Type 1 Diabetes Patients Using Continuous Subcutaneous Insulin Infusion Therapy: Feeling Burdened Correlated with Factors

Background

The purpose of this study was to investigate factors related to feelings of being burdened in type 1 diabetes patients using continuous subcutaneous insulin infusion (CSII) therapy.

Methods

Participants were 106 subscribers to the Diabetes Network’s e-mail newsletter. An online survey was used. Eligible participants were aged at least 20 years, had type 1 diabetes, and were using CSII. Survey questions concerned whether participants found CSII burdensome, and seven potential reasons for feelings of burden. Analysis calculated correlations among participants’ demographic and treatment-related factors, and among participants’ reasons for feeling CSII to be burdensome.

Results

Regarding demographic and treatment-related factors, gender was found to be weakly negatively correlated with the following variables: employment status, and whether participants had discussed their concerns with a doctor. Employment status was found to be weakly correlated with diabetes duration; employment status and diabetes duration were found to be weakly correlated with age. Regarding reasons for finding CSII therapy burdensome, “It takes too much time” was found to be strongly positively correlated with “It interferes with work responsibilities”; 16 weak positive correlations were also found.

Conclusion

To explain our results, we suggest that medical expenses, glycemic control, scheduling outpatient visits around home and work responsibilities, and interacting with medical staff may have caused participants to find CSII therapy burdensome. Most participants had never discussed their treatment concerns with a doctor. This suggests that nurses may be able to mitigate feeling burdened in participants using CSII therapy.     

Insulin resistance in Nigerians with essential hypertension

Background

Reports on the association between hypertension and insulin resistance have been inconsistent even though most studies show a definite association. It is also not certain if the association between insulin resistance and hypertension applies to all populations.

Objective

To determine the prevalence of insulin resistance in hypertensive Nigerians and to examine the association of insulin resistance with hypertension and some anthropometric indices.

Methods

Thirty five adults with essential hypertension and thirty five normotensives were studied. Anthropometric parameters, blood pressure, fasting glucose and insulin were measured. Homeostasis model assessment (HOMA) was used to determine insulin resistance (IR).

Results

The hypertensive subjects had significantly higher fasting insulin and HOMA-IR compared with normotensives (p =0.02 and 0.04) respectively. There were significant correlations between HOMA-IR, BMI, waist and hip circumference in subjects with hypertension. At multiple linear regression, hypertension and body mass index were found to be the only significant predictors of insulin resistance.

Conclusion

The hypertensives we studied had a higher occurrence of insulin resistance compared to the normotensives. This makes it necessary for persons with hypertensive to have regular screening for diabetes and other categories of glucose intolerance as the increased insulin increases their risk of developing type 2 diabetes mellitus.     

The Role of Insulin Resistance in Diabetic Neuropathy in Koreans with Type 2 Diabetes Mellitus: A 6-Year Follow-Up Study

Purpose

We previously reported that insulin resistance, low high-density lipoprotein (HDL) cholesterol, and glycaemic exposure Index are independently associated with peripheral neuropathy in Korean patients with type 2 diabetes mellitus. We followed the patients who participated in that study in 2006 for another 6 years to determine the relationship between insulin resistance and neuropathy.

Materials and Methods

This study involved 48 of the original 86 Korean patients with type 2 diabetes mellitus who were referred to the Neurology clinic for the assessment of diabetic neuropathy from January 2006 to December 2006. These 48 patients received management for glycaemic control and prevention of diabetic complications in the outpatient clinic up to 2012. We reviewed blood test results and the nerve conduction study findings of these patients, taken over a 6-year period.

Results

Low HDL cholesterol and high triglycerides significantly influenced the development of diabetic neuropathy. Kitt value (1/insulin resistance) in the previous study affected the occurrence of neuropathy, despite adequate glycaemic control with HbA1c <7%. Insulin resistance affected the development of diabetic neuropathy after 6 years: insulin resistance in 2006 showed a positive correlation with a change in sural sensory nerve action potential in 2012.

