Telemonitoring in diabetes: evolution of concepts and technologies, with a focus on results of the more recent studies

The Effectiveness of Telemedicine in Patients with Rheumatoid Arthritis: An Overview of Systematic Reviews and Meta-Analysis

Introduction: Although telemedicine is widely used in the field of rheumatoid arthritis (RA), many systematic reviews have evaluated telemedicine, but we still have no clear effect on RA and no evidence summary. Our aim is to determine the effectiveness of telemedicine on different health outcomes of RA. Methods: The following sources were used: PubMed, Cochrane, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Embase. The publication period was from the establishment of the database to May 12, 2022. Methodological and reporting qualities were assessed using A Measurement Tool to Assess Systematic Reviews 2 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Each intervention's evidence of effect was graded in accordance with the Grades of Recommendations Assessment, Development and Evaluation standards. The comparison of systematic reviews and the investigation of the impact of telemedicine on various outcomes were carried out through a meta-analysis of original studies. Results: Eight systematic reviews were included. The results showed that telemedicine imparted significant improvements in patients with RA in terms of disease activity, function, physical activity, self-efficacy, and knowledge. Conclusions: Telemedicine can improve the overall standard of care for patients with RA. In the future, standardized telemedicine processes should be developed to protect patients.

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.

Effectiveness of telemonitoring intervention on glycaemic control in patients with type 2 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a rising global health concern that requires long-term treatment and close monitoring. Telemonitoring has been shown to be a promising tool to facilitate patient-physician interaction and improve glycaemic control.

METHOD

Randomised controlled trials (RCT) of telemonitoring in T2DM published between 1990 and 2021 were searched through multiple electronic databases. The primary outcome variables included HbA1c and fasting blood glucose (FBG), and BMI was a secondary outcome variable.

RESULTS

Thirty RCT with a total of 4,678 participants were included in this study. Twenty-six studies reported on HbA1c, which was shown to be significantly lower in participants on telemonitoring when compared to conventional care. Ten studies investigated FBG which collectively showed no statistically significant difference. Subgroup analysis demonstrated the effect of telemonitoring on glycaemic control is influenced by a range of factors concerning system practicality, user engagement, patient characteristics and disease education.

CONCLUSION

Telemonitoring exhibited a great potential to improve T2DM management. Several technical features and patient factors may influence the effectiveness of telemonitoring. Further studies are needed to verify the findings and address limitations before its implementation into routine practice.

Emerging Diabetes Technologies: Continuous Glucose Monitors/Artificial Pancreases

Over the past decade there have been many advances in diabetes technologies, such as continuous glucose monitors (CGM s), insulin-delivery devices, and hybrid closed loop systems . Now most CGMs (Medtronic-Guardian, Dexcom-G6, and Abbott-Libre-2) have MARD values of < 10%, in contrast to two decades ago when the MARD used to be > 20%. In addition, the majority of the new CGMs do not require calibrations, and the latest CGMs last for 10-14 days. An implantable 6-months CGM by Eversense-3 is now approved in the USA and Europe. Recently, the FDA approved Libre 3 which provides real-time glucose values every minute. Even though it is approved as an iCGM it is not interoperable with automatic-insulin-delivery (AID) systems. The newer CGMs that are likely to be launched in the next few months in the USA include the 10-11 days Dexcom G7 (60% smaller than the existing G6), and the 7-days Medtronic Guardian 4. Most of the newer CGM have several features like automatic initialization, easy insertion, predictive alarms, and alerts. It has also been noticed that an arm insertion site might have better accuracy than abdomen or other sites, like the buttock for kids. Lag time between YSI and different sensors have been reported differently, sometimes it is down to 2-3 min; however, in many instances, it is still 15-20 min, especially when the rate of change of glucose is > 2 mg/min. We believe that in the next decade there will be a significant increase in the number of people who use CGM for their day-to-day diabetes care.

Application and prospect of artificial intellingence in diabetes care

Diabetes is one of the fastest-growing non-communicable diseases, becoming an important public health concern worldwide as well as in China. Currently, China has the largest population living with diabetes. Artificial intelligence (AI) is a fast-growing field and its applications to diabetes could enable the delivery of better management services for people with diabetes. This perspective summarized the latest findings of digital technologies and AI use in the following areas of diabetes care, mainly including screening and risk predictions of diabetes and diabetic complications, precise monitoring and intervention combined with new technologies, and mobile health application in self-management support for people with diabetes. Challenges to promote further use of AI in diabetes care included data standardization and integration, performance of AI-based medical devices, motivation of patients, and sensitivity to privacy. In summary, although the AI applications in clinical practice is still at an early stage, we are moving toward a new paradigm for diabetes care with the rapid development and emerging application of AI.

