copenhagen, Denmark
| | - H Konradsen
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
| | | | | | - F K Knop
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, University of Copenhagen, Gentofte
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - T Vilsbøll
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, University of Copenhagen, Gentofte
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen
| | - M E Røder
- Clinical Metabolic Physiology, Steno Diabetes Center Copenhagen, University of Copenhagen, Gentofte
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
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Costello AG, Nugent BD, Conover N, Moore A, Dempsey K, Tersak JM. Shared Care of Childhood Cancer Survivors: A Telemedicine Feasibility Study. J Adolesc Young Adult Oncol 2017; 6:535-541. [PMID: 28657408 DOI: 10.1089/jayao.2017.0013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE With an increasing number of childhood cancer survivors (CCSs), determining the best model of survivorship transition care is becoming a growing priority. Shared care between pediatric oncology and adult primary care is often necessary, making survivorship a time of transition, but effective standard models are lacking. We sought to provide a more integrated approach to transition using telemedicine. METHODS Recruited primary care provider/CCS dyads were instructed to log-in to a password-protected virtual meeting room using telemedicine equipment at the time or a regularly scheduled office visit. Dyads were joined by a pediatric survivorship clinic team member who conducted the telemedicine portion of the transition visit, which consisted of the review of an individualized treatment summary and care plan. Postquestionnaires were developed to evaluate key points such as fund of knowledge, satisfaction with the visit, and effectiveness of this electronic tool. RESULTS There were 19 transition visits conducted, 13 of which used the telemedicine equipment as planned. Those that did not use the equipment were primarily unable to due to technical difficulties. Postquestionnaires were overall positive, confirming increased knowledge, comfort and abilities, and patient satisfaction in survivorship care. Negative comments were primarily related to equipment difficulties. CONCLUSIONS A gap still remains in helping CCSs transition from oncology to primary care and this pilot study offered insights into how we might better bridge that gap through the use of telemedicine. Further research is needed to refine the transition process for CCSs, including evaluation and testing models for standard of care.
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Affiliation(s)
- Aimee G Costello
- 1 Division of Hematology, Oncology, and Blood and Marrow Transplant, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Bethany D Nugent
- 2 School of Nursing, University of Pittsburgh , Pittsburgh, Pennsylvania.,3 Department of Pediatrics, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Noelle Conover
- 1 Division of Hematology, Oncology, and Blood and Marrow Transplant, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania.,3 Department of Pediatrics, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Amanda Moore
- 1 Division of Hematology, Oncology, and Blood and Marrow Transplant, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Kathleen Dempsey
- 1 Division of Hematology, Oncology, and Blood and Marrow Transplant, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Jean M Tersak
- 1 Division of Hematology, Oncology, and Blood and Marrow Transplant, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania.,3 Department of Pediatrics, University of Pittsburgh , Pittsburgh, Pennsylvania
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[Results of a telemedicine program for primary care patients with type 2 diabetes]. GACETA SANITARIA 2014; 29:55-8. [PMID: 25440441 DOI: 10.1016/j.gaceta.2014.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/05/2014] [Accepted: 08/08/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the impact of a telemedicine program on self-perceived health in patients with type 2 diabetes in primary care, as well as patient acceptance of and satisfaction with this program. METHOD We conducted an 18-month follow-up through telemedicine in 52 diabetic patients. The study design was non-experimental (before and after). In addition to weekly electronic transmission of fasting glucose levels, we regularly provided advice to patients about healthy habits. RESULTS No statistically significant differences were observed when mean blood glucose values were compared during follow-up. However, at the end of participation, the mean score in self-perceived health was significantly higher than at the initial assessment (70.5±12.8 vs. 62.8±15.0, p=0.02). After 18 months of participation in the telemedicine program, 57.7% of patients were satisfied and 38.5% were very satisfied. CONCLUSIONS Although glycemic control did not improve during the follow-up, electronic transmission of information was found to be feasible and satisfactory for patients. The patients reported a higher level of self-perceived health.
