Systematic review of 40 studies out of 852

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Contribution of e-health to diabetes care

• Systematic review of 40 studies (out of 852)
• Teleconsultation and videoconsultation

J (Lisette) Van Gemert-Pijnen PhD F (Fenne)
Verhoeven MSc Behavioural Sciences
j.vangemert-pijnen_at_utwente.nl
J (Lisette) Van Gemert-Pijnen PhD F (Fenne)
Verhoeven MSc Behavioural Sciences
j.vangemert-pijnen_at_utwente.nl
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focus of review

• Feasibility of technology
• easy to use
• Clinical values
• e.g. HbA1c, dietary values, blood pressure
• Quality of life social functioning, general
  health, well-being
• Control of care
• (patient) able to cope with diabetes/self-control
  (provider) better disease control
• Communication
• patient-provider among providers
• Cost effectiveness saving time and reduction of
  service utilization
• Transparency standardization of guidelines
• Equity access to care

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Bring your doctor into your home
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teleconsultation

• no face to face and no synchronous communication
  between patient and care providers, or among
  care providers. Via e-mail, internet, sms
  messages
• monitoring and telecare

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videoconsultation

• Face to face , synchronous communication between
  care providers and one or more patients
  simultaneously
• real-time contact via
• video-equipment
• personal feedback
• from 2005 also combined
• with telemonitoring

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search and data extraction

• medline, picarta, psychinfo, science direct,
  telemedicine information exchange, web of
  science, google scholar
• diabetes care, effective health care, IJMI, JMIR,
  telemedicine and e-health, telemedicine and
  telecare
• bibliographical details (design, population,
  intervention)
• methodological quality, contribution to quality
  of care http//www.york.ac.uk/inst/crd/clibsec1.pd
  f

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40 studies..

• Our research identified 852 potentially relevant
  articles. Of these studies only 40 were subjected
  to full review

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inclusion criteria

• developed for type 1, 2, and/ or gestational
  diabetics
• electronic care taking place between care
  providers and patients(groups) or between care
  providers mutually and patients
• synchronous or asynchronous communication between
  patient and care providers
• at least one of the quality of care aspects
  behaviour, control of care, costeffectiveness
  (not solely clinical aspects)
• no restrictions imposed for study design or
  nature of the results

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exclusion criteria

• aimed at broader target groups than diabetics
• not aimed at patient-provider interaction but
  solely reporting technical aspects of the used
  technology, or solely aimed at reporting
  metabolic control and clinical outcomes
• published before 1995
• published in other language than English

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effects teleconsultation (n23)

• improved medical control (HbA1c, dietary levels)
• monitoring and telecare
• reliable disease control
• intensified information exchange
• patient-providers among providers
• satisfied with technology
• safety, consultation irrespective of time, place
• cost effective
• costs per patient saving time patients,
  reduction of unscheduled visits, hospital
  admissions

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effects videoconsultation (n11)

• improved Quality of life
• physical functioning, general health, social
  functioning, emotional well-being
• improved coping with diabetes
• self consciousness, dialogue with care providers
• better knowledge
• patients, local physicians and specialists
• cost savings
• reduced service utilization, saving time
• costs per patient, limited interference with
  daily life
• less routine control consultations

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limitations

• interventions inevitably lead to improved control
  
• selection of motivated, inexperienced patients
• more involvement of clinicians
• short intervention period, no follow-up
• inadequate measurement of interventions
• unclear relationship between interventions and
  outcomes
• incompetent methods to assess changes in
  behaviour and costs
• unclear vision about technology to support care
• grounding lacks
• focus limited to RCT (evidence based medicine)

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limitations 2

• lack of education
• lack of training to solve health problems via
  internet, e-mail (patients as well as providers)
• limited use of the full possibilities of
  technology
• lack of cooperation
• confrontation leads to frustration and
  obstruction of data sending (teleconsultation
  ceiling)

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who benefits?
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potentials

• An integrated care approach seems to be the key
  for diabetes-care
• a combination of clinical, organizational,
  economical and behavioural outcomes
• wellsupported clinical infrastructure
• conducive health policy environment
• interventions aimed at individuals and community
• training of staff and patients and (online)
  personal coach

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• Answers??

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To Educate - To Enlighten - To Entertain people
with diabetes of all ages! They carry on, they
are super-heroes
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resistance to change?
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Aimed and achieved objectives (3)
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Aimed and achieved objectives(2)
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Proven evidence achieved objectives
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Strong evidence teleconsultation studies

• Branger, 1999 (5)
• Cheitlin-Cherry ,2002 (7)
• Tsang, 2001 (36)
• Rutten, 2001 (33)
• Gomez, 2002 (19)
• Biermann, 2002 (4)
• Farmer, 2005 (14)
• McMahon, 2005 (31)
• Jansa,2006 (23)
• Kim, 2006 (24)
• Strong evidence SD intervention group

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relevant studies videoconsultation

• Dansky, 2001 (12) (SD intervention)
• SD, but not limited to intervention group, or 1
  condition design
• Abrahamian, 2002 (1) Yip 2002 (40)
• Izquierdo, 2003 (22)
• Wilbright 2004 (39)
• Chan, 2005 (6)
• Malassanos 2005 (27)
• Clemensen, 2005 (11)

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relevant studies video and teleconsultation

• Chumbler, 2005 (8,9,10) Sd intervention group
• SD, but not limited to intervention group, or 1
  condition design)
• Whitlock, 2000 (37)
• Gelfland, 2003 (18),
• Starren, 2005 (34)

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Diabetes Super Heroes

• they are parents, children, workers, writers --
  they are many things. They live with diabetes,
  but they don't let it get in the way of their
  success. They carry on. They are Diabetes
  Super-Heroes.
• Among our members are sites that concentrate on
  special diets, nutrition, celebrity diabetics,
  diabetes books, diabetes stories, diabetes
  information, news research, insulin pumping and
  diabetes monitors

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In- and exclusionprocess (1)

• Titles and abstracts of the studies identified by
  the outlined search strategy were read to
  determine their potential eligibility for the
  review.
• Source material designated as in or uncertain
  was obtained for further review.
• A second investigator assessed those studies on
  relevance to enhance interrater reliability.
• Our research identified 852 potentially relevant
  articles. Of these studies, 40 were subjected to
  full review with the formal scoring methods.

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improvements teleconsultation (n23)

• HbA1c decreased(SDI, n3)
• I compared to C periods (-0.825, Plt0.05)
  (cross-over design)
• I (-1.15), increased in C (0.07), Plt0.05
• I (-1.6) and in C (-1.2), plt0.05

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monitoring, telecare

• Patients send data daily or weekly via
  glucometers, pc, internet, websites, e-mail
• data analysis automatically
• computer generated feedback (alert, reminders) or
  personal feedback via e-mail, phone ..

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in- and exclusion process

• possible relevant studies identified

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aimed and achieved objectives
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Proven evidence achieved objectives
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every day control
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40 studies met our criteria (from 852)