Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus Medicare payments, healthcare service use, and telemedicine implementation costs in a randomized trial comparing telemedicine case management with usual care in medically underserved participants with diabetes mellitus (IDEATel) Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial. The Informatics for Diabetes and Education Telemedicine (IDEATel) project. [Disease management for heart failure patients: role of wireless technologies for telemedicine. The ICAROS project]. Telemedicine Experience for Chronic Care in COPD Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes Tele-Mum: A Feasibility Study for a Randomized Controlled Trial Exploring the Potential for Telemedicine in the Diabetes Care of Those with Gestational Diabetes. An integrated wound-care pathway, supported by telemedicine, and competent wound management - Essential in follow-up care of adults with diabetic foot ulcers Costs to Medicare of the Informatics for Diabetes Education and Telemedicine (IDEATel) Home Telemedicine Demonstration Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project Managing hypertension in urban underserved subjects using telemedicine--a clinical trial. Telemedicine compared with standard care in type 2 diabetes mellitus: A randomized trial in an outpatient clinic Telemedicine for the Medicare population: pediatric, obstetric, and clinician-indirect home interventions. Telemedicine versus face to face patient care: effects on professional practice and health care outcomes. Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project. Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial. Smart Care Based on Telemonitoring and Telemedicine for Type 2 Diabetes Care: Multi-Center Randomized Controlled Trial. Telemedicine improves diagnosis of essential hypertension compared with usual care Glycemic Control and Health Disparities in Older Ethnically Diverse Underserved Adults With Diabetes Telemedicine improved diabetic management. Lessened decline in physical activity and impairment of older adults with diabetes with telemedicine and pedometer use: results from the IDEATel study.
CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care . OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older , ethnically diverse , medically underserved patients with diabetes . DESIGN , Setting , and Patients A r and omized controlled trial was conducted , comparing telemedicine case management to usual care , with blinded outcome evaluation , in 1,665 Medicare recipients with diabetes , aged > /= 55 years , residing in federally design ated medically underserved areas of New York State . Interventions Home telemedicine unit with nurse case management versus usual care . Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c ( HgbA1c ) , low density lipoprotein ( LDL ) cholesterol , and blood pressure levels . RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints ( HgbA1c , p = 0.001 ; LDL , p < 0.001 ; systolic and diastolic blood pressure , p = 0.024 ; p < 0.001 ) . Estimated differences ( 95 % CI ) in year 5 were 0.29 ( 0.12 , 0.46)% for HgbA1c , 3.84 ( -0.08 , 7.77 ) mg/dL for LDL cholesterol , and 4.32 ( 1.93 , 6.72 ) mm Hg for systolic and 2.64 ( 1.53 , 3.74 ) mm Hg for diastolic blood pressure . There were 176 deaths in the intervention group and 169 in the usual care group ( hazard ratio 1.01 [ 0.82 , 1.24 ] ) . CONCLUSIONS Telemedicine case management result ed in net improvements in HgbA1c , LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries . Mortality was not different between the groups , although power was limited . Trial Registration http:// clinical trials.gov Identifier : NCT00271739 BACKGROUND Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness . METHODS The authors conducted a r and omized , controlled trial comparing telemedicine case management to usual care , with blinding of those obtaining outcome data , in 1,665 Medicare recipients with diabetes , aged 55 years or greater , and living in federally design ated medically underserved areas of New York State . The primary endpoints were HgbA1c , blood pressure , and low-density lipoprotein ( LDL ) cholesterol levels . RESULTS In the intervention group ( n = 844 ) , mean HgbA1c improved over one year from 7.35 % to 6.97 % and from 8.35 % to 7.42 % in the subgroup with baseline HgbA1c > or = 7 % ( n = 353 ) . In the usual care group ( n = 821 ) mean HgbA1c improved over one year from 7.42 % to 7.17 % . Adjusted net reductions ( one-year minus baseline mean values in each group , compared between groups ) favoring the intervention were as follows : HgbA1c , 0.18 % ( p = 0.006 ) , systolic and diastolic blood pressure , 3.4 ( p = 0.001 ) and 1.9 mm Hg ( p < 0.001 ) , and LDL cholesterol , 9.5 mg/dL ( p < 0.001 ) . In the subgroup with baseline HgbA1c > or = 7 % , net adjusted reduction in HgbA1c favoring the intervention group was 0.32 % ( p = 0.002 ) . Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York . CONCLUSION Telemedicine case management improved glycemic control , blood pressure levels , and total and LDL cholesterol levels at one year of follow-up Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures , as measured by Medicare cl aims , and to assess the costs of developing and implementing the telemedicine intervention . Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine ( IDEATel ) , a r and omized controlled trial comparing telemedicine case management of diabetes to usual care . Participants were aged 55 years or older , and resided in federally design ated medically underserved areas of New York State . Measurements We analyzed Medicare cl aims payments for each participant for up to 60 study months from date of r and omization , until their death , or until December 31 , 2006 ( whichever happened first ) . We also analyzed study expenditures for the telemedicine intervention over six budget years ( February 28 , 2000- February 27 , 2006 ) . Results Mean annual Medicare payments ( SE ) were similar in the usual care and telemedicine groups , $ 9040 ( $ 386 ) and $ 9669 ( $ 443 ) per participant , respectively ( p>0.05 ) . Sensitivity analyses , including stratification by censored status , adjustment by enrollment site , and semi-parametric weighting by probability of dropping-out , rendered similar results . Over six budget years 28 821 participant/months of telemedicine intervention were delivered , at an estimated cost of $ 622 per participant/month . Conclusion Telemedicine case management was not associated with a reduction in Medicare cl aims in this medically underserved population . The cost of implementing the telemedicine intervention was high , largely representing special purpose hardware and software costs required at the time . Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used BACKGROUND Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems . In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus ( PPDM ) despite clinic-based care , we evaluated a comprehensive telemedicine intervention that we specifically design ed for delivery using existing Veterans Health Administration ( VHA ) clinical staffing and equipment . MATERIAL S AND METHODS We conducted a 6-month r and omized trial among 50 veterans with PPDM ; all maintained hemoglobin A1c ( HbA1c ) levels continuously > 9.0 % for > 1 year despite clinic-based management . Participants received usual care or a telemedicine intervention combining telemonitoring , medication management , self-management support , and depression management ; existing VHA clinical staff delivered the intervention . Using linear mixed models , we examined HbA1c , diabetes self-care ( measured by the Self-Care Inventory-Revised question naire ) , depression , and blood pressure . RESULTS At baseline , the model-estimated common HbA1c intercept was 10.5 % . By 6 months , estimated HbA1c had improved by 1.3 % for intervention participants and 0.3 % for usual care ( estimated difference , -1.0 % , 95 % confidence interval [ CI ] , -2.0 % , 0.0 % ; p = 0.050 ) . Intervention participants ' diabetes self-care ( estimated difference , 7.0 ; 95 % CI , 0.1 , 14.0 ; p = 0.047 ) , systolic blood pressure ( -7.7 mm Hg ; 95 % CI , -14.8 , -0.6 ; p = 0.035 ) , and diastolic blood pressure ( -5.6 mm Hg ; 95 % CI , -9.9 , -1.2 ; p = 0.013 ) were improved versus usual care by 6 months . Depressive symptoms were similar between groups . CONCLUSIONS A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care . Because we specifically design ed this intervention with scalability in mind , it may represent a practical , real-world strategy to reduce the burden of poor diabetes control among veterans Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness . We conducted a r and omized controlled trial comparing telemedicine case management to usual care , with blinding of those obtaining outcome data , in 1,665 Medicare recipients with diabetes , aged 55 years or greater , and living in federally design ated medically underserved areas of New York State . In New York City , 98 % of participants were black or Hispanic , 69 % were Medicaid-eligible , and 93 % reported annual household income < or = $ 20,000 . In upstate New York , 91 % were white , 14 % Medicaid eligible , and 50 % reported annual household income < or = $ 20,000 . A baseline survey found that 95 % of participants in New York City and 67 % in upstate New York reported that they did not know how to use a computer . The primary endpoints were HgbA1c , blood pressure , and low density lipoprotein ( LDL ) cholesterol levels . In the intervention group ( N = 844 ) , mean HgbA1c improved over 1 year from 7.35 % to 6.97 % , and from 8.35 % to 7.42 % in the subgroup with baseline HgbA1c > or = 7 % ( N = 353 ) . In the usual care group ( N = 821 ) , mean HgbA1c improved over 1 year from 7.42 % to 7.17 % . Adjusted net reductions ( 1-year minus baseline mean values in each group , compared between groups ) favoring the intervention were as follows : HgbA1c , 0.18 % ( p = 0.006 ) , systolic and diastolic blood pressure , 3.4 ( p = 0.001 ) and 1.9 mmHg ( p < 0.001 ) , and LDL cholesterol , 9.5 mg/dl ( p < 0.001 ) . In the subgroup with baseline HgbA1c > or = 7 % , net adjusted reduction in HgbA1c favoring the intervention group was 0.32 % ( p = 0.002 ) . Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dl . The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York . A satisfaction survey of intervention group participants ( N = 346 respondents ) showed high levels of satisfaction with major intervention components . A satisfaction survey of participating primary care physicians ( N = 116 respondents ) showed positive perceptions for acceptability , impact on patients and communication .  Telemedicine case management  improved glycemic control , blood pressure levels , and total and LDL-cholesterol levels at 1 year of follow-up . Telemedicine is an effective method for translating modern approaches to disease management into effective care for underserved population Healthcare costs for heart failure are increasing . The need for a better care , however , has to be matched with a policy of cost containment . A way to improve the cost-effectiveness of heart failure care is the disease management approach , in which therapy , education and follow-up are tailored for each patient by a multidisciplinary team . Such a complex intervention can be facilitated by the use of telemedicine , which allows the remote control of considerable amounts of clinical data . In Italy , a few studies with telemedicine have been reported . A recent development in this field is represented by the ICAROS project ( Integrated Care vs Conventional Intervention in Cardiac Failure Patients : R and omized Open Label Study ) , whose aim is to improve the clinical and psychological care of heart failure patients employing advanced wireless telecommunication technology . So far , we r and omized 60 patients : 30 in usual ambulatory care , 30 in an intensive treatment group . The latter patients were instructed to use a portable computer to get in touch daily with the heart failure clinic and receive feedback instruction for the management of drug therapy and daily problems .  