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Luley C, Blaik A, Reschke K, Klose S, Westphal S. Weight loss in obese patients with type 2 diabetes: effects of telemonitoring plus a diet combination - the Active Body Control (ABC) Program. Diabetes Res Clin Pract 2011; 91:286-92. [PMID: 21168231 DOI: 10.1016/j.diabres.2010.11.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 10/14/2010] [Accepted: 11/16/2010] [Indexed: 02/07/2023]
Abstract
AIMS We evaluate the efficacy of the "Active Body Control (ABC) Program" for weight reduction in patients with type 2 diabetes. METHODS The ABC program combines telemonitoring of the physical activity with a low-calorie diet also preferring carbohydrates with low glycemic indexes. In this 6-month, randomized, clinical trial 35 patients (aged 57 ± 9 years; BMI=35.3 ± 5.7 kg/m(2)) were treated according to the ABC program and 35 control patients (aged 58 ± 7 years; BMI=34.8 ± 5.9 kg/m(2)) received standard therapy. RESULTS After 6 months the mean weight loss in the intervention group was 11.8 kg ± 8.0 kg. Glucose and HbA1c were lowered by respectively 1.0 mmol/l and 0.8 percentage points (p=0.000, respectively). The proportion of patients with HbA1c>7% fell from 57% to 26%. Antidiabetic drugs were discontinued in 13 patients (39%) and reduced in 14 (42%). The reduction of costs on medication per patient was € 83 in 6 months. In the control group, there were no relevant changes in body weight, laboratory values or drug treatment. CONCLUSIONS The ABC program effectively lowers body weight, Hb1Ac and antidiabetic drug use in patients with type 2 diabetes.
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Affiliation(s)
- Claus Luley
- Institute of Clinical Chemistry, Otto-von-Guericke-University Magdeburg, 39120 Magdeburg, Leipziger Strasse 44, Germany
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Mohamed H. How Effective is Systematic Care of Diabetic Patients? Qatar Med J 2010. [DOI: 10.5339/qmj.2010.2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
With the ultimate goal of improving medical care for diabetes, a study of four Primary Healthcare Centers (PHC) surveyed the composition of PHC population, completeness of patient data, changes in biochemical variables two years before and after establishing specialized diabetic clinics. Patients with diabetes of less than four years duration were excluded from the study. Most (71.7%) of 403 patients with Type II diabetes were aged 40-59 years. Diabetes regulation (HbA1 C), lipid levels (total cholesterol), systolic blood pressure and creatinine improved significantly after inclusion in the specialized diabetic clinic demonstrating that the introduction of systematic care for diabetic patients was effective and lead to an improvement in the recorded process measures and outcome criteria.
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Tran AT, Diep LM, Cooper JG, Claudi T, Straand J, Birkeland K, Ingskog W, Jenum AK. Quality of care for patients with type 2 diabetes in general practice according to patients' ethnic background: a cross-sectional study from Oslo, Norway. BMC Health Serv Res 2010; 10:145. [PMID: 20507647 PMCID: PMC2887836 DOI: 10.1186/1472-6963-10-145] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 05/28/2010] [Indexed: 11/17/2022] Open
Abstract
Background In recent decades immigration to Norway from Asia, Africa and Eastern Europe has increased rapidly. The aim of this study was to assess the quality of care for type 2 diabetes mellitus (T2DM) patients from these ethnic minority groups compared with the care received by Norwegians. Methods In 2006, electronic medical record data were screened at 11 practices (49 GPs; 58857 patients). 1653 T2DM patients cared for in general practice were identified. Ethnicity was defined as self-reported country of birth. Chi-squared tests, one-way ANOVAs, multiple regression, linear mixed effect models and generalized linear mixed models were used. Results Diabetes was diagnosed at a younger age in patients from the ethnic minority groups (South Asians (SA): mean age 44.9 years, Middle East/North Africa (MENA): 47.2 years, East Asians (EA): 52.0 years, others: 49.0 years) compared with Norwegians (59.7 years, p < 0.001). HbA1c, systolic blood pressure (SBP) and s-cholesterol were measured in >85% of patients in all groups with minor differences between minority groups and Norwegians. A greater proportion of the minority groups were prescribed hypoglycaemic medications compared with Norwegians (≥79% vs. 72%, p < 0.001). After adjusting for age, gender, diabetes duration, practice and physician unit, HbA1c (geometric mean) for Norwegians was 6.9% compared to 7.3-7.5% in the minority groups (p < 0.05). The proportion with poor glycaemic control (HbA1c > 9%) was higher in minority groups (SA: 19.6%, MENA: 18.9% vs. Norwegians: 5.6%, p < 0.001. No significant ethnic differences were found in the proportions reaching the combined target: HbA1c ≤ 7.5%, SBP ≤ 140 mmHg, diastolic blood pressure (DBP) ≤ 85 mmHg and total s-cholesterol ≤5.0 mmol/L (Norwegians: 25.5%, SA: 24.9%, MENA: 26.9%, EA: 26.1%, others:17.5%). Conclusions Mean age at the time of diagnosis of T2DM was 8-15 years younger in minority groups compared with Norwegians. Recording of important processes of care measures is high in all groups. Only one in four of most patient groups achieved all four treatment targets and prescribing habits may be sub-optimal. Patients from minority groups have worse glycaemic control than Norwegians which implies that it might be necessary to improve the guidelines to meet the needs of specific ethnic groups.
