Telemedicine as a tool for intensive management of diabetes

There are caregivers and healthcare organisations by the use several reasons why the DIABTel system adds to of the new telemedicine procedures. On the other the initial workload: 1 learning process for the hand, this type of experience implies an important new tool; 2 assistance to patients when they effort and resources expenditure to set up and require technical support; 3 need for organisa- maintain the system.

In the DIABTel pilot the tional and clinical protocol changes; and finally evaluation was scheduled within a 2 years project 4 system refinement tasks to adjust to the care and the system was running at the hospital during team requirements. A 3-month period was required for One of the most critical issues in the feasibility technical verification and testing with volunteer pilot study was the installation and maintenance patients and the last 14 months were used for the of the system in the hospital environment.

Techni- clinical experience described in this paper. During cal and administrative problems arose before the all the pilot study clinical and technical people service was implemented and clinically operative. It was also crucial to nance and usability evaluation tasks.

Furthermore, pa- treatment of chronic patients. In diabetes care, tients show at the end of the study a high accep- telemedicine can give people the tools they need tance of the system and assessed DIABTel as to take better control of their illness. This paper useful for therapy management; effective to im- has presented a complete telemedicine system prove patient— doctor communication; and helpful devoted to diabetes care and the experience of its to increase their autonomy, without decreasing use in clinical routine.

The pilot study carried out the required doctor supervision. This work is currently funded by the usage and its potential benefits for diabetes care. European M2DM Project [29]. These benefits over conventional methods are as The conclusions and the clinical impressions follows: 1 the increase of the quality and quan- drawn during the pilot study establish the rele- tity of the information collected by patients af- vance of DIABTel as a potentially important tool fording a better decision-making process for in the intensive management of diabetes.

The next doctors and patients; 2 the improvement on the step is to extend the study to an increased number number of therapy adjustments to be performed of people and to other patient groups newly by doctors; 3 a better physician— patient commu- diagnosed patients, pump treated Type I patients nication procedure; and 4 the positive trend of and pregnant patients to continuously advance in the impact of the system to enhance the metabolic the creation of new telemedicine diabetes care control of patients.

The tremendous impact of the new The Web-based access to the MW is one of the information technologies will allow integration of main aspects for development in the near future. LifeScan also sup- The final goal would be to provide an integrated ported the pilot study and provided Glucose Me- tool for all parties involved in the diabetes patient ters.

The authors wish to thank Francisco care at any level hospital or primary care , with Campoy for his support of the pilot study.

The rapid growth and development of informa- [1] W. Today the seamless integra- News 5— At the development and progression of long-term complica- present the research team is developing a multi- tions in insulin-dependent diabetes mellitus, N. Zimmet, Diabetes epidemiology as a tool to trigger their education and shared care between profes- diabetes research and care, Diabetologia 42 — sionals [28]. Carson, S. Andreassen, D. Cavan, E. Meth- ods Progr. Del Pozo, M. Hernando, Telemedicine [21] M.

Hernando, E. Corcoy, F. Meth- [9] E. Lehmann Ed. Part 1 Databases, algorithms [22] E. Ortiz, N. Malpica, H. Rahms, A broadband multimedia collaborative system [10] E. Part 2 Models and educa- Trans. Corcoy, E. Shortliffe, Health care and the next generation [24] E. Arredondo, M. Sanz, E. Internet, Ann. Hernando, A telemedicine distributed decision-support [13] B.

Pal, Internet helps communication between doctors system for diabetes management, In: Proceedings 14th and patients, Br. Del Pozo, E. Telemedicine approach to diabetes management, Diab. Montani, R. Bellazzi, L. Portinale, G. Billiard, V. Rohmer, M. Roques, M. Joseph, S. Fiocchi, M. Stefanelli, Diabetic patients management ex- Suraniti, P. Giraud, J. Limal, P.

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Telecare 6 3 — Dinneen, S. Bjornsen, B. Zimmerman, C. Gorman, J. Knudsen, R. Rizza, S. Smith, S. Levy, P. Ferrand, V.

Albisser, R. The goal of the study is to evaluate the feasibility, acceptability, effectiveness, and cost-effectiveness of telemedicine. The focal point of the intervention is the home telemedicine unit, which provides four functions: synchronous videoconferencing over standard telephone lines, electronic transmission for fingerstick glucose and blood pressure readings, secure Web-based messaging and clinical data review, and access to Web-based educational materials 13 , Georgetown University recently tested a telemedicine program called MyCareTeam The article by Chase et al.