At the first year of follow-up , the treatment group showed good compliance to drug prescriptions , and could easily h and le the portable computer . The preliminary results of this ongoing study support the feasibility and appropriateness of new technologies for the management of heart failure , even in elderly patients in whom a limited expertise with these appliances could have been anticipated Information and telecommunication technologies are called to play a major role in the changes that healthcare systems have to face to cope with chronic disease . This paper reports a telemedicine experience for the home care of chronic patients suffering from chronic obstructive pulmonary disease ( COPD ) and an integrated system design ed to carry out this experience . To determine the impact on health , the chronic care telemedicine system was used during one year ( 2002 ) with 157 COPD patients in a clinical experiment ; endpoints were readmissions and mortality . Patients in the intervention group were followed up at their homes and could contact the care team at any time through the call center . The care team shared a unique electronic chronic patient record ( ECPR ) accessible through the web-based patient management module or the home visit units . Results suggest that integrated home telemedicine services can support health professionals caring for patients with chronic disease , and improve their health . We have found that simple telemedicine services ( ubiquitous access to ECPR , ECPR shared by care team , accessibility to case manager , problem reporting integrated in ECPR ) can increase the number of patients that were not readmitted ( 51 % intervention , 33 % control ) , are acceptable to professionals , and involve low installation and exploitation costs . Further research is needed to determine the role of telemonitoring and televisit services for this kind of Diabetes case management ( DCM ) may improve medical outcomes ( 1,2 ) . Case managers coordinate care and often provide a mix of interventions , e.g. , telephone outreach , education , reminders . However , the efficacy of DCM is unclear . Three systematic review s lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid , weight , or blood pressure benefits ( 3–5 ) . DCM studies typically target biomedical outcomes and ignore potential psychosocial effects . Yet , psychosocial variables ( e.g. , depression , anxiety , social support ) relate to hyperglycemia , complications , adherence , and quality of life ( 6–11 ) . Thus , a positive impact of DCM on these factors is important . Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction ( cluster visit ) ( 12 ) and quality of life ( dietitian-led DCM group ) ( 13 ) . Because barriers ( e.g. , distance , weather ) limit DCM access , telemedicine can be used . A review of telemedicine versus face-to-face trials concluded that , while feasible and acceptable , there is little evidence that telemedicine has clinical benefits ( 14 ) . Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients ( 15 ) . The intervention result ed in significant improvements in glycemic control , blood pressure , and total and LDL cholesterol ( 16 ) . The purpose of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project , funded by the Centers for Medicare and Medicaid Services , is to evaluate the feasibility and effectiveness of telemedicine with a diverse , medically underserved , elderly diabetic sample . The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes . A detailed description of the IDEATel study design has been previously reported ( 15,16 ) . Medicare recipients were recruited if they were aged ≥55 years , diagnosed with diabetes , and without moderate/severe impairments or comorbidities . Research nurses blinded to the groups BACKGROUND The incidence of gestational diabetes mellitus (GDM)--hyperglycemia with onset or first recognition during pregnancy -- is increasing and will have a significant impact on diabetes services . This study aim ed to determine the feasibility and acceptability of using telemedicine in the diabetes care of women with GDM and the possibility of replacing alternate ( one in every two ) diabetes review appointments with telemedicine . SUBJECTS AND METHODS A feasibility study for a r and omized controlled trial was conducted across two sites . Fifty women with GDM were r and omized to usual care ( n = 26 ) or usual care plus telemedicine ( n = 24 ) . Telemedicine entailed weekly blood pressure and weight measurements and transmission of these data , along with blood glucose readings , for review by the healthcare team . Patients were contacted about these results as necessary . Patients completed question naires to measure their satisfaction with telemedicine or blood glucose monitoring .  The intervention group and healthcare providers also took part in qualitative interviews . Analysis involved descriptive statistics for the satisfaction question naires and framework analysis for the qualitative interviews . RESULTS Eighty-nine percent of patients were satisfied with telemedicine and would use it again . Both HCPs and patients found the equipment easy to use and were positive about using it to replace alternate diabetes review appointments in the future . If used in this way , healthcare providers felt that protected time in which to perform the telemedicine review would be necessary . CONCLUSIONS Telemedicine may help meet the growing dem and on diabetes services due to increasing numbers of women being diagnosed with GDM INTRODUCTION Diabetic foot ulcers are a feared complication of diabetes . Care delivered via telemedicine is suggested to be a more integrated care pathway to manage diabetic foot ulcers than traditionally delivered healthcare . Our aim was to explore patients ' experiences with telemedicine follow-up care as compared to traditional care . METHODS Interpretive description was used as an analysis strategy . Data were collected using individual semi-structured interviews in the