Tele-Assessment of Functional Capacity through the Six-Minute Walk Test in Patients with Diabetes Mellitus Type 2: Validity and Reliability of Repeated Measurements

A tele-assessed 6MWT (TL 6MWT) could be an alternative method of evaluating functional capacity in patients with diabetes mellitus type 2 (DM2). This study aimed to assess the validity and reliability of a TL 6MWT. The functional capacity of 28 patients with DM2 (75% men) aged 61 ± 13 years was evaluated twice via an indoor, center-based 6MWT (CB 6MWT) and twice outside each patient's home via a web-based platform TL 6MWT. The study showed a high statistically significant correlation between the CB and TL 6MWT (Pearson's r = 0.76, p < 0.001). Reliability testing showed no statistically significant differences in the distance covered (CB1: 492 ± 84 m and CB2: 506 ± 86 m versus TL1: 534 ± 87 m and TL2: 542 ± 93 m, respectively) and in the best distance of the TL 6MWT (545 ± 93 m) compared to the best CB distance (521 ± 83 m). Strong internal reliability for both the CB (intraclass correlation coefficient (ICC) = 0.93) and the TL 6MWT (ICC = 0.98) was found. The results indicate that a TL 6MWT performed outdoors can be a highly valid and reliable tool to assess functional capacity in patients with DM2. No learning effect between the TL and CB assessment was found, minimizing the need for repetition.

COVID-19 Pandemic and Remote Consultations in Children: A Bibliometric Analysis

Telemedicine is becoming a standard method of consultation, and the COVID-19 pandemic has increased its need. Telemedicine is suitable for non-communicable diseases (NCDs) in the pediatric population, as these are chronic conditions that affect many children worldwide. The aim of this study was to analyze the bibliometric parameters of publications on the use of telemedicine for the most common NCDs in children before and after the COVID-19 pandemic. Following the electronic search, 585 records were selected. "Metabolic diseases" was the most frequent topic before and after the pandemic, accounting for 34.76% in 2017-2019 and 33.97% in 2020-2022. The average IF of the journals from which records were retrieved was 5.46 ± 4.62 before and 4.58 ± 2.82 after the pandemic, with no significant variation. The number of citations per reference averaged 14.71 ± 17.16 in 2017-2019 (95% CI: 12.07; 17.36) and 5.54 ± 13.71 in 2020-2022 (95% CI: 4.23; 6.86). Asthma, metabolic diseases, and neurodevelopmental disorders were the most explored topics. A relevant finding concerns the increasing number of observational studies after the pandemic, with a reduction of the interventional studies. The latter type of study should be recommended as it can increase the evaluation of new strategies for the management of NCDs.

Technology-Delivered Motivational Interviewing to Improve Health Outcomes in Patients with Chronic Conditions. A Systematic Review of the Literature

AIM

Provide an overview of remote Motivational Interviewing (MI) interventions for chronically-ill patients, and understand their degree of effectiveness on different health outcomes.

METHODS AND RESULTS

A systematic review with meta-analysis was conducted using the following databases: PubMed, CINAHL, PsychInfo, and Web of Science. Eligibility criteria included studies that administered remote MI alone or in combination with other remote approaches. A narrative synthesis and two meta-analyses were performed. Fifteen studies met the inclusion criteria. MI administration almost exclusively occurred by telephone and individual sessions. Eight studies reported treatment fidelity aspects, and four declared adopting a theoretical framework. Most targeted outcomes were therapeutic adherence, physical activity, depression, quality of life, and mortality. Risk of bias varied markedly, with the largest source resulting from selection process and intervention performance. The two meta-analyses indicated a significant effect of MI on depression (Standardized Mean Difference = -0.20, 95%CI: -0.34, -0.05, Z = 2.73, p = 0.006, I2 = 0%), and no effect of MI on glycosylated hemoglobin (Mean Difference = -0.02, 95%CI: -0.48, 0.45), p = 0.94, I2 = 84%).

CONCLUSION

Remote MI can be a promising approach for improving depression in chronic disease patients. However, studies are inconclusive due to risks of bias, heterogeneity, and lack of reporting of interventionist's training, treatment fidelity, and theoretical frameworks' use. More studies with solid designs are needed to inform clinical decision-making and research.