Conclusion

Diabetic neuropathy can be affected by previous insulin resistance despite regular glycaemic control. Dyslipidaemia should be controlled in patients who show high insulin resistance because HDL cholesterol and triglycerides are strongly correlated with later development of diabetic neuropathy.     

Patients' experiences of self-monitoring blood pressure and self-titration of medication: the TASMINH2 trial qualitative study

Background

Self-management of hypertension, comprising self-monitoring of blood pressure with self-titration of medication, improves blood pressure control, but little is known regarding the views of patients undertaking it.

Aim

To explore patients’ views of self-monitoring blood pressure and self-titration of antihypertensive medication.

Design and setting

Qualitative study embedded within the randomised controlled trial TASMINH2 (Telemonitoirng and Self Management in the Control of Hypertension) trial of patient self-management of hypertension from 24 general practices in the West Midlands.

Method

Taped and transcribed semi-structured interviews with 23 intervention patients were used. Six family members were also interviewed. Analysis was by a constant comparative method.

Results

Patients were confident about self-monitoring and many felt their multiple home readings were more valid than single office readings taken by their GP. Although many patients self-titrated medication when required, others lacked the confidence to increase medication without reconsulting with their GP. Patients were more comfortable with titrating medication if their blood pressure readings were substantially above target, but were reluctant to implement such a change if readings were borderline. Many planned to continue self-monitoring after the study finished and report home readings to their GP, but few wished to continue with a self-management plan.

Conclusion

Participants valued the additional information and many felt confident in both self-monitoring blood pressure and self-titrating medication. The reluctance to change medication for borderline readings suggests behaviour similar to the clinical inertia seen for physicians in analogous circumstances. Additional support for those lacking in confidence to implement prearranged medication changes may allow more patients to undertake self-management.     

Patient related factors for optimal blood pressure control in patients with hypertension

Background

Patient related factors hindering optimal blood pressure (BP) control in patients with hypertension are unclear.

Objectives

To investigate the barriers to optimal hypertension management.

Methods

A survey on the awareness and management of hypertension was conducted in 556 patients (365 males, mean age 60.9 ± 10.1) from a rural community.

Results

Of the 556 patients who had a clinical diagnosis of hypertension, 127 (22.8%) were unaware the existence of the condition and received no therapy. In the 429 patients who were aware the presence of hypertension, 206 (48.0%) did not receive any antihypertensive medication at the time of this study. Fifty-four (12.5%) had a BP of less than 140/90 mm Hg. Only 21 (4.9%) received formal counselling or education from health professionals and 74 (17.2%) were aware of the optimal level of BP. Difficulty in accessing a specialist doctor was reported by 126 (29.4%). In 279 (65.0%), missing regular antihypertensive medications was reported in the 4-week period prior to this study. Omitting prescribed antihypertensive drugs due to the costs was reported by 169 (39.4%).

Conclusion

Inadequate counselling, lack of understanding on the disease, difficulties in accessing specialist care and poor medication adherence are the barriers to optimal BP control.     

Improvement in medication adherence and self-management of diabetes with a clinical pharmacy program: a randomized controlled trial in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital

OBJECTIVE:

To evaluate the impact of a clinical pharmacy program on health outcomes in patients with type 2 diabetes undergoing insulin therapy at a teaching hospital in Brazil.

METHOD:

A randomized controlled trial with a 6-month follow-up period was performed in 70 adults, aged 45 years or older, with type 2 diabetes who were taking insulin and who had an HbA1c level ≥8%. Patients in the control group (CG) (n = 36) received standard care, patients in the intervention group (IG) (n = 34) received an individualized pharmacotherapeutic care plan and diabetes education. The primary outcome measure was change in HbA1c. Secondary outcomes included diabetes and medication knowledge, adherence to medication, insulin injection and home blood glucose monitoring techniques and diabetes-related quality of life. Outcomes were evaluated at baseline and 6 months using questionnaires.

RESULTS:

Diabetes knowledge, medication knowledge, adherence to medication and correct insulin injection and home blood glucose monitoring techniques significantly improved in the intervention group but remained unchanged in the control group. At the end of the study, mean HbA1c values in the control group remained unchanged but were significantly reduced in the intervention group. Diabetes-related quality of life significantly improved in the intervention group but worsened significantly in the control group.