context of a larger ongoing clustered r and omized controlled trial . Twenty-four patients ( 13 in the intervention group ; 11 in the control group ) , aged 38 - 88 years were purposively recruited from the RCT in order to obtain a diverse sample in terms of group composition ( intervention vs. control ) , age , gender , marital status , setting , and comorbidities present . The control group received traditional care . RESULTS Three themes emerged from the interpretive analysis : competence of healthcare professionals , continuity of care , and easy access . This was independed of types of follow-up that had limited impact on the patients ' follow-up experiences . Competence of healthcare professionals and continuity of care were crucial , because they can either enhance or jeopardize wound care . If these two latter factors were absent , patients would lose confidence in the wound care process . If this happened , patients pointed out that the expert knowledge of a specialist clinic was essential to receive good care . When telemedicine functioned optimally , telemedicine was an advantage in the treatment , because the images quickly captured changes in the wound healing that immediately could be corrected . Easy access is important for patients , but the importance of accessibility appears to be primary when the other two factors were present . CONCLUSION The best wound care pathway for patients with diabetes foot ulcers is depended on a combination of competence and professional skills in wound management , and continuity of care . If telemedicine is functioning as intended , it can be an important additional tool OBJECTIVE To estimate the impacts on Medicare costs of providing a particular type of home telemedicine to eligible Medicare beneficiaries with type 2 diabetes . RESEARCH DESIGN AND METHODS Two cohorts of beneficiaries ( n = 1,665 and 504 , respectively ) living in two medically underserved areas of New York between 2000 and 2007 were r and omized to intensive nurse case management via televisits or usual care .  Medicare service use and costs covering a 6-year follow-up period were drawn from cl aims data . Impacts were estimated using regression analyses . RESULTS Informatics for Diabetes Education and Telemedicine ( IDEATel ) did not reduce Medicare costs in either site . Total costs were between 71 and 116 % higher for the treatment group than for the control group . CONCLUSIONS Although IDEATel had modest effects on clinical outcomes ( reported elsewhere ) , it did not reduce Medicare use or costs for health services . The intervention 's costs were excessive ( over $ 8,000 per person per year ) compared with programs with similar-sized clinical impacts Objectives . Adherence to diabetes self care is poor for Hispanic American and African-American patients . This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients . We also examined whether adherence mediated the effect of the intervention on glycemic control ( A1c ) . Design . The Informatics for Diabetes Education and Telemedicine project r and omized medically underserved Medicare patients ( n=1665 ) to telemedicine case management ( televideo educator visits , individualized goal - setting /problem solving ) or usual care .  Hispanic and African-American educators delivered the intervention in Spanish if needed . Main outcome measures . Annual assessment included A1c and self-reported adherence ( Summary of Diabetes Self-Care Activities scale ) . A simple model ( only time and group terms ) and a model with covariates ( e.g. , age ) were examined for baseline and 5 years of follow-up . SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c , by performing tests of the mediating path coefficients . Results . Over time , self-reported adherence improved for the treatment group compared to usual care ( p<0.001 ) . There was no significant interaction with racial/ethnic group membership , i.e. , all groups improved . However , minority subjects were consistently less adherent than whites . Also , greater comorbidity and diabetes symptoms predicted poorer adherence , greater duration of diabetes and more years of education predicted better adherence . Adherence was a significant mediator of A1c ( p<0.001 ) . Conclusions . A unique , tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care . However , African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention . The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity BACKGROUND We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure ( BP ) in underserved subjects with hypertension . METHODS A total of 241 patients with systolic BP ≥140 mm Hg were r and omized to usual care ( C ; n = 121 ) or telemedicine  ( T ; n = 120 ) . The T group reported BP , heart rate , weight , steps/day , and tobacco use twice weekly . The primary outcome was BP control at 6 months . RESULTS Average age was 59.6 years , average body mass index was 33.7 kg/m(2 ) , 79 % were female , 81 % were African American , 15 % were white , 53 % were at or below the federal poverty level , 18 % were smokers , and 32 % had diabetes . Six-month follow-up was achieved in 206 subjects ( C : 107 , T : 99 ) . Goal BP was achieved in 52.3 % in C and 54.5 % in T ( P = .43 ) . Systolic BP change ( C : -13.9 mm Hg , T : -18.2 ; P = .118 ) was similar in both groups . Subjects in the T group reported BP 7.7 ± 6.9 d/mo . Results were not affected by age , sex , ethnicity , education , or income . In nondiabetic T subjects , goal BP was achieved in 58.2 % compared with 45.2 % of diabetic T subjects ( P = .024 ) . Nondiabetic T subjects demonstrated a greater reduction in systolic BP ( T : -19 ± 20 mm Hg , C : -12 ± 19 mm Hg ; P = .037 ) . No difference in BP response between C and T was noted in patients with diabetes . CONCLUSION In hypertensive subjects , engagement in a system of care with or without telemedicine result ed in significant BP reduction . Telemedicine for nondiabetic patients result ed in a greater reduction in systolic BP compared with usual care . Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects Introduction Good metabolic control is important in type 2 diabetes mellitus to improve quality of life , work ability and life expectancy , and the use of telemedicine has proved efficient as an add-on to the usual treatment . However , few studies in type 2 diabetes patients have directly compared telemedicine with conventional outpatient treatment , and we wanted to evaluate whether telemedicine , compared with st and ard care , provides equivalent clinical outcomes . Methods Forty patients with type 2 diabetes mellitus allocated from October 2011–July 2012 were r and omized to either treatment at home by video conferences only or st and ard outpatient treatment . Primary outcomes were HbA1c and blood glucose levels and secondary outcomes were 24-hour blood pressure , cholesterol levels and albuminuria . The video-telephone was a broadb and solution installed and serviced by the Danish Telephone Company ( TDC ) . Results The improvements in the two treatments , given as changes in percentage of telemedicine vs st and ard , showed significant differences in HbA1c ( −15 vs −11 % ) , mean blood glucose ( −18 vs −13 % ) and in cholesterol ( −7 vs −6 % ) . No differences in LDL ( −4 vs −6 % ) , weight ( −1 vs 2 % ) , diastolic diurnal blood pressure ( −1 vs −7 % ) , and systolic diurnal blood pressure ( 0 vs −1 % ) were found . Nine consultations were missed in the st and ard outpatient group and none in the telemedicine group . Conclusions In the direct comparison of home video consultations vs st and ard outpatient treatment in type 2 diabetes mellitus , telemedicine was a safe and available option with favourable outcomes after six months treatment BACKGROUND This report is a supplement to an earlier evidence report ,  Telemedicine for the Medicare Population , which was intended to help policymakers weigh the evidence relevant to coverage of telemedicine services under Medicare . That report focused on telemedicine programs and clinical setting s that had been used with or were likely to be applied to Medicare beneficiaries . While we prepared that report , it became apparent that there are also telemedicine studies among non-Medicare beneficiaries -- e.g . , children and pregnant women -- that could inform policymakers and provide more comprehensive evidence of the state of the science regarding telemedicine applications . In addition , the first evidence report only partially included a class of telemedicine applications ( called self-monitoring/testing telemedicine ) in which the beneficiary used a home computer  or modern-driven telephone system  to either report information or access information and support from Internet re sources and indirectly interact with a clinician . Self-monitoring/testing applications in the first report required direct interaction with a clinician . The goal of this report is to systematic ally review the evidence in the clinical areas of pediatric and obstetric telemedicine as well as home-based telemedicine where there is indirect involvement of the health care professional . ( In this report , we will refer to the latter as clinician-indirect home telemedicine . ) Specifically , the report summarizes scientific evidence on the diagnostic accuracy , access , clinical outcomes , satisfaction , and cost-effectiveness of services provided by telemedicine technologies for these patient groups . It also identifies gaps in the evidence and makes recommendations for evaluating telemedicine services for these population s in the future . The evidence is clustered according to three categories of telemedicine service defined in our original report : store- and -forward , self-monitoring/testing , and clinician-interactive services . The three clinical practice areas review ed in this report are defined as follows . The term pediatric applies to any telemedicine study in which the sample consisted wholly or partially of persons aged 18 or younger , including studies with neonatal sample s. The term obstetric applies to any telemedicine study in which the sample consisted entirely of women seeking pregnancy-related care . The term clinician-indirect home telemedicine applies to home-based telemedicine ( called self-monitoring/testing in our original report ) where a telemedicine application used in the home has only indirect involvement by the health care professional . Interactive home telemedicine was applied in this report to all patient population s. KEY QUESTIONS The key questions that served as a guide for review ing the literature in the evaluation of pediatric , obstetric , and clinician-indirect  home telemedicine applications were derived by consensus among the evidence - review team based on the analytic framework established for the original evidence report . For the current report , the questions were applied to studies in all three practice areas as a whole group within each of the three categories of telemedicine services : store- and -forward ; self-monitoring/testing ; and clinician-interactive . The specific key questions were : 1 . Does telemedicine result in comparable diagnosis and appropriateness of recommendations for management ? 2 . Does the availability of telemedicine provide comparable access to care ? 3 . Does telemedicine result in comparable health outcomes ? 4 . Does telemedicine result in comparable patient or clinician satisfaction with care ? 