Digital health in older adults for the prevention and management of cardiovascular diseases and frailty. A clinical consensus statement from the ESC Council for Cardiology Practice/Taskforce on Geriatric Cardiology, the ESC Digital Health Committee and the ESC Working Group on e-Cardiology

Digital health technology is receiving increasing attention in cardiology. The rise of accessibility of digital health tools including wearable technologies and smart phone applications used in medical practice has created a new era in healthcare. The coronavirus pandemic has provided a new impetus for changes in delivering medical assistance across the world. This Consensus document discusses the potential implementation of digital health technology in older adults, suggesting a practical approach to general cardiologists working in an ambulatory outpatient clinic, highlighting the potential benefit and challenges of digital health in older patients with, or at risk of, cardiovascular disease. Advancing age may lead to a progressive loss of independence, to frailty, and to increasing degrees of disability. In geriatric cardiology, digital health technology may serve as an additional tool both in cardiovascular prevention and treatment that may help by (i) supporting self-caring patients with cardiovascular disease to maintain their independence and improve the management of their cardiovascular disease and (ii) improving the prevention, detection, and management of frailty and supporting collaboration with caregivers. Digital health technology has the potential to be useful for every field of cardiology, but notably in an office-based setting with frequent contact with ambulatory older adults who may be pre-frail or frail but who are still able to live at home. Cardiologists and other healthcare professionals should increase their digital health skills and learn how best to apply and integrate new technologies into daily practice and how to engage older people and their caregivers in a tailored programme of care.

Efficacy of the mHealth application in patients with type 2 diabetes transitioning from inpatient to outpatient care: A randomized controlled clinical trial

INTRODUCTION

No studies have assessed the efficacy of telemedicine using a platform for recording and adjusting insulin doses in patients with diabetes mellitus type 2 (DM2) transitioning from inpatient to outpatient care. This study aimed to assess, in a population of patients with DM2, discharged from a tertiary referral hospital, whether treatment based on the use of an mHealth application was associated with better glycemic control at the 3-month follow-up, than standard care.

METHODS

This open, randomized, controlled clinical trial included adult DM2 patients who were transitioning from inpatient to outpatient care. The efficacy and safety of patient management with and without mHealth was compared at the 3-month follow-up. The primary outcome was the change in the Glycosylated hemoglobin (HbA1c) levels. The secondary outcomes were the rates of hypoglycemic and hyperglycemic events and treatment satisfaction measured using the Insulin Treatment Satisfaction Questionnaire (ITSQ).

RESULTS

In total, 86 patients (41 using mHealth) were included in the clinical trial. HbA1c levels showed a significant decrease in both groups. The mean HbA1c level was significantly lower in the mHealth group. Patients using mHealth showed decreased incidence rate ratios of hypoglycemia 3.0 mmol/L [<54 mg/dl], hypoglycemia ranging from 3.0 to 3.8 mmol/L [54 to 70 mg/dl] and severe hypoglycemia. The level of satisfaction assessed using the ITSQ was higher in the mHealth group.

CONCLUSION

Using mHealth in patients with DM2 transitioning from inpatient to outpatient care improves metabolic control and may reduce the hypoglycemia rates.

Adherence and Persistence to Insulin Therapy in People with Diabetes: Impact of Connected Insulin Pen Delivery Ecosystem

Diabetes is an increasing public health problem, and insulin is the mainstay for treatment of type 1 diabetes. In type 2 diabetes treatment, insulin therapy is used after oral or other injectable agents become inadequate to achieve glycemic control. Despite the advances in insulin therapy, management of diabetes remains challenging. Numerous studies have reported low adherence and persistence to insulin therapy, which acts as a barrier to successful glycemic control and diabetes management. The aim of this targeted review article is to provide an overview of adherence and persistence to insulin therapy in people with diabetes and to discuss the impact of the emergence of a new connected ecosystem of increasingly sophisticated insulin pens, glucose monitoring systems, telemedicine, and mHealth on diabetes management. With the emergence of a connected diabetes ecosystem, we have entered an era of advanced personalized insulin delivery, which will have the potential to enhance diabetes self-management and clinical management. Early systems promise to unlock the potential to address missed or late bolus insulin delivery, which should help to address non-adherence and non-persistence. Over time, improvements in this ecosystem have the potential to combine insulin data with previously missing contextualized patient data, including meal, glucose, and activity data to support personalized clinical decisions and ultimately revolutionize insulin therapy.

