Effectiveness of Remotely Delivered Interventions to Simultaneously Optimize Management of Hypertension, Hyperglycemia and Dyslipidemia in People With Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Effectiveness of educational interventions for diabetes-related foot disease: A systematic review and meta-analysis

This systematic review and meta-analysis pooled evidence from randomised controlled trials (RCTs) on the effectiveness of educational programs for people with or at risk of diabetes-related foot disease (DFD). A systematic search identified RCTs evaluating the effectiveness of educational programs in preventing or managing DFD. The primary outcome was risk of developing a foot ulcer. Secondary outcomes included any amputation, mortality, changes in cardiovascular risk factors, foot-care knowledge and self-care behaviours. Meta-analyses were performed using random effects models. Risk of bias was assessed using Cochrane's ROB-2 tool. Education programs were tested in 29 RCTs (n = 3891) and reduced risk of a foot ulcer by approximately half although the upper 95% confidence interval (CI) reached 1.00 (odds ratio [OR], OR 0.54; 95% CI 0.29, 1.00, I2  = 65%). Education programs reduced risk of any amputation (OR 0.34; 95% CI 0.13, 0.88, I2  = 38%) and HbA1c levels (standardized mean difference -0.73; 95% CI -1.26, -0.20, I2  = 93%) without affecting all-cause mortality (OR 1.09; 95% CI 0.57, 2.07, I2  = 0%). Education programs mostly significantly improved DFD knowledge (13 of 16 trials) and self-care behaviour scores (19 of 20 trials). Only one trial was deemed at low risk of bias. Previously tested education programs have mostly effectively improved participants' knowledge and self-care behaviours and reduced risk of foot ulceration and amputation. Larger high quality trials with longer follow-up are needed.

Older Patient Receptivity to the Integration of Patient Portals and Telehealth in Urogynecology: Promoters and Deterrents

IMPORTANCE

Limited studies focus on the integration of online portals, including telehealth services, in urogynecology while identifying promoters and deterrents of utilization, especially for the older population.

OBJECTIVE

This study aimed to identify facilitators, concerns, technical or personal issues encountered, and the desired features of the online patient portals among older urogynecology patients.

STUDY DESIGN

This is a secondary analysis of a cross-sectional study of older patients (≥65 years). The survey was devised using 2 focus groups with questions addressing older patient practicality and comfort with virtual visits for menopause and urogynecology-specific conditions.

RESULTS

A total of 205 patients completed the study. Promoters of use included health care professional encouragement, enrollment on site with concurrent education, and clarification of relevance of the virtual care to one's care. Patients who were uncomfortable with portal use reported anxiety and technical issues as deterrents for using such technology. More than half of the patients were comfortable having online visits for preoperative (51.7%), postoperative (66.3%), and medical management (73.7%). Up to 60.5% of the patients believed that virtual visits were equally stressful as in-person visits, whereas 24.4% believed that the logistics of in-person visits were the cause of stress.

CONCLUSIONS

To improve access to care, augment the utilization of online patient portals, and combat ageism, enhancing the older urogynecologic patient's portal experience is vital. Investment in this population's needs includes education of patients, active enrollment, and engagement by health care systems, and addressing technical concerns.

Effectiveness of the Telemedical Lifestyle Intervention Program TeLIPro for Improvement of HbA1c in Type 2 Diabetes: A Randomized-Controlled Trial in a Real-Life Setting