5 . Does telemedicine result in comparable costs of care and /or cost-effectiveness ? METHODS We search ed for peer- review ed literature using several bibliographic data bases . In addition , we conducted h and search es of leading telemedicine journals and identified key papers from the reference lists of journal articles . For our original evidence report on telemedicine for the Medicare population , we design ed a search to find any publications about telemedicine and used it to search the MEDLINE , CINAHL , and HealthSTAR data bases for all years the data bases were available . Through this process , we captured studies of pediatric , obstetric , and clinician-indirect home telemedicine ; however , they were excluded from the original report since they were outside its scope . For this supplemental report , we review ed our original search results and identified studies relevant to this report . We identified additional studies from the reference lists of included papers and from h and search ing two peer- review ed telemedicine publications , the Journal of Telemedicine and Telecare and Telemedicine Journal . We critically appraised the included studies for each study area and key question and discussed the strengths and limitations of the most important studies at weekly meetings of the research team . We also developed recommendations for research to address telemedicine knowledge gaps . To match these gaps with the capabilities of specific research methods , we classified the telemedicine services according to the type of evidence that would be needed to determine whether the specific goals of covering such services had been met . We emphasized the relationship between the type and level of evidence found in the systematic review of effectiveness and the types of studies that might be funded to address the gaps in knowledge in this growing field of research . FINDINGS We identified a total of 28 eligible studies . In the new clinical areas , we found few studies in store- and -forward telemedicine . There is some evidence of comparable diagnosis and management decisions made using store- and -forward telemedicine from the areas of pediatric dental screening , pediatric ophthalmology , and neonatalogy . In self-monitoring/testing telemedicine for the areas of pediatrics , obstetrics , and clinician-indirect home telemedicine , there is evidence that access to care can be improved when patients and families have the opportunity to receive telehealth care at home rather than in-person care in a clinic or hospital . Access is particularly enhanced when the telehealth system enables timely communication between patients or families and care providers that allows self-management and necessary adjustments that may prevent hospitalization . There is some evidence that this form of telemedicine improves health outcomes , but the study sample sizes are usually small , and even when they are not , the treatment effects are small . There is also some evidence for the efficacy of clinician-interactive telemedicine , but the studies do not clearly define which technologies provide benefit or cost-efficiency . Some promising areas for diagnosis include emergency medicine , psychiatry , and cardiology . Most of the studies measuring access to care provide evidence that it is improved . Although none of these studies were r and omized controlled trials , they provide some evidence of access improvement over prior conditions . Clinician-interactive telemedicine was the only area for which any cost studies were found . The three cost studies did not adequately demonstrate that telemedicine reduces costs of care ( except comparing only selected costs ) . No study addressed cost-effectiveness . CONCLUSIONS This supplemental report covering the areas of pediatrics , obstetrics , and indirect-clinician home telemedicine echoes the findings of our initial report for the Medicare domain , which is that while the use of telemedicine is small but growing , the evidence for its efficacy is incomplete . Many of the studies are small and /or method ologically limited , so it can not be determined whether telemedicine is efficacious . Future studies should focus on the use of telemedicine in conditions where burden of illness and /or barriers to access for care are significant . Use of recent innovations in the design of r and omized controlled trials for emerging technologies would lead to higher quality studies . Journals publishing telemedicine evaluation studies must set high st and ards for method ologic quality so that evidence reports need not rely on studies with marginal method ologies Background Telemedicine is the use of telecommunications technology for medical diagnosis and patient care . From its beginnings telemedicine has been used in a variety of health care fields , although widespread interest among healthcare providers has only now become apparent with the development of more sophisticated technology . Objectives To assess the effects of telemedicine as an alternative to face-to-face patient care . Search methods We search ed the Effective Practice and Organisation of Care Group 's specialised register , The Cochrane Library , MEDLINE ( 1966-August 1999 ) , EMBASE ( to 1996 ) , CINAHL ( to August 1999 ) , Inspec ( to August 1996 ) , Healthstar ( 1983 - 1996 ) , OCLC , Sigle ( to 1999 ) , Assia , SCI ( 1981 - 1997 ) , SSCI ( 1981 - 1997 ) , DHSS- Data . We h and search ed the Journal of Telemedicine and Telecare ( 1995 - 1999 ) , Telemedicine Journal ( 1995 - 1999 ) and reference lists of articles . We also h and search ed conference proceedings and contacted experts in countries identified as having an interest in telemedicine . Selection criteria R and omised trials , controlled before and after studies and interrupted time series comparing telemedicine with face-to-face patient care .  The participants were qualified health professionals and patients receiving care through telemedicine .  