Telemedicine and type 1 diabetes: Is technology per se sufficient to improve glycaemic control?

AimIn the TELEDIAB-1 study, the Diabeo system (a smartphone coupled to a website) improved HbA_1c by 0.9% vs controls in patients with chronic, poorly controlled type 1 diabetes. The system provided two main functions: automated advice on the insulin doses required; and remote monitoring by teleconsultation. The question is: how much did each function contribute to the improvement in HbA_1c?MethodsEach patient received a smartphone with an insulin dose advisor (IDA) and with (G3 group) or without (G2 group) the telemonitoring/teleconsultation function. Patients were classified as “high users” if the proportion of “informed” meals using the IDA exceeded 67% (median) and as “low users” if not. Also analyzed was the respective impact of the IDA function and teleconsultations on the final HbA_1c levels.ResultsAmong the high users, the proportion of informed meals remained stable from baseline to the end of the study 6 months later (from 78.1 ± 21.5% to 73.8 ± 25.1%; P = 0.107), but decreased in the low users (from 36.6 ± 29.4% to 26.7 ± 28.4%; P = 0.005). As expected, HbA_1c improved in high users from 8.7% [range: 8.3–9.2%] to 8.2% [range: 7.8–8.7%] in patients with (n = 26) vs without (n = 30) the benefit of telemonitoring/teleconsultation (−0.49 ± 0.60% vs −0.52 ± 0.73%, respectively; P = 0.879). However, although HbA_1c also improved in low users from 9.0% [8.5–10.1] to 8.5% [7.9–9.6], those receiving support via teleconsultation tended to show greater improvement than the others (−0.93 ± 0.97 vs −0.46 ± 1.05, respectively; P = 0.084).ConclusionThe Diabeo system improved glycaemic control in both high and low users who avidly used the IDA function, while the greatest improvement was seen in the low users who had the motivational support of teleconsultations.     

Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: A qualitative study embedded in a randomized controlled trial

ObjectiveTo explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD).MethodsSemi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient–practitioner relationships. Transcribed data were analyzed using the Framework approach.Results38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring.ConclusionTelemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of ‘compliant self-management’ may paradoxically have promoted dependence on professionals.Practice implicationsPatients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support.     

Does Home Telemonitoring after Pulmonary Rehabilitation Reduce Healthcare Use in Optimized COPD?? A Pilot Randomized Trial

ABSTRACT

Aim. To see if home telemonitors reduce healthcare use in those with optimized chronic obstructive pulmonary disease (COPD). Methods. We randomized 40 stable patients with moderate to severe COPD, who had completed at least 12 sessions of outpatient pulmonary rehabilitation (PR), to receive standard care (Controls) for 52 weeks or standard care plus Docobo HealthHUB monitors at home for 26 weeks followed by 26 weeks standard care (Tm Group). During the monitoring period, the Tm Group completed symptoms and physical observations twice daily which were stored and then uploaded at 2 am through a freephone landline. Nurses could access the data through a secure web site and received alerting e-mails if certain combinations of data occurred. Results. There were fewer primary care contacts for chest problems (p < 0.03) in the Tm group, but no differences between the groups in emergency room visits, hospital admissions, days in hospital or contacts to the specialist COPD community nurse team, during the monitoring period. After the monitors were removed, there were no differences between the groups for any of the health care contacts (p > 0.20 throughout). Conclusion. In stable, optimized COPD patients who have already completed PR, telemonitoring in addition to best care, reduces primary care chest contacts but not hospital or specialist team utilization.     

区域移动医疗健康服务体系研究

基于重庆市区域卫生信息平台,结合体域网技术,提出一个以疾病预防为主、分级协作的区域化移动医疗健康服务体系,具体介绍两级区域卫生信息平台建设、平台数据库设计、医疗健康监护中心及其终端设计情况,增加医疗资源利用率和优质资源的可及性。     

Telemonitoring in patients with heart failure, the TEHAF study: Study protocol of an ongoing prospective randomised trial

Background

As the prevalence of heart failure (HF) rises sharply, the costs related to the care of these patients increases in parallel. Considering the already limited resources and manpower, in the future the demand for care may exceed the supply. Therefore, health care systems are encouraged to develop innovative strategies to deal with the burden of HF to improve the quality of care in order to medical outcomes and patients’ quality of life. For that reason new management systems - such as telemonitoring - have to be explored.

Objectives

This paper outlines the study protocol of a tailor-made telemonitoring program in ambulant patients with HF.

Design and methods

A prospective randomised controlled trial is carried out at 3 hospitals in the South-Limburg area in the Netherlands. Primary outcome measures are hospital admissions and cost-effectiveness. Secondary outcomes are effects on therapy compliance, level of disease specific knowledge and quality of life. Also determinants are studied of most and less benefited patients in the intervention group.

Power calculation

It is estimated that 390 patients have to be included in the study, with 185 in each arm.

Results

Inclusion started in September 2007 with a follow-up time of 12 months. First results are expected at the end of 2010.     

Nursing and information and communication technology (ICT): a discussion of trends and future directions

This paper traces the development of information and communication (ICT) within health care and the emergence of telehealth as a key component of modern health care delivery as health care moves from the ‘face to face age’ to the ‘information age’. The paper examines the interface of ICT and nursing practice and highlights the limited evidence relating to the nursing contribution within telehealth particularly beyond data input and output analysis for other health care personnel. Additionally, the absence of research relating to the impact of ICT upon nurses and their working lives is identified. The paper concludes that nurses need to engage more fully with ICT so that they contribute to shaping the care system and emerge as leaders of the new care systems delivering future clinical activity.     

Diagnostic accuracy of a new detection algorithm for atrial fibrillation in cardiac telemonitoring with portable electrocardiogram devices

Background

Telemedical approaches targeting cardiac outpatients try to include electrocardiogram (ECG) analysis. Increasing numbers of monitored patients require automated preanalysis of the ECG to prioritize the evaluation for the clinical professional to enable an efficient intervention.

Methods

ECGs were recorded from 60 patients, both with a standard 12-lead ECG and with a new handheld ECG device having dry electrodes for direct skin contact. Recordings of the handheld device were automatically analyzed by a new algorithm. The 12-lead recordings were evaluated by a blinded cardiologist and then compared to the automated analysis of the handheld ECG. Sensitivity and specificity of the algorithm for the detection of atrial fibrillation (AF) were calculated.

Results

A total of 60 ECG strips having 122 ± 36 beats were registered. One hundred percent of the ECG strips were sufficient for automated heart rate count; 96.6%, for automated AF analysis; and 80%, for PQ, QRS, and QTc time measurements. AF detection had a sensitivity of 92.9% and a specificity of 90.9%. There was no difference in heart rate count between automated and manual analysis (median, 71 vs 70 beats per minute; P = .51). Automated measurements of a summary complex showed no difference for PQ time (165 vs 161 milliseconds, P = .50) but overestimated QRS (119 vs 90 milliseconds, P = .001) and QTc (489 vs 417 milliseconds, P < .001) times as compared to the 12-lead recordings analyzed manually.

Conclusion

The new algorithm is suitable for automated preanalysis of the ECG data with regard to AF. It could be used for rapid selection of ECGs with relevant rhythm abnormalities from a large pool. Electrocardiographic data remain to be evaluated by health care professionals for exact diagnosis.