Long-term Effects of Remote Patient Monitoring in Patients Living with Diabetes: A Retrospective Look at Participants of the Mississippi Diabetes Telehealth Network Study

INTRODUCTION

Remote patient monitoring (RPM) has demonstrated value as a tool to aid patients in management of their chronic illness in the home. Although the Mississippi Diabetes Telehealth Network Study (MSDTNS) was successful in reducing HbgA1c levels for patients participating in RPM in the Mississippi Delta, the long-term effect of RPM on patients and how to support patients to maintain the treatment effect after discharge remain unclear.

OBJECTIVE

This study evaluated the long-term effectiveness of an RPM program after the intervention was withdrawn.

MATERIALS AND METHODS

A retrospective review of medical records of patients who completed all phases of the MSDTNS from 2014 to 2016 was performed over a period of 6 months. Data collected included HbgA1c values, demographics, and changes in social determinants of health.

RESULTS

Of the 31 participants, African Americans displayed a significant difference in HbgA1c values compared with Caucasians since the end of the MSDTNS. No significant effect of other variables, such as income, marital status, insurance coverage, or age, on the change in HbgA1c values was detected since the end of the original study.

CONCLUSIONS AND RELEVANCE

This limited study implies that African Americans are at higher risk for an increase in hemoglobin A1C after the program is completed. More investigation is needed to identify ways to reduce their risk and equalize the long-term effects of RPM on clinical outcomes of patients in rural or underserved communities.

Type 1 diabetes and the challenges of emotional support in crisis situations: results from a feasibility study of a multidisciplinary teleintervention

The association between type 1 diabetes and mental health disorders could be exacerbated in a stressful environment. This study aimed to evaluate the feasibility of a teleguided intervention on emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. This study was performed during the social distancing period in the COVID-19 outbreak in Brazil. Individuals with type 1 diabetes aged ≥ 18 years were selected to receive a teleguided multidisciplinary intervention or the usual care plus an educational website access. The proposed intervention aimed addressing aspects of mental health, diabetes care and lifestyle habits during the pandemic. The feasibility outcome included the assessment of recruitment capability and adherence to the proposed intervention. Moreover, we evaluated the presence of positive screening for emotional disorders (Self Report Questionnaire 20) after a 16-week intervention, patients' perceptions of pandemic-related changes, diabetes-related emotional distress, eating disorders, and sleep disorders. Data were analyzed with the intent-to-treat principle. Fifty-eight individuals (mean age, 43.8 ± 13.6 years) were included (intervention group, n = 29; control group, n = 29). At the end of the study, a total of 5 participants withdrew from the study in the intervention group compared to only 1 in the control group. Participants who dropout from the study had similar mean age, sex and income to those who remained in the study. The analysis of mental health disorders was not different between the groups at the follow up: a positive screening result was found in 48.3% and 34.5% of participants in the intervention and control groups, respectively (P = 0.29). The intervention group felt more supported in their diabetes care during the social distancing period (82.8% vs. 48.3% in the control group, P < 0.01). Our study identified a disproportionate higher number of withdrawals in the intervention group when compared to the control group. This difference may have compromised the power of the study for the proposed assessments and should be reevaluated in future studies.Trial registration: ClinicalTrials.gov (NCT04344210). Date of registration: 14/04/2020.

Health information exchange in relation to point-of-care testing in home care: Issues in Japan

BACKGROUND

Laboratory tests, especially point-of-care testing (POCT), and related health information exchange (HIE) are necessary for patient management in the home care setting, where clinic-hospital cooperation and interprofessional collaboration are important.

METHODS

We raised the issues ahead of HIE in relation to POCT in home care in Japan, including issues in electronic medical record use, localized interprofessional collaboration networks with information and communication technology, personal health record use and open connectivity.

RESULTS

HIE system may depend on the initiatives of expert communities with non-expert partnership, as well as national healthcare policies.

CONCLUSION

We promote future challenges in this growing area.

Role of Telemedicine in Diabetes Management

INTRODUCTION

Telemedicine is a growing arena that may increase access to care for patients with diabetes. It has more relevance for rural populations or those with limited physical access to health care, for improving diabetes care. Telemedicine can also be used to offer diabetes self-education and transportation barriers for patients living in under-resourced areas or with disabilities.