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Affiliation(s)
- Anh T Tran
- Section of General Practice, Institute of Health and Community, University of Oslo, Oslo, Norway.
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Verhoeven F, Tanja-Dijkstra K, Nijland N, Eysenbach G, van Gemert-Pijnen L. Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review. J Diabetes Sci Technol 2010; 4:666-84. [PMID: 20513335 PMCID: PMC2901046 DOI: 10.1177/193229681000400323] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIM A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education. METHODS Electronic databases were searched for relevant publications about asynchronous and synchronous tele-consultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard meta-analytical methods. RESULTS Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient-caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient-provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (chi(2) = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference -0.10; 95% confidence interval -0.39 to 0.18). CONCLUSION The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients' needs.
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Affiliation(s)
- Fenne Verhoeven
- Faculty of Behavioral Sciences, Department of Psychology and Communication of Health and Risk, University of Twente, Enschede, The Netherlands
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Smith SA, Shah ND, Bryant SC, Christianson TJH, Bjornsen SS, Giesler PD, Krause K, Erwin PJ, Montori VM. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Mayo Clin Proc 2008; 83:747-57. [PMID: 18613991 DOI: 10.4065/83.7.747] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model (CCM). PARTICIPANTS AND METHODS As part of the CCM, 97 primary care physicians at 6 primary care practices in Rochester, MN, referred 639 patients to an on-site diabetes educator between July 1, 2001, and December 31, 2003. On first referral, physicians were centrally randomized to receive a telemedicine intervention (specialty advice and evidence-based messages regarding medication management for cardiovascular risk) or no intervention, keeping outcome assessors and data analysts blinded to group assignment. After each subsequent clinical encounter, endocrinologists reviewed an abstract from the patient's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail. Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes. Outcome measures included diabetes care processes (diabetes test completion), outcomes (metabolic and cardiovascular risk factors, estimated coronary artery disease risk), and patient costs (payer perspective). RESULTS During the intervention, 951 (70%) of the 1361 endocrinology reviews detected performance gaps and resulted in a message; primary care physicians reported using 49% of messages in patient care. With a mean of 21 months' follow-up, the intervention, compared with control, did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease (adjusted mean difference, -1%; 95% confidence interval, -19% to 17%). The intervention group incurred lower costs (P=.02) but not in diabetes-related costs. CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care.
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Affiliation(s)
- Steven A Smith
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA.