Address correspondence to David C. E-mail: klonoff compuserve. Sign In or Create an Account. Advanced Search. User Tools. Sign In. Skip Nav Destination Article Navigation. Close mobile search navigation Article navigation. Volume 26, Issue 5. Previous Article Next Article. Article Navigation. Editorials May 01 Diabetes and Telemedicine : Is the technology sound, effective, cost-effective, and practical?

Klonoff, MD David C. Klonoff, MD. From the Dorothy L. This Site. Google Scholar. Diabetes Care ;26 5 — Get Permissions. Diabetes Care. Merrell RC: Current status of telemedicine technology: potential applications to the management of diabetes. Diabetes Technol Ther. Hufford MR, Kolterman O: Helping patients to succeed: applying handheld technology to a clinical trial in type 1 diabetes. N Engl J Med. Smith SP: Internet visits: a new approach to chronic disease management. J Med Pract Manage. Ann Med.

Wilson M: The future of telemedicine. Stud Health Technol Inform. A randomized, controlled trial. Comput Methods Programs Biomed. J Am Med Inform Assoc. We were also unable to assess these interactions in our meta-regression analyses due to the small number of trials for each outcomes as well as the substantial heterogeneity of results.

Most of the trials included had only reported HbA1c concentrations, with very few reporting other key aspects of diabetes managements. As such, we urge caution when interpreting results for other secondary outcomes, though our preliminary analyses suggest some consistency across outcomes. The evidences presented in this review are in agreement with other systematic reviews which suggest that telemedicine is useful in improving patient care Supplemental Table S11 , with similar magnitude of improvements.

The present review also showed that telemedicine strategies were associated with additional clinical benefits beyond glycaemic control and these included improvement in blood pressure and triglyceride levels.

In our review, we also found that the definition of usual care was inconsistent across all studies. These varied from regular clinic visit every 3 to 6 months to a more intensive form of usual care, including drug therapy review, dietary counseling and health coaching.

While we attempted to stratify the various elements that constituted to usual care, the descriptions provided by most studies were not sufficiently detailed.

As such, it is possible that the relative effectiveness of telemedicine noted in this study maybe underestimated, especially if implemented in routine clinical practice.

In the present review, a high level of clinical heterogeneity of studies was found and this was probably due to the diverse patient population recruited. Such variation is expected for an analysis of complex intervention and hence, a meta-regression approach was utilized in the present study. This could be attributed to several reasons. Firstly, the different settings where these studies were conducted could mean that some of the contextual such as health care system and cultural factors may have played a role in the implementation process and thus affected the outcomes 30 , In addition, most of the studies conducted in Asian countries had smaller sample sizes and were conducted over a shorter period of time.

This might have increased adherence to the intervention and hence a better success rate. Similarly, the implementation of intervention could also be more intense in studies with smaller sample size. Lastly, there could be variation in the dissemination and implementation dimensions of such intervention between the continents. The present study has several important limitations that warrant mentioning.

Firstly, the high level of heterogeneity in the results suggests that the results should be interpreted with caution. This could be attributed to the variation in types of telemedicine technology used, population studied as well as healthcare personals involved. Secondly, as with all meta-regression analyses, we used summary data which made the findings vulnerable to ecological fallacy, and thus these findings may not be applicable to an individual.

In addition, there is limited statistical power with these analyses Thirdly, the lack of long term follow-up minimum 1 to 2 years studies may limit the interpretation of the results to only short-term effects of included interventions and not long-term outcomes such as mortality.

The sustainability and cost-effectiveness of these interventions may also be questionable. Most of the results used in the meta-analyses were based upon per protocol analysis, which may have resulted in higher result estimates.

Due to the complexity of interventions involved, compounded by a lack of description in most studies, misclassified interventions could not be ruled out. To minimize the misclassification of interventions, two authors independently assessed each study and reviewed other pertaining report of the same study to obtain additional information.

The lack of reporting for many trials had also limited our ability to perform several subgroup analyses such as roles of interventionist and healthcare setting on the impact of telemedicine. Finally, only a few studies had provided data on adverse events, quality-of-life measures or even cost-effectiveness analyses and hence, the data should be interpreted with caution. Investments in information technology will increase over the next few years. The network meta-analysis in the present study substantiates that individual focused telemedicine intervention such as education, small group discussion as well as structural changes replacing clinic visits with remote consultations is effective in reducing HbA1c.