METHOD

"This review explores the landscape of telemedicine approaches and evidence for incorporation into general practice.

RESULTS & DISCUSSION

Telehealth platforms have been shown to be both feasible and effective for health care delivery in diabetes, although there are many caveats that require tailoring to the institution, clinician, and patient population. Research in diabetes telehealth should focus next on how to increase access to patients who are known to be marginalized from traditional models of health care.

Type 1 diabetes and the challenges of emotional support in crisis situations: results from a randomized clinical trial of a multidisciplinary teleintervention

The association between type 1 diabetes and mental health disorders could be exacerbated in a stressful environment. This study aimed to evaluate the effectiveness of a teleguided intervention on emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. An open-label clinical trial was performed during the social distancing period in the COVID-19 outbreak in Brazil. Individuals with type 1 diabetes aged ≥ 18 years were randomized to receive a teleguided multidisciplinary intervention or the usual care plus an educational website access. The primary outcome was a positive screening for emotional disorders (Self Report Questionnaire 20) after a 16-week intervention. Secondary outcomes included evaluation of patients’ perceptions of pandemic-related changes, diabetes-related emotional distress, eating disorders, and sleep disorders. Data were analyzed with the intent‐to‐treat principle. Fifty-eight individuals (mean age, 43.8 ± 13.6 years) were included (intervention group, n = 29; control group, n = 29). The primary outcome was not different between the groups. The intervention group felt more supported in their diabetes care during the social distancing period (82.8% vs. 48.3% in the control group, P < 0.01). Both groups reported a similar self-perceived worsening of physical activity habits and mental health during the outbreak. There was no benefit to using the telehealth strategy proposed for emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. Further studies are needed to determine the impact on metabolic parameters and to understand why it is so difficult to emotionally support these patients.

Trail Registration: ClinicalTrials.gov (NCT04344210), 14/04/2020.

Patients' and Providers' Perspectives on and Needs of Telemonitoring to Support Clinical Management and Self-care of People at High Risk for Preeclampsia: Qualitative Study

Background

Preeclampsia is one of the leading causes of maternal mortality worldwide, with a global prevalence at 2%-8% of pregnancies. Patients at high risk for preeclampsia (PHRPE) have an increased risk of complications, such as fetal growth restriction, preterm delivery, abnormal clotting, and liver and kidney disease. Telemonitoring for PHRPE may allow for timelier diagnosis and enhanced management, which may improve maternal and perinatal outcomes.

Objective

The objective of this study is to determine the perceptions and needs of PHRPE and their health care providers with respect to telemonitoring through semistructured interviews with both groups. This study explored (1) what the needs and challenges of monitoring PHRPE are during pregnancy and in the postpartum period and (2) what features are required in a telemonitoring program to support self-care and clinical management of PHRPE.

Methods

This study used a qualitative descriptive approach, and thematic analysis was conducted. PHRPE and health care providers from a high-risk obstetrical clinic in a large academic hospital in Toronto, Canada, were asked to participate in individual semistructured interviews. Two researchers jointly developed a coding framework and separately coded each interview to ensure that the interviews were double-coded. The software program NVivo version 12 was used to help organize the codes.

Results

In total, 7 PHRPE and 5 health care providers, which included a nurse practitioner and physicians, participated in the semistructured interviews. Using thematic analysis, perceptions on the benefits, barriers, and desired features were determined. Perceived benefits of telemonitoring for PHRPE included close monitoring of home blood pressure (BP) measurements and appropriate interventions for abnormal BP readings; the development of a tailored telemonitoring system for pregnant patients; and facilitation of self-management. Perceived barriers to telemonitoring for PHRPE included financial and personal barriers, as well as the potential for increased clinician workload. Desired features of a secure platform for PHRPE included the facilitation of self-management for patients and decision making for clinicians, as well as the inclusion of evidence-based action prompts.

Conclusions

The perceptions of patients and providers on the use of telemonitoring for PHRPE support the need for a telemonitoring program for the management of PHRPE. Recommendations from this study include the specific features of a telemonitoring program for PHRPE, as well as the use of frameworks and design processes in the design and implementation of a telemonitoring program for PHRPE.

