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TELEmedicine and diabetes : the clinical evidence One big study, lot of small studies and some meta-analyses and systematic reviews The big study: IDEATEL Shea S, Starren J, Weinstock RS, Knudson PE, Teresi J, Holmes D, Palmas W, Field L, Goland R, Tuck C, WALTER PALMAS et.al. Recruitment and Enrollment of Rural and Urban Medically Underserved Elderly into a Randomized Trial of Telemedicine Case Management for Diabetes Care Moreno et.al Costs to Medicare of the IDEATel Home Telemedicine Demonstration: Findings from and Independent Evaluation. Diabetes Care 32:1202–1204, 2009 This study included patients more than 55 years in a federally underserved aread in New York , USA which need not to be computer literate. The originally eligible 9600 persons were randomized 1:1 to telemedicine and conventional therapy . Telecare patients received the HTU (through American Telecare) that cost approx. 3400 US$. It consists of a computer with internet and email, a videoconferencing system, and a glucose monitoring system ( Lifescan). Equipment with HL7-Standad and SSL-tunnel for upload of data (e.g to EMR). Case managers interacted with patients through HTU and case management software. Written remarks from case managers were supervised by diabetologists and changes were recommended by them. Private practicioners were informed by fax or email. Usual care was done by private pracitioners, they received guidelines, but nothing more.The groupes shrinked to 650 in the telecare group and to 750 in the usual care group. After one year HbA1c was 0,2% different between groups , favouring telecare (significant). In the Subgroup with HbA1c > 7%, the HbA1c improved from 8,5 to 7.78%. RR improves by 3.5 mmHG and LDL by 9 mmHG. There were 28 televisits in 1,5 years on average per patient, 560 glucose values were transfered and 98 blodd pressure values. The individual web site was opened 7 times and the educational web site 2 times. This approach it did not reduce Medicare use or costs for health services. The authorth conclude, that " The intervention's costs were excessive (over $8,000 per person per year) compared to programs with similar-sized clinical impacts". The pilot studies H. PETER CHASE et.al; Modem Transmission of Glucose Values Reduces the Costs and Need for Clinic Visits This study included 30 adolescents with diabetes in the telecare group and 33 in the control group. After six month there were equal improvements in HbA1c and other parameters , however, cost in the telecare group were lovwer than in the conventional group. This study ues the Roche Modem for data transmission. Sheila L Whittaker et.al. Success factors in the long-term sustainability his study focuses not on the technical implementation but is a good example how quality management brings diabetes care forward. The authors lok back on a ten year experiance with continuous improvement of their program. The continuous quality improvement (CQI) team focuses much on sustainability . The following three success factors were identified:
M. Jansa et.al. :Telecare in a structured therapeutic education programme addressed to patients with type 1 diabetes and poor metabolic control This study from Spain focuses both on metabolic outcome and costs . 40 Patients with type-1-diabetes were randomized. There were similar improvements of HbA1c in both groups, but costs were different favouring telecare. The system used was called glucobeep and is a relatively simple system, where the patient places a device on the microphone of the telephone. E.Biermann, W.Dietrich J. Rihl, E. Standl; Are there time and cost savings by using telemanagement for patients on intensified insulin therapy: A randomised controlled trial ; This pilot study , which used a modem for data transmission found no significant difference beween the telecare group and the conventional group with respect to medical outcome (HbA1c , hypo), but costs in the telecare group were lower. The study design was : face to face visits in the conventional group were equal in frequency and intensity compared to the telecare visits. Telecare was finished once the quality goals were achieved. VICTOR M. MONTORI et.al.;Telecare for Patients With Type 1Diabetes and Inadequate Glycemic Control This study with 31 patients with type-1-diabetes uses the Roche Modem in the telecare group. After 6 month, the telecare group had and HbA1c of 7,8% compared to 8,2% in the control