CONCLUSION:

The program improved health outcomes and resulted in better glycemic control in patients with type 2 diabetes undergoing insulin therapy.     

Neighborhood of Residence is Associated with Daily Adherence to CPAP Therapy

Study Objectives:

Adherence to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea is poor. Risk factors for nonadherence are not well understood but may reflect individual or neighborhood socioeconomic factors. We sought to determine the association of socioeconomic status and initial CPAP adherence.

Design:

Retrospective cohort study, 2005 to 2006.

Setting:

Philadelphia VA Medical Center.

Participants:

Of 330 consecutive veterans who met study criteria for initiation of CPAP therapy for newly diagnosed sleep apnea, 266 had complete data for study inclusion.

Interventions:

N/A.

Measurements:

Through a multivariable logistic regression model, using an outcome of objectively measured CPAP use ≥ 4 h daily during the first week of treatment, we tested whether patients from higher socioeconomic neighborhoods had higher CPAP adherence. We measured neighborhood socioeconomic status with an index derived from the 2000 U.S. Census at the block group-level composed of median household income, male and female employment, adult high school completion, married households, and minority composition.

Results:

CPAP adherence ≥ 4 h occurred on 48.9% of 1,805 patient-days observed for the 266 subjects. After adjustment for individual sociodemographic characteristics and medical comorbidity, the probability of daily CPAP use ≥ 4 h ranged from 34.1% (95% CI, 26.4–42.7) for subjects from a low socioeconomic neighborhood (5th percentile) to 62.3% (95% CI, 53.8–70.1) for subjects from a high (95th percentile) neighborhood.

Conclusions:

In a retrospective cohort of veterans, initial CPAP adherence was closely associated with higher neighborhood socioeconomic factors. Future investigation should target specific impediments to adherence in the home and neighborhood environment.

Citation:

Platt AB; Field SH; Asch DA; Chen Z; Gupta R; Roche DF; Gurubhagavatula I; Christie JD; Kuna ST. Neighborhood of residence is associated with daily adherence to CPAP therapy. SLEEP 2009;32(6):799-806.     

Personal barriers to antiretroviral therapy adherence: case studies from a rural Uganda prospective clinical cohort

Background

Although good adherence to antiretroviral therapy (ART) is essential for successful treatment outcomes, some patients may have specific personal barriers to ART adherence.

Objectives

To study specific personal barriers to ART adherence.

Methods

Quantitative data on patients'' health status, ART adherence, CD4 cell counts and viral loads were collected, and qualitative data on life experiences of five patients with poor ART outcomes and adherence were also collected.

Results

Out of 35 patients with poor immunological and virological ART outcomes, 17 (49%) also had poor ART adherence. Patient 1 had no living child and did not disclose her HIV serostatus to her spouse because she wanted to have a child. Patient 2 was an orphan with neither social nor family support. Patient 3 stopped ART when she conceived, returned to the study clinic when pregnant again and was sickly. She was switched to second-line ART with satisfactory outcomes. Patient 4, a 14 year old orphan had missed ART for 2 months when his treatment supporter was away. Patient 5 aged 66 years stopped ART which he blamed for his erectile dysfunction.

Conclusion

ART adherence counselling should target specific personal barriers to ART adherence like: lack of family support, health and sexual life concerns, desire to have children and family instability.     

Clinical Outcomes and Prognostic Factors of Empirical Antifungal Therapy with Itraconazole in the Patients with Hematological Malignancies: A Prospective Multicenter Observational Study in Korea

Purpose

To identify prognostic factors for the outcomes of empirical antifungal therapy, we performed a multicenter, prospective, observational study in immunocompromised patients with hematological malignancies.

Materials and Methods

Three hundred seventy-six patients (median age of 48) who had neutropenic fever and who received intravenous (IV) itraconazole as an empirical antifungal therapy for 3 or more days were analyzed. The patients with possible or probable categories of invasive fungal disease (IFD) were enrolled.

