The empirical evidence for the telemedicine intervention in diabetes management

Trends and frontiers of research on telemedicine from 1971 to 2022: A scientometric and visualisation analysis

BACKGROUND

With the continuous development of the Internet and information technology, telemedicine has gradually become a popular medical model, which has always attracted much attention. Especially in recent years, research has shown a rapid increase in the use of telemedicine due to the impact of COVID-19. We have conducted a scientific metrological analysis of telemedicine to identify its hot spots and frontiers and promote cooperation and development.

METHODS

We retrieved 19,171 articles related to telemedicine published from 1971 to 2022 in the Web of Science (WOS) database. Then, we conducted co-author network analysis (author, institution, country), co-citation analysis (author, journal, literature) and burst analysis (thematic trends and frontier topics).

RESULTS

The number of publications has been on the rise since 1993 and began to rise rapidly in 1997. Influenced by the COVID-19 pandemic, the number of articles doubled in 2020 compared to the prior year. The United States produced the greatest number of articles (43.4%). Although studies in Greece are fewer and more recent, the country is demonstrating tremendous development potential in this field and is an active contributor to telemedicine research. The main research topics identified include the application, system and services of telemedicine; the application of telemedicine in providing medical services to rural and remote areas where medical resources are scarce; the quality control of medical images in telemedicine; the application of telemedicine in chronic disease care; and the comparison of in-person medical care and telemedicine. Emerging topics include the application and impact of telemedicine during the COVID-19 pandemic.

CONCLUSION

The main telemedicine research fields over the past 52 years are identified, the meanings of analyses results are discussed, and emerging trends are highlighted.

A Comprehensive Review of the Vascular Consequences of Diabetes in the Lower Extremities: Current Approaches to Management and Evaluation of Clinical Outcomes

Diabetes mellitus is a global health concern characterized by chronic hyperglycemia, and its vascular consequences in the lower extremities pose significant challenges for individuals living with the condition. This comprehensive review delves into the multifaceted landscape of diabetes-related vascular complications in the lower limbs, with a primary focus on current strategies for management and the evaluation of clinical outcomes. This review achieves several critical objectives by synthesizing existing knowledge and research findings. It elucidates the intricate pathophysiological mechanisms underpinning these complications, shedding light on the cellular and molecular processes involved. Additionally, it outlines clinical assessment and diagnostic strategies used to identify and stratify risk, ranging from cutting-edge imaging techniques to clinical examinations. The review comprehensively examines current management strategies, encompassing lifestyle modifications, pharmacological interventions, surgical procedures, and wound care practices. Moreover, it assesses and analyzes clinical outcomes, including limb salvage rates, amputation rates, and overall quality of life for individuals undergoing treatment. In addressing the challenges faced in managing these complications, this review aims to contribute to improved patient care. It proposes future research directions to enhance the management and outcomes of diabetes-related vascular consequences in the lower extremities.

Exploring the Challenges and Opportunities of Adopting and Using Telemedicine for Diabetes Care and Management: Qualitative Semistructured Interview Study Among Health Care Providers and Patients With Diabetes

BACKGROUND

Around the world, over half of the global population experiences noncommunicable diseases, resulting in premature death. Health care providers (HCPs) can deliver medical treatment from a distance by using digital advancements such as telemedicine. However, there is a limited understanding of the difficulties and opportunities of implementing telemedicine solutions in different socioeconomic and cultural environments, including Kuwait.

OBJECTIVE

The purpose of this study is to (1) examine the obstacles and benefits of telemedicine in the context of diabetes treatment and management, as perceived by both HCPs and patients with diabetes; (2) investigate the nonfunctional requirements for telemedicine applications used in diabetes care and management; and (3) provide suggestions to enhance the integration and adoption of telemedicine in Kuwait's health care system for diabetes care and management.

METHODS

The research used a qualitative and exploratory design, with semistructured interviews as the main data collection method. Participants were recruited on the internet through social media platforms due to the COVID-19 pandemic. The results were analyzed using thematic analysis and the Framework Method. The "diffusion of innovation" model was used as a perspective to interpret the findings.

RESULTS

A total of 20 participants were included in this study-10 HCPs and 10 patients with diabetes-all of whom supported telemedicine. The HCPs reported that many diabetes cases could be managed through telemedicine, with only a few requiring in-person visits. Patients with diabetes noted the convenience and time-saving aspect of telemedicine. Both groups recommended the creation of a secure and user-friendly telemedicine system similar to popular social media platforms. Additionally, participants emphasized the importance of telemedicine during the pandemic as a way to prioritize patient safety.

CONCLUSIONS

The results of this study provide valuable insights into the needs and preferences of both HCPs and patients with diabetes in a resource-rich country like Kuwait to embrace telemedicine. The COVID-19 pandemic has changed the way medical care is provided and has pushed both groups to consider digital solutions for ongoing diabetes management and treatment.

Organisational models supported by technology for the management of diabetic disease and its complications in a diabetic clinic setting: study protocol for a randomised controlled trial targeting type 2 diabetes individuals with non-ideal glycaemic values (Telemechron study)

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a non-communicable disease representing one of the most serious public health challenges of the twenty-first century. Its incidence continues to rise in both developed and developing countries, causing the death of 1.5 million people every year. The use of technology (e.g. smartphone application-App) in the health field has progressively increased as it has been proved to be effective in helping individuals manage their long-term diseases. Therefore, it has the potential to reduce the use of health service and its related costs. The objective of this study is to evaluate the impact of using a digital platform called "TreC Diabete" embedded into a novel organisational asset targeting poorly controlled T2DM individuals in the Autonomous Province of Trento (PAT), Italy.

METHODS

This trial was designed as a multi-centre, open-label, randomised, superiority study with two parallel groups and a 1:1 allocation ratio. Individuals regularly attending outpatient diabetes clinics, providing informed consent, are randomised to be prescribed TreC Diabete platform as part of their personalised care plan. Healthcare staff members will remotely assess the data shared by the participants through the App by using a dedicated online medical dashboard. The primary end-point is the evaluation of the Hb1Ac level at 12-month post-randomisation. Data will be analysed on an intention-to-treat (ITT) basis.

DISCUSSION

This trial is the first conducted in the PAT area for the use of an App specifically designed for individuals with poorly controlled T2DM. If the effects of introducing this specific App within a new organisational asset are positive, the digital platform will represent a possible way for people diagnosed with T2DM to better manage their health in the future. Results will be disseminated through conferences and peer-reviewed journals once the study is completed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05629221. Registered on November 29, 2022, prior start of inclusion.

Telemedicine and the standard of care: a call for a new approach?