Benefits of Telemonitoring of Pulmonary Function—3-Month Follow-Up of Home Electronic Spirometry in Patients with Duchenne Muscular Dystrophy

Background: In patients with Duchenne Muscular Dystrophy (DMD), the respiratory system determines the quality and length of life; therefore, the search for easy and safe everyday monitoring of the pulmonary function is currently extremely important, particularly in the COVID-19 pandemic. The aim of the study was to evaluate the influence of a three-month home electronic spirometry (e-spirometry) monitoring of the pulmonary function and strength of respiratory muscles as well as the patients’ benefits from this telemetric program. Methods: Twenty-one boys with DMD (aged 7–22; non-ambulatory-11) received a remote electronic spirometer for home use with a special application dedicated for patients and connected with a doctor platform. Control of the hospital spirometry (forced vital capacity-FVC, forced expiratory volume in 1 second-FEV1, peak expiratory flow-PEF) and respiratory muscle strength (maximal inspiratory-MIP and expiratory pressures-MEP) before and after the three-month monitoring were performed as well telemonitoring benefit survey. Results: A total of 1403 measurements were performed; 15 of the participants were able to achieve correct attempts. There were no differences between the hospital and the home spirometry results as well as between respiratory muscle strength during v1 vs. v2 visits for the whole study group (all parameters p > 0.05); the six participants achieved increased value of FVC during the study period. There was a positive correlation between ΔFVC and the number of assessments during the home spirometry (r = 0.7, p < 0.001). Differences between FVC and MIP_cmH2O (r = 0.58; p = 0.01), MEP_cmH2O (r = 0.75; p < 0.001) was revealed. The mean general satisfaction rating of the telemonitoring was 4.46/5 (SD 0.66) after one month and 4.91/5 (SD 0.28) after three months. The most reported benefit of the home monitoring was the improvement in breathing (38% of participants after one month, 52% after three months of telemonitoring). Forgetting about the procedures was the most common reason for irregular measurements; the participants reported also increased motivation but less time to perform tests. Conclusions: The study indicates high compliance of the home telemonitoring results with the examination in the hospital. Benefits from home spirometry were visible for all participants; the most important benefit was breathing improvement. The remote home spirometry is usable for everyday monitoring of the pulmonary function in DMD patients as well can be also treated as respiratory muscle training.

Intelligent Telehealth in Pharmacovigilance: A Future Perspective

Pharmacovigilance improves patient safety by detecting and preventing adverse drug events. However, challenges exist that limit adverse drug event detection, resulting in many adverse drug events being underreported or inaccurately reported. One challenge includes having access to large data sets from various sources including electronic health records and wearable medical devices. Artificial intelligence, including machine learning methods, such as natural language processing and deep learning, can detect and extract information about adverse drug events, thus automating the pharmacovigilance process and improving the surveillance of known and documented adverse drug events. In addition, with the increased demand for telehealth services, for managing both acute and chronic diseases, artificial intelligence methods can play a role in detecting and preventing adverse drug events. In this review, we discuss two use cases of how artificial intelligence methods may be useful to improve the quality of pharmacovigilance and the role of artificial intelligence in telehealth practices.

Glycemic Disorder Risk Remote Monitoring Program in the COVID-19 Very Elderly Patients: Preliminary Results

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has necessitated the use of new technologies and new processes to care for hospitalized patients, including diabetes patients. This was the basis for the “GER-e-TEC COVID study,” an experiment involving the use of the smart MyPredi^TM e-platform to automatically detect the exacerbation of glycemic disorder risk in COVID-19 older diabetic patients.

Methods: The MyPredi^TM platform is connected to a medical analysis system that receives physiological data from medical sensors in real time and analyzes this data to generate (when necessary) alerts. An experiment was conducted between December 14th, 2020 and February 25th, 2021 to test this alert system. During this time, the platform was used on COVID-19 patients being monitored in an internal medicine COVID-19 unit at the University Hospital of Strasbourg. The alerts were compiled and analyzed in terms of sensitivity, specificity, positive and negative predictive values with respect to clinical data.

Results: 10 older diabetic COVID-19 patients in total were monitored remotely, six of whom were male. The mean age of the patients was 84.1 years. The patients used the telemedicine solution for an average of 14.5 days. 142 alerts were emitted for the glycemic disorder risk indicating hyperglycemia, with an average of 20.3 alerts per patient and a standard deviation of 26.6. In our study, we did not note any hypoglycemia, so the system emitted any alerts. For the sensitivity of alerts emitted, the results were extremely satisfactory, and also in terms of positive and negative predictive values. In terms of survival analysis, the number of alerts and gender played no role in the length of the hospital stay, regardless of the reason for the hospitalization (COVID-19 management).