Results

The overall success rate was 51.3% (196/376). Age >50 years, underlying lung disease (co-morbidity), poor performance status [Eastern Cooperative Oncology Group (ECOG) ≥2], radiologic evidence of IFD, longer duration of baseline neutropenic fever (≥4 days), no antifungal prophylaxis or prophylactic use of antifungal agents other than itraconazole, and high tumor burden were associated with decreased success rate in univariate analysis. In multivariate analysis, age >50 years (p=0.009) and poor ECOG performance status (p=0.005) were significantly associated with poor outcomes of empirical antifungal therapy. Twenty-two patients (5.9%) discontinued itraconazole therapy due to toxicity.

Conclusion

We concluded that empirical antifungal therapy with IV itraconazole in immunocompromised patients is effective and safe. Additionally, age over 50 years and poor performance status were poor prognostic factors for the outcomes of empirical antifungal therapy with IV itraconazole.     

Impact of glycemic control on the incidence of acute kidney injury in critically ill patients: a comparison of two strategies using the RIFLE criteria

OBJECTIVE:

To compare the renal outcome in patients submitted to two different regimens of glycemic control, using the RIFLE criteria to define acute kidney injury.

INTRODUCTION:

The impact of intensive insulin therapy on renal function outcome is controversial. The lack of a criterion for AKI definition may play a role on that.

METHODS:

Included as the subjects were 228 randomly selected, critically ill patients engaged in intensive insulin therapy or in a carbohydrate-restrictive strategy. Renal outcome was evaluated through the comparison of the last RIFLE score obtained during the ICU stay and the RIFLE score at admission; the outcome was classified as favorable, stable or unfavorable.

RESULTS:

The two groups were comparable regarding demographic data. AKI developed in 52% of the patients and was associated with a higher mortality (39.4%) compared with those who did not have AKI (8.2%) (p<0.001). Renal function outcome was comparable between the two groups (p = 0.37). We observed a significant correlation between blood glucose levels and the incidence of acute kidney injury (p = 0.007). In the multivariate logistic regression analysis, only APACHE III scores higher than 60 were identified as an independent risk factor for unfavorable renal outcome. APACHE III scores>60, acute kidney injury and hypoglycemia were risk factors for mortality.

CONCLUSION:

Intensive insulin therapy and a carbohydrate-restrictive strategy were comparable regarding the incidence of acute kidney injury evaluated using RIFLE criteria.     

The outcome of non-carbapenem-based empirical antibacterial therapy and VRE colonisation in patients with hematological malignancies

Background

Febrile neutropenia (FN) is generally a complication of cancer chemotherapy.

Objectives

We retrospectively evaluated the febrile neutropenia episodes and their outcomes with respect to modification rates of non-carbapenem-based empirical antibacterial therapy and vancomycin-resistant enterococcus (VRE) colonisation that caused to VRE bacteremia in patients with hematological malignancies.

Methods

All consecutive patients, who were older than 14 years of age and developed febrile neutropenia episodes due to hematological malignancies from September 2010 to November 2011 at the hematology department were included into the study.

Results

In total, 86 consecutive neutropenic patients and their 151 febrile episodes were evaluated. The mean MASCC prognostic index score was 18,72 ± 9,43. Among 86 patients, 28 patients experienced a total of 30 bacteremia episodes of bacterial origin. Modification rates of both, empirical monotherapy and combination therapies, were found similar, statistically (P = 0,840).

Conclusions

Our results suggest that initiating of non-carbapenem based therapy does not provide high response rates in the treatment of febrile neutropenia attacks. Furthermore, non-carbapenem-based empirical therapy provides benefit in regard to cost-effectiveness and antimicrobial stewardship when local antibiotic resistance patterns of gram-negative bacteria are considered. Patients who are colonized with VRE are more likely to develop bacteremia with VRE strains as a result of invasive procedures and severe damage of mucosal barriers observed in this group of patients.     

A virtual clinic for diabetes self-management: pilot study

Background

Internet-based interventions to assist in diabetes management have the potential to provide patients with the information and support they need to become effective self-managers.

Objective

To assess the feasibility, acceptability, and effectiveness of an Internet-based virtual clinic designed to facilitate self-management in patients who used insulin pumps to manage their diabetes.

