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      The Contribution of Teleconsultation and Videoconferencing to Diabetes Care: A Systematic Literature Review

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          Abstract

          Background

          A systematic literature review was carried out to study the benefits of teleconsultation and videoconferencing on the multifaceted process of diabetes care. Previous reviews focused primarily on usability of technology and considered mainly one-sided interventions.

          Objective

          The objective was to determine the benefits and deficiencies of teleconsultation and videoconferencing regarding clinical, behavioral, and care coordination outcomes of diabetes care.

          Methods

          Electronic databases (Medline, PiCarta, PsycINFO, ScienceDirect, Telemedicine Information Exchange, ISI Web of Science, Google Scholar) were searched for relevant publications. The contribution to diabetes care was examined for clinical outcomes (eg, HbA 1c, blood pressure, quality of life), behavioral outcomes (patient-caregiver interaction, self-care), and care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of care access). Randomized controlled trials (RCTs) with HbA 1c as an outcome were pooled using standard meta-analytical methods.

          Results

          Of 852 publications identified, 39 met the inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1, type 2, or gestational diabetes. Studies that evaluated teleconsultation or videoconferencing not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (eg, HbA 1c). There were 22 interventions related to teleconsultation, 13 to videoconferencing, and 4 to combined teleconsultation and videoconferencing. The heterogeneous nature of the identified videoconferencing studies did not permit a formal meta-analysis. Pooled results from the six RCTs of the identified teleconsultation studies did not show a significant reduction in HbA 1c (0.03%, 95% CI = - 0.31% to 0.24%) compared to usual care. There was no significant statistical heterogeneity among the pooled RCTs ( χ 2 7= 7.99, P = .33). It can be concluded that in the period under review (1994-2006) 39 studies had a scope broader than clinical outcomes and involved interventions allowing patient-caregiver interaction. Most of the reported improvements concerned satisfaction with technology (26/39 studies), improved metabolic control (21/39), and cost reductions (16/39). Improvements in quality of life (6/39 studies), transparency (5/39), and better access to care (4/39) were hardly observed. Teleconsultation programs involving daily monitoring of clinical data, education, and personal feedback proved to be most successful in realizing behavioral change and reducing costs. The benefits of videoconferencing were mainly related to its effects on socioeconomic factors such as education and cost reduction, but also on monitoring disease. Additionally, videoconferencing seemed to maintain quality of care while producing cost savings.

          Conclusions

          The selected studies suggest that both teleconsultation and videoconferencing are practical, cost-effective, and reliable ways of delivering a worthwhile health care service to diabetics. However, the diversity in study design and reported findings makes a strong conclusion premature. To further the contribution of technology to diabetes care, interactive systems should be developed that integrate monitoring and personalized feedback functions.

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          Most cited references 62

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          To investigate effectiveness, definitions, and components of integrated care programmes for chronically ill patients on the basis of systematic reviews. Literature review from January 1996 to May 2004. Definitions and components of integrated care programmes and all effects reported on the quality of care. Searches in the Medline and Cochrane databases identified 13 systematic reviews of integrated care programmes for chronically ill patients. Despite considerable heterogeneity in interventions, patient populations, and processes and outcomes of care, integrated care programmes seemed to have positive effects on the quality of patient care. No consistent definitions were present for the management of patients with chronic illnesses. In all the reviews the aims of integrated care programmes were very similar, namely reducing fragmentation and improving continuity and coordination of care, but the focus and content of the programmes differed widely. The most common components of integrated care programmes were self-management support and patient education, often combined with structured clinical follow-up and case management; a multidisciplinary patient care team; multidisciplinary clinical pathways and feedback, reminders, and education for professionals. Integrated care programmes seemed to have positive effects on the quality of care. However, integrated care programmes have widely varying definitions and components and failure to recognize these variations leads to inappropriate conclusions about the effectiveness of these programmes and to inappropriate application of research results. To compare programmes and better understand the (cost) effectiveness of the programmes, consistent definitions must be used and component interventions must be well described.
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            Web-based care management in patients with poorly controlled diabetes.

             B Levine,  H Gomes,  P Conlin (2005)
            To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes. For this study, 104 patients with diabetes and HbA(1c) (A1C) > or =9.0% who received their care at a Department of Veterans Affairs medical center were recruited. All participants completed a diabetes education class and were randomized to continue with their usual care (n = 52) or receive web-based care management (n = 52). The web-based group received a notebook computer, glucose and blood pressure monitoring devices, and access to a care management website. The website provided educational modules, accepted uploads from monitoring devices, and had an internal messaging system for patients to communicate with the care manager. Participants receiving web-based care management had lower A1C over 12 months (P < 0.05) when compared with education and usual care. Persistent website users had greater improvement in A1C when compared with intermittent users (-1.9 vs. -1.2%; P = 0.051) or education and usual care (-1.4%; P < 0.05). A larger number of website data uploads was associated with a larger decline in A1C (highest tertile -2.1%, lowest tertile -1.0%; P < 0.02). Hypertensive participants in the web-based group had a greater reduction in systolic blood pressure (P < 0.01). HDL cholesterol rose and triglycerides fell in the web-based group (P < 0.05). Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes.
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              Improving the quality of health care for chronic conditions.

              Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.
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                Author and article information

                Contributors
                Journal
                J Med Internet Res
                JMIR
                Journal of Medical Internet Research
                Gunther Eysenbach (Centre for Global eHealth Innovation, Toronto, Canada )
                1438-8871
                Oct-Dec 2007
                14 December 2007
                : 9
                : 5
                Affiliations
                3simpleDepartment of Marketing Communication and Consumer Psychology Faculty of Behavioral SciencessimpleUniversity of Twente EnschedeThe Netherlands
                2simpleDepartment of Psychology and Communication of Health Faculty of Behavioral SciencessimpleUniversity of Twente EnschedeThe Netherlands
                1simpleDepartment of Technical and Professional Communication Faculty of Behavioral SciencessimpleUniversity of Twente EnschedeThe Netherlands
                Article
                v9i5e37
                10.2196/jmir.9.5.e37
                2270420
                18093904
                © Fenne Verhoeven, Lisette van Gemert-Pijnen, Karin Dijkstra, Nicol Nijland, Erwin Seydel, Michaël Steehouder. Originally published in the Journal of Medical Internet Research (http://www.jmir.org, 14.12.2007). Except where otherwise noted, articles published in the Journal of Medical Internet Research are distributed under the terms of the Creative Commons Attribution License (http://www.creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited, including full bibliographic details and the URL (see "please cite as" above), and this statement is included.
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