Telemedicine, understood as the provision of health care by a health professional to a patient who is physically not in the same location as the health professional, has many actual and potential benefits. It also has some disadvantages though, including a higher risk of misdiagnosis or another unfavorable outcome of certain remotely-provided services. In principle, the regime of legal liability for medical malpractice is the same for telemedicine as for traditional physical care. The general outline of the standard of care, which includes respect for medical science, the patient's individuality and objective possibilities, is abstract and flexible enough to be used for remote care without the need for redefinition. The quality of health care should be evaluated on the basis of the whole scale of risks and benefits it brings to a particular patient, including accessibility and comfort. In general, it should be permissible to provide a medical service remotely on the condition that its overall quality is at least as good as its comparable physical alternative. In other words, certain decrease in quality of some aspects of remote care can be compensated by other advantages. In terms of public health, support for telemedicine may bring a great improvement in the access to health care, and thus help significantly the individual members of the population. From the individual perspective, respect for personal autonomy implies that a patient should have every right to opt for a remote service, provided that there exists a true choice between meaningful options which is made on the basis of full information. If telemedicine is to fulfill its potential without sacrificing the protection of patients and their rights, reasonable guidelines for remote services need to be defined for particular medical fields, and for specific procedures within them. Among other issues, these guidelines must address the question of when it is necessary to refer the patient to physical care.

Implementation of Healthy Living Community Movement Supported Automatic Telehealth Machine for Public Health at Poltekkes Kemenkes Palu

Background: Indonesia faces serious challenges from a double burden disease caused by changes in people's lifestyles. Since 2010, Non-communicable diseases (NCDs) include hypertension, stroke, heart disease, and diabetes have taken up a growing share of health-care resources. The coronavirus disease epidemic of 2019 (COVID 19) caused by the new coronavirus SARS-CoV2 is the most serious global health issue. Patients with COVID-19 had more hypertension, diabetes, and other cardiovascular diseases, which all require routine health monitoring. Health monitoring will greatly develop along with the development of technology and information 4.0. This includes nursing services in the future that will take advantage of developments in information technology. Objective: This study aims to implement the healthy living community movement programs using Automatic Telehealth Machine (ATMs) as internet of things for health checking and education at Politeknik Kesehatan Kemenkes Palu. Methods: This research method is a quasi-experimental intervention research. The population of study were 167 employees of Poltekkes Kemenkes Palu. Sampling process used simple random sampling method with sample size consist of 96 people. The study revealed that majority of respondents were gender and aged, physical activity was generally good, and fruits intake was also good.  The measuring instrument used are ATMs device and a questionnaire that has been tested for validity and reliability. Analysis of research data using univariate test (frequency distribution) and bivariate test (t test or alternatives) Results: The variables that were significantly related to systole were gender and age category (p = 0.03). The variables which were significantly related to diastole were gender (p = 0.02) and age category (p = 0.01). The results revealed that gender, age, physical activity and fruits intake was not associated with total cholesterol levels. Conclusions: Automatic Telehealth Machine (ATMs) can be implemented for health checking and education in healthy living community movement programs

The Impact of Telemonitoring on Improving Glycemic and Metabolic Control in Previously Lost-to-Follow-Up Patients with Type 2 Diabetes Mellitus: A Single-Center Interventional Study in the United Arab Emirates

BACKGROUND

Telemonitoring (TM), mobile-phone technology for health, and bluetooth-enabled self-monitoring devices represent innovative solutions for proper glycemic control, compliance and monitoring, and access to providers.

OBJECTIVE

In this study, we evaluated the impact of TM devices on glycemic control and the compliance of 38 previously lost-to-follow-up (LTFU) patients with type 2 diabetes mellitus (T2DM).

METHODS

This was an interventional single-center study that randomly recruited LTFU patients from the Dubai Diabetes Center (DDC), UAE. After contact and recruitment by phone, patients had an initial visit at which they were provided with home-based TM devices. A follow-up visit was conducted three months later.

RESULTS

The mean HbA1c decreased significantly from 10.3 ± 1.9% at baseline to 7.4 ± 1.5% at the end of follow-up, with a mean difference (MD) of -2.9% [95% CI: -3.6 to -2.2]. The percentage of patients with HbA1c <7% was 50% after three months. Home-based blood sugar monitor devices showed a significant reduction in fasting blood glucose (FBG) after three months (MD = -40.1 mg/dL, 95% CI: -70.8 to -9.3). A significant reduction was observed in terms of body weight after three months (MD = -1.3 kg, 95% CI: -2.5 to -0.08). The mean number of days the participants used a device was the highest for portable pill dispensers (86.5 ± 22.8 days), followed by a OneTouch® blood glucose monitor (72.9 ± 23.5 days).

CONCLUSIONS

TM led to significant improvements in overall diabetes outcomes, including glycemic control and body weight, indicating its effectiveness in a challenging population of T2DM patients who had previously been lost to follow-up.

The Sociological Perspective of Users' Invisible Work: A Qualitative Research Framework for Studying Digital Health Innovations Integration

BACKGROUND

When new technology is integrated into a care pathway, it faces resistance due to the changes it introduces into the existing context. To understand the success or failure of digital health innovations, it is necessary to pay attention to the adjustments that users must perform to make them work, by reshaping the context and sometimes by altering the ways in which they perform activities. This adaptation work, most of which remains invisible, constitutes an important factor in the success of innovations and the ways in which they transform care practices.

OBJECTIVE

This work aims to present a sociological framework for studying new health technology uses through a qualitative analysis of the different types of tasks and activities that users, both health professionals and patients, must perform to integrate these technologies and make them work in their daily routine.

METHODS

This paper uses a three-part method to structure a theoretical model to study users' invisible work. The first part of the method includes a thematic literature review, previously published by one of the coauthors, of major sociological studies conducted on digital health innovations integration into existing care organizations and practices. The second part extends this review to introduce definitions and applications of the users' invisible work concept. The third part consists of producing a theoretical framework to study the concept according to the different contexts and practices of the users.

RESULTS

The paper proposes four dimensions (organizational, interactional, practical, and experiential), each composed of a set of criteria that allow a comparative analysis of different users' work according to different health technologies.

CONCLUSIONS

This framework can be applied both as an analytical tool in a research protocol and as an agenda to identify less visible adoption criteria for digital health technologies.

Factors Influencing the Acceptance of Pediatric Telemedicine Services in China: A Cross-Sectional Study

Background: Pediatrician workforce shortages have aroused great attention from health authorities in China. Telemedicine services have been known to enhance the management of children's health, yet the rate of adoption and usage in Chinese hospitals still at a quite low level, and the factors influencing the acceptance of telemedicine services remains unclear. Objective: The purpose of this empirical study was to evaluate the reliability and validity of a technology acceptance measurement instrument applied in healthcare, to investigate the perception of telemedicine services on the provider-side and demand-side, and to determine the factors that may drive individuals to adopt telemedicine services. Methods: A cross-sectional survey study based at Shanghai Children's Hospital, Shanghai Jiao Tong University, was conducted in March 2020. A total of 456 valid responses were obtained by convenience sampling. The internal consistency of items was assessed by Cronbach's alpha (α), composite reliability (CR) and average variance extracted (AVE) to evaluate both the reliability and validity of the questionnaire. Structural equation modeling analysis was used to test and verify the interrelationships among relevant variables. Results: Price value is the strongest predictor (β = 0.30, p = 0.02), facilitating conditions (β = 0.28, p = 0.01) and hedonic motivation (β = 0.13, p = 0.04) also have significantly positive direct effects on telemedicine acceptance. The results showed the perception of child patients' families were significantly more acceptable to telemedicine services than pediatricians (t = -2.99, p < 0.01). Participants with no prior experience and lower education may be more willing to adopt telemedicine. Conclusion: Telemedicine will likely continue to have an integral role in pediatric health care delivery, and the findings can assist policy makers and hospital administrators in determining the more valued characteristics of telemedicine services from a behavioral perspective. Future attention will be paid to the pricing, training and service quality of telemedicine in China.