Methods

For a period of 6 months, 17 patients joined the virtual clinic. The system allowed patients to communicate with health professionals, interact with peers and access information. HbA1c, quality of life, and self-efficacy were monitored at baseline and after 6 months. Questionnaires and qualitative interviews examined patient experiences.

Results

Participants found the virtual clinic easy to use and positively rated its design. Peer support was the most valued aspect and the discussion boards the most used component. All participants highly rated the virtual clinic in terms of improving communication with peers, but few agreed it had improved communication with health care professionals. No significant improvements in physiological and psychological measurements were found. Regarding HbA1c measurements, there was no significant difference found between the pre- and post-test results (P = .53). Mean ADDQoL scores at baseline were -2.1 (SD 1.1, range -3.4 to -0.5) compared to -2.0 (SD 1.2, range, -4.6 to -0.4) post-test (n = 12), (P = .62). Surprisingly, patients’ confidence in their ability to perform self-care tasks was found to be significantly reduced from baseline to follow up (P = .045).

Conclusions

An Internet-based system to aid the management of diabetes appears feasible and well accepted by patients. The pilot study did not identify evidence of an impact on improving quality of life or self-efficacy in patients who used insulin pump therapy.     

Effects of twice-daily injections of premixed insulin analog on glycemic control in type 2 diabetic patients

Purpose

Premixed insulin is effective to improve glycemic control; however, clinicians may be less likely to know which premixed insulin is appropriate for which patients. This study aimed to evaluate the effects of twice-daily injections of premixed insulin lispro on glycemic control in type 2 diabetic patients.

Materials and Methods

Forty type 2 diabetic patients, who had been treated with twice-daily injections of human protamine mixture 30/70 insulin for at least 12 months, were divided into two groups; one group whose blood glucose 2 hours after breakfast was greater than 200 mg/dL, was switched to lispro mix50, and the other group whose blood glucose 2 hours after breakfast < 200 was switched to lispro mix25.

Results

Glycated haemoglobin (HbA1c) significantly improved in the Mix50 group from 8.3% to 7.5% (at 12 weeks; p < 0.05), and to 7.5% (at 24 weeks; p < 0.05). On the other hand, HbA1c levels in the Mix25 group were slightly decreased from 8.1% to 7.7% at 12 weeks (p < 0.05), and to 7.9% at 24 weeks (not significant). Both postprandial plasma glucose and fasting plasma glucose levels were significantly improved in the Mix50 group, but not in the Mix25 group. Overall, 95% of subjects preferred premixed lispro insulin from human insulin in the viewpoint of the timing of insulin injection by questionnaire analysis.

Conclusion

Switching from human protamine mixture 30/70 insulin to lispro mix50 twice-daily injection therapy in patients with high postprandial plasma glucose could improve their glycemic control and quality of life.     

Optimal Waist Circumference Cutoff Value Reflecting Insulin Resistance as a Diagnostic Criterion of Metabolic Syndrome in a Nondiabetic Korean Population Aged 40 Years and Over: The Chungju Metabolic Disease Cohort (CMC) Study

Purpose

We aimed at determining the cutoff value of waist circumference with respect to its ability to reflect insulin resistance in a Korean population.

Materials and Methods

A total of 8,817 subjects aged 40 years and over were analyzed. Insulin resistant individuals were defined as those who had the highest quartile value of the homeostasis model assessment of insulin resistance (HOMA-IR) in a non-diabetic population. Receiver operating characteristic (ROC) curve analysis and multiple logistic regression analysis were applied.

Results

The cutoff value of waist circumference reflecting insulin resistance from the ROC analysis was 84.4 cm for men and 80.6 cm for women. Sensitivity and specificity were 70.0% and 54.2% in men and 71.1% and 59.3% in women, respectively. After being controlled for other covariates, the odds ratio for the risk of insulin resistance using < 70 cm of waist circumference as a reference increased significantly in the category of 85.0-89.9 cm for men and 80.0-84.9 cm for women. In addition, statistically significant associations were consistently observed over the category of 85.0-89.9 cm for men and 80.0-84.9 cm for women.