Conclusion: This work is a pilot study with preliminary results. To date, relatively few projects and trials in diabetic patients have been run within the “telemedicine 2.0” setting, particularly using AI, ICT and the Web 2.0 in the era of COVID-19 disease.

Awareness and readiness to use telemonitoring to support diabetes care among care providers at teaching hospitals in Ethiopia: an institution-based cross-sectional study

OBJECTIVES

This survey aimed to assess the awareness and readiness of healthcare providers to use telemonitoring (TM) technologies for managing diabetes patients as well as to identify associated factors in Ethiopia.

DESIGN

An institution-based cross-sectional quantitative survey was conducted by using a pretested self-administered questionnaire from February to March 2020. Data analysis used a binary logistic regression and partial proportional odds model for factor identification.

PARTICIPANTS

Randomly selected 423 study physicians and nurses.

SETTING

This study was conducted at the University of Gondar and Tibebe Ghion specialised teaching referral hospitals.

OUTCOME MEASURES

Awareness and readiness towards TM in diabetes care.

RESULT

Out of 406 healthcare providers (69.7%, n=283 nurses and 30.3%, n=123 physicians) who completed the survey, 345 (38.7%) heard about TM, when it came to readiness, 321 (25.1%) and 121 (65.5%) of respondents had average and low readiness towards TM, respectively. The result of regression analysis shows that awareness towards TM was higher among respondents who had access to a computer (adjusted OR (AOR): 2.8 (95% CI 1.1 to 7.1)), computer-related training (AOR: 4.6 (95% CI 1.63 to 12.95)) and those who had the experience of supporting patients through digital tools (AOR: 1.7 (95% CI 1.0 to 2.8)). Self-perceived innovators and those who had access to a computer, computer-related training and favourable attitude towards TM had significantly higher readiness to use TM.

CONCLUSION

The findings of this survey revealed low awareness and readiness of participant's towards TM. However, this study suggests the need of improving participant's attitudes, access to smartphones and computers and technical skills to fill this gap.

Effects of remote care of patients with poorly controlled type 1 diabetes included in an experimental telemonitoring programme

AIM

To assess, in a real-life setting, the effectiveness of telemonitoring adults with type 1 diabetes (T1D) using continuous glucose monitoring in a telemedicine experiment.

METHODS

Experimentation in Telemedicine for the Improvement of Healthcare Pathways (ETAPES), an experimental telehealth programme for five chronic diseases, is supported by the French national healthcare system to promote telemedical care. Using data from a single university hospital centre, 72 adults were studied, including 42 subjects (58%) receiving insulin pump therapy and 30 (42%) receiving multiple daily injections, with a median age of 35.5 years [28.0; 45.0] and poorly controlled type 1 diabetes (T1D) with a mean ± standard error of mean (SEM) HbA1c value of 8.69 ± 0.13%. The primary study outcome was the difference in HbA1c values between baseline and the end of a 6-month follow-up. Other end points of interest were mean blood glucose, glucose management indicator (GMI) level and % time in range (3.9-10 mmol/L) or below or above range.

RESULTS

At month 6, mean HbA1c levels were significantly reduced by -0.5% (P < 0.001) as were also mean blood glucose levels (P = 0.015), with a significant increase of 6.75 ± 1.36% of time in range at month 3 and of 4.98 ± 1.4% at month 6. Such improvements did not depend on age, gender or type of insulin therapy, but were inversely correlated to initial HbA1c values on multivariate analysis (P < 0.001).

CONCLUSION

Although the use of telehealth monitoring offers efficacy and safety in the metabolic control of patients with T1D, it does not fulfil all of these patients' clinical needs. As such, this new healthcare pathway cannot replace, but is a useful complement to, face-to-face in-person clinical visits.

2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society

Supplemental Digital Content is available in the text.

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health (“mHealth”) technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self‐management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

Factors influencing healthcare providers' attitude and willingness to use information technology in diabetes management

BACKGROUND

The use of information technologies could help to improve communications between patients and care providers, might improve overall patient management practice. However, the potential for implementing these patient management options in Ethiopia has not been well documented. This institution-based survey aimed to describe the attitude and willingness of care providers towards the use of information technologies for managing diabetes patients, and factors influencing their interest.

METHODS

A cross-sectional quantitative survey was conducted on 423 study participants from February to March 2020 at two teaching hospitals in Northwest Ethiopia, where remote monitoring patients had not been implemented. A pretested self-administered questionnaire was used to collect the required data. Other than descriptive statistics, the binary logistic regression analysis method was used to identify factors associated with attitude. Also, the negative binomial regression method was used to identify factors associated with willingness to use information technologies.