Telemedicine for Disparity Patients With Diabetes: The Feasibility of Utilizing Telehealth in the Management of Uncontrolled Type 2 Diabetes in Black and Hispanic Disparity Patients; A Pilot Study

BACKGROUND

Non-Hispanic Black (NHB) and Hispanic/Latinx (H/L) patients bear a disproportionate burden of type 2 diabetes and associated complications. Regular visits to a primary care doctor or diabetes specialist are warranted to maintain glycemic control, but for a myriad of reasons disparity populations may have difficulties receiving diabetes care. We seek to determine the feasibility of telehealth added to care as usual and secondarily to improve health outcomes (hemoglobin A1c [HbA1c]) in NHB and H/L with uncontrolled type 2 diabetes managed with two or three noninsulin agents.

METHODS

Twenty-nine patients were randomized to monthly phone calls or weekly to biweekly telehealth visits. Feasibility outcomes were summarized descriptively for the telehealth arm. Differences scores for A1C level and surveys were computed between baseline and three months and compared across arms using a two-sample t test or Mann-Whitney U test.

RESULTS

Patients in the telehealth arm completed a median of eight visits (IQR: 5, 8), and 53% of those in the telephone arm completed 100% of their calls. Change in HbA1c was greater for those in the telephone arm (-2.57 vs -2.07%, P = .70) but the mean baseline HbA1c was higher in the telephone group (11.1% vs 10.3%). Although the change in HbA1c was not statistically different across arms, it was clinically significant.

CONCLUSIONS

Augmenting care as usual with telehealth provided by telephone or tablet can be of benefit in improving glycemic control in NHB and H/L with type 2 diabetes. Larger studies need to explore this further.

Telemedicine assists in the management of proatherogenic dyslipidemia and postprandial glucose variability in patients with type 2 diabetes mellitus: a cross-sectional study

OBJECTIVE

Coronary heart disease (CHD) is a prevalent complication of type 2 diabetes mellitus (T2DM). The proatherogenic low-density lipoprotein (LDL) cholesterol is an established risk factor of cardiovascular disease, and evidence also suggests that postprandial plasma glucose (PPG) levels closely delineate CHD mortality in diabetes. The investigators hypothesized that the addition of telehealth consultation to standard antidiabetic therapy may help to reduce postprandial glucose variability and plasma LDL cholesterol levels in patients with T2DM.

METHODS

This cross-sectional study enrolled patients with newly diagnosed T2DM who received standard antidiabetic therapy with or without additional telehealth consultation. Participants received blood tests for plasma lipid profile and glucose levels at the diagnosis of diabetes and after 1 month of therapeutic intervention. Laboratory results were compared between treatment groups to determine the efficacy of complementary telehealth consultation.

RESULTS

In this study, 375 participants were enrolled. The standard treatment group had considerably greater levels of plasma LDL cholesterol than recipients of telehealth consultation (110 mg/dL vs 93.1 mg/dL, P < 0.001). Moreover, patients receiving standard treatment had greater levels of fasting plasma glucose (104 mg/dL vs 98.5 mg/dL, P = 0.027), 2-h PPG (169 mg/dL vs 111 mg/dL, P < 0.001), and postprandial glucose variability (65.4 mg/dL vs 12.8 mg/dL, P < 0.001) than participants under telehealth consultation.

CONCLUSIONS

Telemedicine in addition to standard antidiabetic therapy helped to reduce plasma LDL cholesterol levels and postprandial glucose variability in patients with newly diagnosed T2DM. Therefore, telehealth consultation is a suitable complement to pharmacologic therapy for diabetic patients to assist in the management of proatherogenic dyslipidemia and postprandial glucose variability.

Challenge of diabetes mellitus and researchers’ contributions to its control

The aim of this review study was to assess the past significant events on diabetes mellitus, transformations that took place over the years in the medical records of treatment, countries involved, and the researchers who brought about the revolutions. This study used the content analysis to report the existence of diabetes mellitus and the treatments provided by researchers to control it. The focus was mainly on three main types of diabetes (type 1, type 2, and type 3 diabetes). Ethical consideration has also helped to boost diabetic studies globally. The research has a history path from pharmaceuticals of organic-based drugs to metal-based drugs with their nanoparticles in addition to the impacts of nanomedicine, biosensors, and telemedicine. Ongoing and future studies in alternative medicine such as vanadium nanoparticles (metal nanoparticles) are promising.

Impact and Challenges of Integrating Artificial Intelligence and Telemedicine into Clinical Ophthalmology

ABSTRACT

Aging populations and worsening burden of chronic, treatable disease is increasingly creating a global shortfall in ophthalmic care provision. Remote and automated systems carry the promise to expand the scale and potential of health care interventions, and reduce strain on health care services through safe, personalized, efficient, and cost-effective services. However, significant challenges remain. Forward planning in service design is paramount to safeguard patient safety, trust in digital services, data privacy, medico-legal implications, and digital exclusion. We explore the impact and challenges facing patients and clinicians in integrating AI and telemedicine into ophthalmic care-and how these may influence its direction.

A Video-Based Technique for Heart Rate and Eye Blinks Rate Estimation: A Potential Solution for Telemonitoring and Remote Healthcare

Current telemedicine and remote healthcare applications foresee different interactions between the doctor and the patient relying on the use of commercial and medical wearable sensors and internet-based video conferencing platforms. Nevertheless, the existing applications necessarily require a contact between the patient and sensors for an objective evaluation of the patient’s state. The proposed study explored an innovative video-based solution for monitoring neurophysiological parameters of potential patients and assessing their mental state. In particular, we investigated the possibility to estimate the heart rate (HR) and eye blinks rate (EBR) of participants while performing laboratory tasks by mean of facial—video analysis. The objectives of the study were focused on: (i) assessing the effectiveness of the proposed technique in estimating the HR and EBR by comparing them with laboratory sensor-based measures and (ii) assessing the capability of the video—based technique in discriminating between the participant’s resting state (Nominal condition) and their active state (Non-nominal condition). The results demonstrated that the HR and EBR estimated through the facial—video technique or the laboratory equipment did not statistically differ (p > 0.1), and that these neurophysiological parameters allowed to discriminate between the Nominal and Non-nominal states (p < 0.02).