Additionally, it provides some important insights for future research development and implementation. This includes a more detailed description of the methodology as well as target other clinical outcomes besides HbA1c, such as quality of life and cost savings. Such information is vital for policy-makers to tailor their choice of interventions to the desired outcomes based on the best available evidence, maximizing available resources in a local healthcare context.

The challenge, however, remains as to how to ensure such evidence does not get lost in translation and can be adopted within reasonable timeframe. Some strategies may include the promotion of access and usage by practitioners through capacity building, dissemination of intervention materials and engaging stakeholders in the planning phase.

The greatest potential of telemedicine lies in providing easy access especially by people in rural areas where healthcare resources are limited.

Assessing the acceptability and implementation challenges of telemedicine in resource poor areas is an important next step to accelerate translation. This can lead to reduced healthcare cost and improved patient outcomes. The funder had no role in the study design, data collection, data analysis and interpretation, writing of the report, or the decision to submit the article for publication.

Dr Lee had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Lee. Acquisition, analysis or interpretation of data: Lee, Chaiyakunapruk, Chua, Chan.

Drafting of manuscript: Lee. Critical revision of the manuscript for important intellectual content: Lee, Chaiyakunapruk, Chua, Chan. Statistical analysis: Lee, Chaiyakunapruk. Obtained funding: Lee. Administrative, technical or material support: Lee, Chua, Chan. Study supervision: Lee. Electronic supplementary material. Supplementary information accompanies this paper at Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Shaun Wen Huey Lee, Email: ude. Nathorn Chaiyakunapruk, Email: ude. National Center for Biotechnology Information , U. Sci Rep. Published online Oct 4. Author information Article notes Copyright and License information Disclaimer. Corresponding author.

Received Feb 3; Accepted Sep This article has been cited by other articles in PMC. Abstract The effects of telemedicine strategies on the management of diabetes is not clear. Introduction Diabetes mellitus is fast becoming a global public health challenge.

Data extraction Data were independently extracted by two reviewers and any discrepancies were resolved through adjudication. Content of intervention and control conditions Since a wide variety of interventions had been tested with the goal of improving quality of care among type 2 diabetes patients, the interventions were characterized according to their telemedicine strategies as described in Table 1 , based upon an adaptations from the American Telemedicine Association 14 , Tricco et al.

Table 1 Taxonomy of classification used in the current study. Telemedicine strategy targeting patient Teleeducation Any intervention that utilizes application of information and communication technologies e. The interaction is directed at patient care from the clinician and communication is interactive and occurs within an episode of care. Telemonitoring Any process which uses an audio, video or telecommunication and electronic information to monitor health status of a patient from a distance which is then transmitted back to the clinician.

This strategy is strictly based on clinical data and excludes clinical skills. Telecase-management A collaborative approach that focuses on the coordination, integration and direct delivery of beneficiary services provided in collaboration with or supplementary to primary care for improving the efficiency, depth or breadth of clinical care.

Telementoring Process of using either audio, video or any telecommunication and electronic information processing technology by a person who has gone through a specific experience to provide individual guidance, mentorship or direction to another person who is new to the experience. Open in a separate window. Outcomes and effect modifiers The primary outcome of interest was glycaemic control based on the absolute change in HbA1c from baseline to end of study.

Statistical analyses For studies that provided sufficient information on glycaemic control HbA1c or fasting plasma glucose , a permutation based meta-analysis with random effects model 18 was performed.

Results Description of studies Information from the database search yielded 6, potentially relevant studies, of which full-text were assessed for eligibility. Table 2 Baseline characteristics of included studies. Eligible studies No. Table 3 Results of pairwise meta-analysis for primary and secondary outcomes of different telemedicine strategies. Comparison No. Network meta-analyses Ninety-three trials 16, participants contributed to the network meta-analyses Figure S3a , appendix. Figure 1. Secondary outcomes Figure 2 presents the estimated effects of different telemedicine strategies on cardiovascular outcomes.

Figure 2. Publication bias and Sensitivity analyses Omission of each study sequentially did not lead to a significant change in the estimates of both primary as well as secondary outcomes, except for the exclusion of study by Shahid et al. Discussion This study is the largest and most comprehensive structured review to date on the effects of telemedicine. Conclusion The greatest potential of telemedicine lies in providing easy access especially by people in rural areas where healthcare resources are limited.

Electronic supplementary material Supplementary Information 2. Author Contributions Dr Lee had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Notes Competing Interests The authors declare that they have no competing interests.