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Verhoeven F, van Gemert-Pijnen L, Dijkstra K, Nijland N, Seydel E, Steehouder M. The contribution of teleconsultation and videoconferencing to diabetes care: a systematic literature review. J Med Internet Res 2007; 9:e37. [PMID: 18093904 PMCID: PMC2270420 DOI: 10.2196/jmir.9.5.e37] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 08/27/2007] [Accepted: 10/12/2007] [Indexed: 11/21/2022] Open
Abstract
Background A systematic literature review was carried out to study the benefits of teleconsultation and videoconferencing on the multifaceted process of diabetes care. Previous reviews focused primarily on usability of technology and considered mainly one-sided interventions. Objective The objective was to determine the benefits and deficiencies of teleconsultation and videoconferencing regarding clinical, behavioral, and care coordination outcomes of diabetes care. Methods Electronic databases (Medline, PiCarta, PsycINFO, ScienceDirect, Telemedicine Information Exchange, ISI Web of Science, Google Scholar) were searched for relevant publications. The contribution to diabetes care was examined for clinical outcomes (eg, HbA1c, blood pressure, quality of life), behavioral outcomes (patient-caregiver interaction, self-care), and care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of care access). Randomized controlled trials (RCTs) with HbA1c as an outcome were pooled using standard meta-analytical methods. Results Of 852 publications identified, 39 met the inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1, type 2, or gestational diabetes. Studies that evaluated teleconsultation or videoconferencing not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (eg, HbA1c). There were 22 interventions related to teleconsultation, 13 to videoconferencing, and 4 to combined teleconsultation and videoconferencing. The heterogeneous nature of the identified videoconferencing studies did not permit a formal meta-analysis. Pooled results from the six RCTs of the identified teleconsultation studies did not show a significant reduction in HbA1c (0.03%, 95% CI = - 0.31% to 0.24%) compared to usual care. There was no significant statistical heterogeneity among the pooled RCTs (χ27= 7.99, P = .33). It can be concluded that in the period under review (1994-2006) 39 studies had a scope broader than clinical outcomes and involved interventions allowing patient-caregiver interaction. Most of the reported improvements concerned satisfaction with technology (26/39 studies), improved metabolic control (21/39), and cost reductions (16/39). Improvements in quality of life (6/39 studies), transparency (5/39), and better access to care (4/39) were hardly observed. Teleconsultation programs involving daily monitoring of clinical data, education, and personal feedback proved to be most successful in realizing behavioral change and reducing costs. The benefits of videoconferencing were mainly related to its effects on socioeconomic factors such as education and cost reduction, but also on monitoring disease. Additionally, videoconferencing seemed to maintain quality of care while producing cost savings. Conclusions The selected studies suggest that both teleconsultation and videoconferencing are practical, cost-effective, and reliable ways of delivering a worthwhile health care service to diabetics. However, the diversity in study design and reported findings makes a strong conclusion premature. To further the contribution of technology to diabetes care, interactive systems should be developed that integrate monitoring and personalized feedback functions.
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Affiliation(s)
- Fenne Verhoeven
- Department of Technical and Professional Communication, University of Twente, Faculty of Behavioral Sciences, PO Box 217, 7500 AE Enschede, The Netherlands.
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van Bruggen JAR, Gorter KJ, Stolk RP, Rutten GEHM. Shared and delegated systems are not quick remedies for improving diabetes care: a systematic review. Prim Care Diabetes 2007; 1:59-68. [PMID: 18632021 DOI: 10.1016/j.pcd.2007.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 04/10/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Type 2 diabetes is an important, chronic condition notorious for its costly and disabling complications. Nowadays, enhanced cooperation is expected to improve the quality of diabetes care and reduce risks for chronically ill patients. It is, however, questionable whether this assumption is evidence based. METHODS Using a structured literature search, we selected systematic reviews, randomised controlled trials (RCTs) and other effect evaluations regarding the sharing and allocation of diabetes care. RESULTS We selected 22 studies to include in this review. The process of care improved in all studies investigating this quality aspect. HbA1c improved in seven reviews and in five other studies. All included reviews and four RCTs were unable to demonstrate a positive effect on blood pressure. Total cholesterol improved in two reviews and five other studies. CONCLUSIONS The sharing and allocation of diabetes care leads to significant reduction in HbA1c and improves the process of care. However, this improvement has not as yet led to better cardiovascular risk management. For a number of reasons, a truly accurate estimation of the results of shared and allocated diabetes care within the Dutch diabetes care system is not possible.
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Affiliation(s)
- J A R van Bruggen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.
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Liao YT, Tang ST, Chen TC, Tsao CH, Lee TC, Huang YF, Young ST. A communication platform for diabetes surveillance. CONFERENCE PROCEEDINGS : ... ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL CONFERENCE 2007; 2004:3313-5. [PMID: 17270990 DOI: 10.1109/iembs.2004.1403931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Diabetes mellitus is a common and precarious chronic disease, which affects cellular metabolism and energy production. The condition is divided into types I and II; the most common form is type II diabetes, which is an adult-onset disease. Blood glucose testing is crucial to diabetes control, and it is effective in reducing the risk of complications and improving life quality. Unfortunately, both elderly patients and their caregivers find it difficult to monitor glucose levels long term. This study developed a communication platform for diabetes surveillance. The developed system prompts diabetics to measure their blood glucose regularly at home, and provides remote care persons with complete information about the patient's measurement. This aids in the improvement in diabetes control, thereby increasing the social activities and life quality of diabetics.