Telehealth Adoption Among Endocrinologists During The Covid-19 Pandemic

OBJECTIVE

Telehealth is a timely solution for delivering health care during the coronavirus disease 2019 (COVID-19) pandemic. The practice of endocrinology is suited to provide virtual care to patients with a variety of endocrine disorders. In this survey, we aimed to gauge the adoption of telehealth practices during the COVID-19 pandemic among endocrinologists in the United States (U.S.).

METHODS

This was a cross-sectional, online survey-based study. Members of the Facebook group "Endocrinologists" were invited to participate in the survey. Characteristics of respondents and their rates of adoption of telehealth were described and analyzed for statistically significant associations using the Pearson chi-square test.

RESULTS

A total of 181 physicians responded to the survey. The majority of respondents were females (75%), younger than or equal to 40 years of age (51%), employed (72%) either by a private group/hospital or by an academic setting, worked in an urban area (88.4%), and were adult endocrinologists (93%). With the COVID-19 outbreak, more than two-fifths (44.2%) of participants switched to completely virtual visits, and an additional 44.2% switched to a majority of virtual visits, with some in-person visits in the outpatient setting. Additionally, there was a significantly higher adoption rate of telehealth among endocrinologists younger than or equal to 40 years of age (P = .02) and among those who practiced in northeastern, midwestern, and the western geographic regions of the U.S. (P = .04).

CONCLUSION

The majority of the responding endocrinologists from the U.S. appeared to have swiftly adapted by using telehealth within a few weeks of COVID-19 being declared a national emergency.

ABBREVIATIONS

CMS = Centers for Medicare and Medicaid Services; COVID-19 = coronavirus disease 2019; PPE = personal protective equipment; U.S. = United States.

Diabetes clinic reinvented: will technology change the future of diabetes care?

Diabetes is a chronic disease that affects nearly 463 million people globally and involves multiple co-morbid conditions that require effective treatment and continuous management. These include lifestyle and behavioral modifications, compliance to diabetes medications and close patient monitoring, all of which can be efficiently conducted via telehealth. Integrating digital technology of telehealth and mobile health into diabetes care may improve diabetes management and increase its efficiency. In this review, we examine recent advances in healthcare technology of diabetes. Moreover, we present an example of a comprehensive virtual diabetes clinic, the "Joslin HOME," as an innovative digital ecosystem for future application in diabetes care. This model utilizes digital health technology and comprises frequent short visits with easy two-way scheduling, focused documentation and simple billing methods. In this new model, a multidisciplinary team is connected with their patients using telehealth and mobile health to overcome the barriers of distance and location. It may possibly extend quality diabetes care to remote, underserved or rural areas.

Telemedicine intervention-reduced blood pressure in a chronic disease population: A meta-analysis

INTRODUCTION

Elevated blood pressure (BP) is a leading risk factor for many chronic diseases. Many investigations conducted using telemedicine (TM)-based interventions have the potential to control BP. The purpose of this study was to assess the efficacy of TM-based interventions in reducing BP.

METHODS

Studies were selected from PubMed, PMC, Web of Science, Embase, Google Scholar, Cochrane Library, the Chinese National Knowledge Infrastructure (CNKI) and the Chinese Biomedical Literature Database (CBM) according to the inclusion and exclusion criteria. The mean and standard deviation changes in systolic BP (SBP) and diastolic BP (DBP) were analysed using standard mean difference (SMD) and 95% confidence intervals (CI) with a random-effects model or fixed-effects model to assess the efficiency of controlling BP. Subgroup analysis, influence analysis and publication bias analysis were also conducted.

RESULTS

Sixteen randomised clinical trials were included in this meta-analysis. A TM-based lifestyle intervention significantly reduced daytime SBP (SMD = -0.18, 95% CI -0.27 to -0.10; p < 0.001) and DBP (SMD = -0.18, 95% CI -0.27 to -0.09; p < 0.001). The results of subgroup analysis indicated that this reduction in BP was reliable when BP interventions lasted for 6 months or longer in populations with cardiovascular disease and hypertension. Moreover, the detection data should be delivered by a device system to ensure accuracy.

DISCUSSION

A TM-based intervention could reduce daytime SBP and DBP in populations with hypertension and cardiovascular disease. This review provides intuitive evidence of a reduction in BP using TM-based interventions.

Internet-Based Medication Management Services Improve Glycated Hemoglobin Levels in Patients with Type 2 Diabetes

Background: Internet-based medication management services might help improve blood glucose control in patients with diabetes. Introduction: This study is a randomized controlled trial designed to explore the effect of telemedicine patient management on blood glucose control in Chinese patients with type 2 diabetes mellitus (T2DM). Materials and Methods: This study included patients with T2DM from the Department of Integrated Traditional Chinese and Western medicine of Tianjin Medical University Chu Hsien-I Memorial Hospital who consulted between January 2019 and December 2019; 120 patients were randomized to the control group (standard care) and the telemedicine group (in-hospital medication evaluation, drug reorganization, medical monitoring, and advice via telemedicine). The primary endpoint was targeted glycated hemoglobin (HbA_1c) <7.0% from baseline to 6 months. The secondary endpoints were the changes in fasting blood glucose (FBG), changes in daily medication cost, changes in the number of drug types taken daily, and hypoglycemic events. Results: Rates of HbA_1c <7% improved in the telemedicine groups (p = 0.019), whereas no changes were seen in the control group (p > 0.999). FBG levels decreased (telemedicine: p = 0.001; control: p = 0.007), but the differences were not statistically significant between groups. Daily medication costs decreased in the telemedicine group (p = 0.001), but the costs were similar between groups. The number of medication types decreased in the telemedicine group (p = 0.001). Hypoglycemic events decreased in the telemedicine group (p = 0.032), but not in the control group (p = 0.854). Discussion: Telemedicine could improve the rate of HbA_1c <7%. Conclusions: An internet-based medication management model was an effective telemedicine method for patients with T2DM.

Fundamental principles of an effective diabetic retinopathy screening program

BACKGROUND

Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults worldwide. Early detection and treatment are necessary to forestall vision loss from DR.

METHODS

A working group of ophthalmic and diabetes experts was established to develop a consensus on the key principles of an effective DR screening program. Recommendations are based on analysis of a structured literature review.

RESULTS

The recommendations for implementing an effective DR screening program are: (1) Examination methods must be suitable for the screening region, and DR classification/grading systems must be systematic and uniformly applied. Two-field retinal imaging is sufficient for DR screening and is preferable to seven-field imaging, and referable DR should be well defined and reliably identifiable by qualified screening staff; (2) in many countries/regions, screening can and should take place outside the ophthalmology clinic; (3) screening staff should be accredited and show evidence of ongoing training; (4) screening programs should adhere to relevant national quality assurance standards; (5) studies that use uniform definitions of risk to determine optimum risk-based screening intervals are required; (6) technology infrastructure should be in place to ensure that high-quality images can be stored securely to protect patient information; (7) although screening for diabetic macular edema (DME) in conjunction with DR evaluations may have merit, there is currently insufficient evidence to support implementation of programs solely for DME screening.