Data collection and analysis Two review ers independently assessed trial quality and extracted data . Main results Seven trials involving more than 800 people were included . One trial was concerned with telemedicine in the emergency department , one with video-consultations between primary health care and the hospital out patients department , and the remainder were concerned with the provision of home care or patient self-monitoring of chronic disease . The studies appeared to be well conducted , although patient numbers were small in all but one . Although none of the studies showed any detrimental effects from the interventions , neither did they show unequivocal benefits and the findings did not constitute evidence of the safety of telemedicine . None of the studies included formal economic analysis . All the technological aspects of the interventions appear to have been reliable , and to have been well accepted by patients . Authors ' conclusions Establishing systems for patient care using telecommunications technologies is feasible , but there is little evidence of clinical benefits . The studies provided variable and inconclusive results for other outcomes such as psychological measures , and no analysable data about the cost effectiveness of telemedicine systems . The review demonstrates the need for further research and the fact that it is feasible to carry out r and omised trials of telemedicine applications . Policy makers should be cautious about recommending increased use and investment in unevaluated technologies BACKGROUND We examine the changes in waist circumference ( WC ) and body mass index ( BMI ) in older adults enrolled in a diabetes telemedicine program . The subjects were elderly Medicare beneficiaries participating in the rural ( upstate New York ) cohort of Informatics and Diabetes Education and Telemedicine , a r and omized , controlled trial using telemedicine to improve diabetes care in which the primary outcome was glycemic control . METHODS Ninety-two percent of the subjects had BMI > 25 kg/m(2 ) , and 65.8 % had a BMI > or = 30 kg/m(2 ) . Intervention subjects received home televisits with a dietitian or nurse educator every 4 - 6 weeks .  Blood glucose and blood pressure values  were review ed , and lifestyle and medication changes were recommended . Non-intervention subjects received usual care through their primary care physicians . Change in WC , BMI , diet , and exercise behaviors and knowledge were examined at baseline and 12 and 24 months . A mixed-effects path analysis was performed to examine direct and indirect effects . RESULTS The telemedicine participants increased diet and exercise knowledge over time ( P < 0.001 ) . It was estimated that women in the  telemedicine  group reduced their WC over the 2 years by 1.2 cm , whereas women in the usual care group increased their WC by almost 1 cm ( P = 0.02 ) . Path analysis demonstrated that the intervention , through improved diet and exercise knowledge , was related to the decrease in WC ( P = 0.006 ) and BMI ( P = 0.004 ) . CONCLUSIONS Diabetes case management using telemedicine improved self-reported diet and exercise knowledge , practice s , and behaviors , which in turn was associated with reductions in WC and BMI at 2 years OBJECTIVE To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities , including American Indian/Alaska Natives . SUBJECTS AND METHODS We conducted a multicenter , r and omized controlled trial and assigned diabetic participants to one of two groups : ( 1 ) telemedicine with a nonmydriatic camera or ( 2 ) traditional surveillance with an eye care provider . For those receiving telemedicine , the criteria for requiring follow-up with an eye care provider were ( 1 ) moderate nonproliferative diabetic retinopathy or higher , ( 2 ) presence of clinical ly significant macular edema , or ( 3 ) " unable to grade " result for diabetic retinopathy or macular edema . RESULTS The telemedicine group ( n=296 ) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group ( n=271 ) ( 94 % versus 56 % , p<0.001 ) . The overall prevalence of diabetic retinopathy at baseline was 21.4 % , and macular edema was present in 1.4 % of participants . In the telemedicine group , 20.5 % would require further evaluation with an eye care provider , and 86 % of these referrals were because of poor- quality digital images . CONCLUSIONS Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations , and most did not require follow-up with an eye care provider . Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider . Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations BACKGROUND This study was performed to determine the effectiveness of the Smart Care service on glucose control based on telemedicine and telemonitoring compared with conventional treatment in patients with type 2 diabetes . MATERIAL S AND METHODS This 24-week prospect i ve multi-center r and omized controlled trial involved 338 adult patients with type 2 diabetes at four university hospitals in South Korea . The patients were r and omly assigned to a control group ( group A , n = 113 ) , a telemonitoring group ( group B , n = 113 ) , or a telemedicine group ( group C , n = 112 ) . Patients in the telemonitoring group visited the outpatient clinic regularly , accompanied by an additional telemonitoring service that included remote glucose monitoring with automated patient decision support by text . Remote glucose monitoring was identical in the telemedicine group , but assessment by outpatient visits was replaced by video conferencing with an endocrinologist . RESULTS The adjusted net reductions in HbA1c concentration after 24 weeks were similar in the conventional , telemonitoring , and telemedicine groups ( -0.66 % ± 1.03 % vs. -0.66 % ± 1.09 % vs. -0.81 % ± 1.05 % ; p > 0.05 for each pairwise comparison ) . Fasting glucose concentrations were lower in the telemonitoring and telemedicine groups than in the conventional group . Rates of hypoglycemia were lower in the telemedicine group than in the other two groups , and compliance with medication was better in the telemonitoring and telemedicine than in the conventional group . No serious adverse events were associated with telemedicine . CONCLUSIONS Telehealthcare was as effective as conventional care at improving glycemia in patients with type 2 diabetes without serious adverse effects A r and omized controlled trial was conducted to assess the efficacy of a telemedicine service for the diagnosis of essential hypertension . The telemedicine service consisted of using an automatic home blood pressure monitor connected to an ordinary telephone line for the transmission of the data to a central computer . After use of the home monitor for a week , the results were converted to a report form and faxed to the patient 's physician . The gold st and ard for assessment of true hypertension status was 24 h ambulatory blood pressure monitoring . A total of 74 patients from outpatient clinics were r and omized into either the  telemedicine service  or  usual care . Use of the telemedicine service significantly improved the detection of essential hypertension compared with usual care : in the telemedicine group , 64 % of patients with essential hypertension were diagnosed ; in the usual care group , 26 % of patients with essential hypertension were diagnosed . Furthermore , diagnosis occurred earlier in the telemedicine group than in patients receiving usual care .  