RESULT

A total of 406 participants (69.7%, n = 283 nurses and 30.3%, n = 123 physicians) were completed survey. Overall, 64% of respondents had a favorable attitude towards remote monitoring, and the majority of them were willing to use voice call (74.4%), text message (62.1%), video conference (61.3%), e-mail (60.6%), and social media (57.4%) as a source of communication to support patients. The result of regression analysis shows that having a computer (AOR = 2.3, 95% CI: [1.3, 3.8]), innovativeness (AOR = 2.8, 95% CI: [1.8, 4.3]), and practice of supporting patient by electronic technologies (AOR = 1.7, 95% CI: [1.1, 2.6]) were significantly associated with attitude to remote monitoring. Attitude towards remote monitoring (IRR = 2.3, 95% CI: 1.1-4.7), computer use (IRR = 1.3, 95% CI: 1.162-3.023), frequently searching health-related information (IRR = 1.7, 95% CI: 1.459-6.570), gender (IRR = 1.2, 95% CI: 1.0-5.1), awareness towards remote monitoring (IRR = 1.4, 95% CI: 1.1-2.7) were significantly associated with willingness to use information technologies.

CONCLUSION

Improving the intention and skill of using computers should be a major point of attention for teaching hospitals who wish to improve their care providers' attitudes to remote monitoring and willingness in using information technologies. Besides, the awareness of professionals is crucial for improving willingness.

Status of Telemonitoring Services in Diabetes Care in Germany: A Narrative Review

BACKGROUND

Diabetes mellitus (DM) as a chronic disease is a great medical, organizational, and financial burden on the German healthcare system, and it has risen in epidemiological importance. To ensure healthcare against the background of rising prevalence rates and to reduce costs, it makes sense to supplement treatment of diabetes patients with telemedical services.

OBJECTIVES

The aim was to evaluate telemonitoring services for DM patients in Germany and the political/legal environment.

MATERIALS AND METHODS

A narrative review was conducted to provide a comprehensive and critical analysis of the current knowledge on interactive telemonitoring offerings and influencing factors. A total of 19 publications were considered as relevant in the screening process, and were included in the content analysis.

RESULTS

The results can be differentiated in terms of political/legal requirements, needs, and supply-related aspects. Only four studies focused on the individual care aspects of telemedical care of DM patients.

CONCLUSION

Telemonitoring measures for chronic diseases in general and for DM in particular have hardly been implemented in Germany so far. Based on the deficiencies and research gaps described earlier, some recommendations can be made. There is a need to set up structure for more interactivity, to expand technical infrastructure, and to close legal gaps. More research focusing on clinical effectiveness is necessary.

The Ethics of Artificial Intelligence in Pathology and Laboratory Medicine: Principles and Practice

Growing numbers of artificial intelligence applications are being developed and applied to pathology and laboratory medicine. These technologies introduce risks and benefits that must be assessed and managed through the lens of ethics. This article describes how long-standing principles of medical and scientific ethics can be applied to artificial intelligence using examples from pathology and laboratory medicine.

Implications of the COVID-19 Pandemic for Cardiovascular Disease and Risk-Factor Management

COVID-19 and our public health responses to the pandemic may have far-reaching implications for cardiovascular (CV) risk, affecting the general population and not only survivors of COVID-19. In this narrative review, we discuss how the pandemic may affect general CV risk for years to come and explore the mitigating potential of telehealth interventions. From a health care perspective, the shift away from in-person office visits may have led many to defer routine risk- factor management and may have had unforeseen effects on continuity of care and adherence. Fear of COVID-19 has led some patients to forego care for acute CV events. Curtailment of routine outpatient laboratory testing has likely delayed intensification of risk-factor–modifying medical therapy, and drug shortages and misinformation may have negative impacts on adherence to antihypertensive, glucose-lowering, and lipid-lowering agents. From a societal perspective, the unprecedented curtailment of social and economic activities has led to loss of income, unemployment, social isolation, decreased physical activity, and increased frequency of depression and anxiety, all of which are known to be associated with worse CV risk-factor control and outcomes. We must embrace and evaluate measures to mitigate these potential harms to avoid an epidemic of CV morbidity and mortality in the coming years that could dwarf the initial health effects of COVID-19.