Conclusion

The optimal cutoff value for waist circumference reflecting insulin resistance is considered to be 85 cm for men and 80 cm for women, suggesting that the Asian criterion of abdominal obesity (90 cm for men and 80 cm for women) as a component of metabolic syndrome (MetS) might not be applicable for middle-aged to older men in Korea.     

Barriers to use of antiretroviral drugs in Rakai district of Uganda

Background

About 75% of people living with HIV/AIDS (PHAs) who need antiretroviral therapy have no access to these drugs in low-income countries.

Objective

To investigate the barriers to use of ART in Rakai district of Uganda

Methods

We interviewed 38 key informants and 384 PHAs. Data was collected on: education/mobilization for ART, sources of information for ART, beliefs regarding ART, social support, use of alternative medicine, stigma/discrimination towards PHAs, distance to ART centres, transport costs to ART centres, waiting time, and on suggestions as how to improve the use of ART.

Results

The major barriers mentioned regarding use of ART included: inadequate mobilization, long waiting time at ART treatment centres, high cost of transport to reach ART centres, stigma/discrimination towards PHAs and inadequate number of health workers to attend to PHAs.

Conclusions

Access to antiretroviral therapy could be ameliorated by: improving community education using innovative approaches such as through music, dance and videos, increasing the number of providers who are able to provide ART as through engagement of non health professionals in ART care, bringing ART nearer to where people live and instituting measures aimed at reducing stigma/discrimination such as through involvement of PHAs in demystisfying HIV/AIDS.     

Insulin Resistance Is an Important Risk Factor for Cognitive Impairment in Elderly Patients with Primary Hypertension

Purpose

Insulin resistance plays a role in the development of dementia and hypertension. We investigated a possible relationship between cognitive impairment and insulin resistance in elderly Chinese patients with primary hypertension.

Materials and Methods

One hundred and thirty-two hypertensive elderly patients (>60 years) were enrolled in this study, and assigned into either the cognitive impairment group (n=61) or the normal cognitive group (n=71). Gender, age, education, body mass index (BMI), waist hip ratio (WHR), total cholesterol (TC), triglyceride (TG), C-reactive protein (CRP), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), creatinine (Cr), fasting plasma glucose (FPG), fasting insulin (FINS), homeostasis model of assessment for insulin resistance index (HOMA-IR), systolic blood pressure, diastolic blood pressure, smoking history, atherosclerosis and the proportion of uncontrolled hypertension were compared between the two groups. Multi-factorial logistic regression analysis was performed.

Results

No significant differences were found in gender, age, TC, CRP, HDL-C, LDL-C, Cr, BP, smoking history, atherosclerosis and the proportion of uncontrolled hypertension between the two groups. The cognitive impairment group had lower education levels, and higher BMI, WHR, TG, FPG, FINS, and HOMA-IR levels than the control group. Logistic regression analysis revealed the levels of education, BMI, WHR, and HOMA-IR as independent factors that predict cognitive impairment in patients.

Conclusion

Our study demonstrates that poor education and increased BMI, WHR, and HOMA-IR are independent risk factors for cognitive impairment in elderly patients with hypertension. Insulin resistance plays an important role in the development of cognitive impairment in primary elderly hypertensive patients.     

Effect of a Low Iodine Diet vs. Restricted Iodine Diet on Postsurgical Preparation for Radioiodine Ablation Therapy in Thyroid Carcinoma Patients

Purpose

The radioiodine ablation therapy is required for patients who underwent a total thyroidectomy. Through a comparative review of a low iodine diet (LID) and a restricted iodine diet (RID), the study aims to suggest guidelines that are suitable for the conditions of Korea.

Materials and Methods

The study was conducted with 101 patients. With 24-hour urine samples from the patients after a 2-week restricted diet and after a 4-week restricted diet, the amount of iodine in the urine was estimated. The consumed radioiodine amounts for 2 hours and 24 hours were calculated.