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Affiliation(s)
- Yi-Ting Liao
- Department of Biomedical Engineering, Yuanpei University of Science and Technology, Hsin-Chu, Taiwan
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Chen YY, Wu YT, Wu CC, Wu SM, Jaw FS. Development of wireless blood glucose meter and diabetes self-management system. CONFERENCE PROCEEDINGS : ... ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL CONFERENCE 2007; 2004:3384-6. [PMID: 17271009 DOI: 10.1109/iembs.2004.1403950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Diabetes is a metabolic disorder that is characterized by high blood glucose and either insufficient or ineffective insulin. Blood glucose measurement is crucial to diabetes control, and it is effective in reducing the risk of complications and improving life quality. Unfortunately, both elderly patients and their caregivers find it difficult to monitor glucose levels long term. This study attempts to develop an intelligent maintenance system for home glucose measurement, wireless data transformation, and information analysis. The developed system prompts diabetics to measure their blood glucose regularly at home, and provides remote caregivers with complete patient information for diagnosis and tracking. This aids in the improvement in diabetes control, thereby increasing the social activities and life quality of diabetics.
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Affiliation(s)
- Y-Y Chen
- Institute of Electrical Engineering, National Taiwan University, Taipei, Taiwan, ROC
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Steuten L, Vrijhoef B, Severens H, van Merode F, Spreeuwenberg C. Are we measuring what matters in health technology assessment of disease management? Systematic literature review. Int J Technol Assess Health Care 2006; 22:47-57. [PMID: 16673680 DOI: 10.1017/s0266462306050835] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES An overview was produced of indicators currently used to assess disease management programs and, based on these findings, provide a framework regarding sets of indicators that should be used when taking the aims and types of disease management programs into account. METHODS A systematic literature review was performed. RESULTS Thirty-six studies met the inclusion criteria. It appeared that a link between aims of disease management and evaluated structure, process, as well as outcome indicators does not exist in a substantial part of published studies on disease management of diabetes and asthma/chronic obstructive pulmonary disease, especially when efficiency of care is concerned. Furthermore, structure indicators are largely missing from the evaluations, although these are of major importance for the interpretation of outcomes for purposes of decision-making. Efficiency of disease management is mainly evaluated by means of process indicators; the use of outcome indicators is less common. Within a framework, structure, process, and outcome indicators for effectiveness and efficiency are recommended for each type of disease management program. CONCLUSIONS The link between aims of disease management and evaluated structure, process, and outcome indicators does not exist in a substantial part of published studies on disease management. The added value of this study mainly lies in the development of a framework to guide the choice of indicators for health technology assessment of disease management.
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Affiliation(s)
- Lotte Steuten
- Department of Health Care Studies, Maastricht University, The Netherlands.
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Al Khaja KAJ, P Sequeira R, Damanhori AHH. Evaluation of drug therapy and risk factors in diabetic hypertensives: a study of the quality of care provided in diabetic clinics in Bahrain. J Eval Clin Pract 2005; 11:121-31. [PMID: 15813710 DOI: 10.1111/j.1365-2753.2005.00511.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate control of blood pressure (BP) and diabetes and the associated risk factors in diabetic hypertensives treated by diabetic clinic primary care physicians. METHODS A retrospective analysis of the medical records of diabetic hypertensives from six primary care diabetic clinics in Bahrain. RESULTS The recommended BP target <130/<85 mmHg and of glycosylated haemoglobin (HbA1C) <7% were achieved in 7.5% and 14.5%, respectively. Most of the patients with uncontrolled BP and HbA(1C) were at high cardiovascular risk. More patients were on antihypertensive monotherapy than on combination therapy (60.6% vs. 36.7%; P<0.0001). The recommended two- and three-antihypertensive drug combinations were less often prescribed. In high-risk patients glycaemic control achieved was poor: antidiabetic combination therapy vs. monotherapy did not significantly differ. Inappropriate prescribing practices, such as the use of immediate-release nifedipine monotherapy, use of sulphonylurea instead of metformin in obese patients, and a trend towards prescribing of glyburide rather than a gliclazide in the elderly, were observed. Lipid-lowering (13.5%) and antiplatelet (12.8%) drugs were infrequently prescribed. CONCLUSIONS Hypertension and diabetes in patients treated at the primary care diabetic clinics were inadequately controlled. In several instances, mono- and combination antihypertensives prescribed were irrational. Lipid-lowering and platelet aggregation inhibition strategies have received little attention. Intensive antihypertensive and antidiabetic complementary combination therapy should be encouraged. Continuous professional education of diabetic clinic physicians and expert-supervised diabetic clinics are desirable.