CONCLUSION

Use of these recommendations may yield more effective DR screening programs that reduce the risk of vision loss worldwide.

Managing Diabetes in Hard to Reach Populations: A Review of Telehealth Interventions

PURPOSE OF REVIEW

Diabetes mellitus is a leading chronic disease worldwide. Access to diabetes care varies widely and is influenced by multiple factors including social, geographic, and economic conditions. The use of technology to expand healthcare may bridge these barriers and improve access. Our aim was to review the evidence for the role of telehealth to expand access to quality diabetes care.

RECENT FINDINGS

There is evidence that application of technology-based programs to deliver healthcare are both feasible and effective. These programs are accepted by both patients and providers, can reduce healthcare costs, and may redress inequalities in healthcare access. Technology-based care models can improve disease management, enhance efficiency and clinical decision-making, promote patient self-management skills, and promote patient centered care. Future research should focus on implementation of technology-based healthcare delivery programs on a larger scale.

Nonmydriatic Retinal Diabetic Screening in the Primary Care Setting: Assessing Degree of Retinopathy and Incidence of Nondiabetic Ocular Diagnoses

Purpose: To study the rates and severity of diabetic retinopathy (DR), rates of nondiabetic ocular disease, and rates of referral to eye care providers in the context of nonmydriatic retinal screening performed in primary care and endocrinology clinics. Materials and Methods: This study is a retrospective chart review of patients who had nonmydriatic retinal imaging in the primary care setting. Presence and severity of DR as well as detection of nondiabetic ocular diseases were analyzed. Referral rates for different types of pathology were determined. Results: A total of 324 patients were imaged and 294 (90.7%) had gradable images. Mild DR was found in at least one eye of 71 (24.1%) patients, moderate in 20 (6.8%), severe in 3 (1.0%), and proliferative DR in 2 (0.6%). Macular edema was found in 13 (4.4%) patients. Nondiabetic ocular diseases were suspected in 106 (36.1%) patients. The most prevalent findings included glaucoma suspect (10.9%), age-related macular degeneration suspect (8.8%), and hypertensive retinopathy (5.4%). Seventy (23.8%) patients were referred to an eye care provider for DR, 66 (22.4%) were referred for nondiabetic eye disease, and 21 (7.1%) were referred for both. Conclusion: One-third of patients were found to have some degree of DR. Suspected nondiabetic disease or other pathologies were found in one-third of the study population. Referral for examination by an eye care provider was recommended for approximately half of the patients.

Remote Monitoring of Diabetes: A Cloud-Connected Digital System for Individuals With Diabetes and Their Health Care Providers

Benefits of telemedicine have been proven in the field of diabetes. Among a number of technical solutions, Diabeo® has been studied in both type 1 and type 2 diabetes with intensive insulin therapy. This digital therapeutic system contains a self-monitoring glucose logbook and offers automated insulin dose recommendations thanks to a fully customizable algorithm. In addition, the cloud-based dedicated software also has features to facilitate remote monitoring, including a platform for diabetes nurses who perform coaching and treatment adjustment. A detailed description of this telemedicine system is provided, as well as results of completed clinical studies. In particular, TeleDiab 1's positive results on HbA1c in type 1 diabetes are detailed. We conclude with a discussion of the role of this telemedicine system within the landscape of mobile apps for diabetes.

Telepsychiatry in intellectual disability psychiatry: literature review

Aims and MethodThe aims of this review were to explore the effectiveness and patient and provider acceptability of telepsychiatry consultations in intellectual disability, contrasting this with direct face-to-face consultations and proposing avenues for further research and innovation. Computerised searches of databases including AMED and EMBASE were conducted. RESULTS: Four USA studies of intellectual disability telepsychiatry services have been reported. The majority (75%) focused on children with intellectual disability. Sample sizes ranged from 38 to 900 participants, with follow-up from 1 to 6 years. Outcome measures varied considerably and included cost savings to patients and healthcare providers, patient and carer satisfaction and new diagnoses.Clinical implicationsThe innovations summarised suggest a requirement to further explore telepsychiatry models. Despite some promising outcomes, there is a relative dearth in the existing literature. Further studies in other healthcare systems are required before concluding that telepsychiatry in intellectual disability is the best approach for providing psychiatric services to this population.Declaration of interestNone.

Telemedicine in Neurological Disorders: Opportunities and Challenges

Introduction: Telemedicine represents an emerging model for the assessment and management of various neurological disorders. Methods: We sought to discuss opportunities and challenges for the integration of telemedicine in the management of common and uncommon neurological disorders by reviewing and appraising studies that evaluate telemedicine as a means to facilitate the access to care, deliver highly specialized visits, diagnostic consultations, rehabilitation, and remote monitoring of neurological disorders. Results: Opportunities for telemedicine in neurological disorders include the replacement of or complement to in-office evaluations, decreased time between follow-up visits, reduction in disparities in access to healthcare, and promotion of education and training through interactions between primary care physicians and tertiary referral centers. Critical challenges include the integration of the systems for data monitoring with an easy-to-use, secure, and cost-effective platform that is both widely adopted by patients and healthcare systems and embraced by international scientific societies. Conclusions: Multiple applications may spawn from a model based on digitalized healthcare services. Integrated efforts from multiple stakeholders will be required to develop an interoperable software platform capable of providing not only a holistic approach to care but also one that reduces disparities in the access to care.

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.

Inequalities in the Use of eHealth Between Socioeconomic Groups Among Patients With Type 1 and Type 2 Diabetes: Cross-Sectional Study

BACKGROUND

The prevalence of diabetes and the use of electronic health (eHealth) are increasing. People with diabetes need frequent monitoring and follow-up of health parameters, and eHealth services can be highly valuable. However, little is known about the use of eHealth in different socioeconomic groups among people with diabetes.

OBJECTIVE

The aim of this study was to investigate the use of 4 different eHealth platforms (apps, search engines, video services, and social media sites) and the association with socioeconomic status (SES) among people diagnosed with type 1 and type 2 diabetes mellitus (T1D and T2D, respectively).

METHODS

We used email survey data from 1250 members of the Norwegian Diabetes Association (aged 18-89 years), collected in 2018. Eligible for analyses were the 1063 respondents having T1D (n=523) and T2D (n=545). 5 respondents reported having both diabetes types and thus entered into both groups. Using descriptive statistics, we estimated the use of the different types of eHealth. By logistic regressions, we studied the associations between the use of these types of eHealth and SES (education and household income), adjusted for gender, age, and self-rated health.