Results

This study was conducted with 47 LID patients and 54 RID patients. The amounts of iodine in urine, the 2-week case and 4-week case for each group showed no significant differences. The amounts of iodine in urine between the two groups were both included in the range of the criteria for radioiodine ablation therapy. Also, 2 hours and 24 hours radioiodine consumption measured after 4-week restrictive diet did not show statistical differences between two groups.

Conclusion

A 2-week RID can be considered as a type of radioiodine ablation therapy after patients undergo a total thyroidectomy.     

Development and Initial Evaluation of an Internet-Based Support System for Face-to-Face Cognitive Behavior Therapy: A Proof of Concept Study

Background

Evidence-based psychological treatments, such as cognitive behavior therapy (CBT), have been found to be effective in treating several anxiety and mood disorders. Nevertheless, issues regarding adherence are common, such as poor patient compliance on homework assignments and therapists’ drifting from strictly evidence-based CBT. The development of Internet-delivered CBT (ICBT) has been intensive in the past decade and results show that guided ICBT can be as effective as face-to-face CBT but also indicate a need to integrate the two forms of CBT delivery.

Objective

In this study, we developed and tested a new treatment format in which ICBT and face-to-face therapy were blended. We designed a support system accessible via the Internet (using a computer or an Apple iPad) for patients and therapists delivering CBT face-to-face. The support system included basic CBT components and a library of interventions gathered from existing ICBT manuals.

Methods

The study involved 15 patients with mild to moderate anxiety or depression (or both). Eight therapists conducted the treatments. All participants were interviewed after the nine-week intervention. Further, patients provided self-reports on clinical measures pre- and post-trial, as well as at a 12-month follow-up.

Results

A reduction was found in symptom scores across all measures. The reliable change index ranged from 60% to 87% for depression and anxiety. Large effect sizes (Cohen’s d) ranging from 1.62 (CI 95% 0.59-2.66) to 2.43 (CI 95% 1.12-3.74) were found. There were no missing data and no treatment dropouts. In addition, the results had been maintained at the 12-month follow-up. Qualitative interviews revealed that the users perceived the support system as beneficial.

Conclusions

The results suggest that modern information technology can effectively blend with face-to-face treatments and be used to facilitate communication and structure in therapy, thus reducing therapist drift.     

Perceptions and experiences of heart failure patients and clinicians on the use of mobile phone-based telemonitoring

Background

Previous trials of heart failure telemonitoring systems have produced inconsistent findings, largely due to diverse interventions and study designs.

Objectives

The objectives of this study are (1) to provide in-depth insight into the effects of telemonitoring on self-care and clinical management, and (2) to determine the features that enable successful heart failure telemonitoring.

Methods

Semi-structured interviews were conducted with 22 heart failure patients attending a heart function clinic who had used a mobile phone-based telemonitoring system for 6 months. The telemonitoring system required the patients to take daily weight and blood pressure readings, weekly single-lead ECGs, and to answer daily symptom questions on a mobile phone. Instructions were sent to the patient’s mobile phone based on their physiological values. Alerts were also sent to a cardiologist’s mobile phone, as required. All clinicians involved in the study were also interviewed post-trial (N = 5). The interviews were recorded, transcribed, and then analyzed using a conventional content analysis approach.

Results

The telemonitoring system improved patient self-care by instructing the patients in real-time how to appropriately modify their lifestyle behaviors. Patients felt more aware of their heart failure condition, less anxiety, and more empowered. Many were willing to partially fund the use of the system. The clinicians were able to manage their patients’ heart failure conditions more effectively, because they had physiological data reported to them frequently to help in their decision-making (eg, for medication titration) and were alerted at the earliest sign of decompensation. Essential characteristics of the telemonitoring system that contributed to improved heart failure management included immediate self-care and clinical feedback (ie, teachable moments), how the system was easy and quick to use, and how the patients and clinicians perceived tangible benefits from telemonitoring. Some clinical concerns included ongoing costs of the telemonitoring system and increased clinical workload. A few patients did not want to be watched long-term while some were concerned they might become dependent on the system.

Conclusions

The success of a telemonitoring system is highly dependent on its features and design. The essential system characteristics identified in this study should be considered when developing telemonitoring solutions.

Key Words