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Affiliation(s)
- Khalid A Jassim Al Khaja
- Associate Professor, Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Bahrain.
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15
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Romero Requena J, Calvo Romero J, Arévalo Lorido J, Pérez Alonso J, Ortiz Descane C, Gutiérrez Montaño C, Carretero Gómez J, Martínez F, Moreno F, Rodríguez A. Control de los factores de riesgo cardiovascular mediante telemedicina. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s0212-8241(05)71546-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Romero Requena J, Calvo Romero J, Arévalo Lorido J, Pérez Alonso J, Ortiz Descane C, Gutiérrez Montaño C, Carretero Gómez J, Martínez F, Moreno F, Rodríguez A. Control de los factores de riesgo cardiovascular mediante telemedicina. HIPERTENSION Y RIESGO VASCULAR 2005. [DOI: 10.1016/s1889-1837(05)71537-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Goudswaard AN, Stolk RP, Zuithoff P, Rutten GEHM. Patient characteristics do not predict poor glycaemic control in type 2 diabetes patients treated in primary care. Eur J Epidemiol 2004; 19:541-5. [PMID: 15330126 DOI: 10.1023/b:ejep.0000032351.42772.e7] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Many diabetic patients in general practice do not achieve good glycaemic control. The aim of this study was to assess which characteristics of type 2 diabetes patients treated in primary care predict poor glycaemic control (HbA1c > or = 7%). Data were collected from the medical records. 1641 patients were included who had mean HbA1c 7.1(SD 1.7)% , and 42% had HbA1c > or = 7%. On univariate analysis younger age; longer duration of diabetes; higher levels of blood glucose at diagnosis; most recent fasting blood glucose (FBG), total cholesterol, and triglyceride; higher body mass index (BMI); treatment with oral hypoglycaemic agents (OHA); treatment with insulin; more GP-visits for diabetes in the last year; and lower educational level were associated with poor control. Both in multiple linear regression and in multiple logistic regression higher levels of FBG (odds ratio (OR): = 1.6, 95% confidence interval (CI): 1.49, 1.70), treatment with OHA (OR: 2.1, 95% CI: 1.41, 3.04), treatment with insulin (OR: 7.2, 95% CI: 4.18, 12.52), lower educational level (OR: 1.26, 95% CI: 1.01, 1.56) were independently associated with poor levels of HbA1c. When FBG levels were excluded from the model, higher blood glucose at diagnosis, higher values for triglyceride and total cholesterol, and younger age predicted poor glycaemic control, but these variables explained only 15% of the variation in HbA1c. In conclusion prediction of poor glycaemic control from patient characteristics in diabetic patients in general practice is hardly possible. FBG appeared to be a strong predictor of HbA1c, which underlines the usefulness of this simple test in daily diabetes care. The worse metabolic control in those treated with either OHA or insulin suggests that current treatment regimes might be not sufficiently applied to reach the targets of care. Providers of diabetes care should be attentive to patients with lower educational level.
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Affiliation(s)
- Alex N Goudswaard
- Julius Center for Health Science and Primary Care, University Medical Center, Utrecht, The Netherlands.
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18
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Steuten LMG, Vrijhoef HJM, van Merode GG, Severens JL, Spreeuwenberg C. The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management. J Clin Epidemiol 2004; 57:881-8. [PMID: 15504631 DOI: 10.1016/j.jclinepi.2004.01.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Systematic reviews aim to summarize the evidence in a particular topic area, giving attention to the identified methodologic quality of published research. Because research in a specific area may be susceptible to specific biases, it is assumed that the methodologic quality of Health Technology Assessment (HTA) of disease management cannot properly be measured with the existing methodologic quality assessment instruments. The purpose of this study was to describe to what extent existing instruments are useful in assessing the methodologic quality of HTA of disease management. STUDY DESIGN AND SETTING An inventory was made of the problems that arise when assessing the methodologic quality of six HTAs of disease management with three different instruments. Based on these findings, a new instrument is proposed and validated. RESULTS Problems mainly concern the items related to the study design, criteria for selection and restriction of patients, baseline and outcome measures, blinding of patients and providers, and the description of (co)-interventions. CONCLUSION With its more specific characteristics, the HTA-DM addresses the problems mentioned. The HTA-DM is a reliable instrument for methodologic quality assessment of HTA of disease management in comparison with the other three instruments.