RESULTS

We found that 87.0% (447/514) of people with T1D and 77.7% (421/542) of people with T2D had used 1 or more forms of eHealth sometimes or often during the previous year. The proportion of people using search engines was the largest in both diagnostic groups, followed by apps, social media, and video services. We found a strong association between a high level of education and the use of search engines, whereas there were no educational differences for the use of apps, social media, or video services. In both diagnostic groups, high income was associated with the use of apps. In people with T1D, lower income was associated with the use of video services.

CONCLUSIONS

This paper indicates a digital divide among people with diabetes in Norway, with consequences that may contribute to sustaining and shaping inequalities in health outcomes. The strong relationship between higher education and the use of search engines, along with the finding that the use of apps, social media, and video services was not associated with education, indicates that adequate communication strategies for audiences with varying education levels should be a focus in future efforts to reduce inequalities in health outcomes.

Key Factors Affecting the Adoption of Telemedicine by Ambulatory Clinics: Insights from a Statewide Survey

Background: Despite demonstrated benefits and improved demand for telemedicine, adoption rates by U.S. ambulatory clinics remain low. There is a critical need to identify why telemedicine adoption rates remain low among ambulatory providers. Introduction: The aim of this study is to evaluate key predictors of telemedicine adoption by ambulatory clinics and assess salient differences between adopters and nonadopters. Three categories of predictors namely clinic characteristics, health information technology (HIT)-related factor, and organizational variables were examined. Materials and Methods: The study used data from a survey of 1,285 clinics in Minnesota (MN) that was collected by Minnesota Department of Health (MDH) in 2016. Exploratory statistical analyses as well as binary logistic regression analyses were carried out using SPSS software. Results: Fifty-five percent of ambulatory clinics in Minnesota had adopted telemedicine. Real-time consultations were adopted in over 26% clinics, remote patient monitoring in 15% clinics, and store-and-forward consultations in about 7% clinics. Originating site teleconsulting was prevalent in 27% clinics, whereas primary care and specialist services through teleconsulting were adopted by 23% clinics. Logistic regression revealed health system-owned clinics, rural clinics, and primary care ones to exhibit higher levels of telemedicine adoption. Clinics with paperless electronic health record (EHR) systems, health information exchange (HIE)-enablement, and better technological infrastructure had higher odds of telemedicine adoption. Furthermore, clinics that had redesigned their workflows also exhibited higher odds of telemedicine adoption. Clinics that faced high costs of telemedicine equipment, lack of demand had lower adoption levels. Clinics that faced high costs for hosting and staffing were more likely to adopt store-and-forward telemedicine and real-time patient monitoring rather than other high-end telemedicine services. Clinics that reported inadequate coverage or reimbursement were more likely to adopt a restrictive set of telemedicine services. Discussion: Telemedicine is not yet very prevalent among Minnesota ambulatory clinics. Over 45% of the clinics do not offer any telemedicine services. The barriers to adoption vary widely and pertain to HIT as well as organizational factors. Conclusion: With increased demand for telemedicine services, policy changes aimed at improving the reimbursement models, digital infrastructure for telemedicine, HIE capabilities, organizational efforts to move toward paperless EHR systems, and redesigning workflows can facilitate in accelerating telemedicine adoption.

Patient-Driven Diabetes Care of the Future in the Technology Era

The growing burden of diabetes is fueled by obesity-inducing lifestyle behaviors including high-calorie diets and lack of physical activity. Challenges in access to diabetes specialists and educators, low adherence to medications, and inadequate motivational support for proper disease self-management contribute to poor glycemic control in patients with diabetes. Simultaneously, high patient volumes and low reimbursement rates limit physicians' time spent on lifestyle behavior counseling. These barriers to efficient diabetes care lead to high rates of diabetes-related complications, driving healthcare costs up and reducing the quality of patients' lives. Considering recent advancements in healthcare delivery technologies such as smartphone applications, telemedicine, m-health, device connectivity, machine-learning technology, and artificial intelligence, there is significant opportunity to achieve better efficiency in diabetes care and increase patient involvement in diabetes self-management, which ultimately may put an end to soaring diabetes-related healthcare expenditures. This review explores the patient-driven diabetes care of the future in the technology era.

Assessment of Psychological Dimensions in Telemedicine Care for Gestational Diabetes Mellitus: A Systematic Review of Qualitative and Quantitative Studies

Background and Objective: Gestational Diabetes Mellitus (GDM) is a complex and wide spread problem and is considered one of the most frequent chronic metabolic conditions during pregnancy. According to a recent consensus conference held in Italy, new technologies can play a role in the so-called process of fertilization of the individual's ecosystem engagement, representing support for systemic collaboration among the main actors. The current systematic review aimed at providing an update of the literature about telemedicine for GDM, considering the role of psychological dimensions such as empowerment/self-efficacy, engagement and satisfaction.

Methods: The review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. The data sources were PubMed, ScienceDirect, Cochrane, and Scopus databases.

Results: Thirteen articles were identified as eligible and relevant for the final qualitative synthesis, but none was specific for the topic of engagement. The quality or research bias of the studies presents methodological limits. Most studies had clinical outcomes as a primary object. Concerning empowerment and self-efficacy, there were only preliminary findings reporting any improvements derived from using telemedicine approaches. Conversely, there were more consistent and positive results concerning the satisfaction of patients and clinicians.

Conclusions: These results are not sufficient to state a conclusive evaluation of positive effects of telemedicine use for GDM care. A more in-depth investigation of engagement and empowerment dimensions is necessary, as some benefits for the management of chronic conditions were already detected. Further investigations will also be necessary concerning the acceptability and feasibility of telemedicine systems by clinicians.

Using a Nurse-Led Telehealth Intervention to Improve Fasting Glucose Levels in Patients With Uncontrolled Type 2 Diabetes Undergoing a Surgical Intervention

BACKGROUND

Uncontrolled diabetes during the perioperative period can result in a variety of adverse postoperative outcomes.

OBJECTIVE

Evaluate a nurse-led telehealth preoperative intervention to improve glycemic control.

METHODS

Provide telehealth diabetes education prior to surgery and evaluate time spent and pre-/post-glucose levels. Between-group differences were used to assess glycemic control.

RESULTS

There was no significant difference in scores for those who received the telephone intervention (M = 167.71, SD = 59.9) and those who did not receive the intervention (M = 171.44, SD = 54.9; t (44) = 0.220, p = .82, two-tailed). The magnitude of the differences in the means was very small (Cohen's d = 0.03). There was a reduction in pre- and post-glucose levels for both groups.

CONCLUSIONS

Although the findings were not statistically significant, there may be some clinical significance.

IMPLICATIONS FOR NURSING

The clinical significance has implications for nursing due to participants choosing to delay surgery and potentially preventing adverse outcomes.