Specificity and positive predictive value were similar in the two groups OBJECTIVE The Informatics for Diabetes Education and Telemedicine ( IDEATel ) project r and omized ethnically diverse underserved older adults with diabetes to a telemedicine intervention or usual care .  Intervention participants had lower A1C levels over 5 years . New analyses were performed to help better underst and this difference . RESEARCH DESIGN AND METHODS IDEATel r and omized Medicare beneficiaries with diabetes ( n = 1,665 ) to receive home video visits with a diabetes educator and upload glucose levels every 4–6 weeks or usual care ( 2000–2007 ) . Annual measurements included BMI , A1C ( primary outcome ) , and completion of question naires . Mixed-model analyses were performed using r and om effects to adjust for clustering within primary care physicians . RESULTS At baseline , A1C levels  ( mean ± SD ) were 7.02 ± 1.25 % in non-Hispanic whites ( n = 821 ) , 7.58 ± 1.78 % in non-Hispanic blacks ( n = 248 ) , and 7.79 ± 1.68 % in Hispanics ( n = 585 ) . Over time , lower A1C levels were associated with more glucose uploads ( P = 0.02 ) and female sex ( P = 0.002 ) . Blacks , Hispanics , and insulin-users had higher A1C levels than non-Hispanic whites ( P < 0.0001 ) . BMI was not associated with A1C levels . Blacks and Hispanics had significantly fewer uploads than non-Hispanic whites over time . Hispanics had the highest baseline A1C levels and showed the greatest improvement in the intervention , but , unlike non-Hispanic whites , Hispanics did not achieve A1C levels < 7.0 % at 5 years . CONCLUSIONS Racial/ethnic disparities were observed in this cohort of underserved older adults with diabetes . The IDEATel telemedicine intervention was associated with improvement in glycemic control , particularly in Hispanics , who had the highest baseline A1C levels , suggesting that telemedicine has the potential to help reduce disparities in diabetes management Effective control of diabetes is known to delay or prevent the end-organ complications of this disease . Can telemedicine improve a patient 's ability to self-manage diabetes  ? Twenty-eight patients entered a study comparing home telemedicine consultation with st and ard outpatient care . A nurse case manager contacted the telemedicine group once a week under the direction of a primary care physician , who contacted the telemedicine group once a month . Laboratory studies and total body weight were measured at the beginning and at the end of the 3-month study . The hemoglobin A1c ( HbA1c ) and total body weight improved significantly in the intervention ( telemedicine ) group , as shown by a 16 % reduction in mean HbA1c level ( from 9.5 to 8.2 % ) and a 4 % mean weight reduction ( from 214.3 to 206.7 pounds ) . Based on our experience , we present a functionally based telemedicine classification system to improve the application of electronic medicine in future studies OBJECTIVE to examine the effects of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) telemedicine intervention and pedometer use on physical activity ( PA ) and impairment in older adults with diabetes . DESIGN r and omised clinical trial . Subjects ethnically diverse medically underserved Medicare beneficiaries with diabetes ( n= 1,650 ) . METHODS participants received home videovisits with a diabetes educator every 4 - 6 weeks or usual care . All received a pedometer . Annual measurements included hemoglobin A1c , Comprehensive Assessment and Referral Evaluation Activities of Daily Living , Diabetes Self-Care Activities , Charlson Comorbidity Index , Luben Social Support and pedometer use . Mixed model analyses were performed using r and om effects to adjust for clustering within primary care physicians . RESULTS in the telemedicine group compared with the usual care group , the rate of decline in PA ( P= 0.0128 ) and physical impairment ( PI ) ( P= 0.0370 ) was significantly less over time . Significant mean endpoint differences were observed for PA ( P= 0.003 ) . Pedometer use was significantly associated with PA ( P= 0.0006 ) and PI ( P < 0.0001 ) . Baseline characteristics associated with greater PA included having fewer comorbid conditions ( P= 0.0054 ) , less depression ( P < 0.0001 ) , more social networking ( P < 0.0001 ) , lower BMI ( P < 0.0001 ) , male gender ( P < 0.0001 ) and lower hemoglobin A1c level ( P= 0.0045 ) . Similar predictors were observed for PI , except duration of diabetes also predicted increased impairment ( P < 0.0001 ) . Significant indirect effects were observed through use of the pedometer on reduced decline in PA ( P= 0.0024 , 0.0013 ) and PI ( P= 0.0024 , P < 0.0001 ) . CONCLUSIONS this telemedicine intervention reduced rates of decline in PA and impairment in older adults with diabetes . Pedometers may be a helpful inexpensive adjunct to diabetes initiatives delivered remotely with emerging technologies . Clinical Trials.gov identifier NCT 00271739
Telemedicine had no convincing effect on quality of life , mortality or hypoglycemia .
INTERPRETATION : Compared with usual care , the addition of telemedicine , especially systems that allowed medication adjustments with or without text messaging or a Web portal , improved HbA1C but not other clinical ly relevant outcomes among patients with diabetes
BACKGROUND : Telemedicine , the use of telecommunications to deliver health services , expertise and information , is a promising but unproven tool for improving the quality of  diabetes care  .
We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care .