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Affiliation(s)
- L M G Steuten
- Department of Health Care Studies, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.
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Goulis DG, Giaglis GD, Boren SA, Lekka I, Bontis E, Balas EA, Maglaveras N, Avramides A. Effectiveness of home-centered care through telemedicine applications for overweight and obese patients: a randomized controlled trial. Int J Obes (Lond) 2004; 28:1391-8. [PMID: 15356664 DOI: 10.1038/sj.ijo.0802773] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine if home-centered monitoring through telemedicine has an impact on clinical characteristics, metabolic profile and quality of life in overweight and obese patients. DESIGN Randomized controlled trial, 6-month duration. SETTING Tertiary care academic hospital. SUBJECTS A total of 122 patients were eligible to participate as they met the inclusion criteria of increased body mass index (BMI>25 kg/m(2)), age>18 and <70 y and ability to operate electronic microdevices. INTERVENTIONS All patients in the control group (n=77) received standard hospital care. Patients in the intervention group (n=45), additionally, measured three times a week, for 6 months, their blood pressure and body weight and transmitted them to an automated call center. These values were not shared with the patients' physician or dietician. MAIN OUTCOME MEASURES Clinical (body weight, BMI, blood pressure), laboratory (fasting plasma glucose, triglycerides, HDL-cholesterol, total cholesterol) and quality of life parameters (SF-36((R)), Visual Analog Scale of European Quality-5 Dimensions, Obesity Assessment Survey). Data were analyzed in an intention-to-treat-way (last observation carried forward). RESULTS Drop-out rate was similar in the control and intervention groups: 12 vs 11 percent, respectively, P=NS. There were no significant differences at baseline between intervention and control groups in all main outcome parameters. There were significant decreases for patients in the intervention group in body weight (from 101.6+/-22.4 to 89.2+/-14.7 kg, P=0.002, P=0.05 vs controls at 6 months), total cholesterol (from 247.6+/-42.0 to 220.7+/-42.6 mg/dl, P=0.002, P=0.05 vs controls at 6 months) and triglycerides (from 148.4+/-35.0 to 122.3+/-31.4 mg/dl, P=0.001, P=0.01 vs controls at 6 months). Intervention group patients made a total of 1997 phone contacts. The number of phone contacts was correlated positively with Social Functioning (SF), Vitality (VT) and Mental Health (MH) scores of SF-36((R)) at baseline (r=0.48, r=0.41, r=0.41, respectively, P=0.05) but not with weight loss. CONCLUSIONS Home-centered, intense treatment through the use of telemedicine can be effective in improving short-term obesity outcomes.
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Affiliation(s)
- D G Goulis
- Department of Endocrinology, Hippocration General Hospital, 49 Constantinoupoleos street, 54642, Thessaloniki, Greece.
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20
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Control de la presión arterial domiciliaria a través de la telemedicina. HIPERTENSION Y RIESGO VASCULAR 2004. [DOI: 10.1016/s1889-1837(04)71458-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Goudswaard AN, Lam K, Stolk RP, Rutten GEHM. Quality of recording of data from patients with type 2 diabetes is not a valid indicator of quality of care. A cross-sectional study. Fam Pract 2003; 20:173-7. [PMID: 12651792 DOI: 10.1093/fampra/20.2.173] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The quality of recording of clinical data in diabetes care in general practices is very variable. It has been suggested that better recording leads to improved glycaemic control. OBJECTIVES The purpose of this study was to assess the completeness of recording by GPs of data from type 2 diabetes patients; to compare recorded and missing data; and to investigate the association between completeness and glycaemic control. METHODS A cross-sectional survey was carried out in 52 general practices. Medical records were scrutinized for the presence of 11 variables. Examining patients through an active approach completed incomplete records. We compared recorded and unrecorded items. Completeness of recording was determined at both patient and practice levels. RESULTS Fifty-two general practices with 1641 type 2 diabetes patients cared for by the GP participated. The frequency of absence of any particular item ranged from 20 to 70%. Weight, systolic blood pressure and HbA(1c) were slightly lower in patients with those items missing on their files, and more such patients were non-smokers (P < 0.05). The percentage of patients with unrecorded variables that exceeded target values ranged from 39 to 75. Neither at practice level nor at patient level was any association between the completeness of the data recording and HbA(1c) found. CONCLUSION Records often were incomplete, which hampers a systematic approach to care of diabetic patients. However, the lack of association between completeness of data recording and control of glycaemia indicates that improved recording is not a valid indicator of good quality of care.