The effectiveness of the multimodal Telemedical Lifestyle Intervention Program (TeLIPro) was proven in the advanced stages of type 2 diabetes mellitus (T2DM). Since its therapeutic potential focusing on telemedical coaching without using a formula diet is unknown, we evaluated improvements in HbA1c, HbA1c normalisation rate, cardiometabolic risk factors, quality-of-life, and eating behaviour in real life. In this randomized-controlled trial, AOK Rhineland/Hamburg insured T2DM patients (n = 1163) were randomized (1:1) into two parallel groups, and 817 received the allocated intervention. In addition to routine care, all participants got scales, step counters, and access to an online portal. The TeLIPro group additionally received equipment for self-monitoring of blood glucose and telemedical coaching. Data were collected at baseline, after 6 and 12 months of intervention as well as after a 6-month follow-up. The primary endpoint after 12 months was (i) the estimated treatment difference (ETD) in HbA1c change and (ii) the HbA1c normalisation rate in those with diabetes duration < 5 years. The TeLIPro group demonstrated significantly stronger improvements in HbA1c (ETD -0.4% (-0.5; -0.2); p < 0.001), body weight, body-mass-index, quality-of-life, and eating behaviour, especially in T2DM patients with diabetes duration ≥ 5 years (ETD -0.5% (-0.7; -0.3); p < 0.001). The HbA1c normalisation rate did not significantly differ between groups (25% vs. 18%). Continuous addition of TeLIPro to routine care is effective in improving HbA1c and health-related lifestyle in T2DM patients with longer diabetes duration in real life.

Perceptions of Australians with diabetes-related foot disease on requirements for effective secondary prevention

INTRODUCTION

Secondary prevention is essential in reducing recurrence of diabetes-related foot disease (DFD) but is frequently poorly implemented in clinical practice.

OBJECTIVE

To explore the perceptions of people with diabetes-related foot disease (DFD) on their self-perceived knowledge in managing DFD, facilitators and barriers influencing their DFD care, and ideas and preferences for a secondary prevention program.

DESIGN

Sixteen people with a history of DFD from Queensland and Victoria, Australia, underwent semi-structured interviews. Interviews were audio-recorded over telephone and transcribed and analysed following a thematic framework. Participants were asked about their experiences and perceptions relating to DFD and factors influencing the care they receive for DFD relevant to the development of a secondary prevention program for DFD.

FINDINGS AND DISCUSSION

Participants had high self-perceived knowledge in managing DFD, especially in implementing healthy lifestyle changes and conducting daily foot checks and foot care, though most received support from family members acting as carers. However, issues with access and adherence to offloading footwear, and a lack of clear education received on footwear and other aspects of DFD care were perceived as major barriers. Improved patient education, provided in a consistent manner by proactive clinicians was perceived as an essential part of secondary prevention. Telehealth was perceived positively through facilitating faster care and considered a good adjunct to standard care. Health and technological literacy were considered potentially major barriers to the effectiveness of remote care.

CONCLUSION

People with DFD require improved access to offloading footwear and education about secondary prevention, which could be provided by telehealth with adequate support.

Health Professionals' Opinions About Secondary Prevention of Diabetes-Related Foot Disease

PURPOSE

The purpose of this study was to explore the perceptions of health professionals regarding the ideal design of a remotely delivered diabetes-related foot disease (DFD) secondary prevention program.

METHODS

A qualitative study involving 33 semistructured phone interviews was conducted with health professionals with experience managing DFD. Interviews discussed the role of health professionals in managing DFD, their experience in using telehealth, perceived management priorities, preferences for a secondary prevention management program, and perceived barriers and facilitators for such a program. Interviews were audio-recorded and transcribed, and inductive thematic analysis was used to derive key themes.

RESULTS

Three themes were derived: (1) barriers in current model of DFD care, (2) facilitators and ideas for a remotely delivered secondary prevention program, and (3) potential challenges in implementation. DFD care remains acute-care focused, with variability in access to care and a lack of "clinical ownership." Patients were perceived as often having poor knowledge and competing priorities, meaning engagement in self-care remains poor. Participants felt a remote secondary prevention program should be simple to follow and individualized to patients' context, with embedded support from a case manager and local multidisciplinary service providers. Challenges to implementation included limited DFD awareness, poor patient motivation, patient-related issues with accessing and using technology, and the inability to accurately assess and treat the foot over telehealth.

CONCLUSIONS

Health professionals felt that an ideal remotely delivered secondary prevention program should be tailored to patients' needs with embedded support from a case manager and complemented with multidisciplinary collaboration with local service providers.