Diabetes Treatment in the Elderly: Incorporating Geriatrics, Technology, and Functional Medicine

PURPOSE OF REVIEW

The current approach to diabetes in the elderly incorporates components from the comprehensive geriatric approach. The most updated guidelines from the American Diabetes Association reflect influence from the consensus made in 2012 with the American Geriatrics Society. Notably, the framework included the evaluation for geriatric syndromes (falls and urinary incontinence), functional and cognitive abilities. The goal for this review is to provide an updated summary of treatment strategies for community-dwelling older adults. We identified the need to expand our approach by addressing innovative approaches and scientific concepts from telemedicine, functional medicine, and geriatrics.

RECENT FINDINGS

Findings on cardiovascular protection with sodium-glucose co-transporter 2 inhibitors (SGLT-2i) and some glucagon-like peptide 1 receptor agonists (GLP-1RA) support their use for older patients with diabetes. However, careful consideration for agent selection must incorporate the presence of geriatric issues, such as geriatric syndromes, or functional and cognitive decline, as they could increase the risk and impact adverse reactions. Telemedicine interventions can improve communication and connection between older patients and their providers, and improve glycemic control. Functional medicine concepts can offer additional adjuvant strategies to support the therapeutic interventions and management of diabetes in the elderly. A systematic review confirmed the efficacy and safety of metformin as first-line therapy of type 2 diabetes in the older adult, but multiple reports highlighted the risk for vitamin B12 deficiency. Randomized controlled trials showed the efficacy and safety of antihyperglycemic agents in the elderly, including some with longer duration and lesser risk for hypoglycemia. Randomized clinical trials showed cardiovascular protection with SGLT-2i (empagliflozin, canagliflozin) and GLP-1RA (liraglutide, semaglutide). The most current guidelines recommend addressing for geriatric syndromes, physical and cognitive function in the elderly, in order to individualize targets and therapeutic strategies. Clinicians managing diabetes in the elderly can play a major role for the early detection and evaluation of geriatric issues in their patients. Telemedicine interventions improve glycemic control, and certain functional medicine strategies could be adjuvant interventions to reduce inflammation and stress, but more studies focused on the elderly population are needed.

Clinical Examination Component of Telemedicine, Telehealth, mHealth, and Connected Health Medical Practices

Telemedicine and telehealth are the practices of medicine at a distance. Performing the equivalent of a complete clinical examination by telemedicine would be unusual. However, components of a more traditional clinical examination are part of the telemedicine workup for specific conditions. Telemedicine clinical examinations are facilitated, and enhanced, through the integration of a class of medical devices referred to as telemedicine peripherals (eg, electronic stethoscopes, tele-ophthalmoscopes, video-otoscopes, and so forth). Direct-to-consumer telehealth is a rapidly expanding segment of the health care service industry.

From Diabetes Care to Diabetes Cure-The Integration of Systems Biology, eHealth, and Behavioral Change

From a biological view, most of the processes involved in insulin resistance, which drives the pathobiology of type 2 diabetes, are reversible. This theoretically makes the disease reversible and curable by changing dietary habits and physical activity, particularly when adopted early in the disease process. Yet, this is not fully implemented and exploited in health care due to numerous obstacles. This article reviews the state of the art in all areas involved in a diabetes cure-focused therapy and discusses the scientific and technological advancements that need to be integrated into a systems approach sustainable lifestyle-based healthcare system and economy. The implementation of lifestyle as cure necessitates personalized and sustained lifestyle adaptations, which can only be established by a systems approach, including all relevant aspects (personalized diagnosis and diet, physical activity and stress management, self-empowerment, motivation, participation and health literacy, all facilitated by blended care and ehealth). Introduction of such a systems approach in type 2 diabetes therapy not only requires a concerted action of many stakeholders but also a change in healthcare economy, with new winners and losers. A "call for action" is put forward to actually initiate this transition. The solution provided for type 2 diabetes is translatable to other lifestyle-related disorders.

Effects of telemonitoring on glycaemic control and healthcare costs in type 2 diabetes: A randomised controlled trial

Introduction

This study examined the effect of a telehealth intervention on the control of type 2 diabetes and subsequent potential cost-savings to the health system.

Methods

This prospective randomised controlled trial randomised adults with type 2 diabetes to the intervention (diabetes program) or control (usual care) arm. Key eligibility criteria included an HbA1c level of at least 58 mmol/mol (7.5%) without severe or unstable comorbidities. All participants continued their usual healthcare, but participants in the intervention arm received additional diabetes care from a diabetes care coordinator via a home monitor that captured clinical measures. Data collected included biomedical, quality of life measures and healthcare (GP, outpatient and inpatient) costs. The primary outcome was HbA1c collected at baseline and 6 months. Analysis was conducted on a complete case intention-to-treat basis. The healthcare system perspective was taken to calculate the incremental cost per percentage-point reduction in HbA1c.

Results

Results from 63 participants from each study arm were analysed. HbA1c in the intervention group decreased from a median 68 mmol/mol (8.4%) to 58 mmol/mol (7.5%), and remained unchanged in the control group at median 65 mmol/mol (8.1%) at the 6-month endpoint. The intervention effect on HbA1c change was statistically significant ( p = .004). Total healthcare costs in the intervention group, including the intervention costs, were lower (mean $3781 vs. $4662; p < .001) compared with usual care.

Discussion

There was a clinically meaningful and statistically significant benefit from the telehealth intervention at a lower cost; thus, telehealth was cost-saving and produced greater health benefits compared with usual care.

Integrating and safeguarding care: The potential role of health information technologies

The increasing burden of chronic diseases is one of the greatest challenges healthcare systems globally are facing. Across the world, compelling demands can be found for a fundamental shift in the organisation of health and social care to meet the needs of chronic patients. Integrated care has gathered momentum to overcome fragmentation of care in order to create care systems which are demand-driven, client-centred and cost-conscious. Health information technology – often referred to as eHealth – is usually considered to be an essential building brick of integrated care. Moreover, health information technology is said to hold potential for improving patient safety in chronic care settings. The current perspective paper explores the role of health information technology in integrating and safeguarding care. We argue that health information technology – which supports integrated care – may create optimal conditions to improve patient safety, but only when well-implemented, state-of-the-art technologies are used.

Improved Medication Adherence and Frequency of Blood Glucose Self-Testing Using an m-Health Platform Versus Usual Care in a Multisite Randomized Clinical Trial Among People with Type 2 Diabetes in India

BACKGROUND

In 2015, India had an estimated 69.2 million people with diabetes and a national prevalence of 8.7%. Evidence is mounting for the benefits of telemedicine in diabetes care, but remains limited on mobile-health (m-Health) interventions.

INTRODUCTION

This study assessed the impact of an m-Health diabetes platform on clinical outcomes, patient-reported outcomes, patient and provider satisfaction, and app usage.

MATERIALS AND METHODS

This open-label, two-arm parallel study enrolled 91 people at 3 sites in India, aged 18-65, with type 2 diabetes, and an A1c between 7.5% and 12.5% (58-113 mmol/mol). Participants were randomly assigned 1:1 to m-Health or usual care and observed for 6 months. All received free visits, laboratory tests, transportation fees, and strips and lancets. Intervention participants received the m-Health app and a mobile phone data stipend.