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Affiliation(s)
- Alex N Goudswaard
- Julius Center for Health Science and Primary Care, University Medical Center, Utrecht, The Netherlands.
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Izquierdo RE, Knudson PE, Meyer S, Kearns J, Ploutz-Snyder R, Weinstock RS. A comparison of diabetes education administered through telemedicine versus in person. Diabetes Care 2003; 26:1002-7. [PMID: 12663564 DOI: 10.2337/diacare.26.4.1002] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether diabetes education can be provided as effectively through telemedicine technology as through in-person encounters with diabetes nurse and nutrition educators. RESEARCH DESIGN AND METHODS A total of 56 adults with diabetes were randomized to receive diabetes education in person (control group) or via telemedicine (telemedicine group) and were followed prospectively. The education consisted of three consultative visits with diabetes nurse and nutrition educators. The in-person and telemedicine groups were compared using measures of glycemic control (HbA(1c)) and questionnaires to assess patient satisfaction and psychosocial functioning as related to diabetes. Outcome measures were obtained at baseline, immediately after the completion of diabetes education, and 3 months after the third educational visit. RESULTS Patient satisfaction was high in the telemedicine group. Problem Areas in Diabetes scale scores improved significantly with diabetes education (adjusted P < 0.05, before vs. immediately after education and 3 months after education), and the attainment of behavior-change goals did not differ between groups. With diabetes education, HbA(1c) improved from 8.6 +/- 1.8% at baseline to 7.8 +/- 1.5% immediately after education and 7.8 +/- 1.8% 3 months after the third educational visit (unadjusted P < 0.001, P = 0.089 adjusted for BMI and age), with similar changes observed in the telemedicine and in-person groups. CONCLUSIONS Diabetes education via telemedicine and in person was equally effective in improving glycemic control, and both methods were well accepted by patients. Reduced diabetes-related stress was observed in both groups. These data suggest that telemedicine can be successfully used to provide diabetes education to patients.
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Redekop WK, Koopmanschap MA, Rutten GEHM, Wolffenbuttel BHR, Stolk RP, Niessen LW. Resource consumption and costs in Dutch patients with type 2 diabetes mellitus. Results from 29 general practices. Diabet Med 2002; 19:246-53. [PMID: 11918627 DOI: 10.1046/j.1464-5491.2002.00654.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS The aims of this study were to estimate the costs incurred by Dutch patients with Type 2 diabetes, examine which patient and/or treatment characteristics are associated with costs, and estimate the medical and non-medical costs of patients with Type 2 diabetes in The Netherlands. METHODS Twenty-nine Dutch general practitioners provided information on all Type 2 diabetes patients in their practice (n = 1371), information on demography, clinical characteristics, treatment type, the presence of complications and the type and amount of medical consumption during the previous 6 months. Medical costs were analysed using multivariate linear regression. Estimates of costs seen in The Netherlands were based on these results plus information from other sources regarding costs of end-stage renal disease, appliances, travel and productivity loss. RESULTS Although only 9% of patients were hospitalized within the previous 6 months, hospitalization costs represented one-third of the medical costs, drug costs 40% and ambulatory costs 26%. Patients using insulin, patients with macrovascular complications only or in combination with microvascular complications incurred higher medical costs than other patients. Age and hyperlipidaemia were also positively related to medical costs. When these results were combined with other data sources, we estimated that patients with Type 2 diabetes are responsible for pound365 500 000 (1 271 000 000 guilders) or 3.4% of the relevant parts of health care costs in 1998. The non-medical costs (travel costs, productivity costs) are limited: 52 500 000 (183 000 000 guilders). CONCLUSIONS Independent determinants of the medical costs of Type 2 diabetes in The Netherlands include age, complications, insulin use and hyperlipidaemia.
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Affiliation(s)
- W K Redekop
- Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, The Netherlands.
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