group. An cost analysis was not performed, the nurse spent 50 min more time for patients in the telecare group . The study is difficult to compare to other telediabetes studies because the control group used a modem for data transmission as well. A meta-analysis is attached. Eberhard Biermann, Norm Bogner, Julian Rihl, and Eberhard Standl : Telecare for Patients with Type 1 Diabetes and Inadequate Glycemic Control: Response to Montori et al. This letter shed light on the question, why some studies find HbA1c improvements through telecare and others do not. The study-design is different! B. Liesenfeld, R.Renner, M.Neese and K.D.Hepp; Telemedical care reduces Hypoglycemias and Improves glycemic Control in Children and Adolescents with Type-1-Diabetes This pilot study finds a reduction of hypoglycemia in young patients with type-1-diabetes, a control group is not included. Augstein P et.al.; Outpatient assessment of Karlsburg Diabetes Management System-based decision support. This study evaluates the KADIS Decision support tool in insulin treated patients (not only type-1), includin continuous glucose monitoring data (CGMS) . R. Bellazzi ;et.al.; Management of Patients with Diabetes Through Information Technology: Tools for Monitoring and Control of the Patients' Metabolic Behaviour The M²DM Project These are two reports on the M2DM project, that was funded by the European Union (EU). The study included 30 tele-patients and 26 controls. The M²DM services will probalbly implemented in the small isle of Pantelleria, near Sicily. B.Rami et.al. ;Telemedical support to improve glycemic control in adolescents In the VIE-DIAB study from Austria , adolescents used a mobile phone and a cross-over design of two groups. Ther was a moderate improvement of HbA1c in the telecare arm. Costs were not considered in this study. Also GPRS (General Packet Radio Service) was used, not without causing problems. E.J. Gomez et al. Telemedicine as a tool for intensive management of daibetes: the DIABTel experiencer Comp. Meth.Prog Biomed. 69 (2002) 163-177 Report on a 6-month cross over study of type-1-diabetic patients from the most active group in Spain. Wojcicki JM ; What we can really expect from telemedicine in intensive diabetes treatment: results from 3-year study on type 1 pregnant diabetic women. The Polish experiance with pregant women demonstartes an improvement in the mean blood glucose. META-ANALYSIS and SYSTEMATIC REVIEWS Pamela S Whitten, et.al. Systematic review of cost effectiveness studies of telemedicine interventions THis very critical systematic review accepted only studies, that fullfilled strict requirements and focuses one the main issue of telemedicine namly the cost-effectiveness. A. Farmer, O. J. Gibson, L. Tarassenko A. Neil: systematic review of telemedicine interventions to support blood glucose self-monitoring in diabetes This metaanalysis , sponsored by Vodaphone and with comments from Prof Paul Glasziou find not strong evidence, that telecare is feasable, but " evidence for their effectiveness in improving HbA1cor reducing costs while maintaining HbA1c levels, or improving other aspects of diabetes management is not strong." However, the focus of this paper is more on HbA1c than on costs. William R Hersh, Mark Helfand; Clinical outcomes resulting from telemedicine interventions: a systematic review This meta-analysis on all aplication in health care has a section related to diabetes mellitus. The authors compare several studies, however, only the study of Marrero rate in the highest score for RCTs. Chandra L. Jackson,: A Systematic Review of Interactive Computer-assisted Technology in Diabetes Care This paper focuses not only on telecare applications in diabetes and gives an overview on other applications in diabetes care, where IT is used. M. Jaana and G. Paré This metaanalysis from Canada surveys 17 studies of diabetes care GUY PARÉ et.al.; ,Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base The same authors are comparing pulmonary diseases, hypertension, heart disease, diabetes on medical outcome and other issues. Verhoeven F, van Gemert-Pijnen L, Dijkstra K, Nijland N, Seydel E, Steehouder M htlm full text free and appendix pdf-download This review is the first to evaluate the benefits of both teleconsultation and videoconferencing for diabetes care, in particular with respect to clinical, behavioral, and care coordination aspects. A systematic search and selection process produced 39 studies. |