RESULTS

A1c change was previously reported as statistically significant. Significantly more participants in intervention than control had improved medication adherence (39.0% vs. 12.8%; p = 0.03) and increased frequency of blood glucose (BG) self-testing (39.0% vs. 10.3%; p = 0.01) at 6 months from baseline. No other outcomes were significantly different. Among m-Health users, 75% of participants actively used the app at week 24. Participants entered 29,668 medications and 2,575 BG readings, sent 497 messages, and received 890 messages. Most participants (80%) were satisfied with all aspects of the app and all seven providers rated the software very acceptable.

DISCUSSION

Participants assigned to m-Health had increased medication adherence and frequency of BG testing compared with usual care participants.

CONCLUSIONS

This tool could be an effective way to expand access to quality chronic disease care and improve outcomes.

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.

Patient Attitudes Toward Telemedicine for Diabetic Retinopathy

INTRODUCTION

Diabetic retinopathy (DR) is the leading cause of new-onset blindness in adults. Telemedicine is a validated, cost-effective method to improve monitoring. However, little is known of patients' attitudes toward telemedicine for DR. Our study explores factors that influence patients' attitudes toward participating in telemedicine.

MATERIALS AND METHODS

Ninety seven participants in a university and the Veterans Administration setting completed a survey. Only people with diabetes mellitus (DM) were included. The main outcome was willingness to participate in telemedicine. The other outcomes were perceived convenience and impact on the patient-physician relationship. Participants reported demographic information, comorbidities, and access to healthcare. Analysis was performed with t-tests and multivariable logistic regression.

RESULTS

Demographic factors were not associated with the outcomes (all p > 0.05). Patients had decreased odds of willingness if they valued the patient-physician relationship (adjusted odds ratio [OR] = 0.08, confidence interval [CI] = 0.02-0.35, p = 0.001) or had a longer duration of diabetes (adjusted OR = 0.93, CI = 0.88-0.99, p = 0.02). Patients had increased odds of willingness if they perceived increased convenience (adjusted OR = 8.10, CI = 1.77-36.97, p = 0.01) or had more systemic comorbidities (adjusted OR = 1.85, CI = 1.10-3.11, p = 0.02).

DISCUSSION

It is critical to understand the attitudes of people with DM where telemedicine shows promise for disease management and end-organ damage prevention. Patients' attitudes are influenced by their health and perceptions, but not by their demographics. Receptive patients focus on convenience, whereas unreceptive patients strongly value their patient-physician relationships or have long-standing DM. Telemedicine monitoring should be designed for people who are in need and receptive to telemedicine.

The Role of Retinal Imaging and Portable Screening Devices in Tele-ophthalmology Applications for Diabetic Retinopathy Management

In the years since its introduction, retinal imaging has transformed our capability to visualize the posterior pole of the eye. Increasing practical advances in mobile technology, regular monitoring, and population screening for diabetic retinopathy management offer the opportunity for further development of cost-effective applications through remote assessment of the diabetic eye using portable retinal cameras, smart-phone-based devices and telemedicine networks. Numerous retinal imaging methods and mobile technologies in tele-ophthalmology applications have been reported for diabetic retinopathy screening and management. They provide several advantages of automation, sensitivity, specificity, portability, and miniaturization for the development of point-of-care diagnostics for eye complications in diabetes. The aim of this paper is to review the role of retinal imaging and mobile technologies in tele-ophthalmology applications for diabetic retinopathy screening and management. At large, although improvements in current technology and telemedicine services are still needed, telemedicine has demonstrated to be a worthy tool to support health caregivers in the effective management and prevention of diabetes and its complications.

Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: a systematic review

OBJECTIVE

To examine reported outcomes of health services delivered by telehealth to Indigenous Australians.

METHODS

Systematic review of the literature. Searches were conducted to identify articles that reported a telehealth service used to provide clinical services to Indigenous Australians. Articles were screened for inclusion using pre-defined criteria. Findings were synthesised narratively and reported using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

RESULTS

14 articles, describing 11 distinct telehealth services, were selected based on the inclusion criteria. Authors of included studies report that telehealth has improved social and emotional wellbeing, clinical outcomes and access to health services for Indigenous Australians. Further, it has reduced travel and improved screening rates. Indigenous people report positive perceptions of their telehealth interaction.

CONCLUSION

Telehealth is used to address poor accessibility to health services and for targeted screening programs for at risk populations. Reported outcomes from existing services demonstrate the potential of telehealth for health service delivery for Indigenous Australians. Confidence in the findings of this review is reduced by the predominance of descriptive studies and small sample sizes in many of the included articles.

IMPLICATIONS

Telehealth models of care facilitated through partnerships between Aboriginal community-controlled health services and public hospitals may improve both patient outcomes and access to specialist services for Indigenous people.

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.

Evidence for Telemedicine for Diabetic Retinal Disease

According to current projections, the number of Americans with diabetes mellitus will increase from 27.8 million in 2007 to 60.7 million in 2030. With the increasing gap between demand for eye care and supply of ophthalmologists and optometrists, and the non-uniform distribution of eye care providers in US counties, barriers to eye examinations will likely increase. Telemedicine assessment of diabetic retinal disease through remote retinal imaging and diagnosis has the potential to meet these growing demands. To establish evidence for a telemedicine program as an effective modality for diabetic retinopathy (DR) assessment, the interpretation of teleretinal images should compare favorably with Early Treatment Diabetic Retinopathy Study film or digital photographs. We review the current evidence on the critical features and characteristics of ocular telehealth programs for DR in the following categories: image gradability, mydriasis, sensitivity and specificity, cost-effectiveness, long-term effectiveness, patient comfort and satisfaction, and improvement of patient related outcomes.

Taking Telemedicine to the Next Level in Diabetes Population Management: a Review of the Endo ECHO Model

Worldwide increases in diabetes prevalence in the face of limited medical resources have prompted international interest in innovative healthcare delivery models. Project ECHO (Extension for Community Healthcare Outcomes) is a "telementoring" program which has been shown to increase capacity for complex disease management in medically underserved regions. In contrast to a traditional telemedicine model which might connect a specialist with one patient, the ECHO model allows for multiple patients to benefit simultaneously by building new expertise. We recently applied the ECHO model to improve health outcomes of patients with complex diabetes (Endo ECHO) living in rural New Mexico. We describe the design of the Endo ECHO intervention and a 4-year, prospective program evaluation assessing health outcomes, utilization patterns, and cost-effectiveness. The Endo ECHO evaluation will demonstrate whether and to what extent this intervention improves outcomes for patients with complex diabetes living in rural New Mexico, and will serve as proof-of-concept for academic medical centers wishing to replicate the model in underserved regions around the world.