Telemedicine Strategy With Home Treatment Save Resources
Condition: Type 2 Diabetes Mellitus
MeSH terms: Diabetes Mellitus, Type 2
Study type: Interventional

Summary: 
      Progress in technology has made telemedicine-based solutions with video consultations
      available in the management and treatment of chronic diseases like diabetes, heart failure
      and lung insufficiency at home. However, no direct comparisons on health outcomes of
      telemedicine using video consultations versus usual outpatient treatment are available.

      We wanted to implement a model of telemedicine and to evaluate health indicators in type 2
      diabetes patients treated by video consultations or the standard outpatient treatment
    

Detailed description: 
      Chronic illnesses, such as asthma, diabetes, heart failure, and hypertension, represent a
      significant burden of disease Chronic diseases also impose huge costs on the health care
      systems responsible for managing them as well as their significance for those affected.

      Non-pharmacological treatment is mandatory for type 2 diabetes patients characterized by
      central obesity, sedentary lifestyle, and overeating (1). Secondary failure to reach
      treatment goals despite an extensive National diabetes rehabilitation program in Denmark is
      often seen (2). Outpatient control shows positive effects on outpatient rehabilitation (3)
      reducing HbA1c, weight, and blood pressure. However, some patients never accomplish good
      diabetes regulation and in others regulation deteriorates over time. New approaches are
      required and need testing to motivate and give feedback to the patients at home. Telemedicine
      has the capacity to achieve this, where a diabetic nurse may optimize motivation, treatment,
      and diet through direct feedback adapted to milieu of the patient in accordance with a
      potential spouse.

      Good metabolic control is important as diabetes is inevitable a factor for increased risk of
      cardiovascular disease, neuropathy, and nephropathy (4). The quality of life and reduction in
      work ability is affected, thus, life expectancy is shortened by 6-8 years. Multi-factorial
      intervention may delay this (5).

      The high incidence of the serious implications strengthens the importance of achieving good
      metabolic control through lifestyle changes. Health education shows reduction in
      cardiovascular risk factors (6-8), which often disappears after the end of the intervention
      (6-8). Good self-care and compliance improve the outcome and reduces diabetes complications
      (9) and we need new tools to achieve higher attendance to the National diabetes program.
      Telemedicine represents a novel tool of educating and controlling chronic diseases. It
      reduced HbA1c for five years with in trials designed to test video-conferencing, clinical
      data entry and review, web-based education materials, and monitored chat groups (10). Home
      telemonitoring was compared with telephone calls reducing the HbA1c levels in type 2 diabetes
      (11) and the technology confer a statistically significant reduction in HbA1c of 0.5 % when
      applied as add-on to standard treatment. It was used adjunctively to a broader telemedicine
      initiative for adults with diabetes. The largest telemedicine study initiated by the Ministry
      of Health in England (Whole Systems Demonstrator) randomized 3320 patients [12] with heart
      failure and diabetes to telemedicine care. It showed that the telemedicine intervention as
      add-on therapy resulted a statistically significant reduction in mortality from 8.3% versus
      4.6%. Similarly, it showed a reduction of number of inpatients and the number of bed days by
      11% and 14%, respectively. The patients' health-related quality of life was unchanged. The
      savings was less than the additional cost of using telemedicine and overall it cost 15% more
      per patient. This point at two important factors when applying telemedicine solutions: First,
      it should preferably replace the standard care and not add-on and, second, be based on the
      patient's own computer, tablet or smartphone, all of which will reduce the cost
      substantially. Telemedicine is available for 98-99% of all inhabitants in Denmark by
      broadband, which allows video conference at home. A few randomized trials with this
      technology are available at present. We aimed at implementing a telemedicine model in our
      setting and the design and method should evaluate the quality of treatment as well as
      technical problems and replace the standard treatment.

      Aim:

      We compared clinical data from a telemedicine group with a standard care group treated by the
      same medical algorithm. We wanted to reduce the barriers for the use of a home monitoring and
      -treatment among elderly, type 2 diabetes patients

      Hypothesis:

      Treatment by telemedicine or standard care in type 2 diabetes patients results in similar
      clinical HbA1c, blood pressure, and lipids.

      Materials and methods:

      Individually visits at the outpatient clinic to plan improvement of glycemic control were
      made before information of the study was given. Individual goals of the treatment and the
      drugs needed to fulfil the objectives were agreed on. The patients received the information
      for the study, and if they wanted to participate, they signed an approval of participation
      and randomization was performed. All medical treatment, control of blood glucose, blood
      pressure, lipids, and education was executed via videotelephone in the telemedicine group In
      the control group patients attended usual procedure in the outpatient clinic with regular
      visits. Summary of recommendations for glycemic, blood pressure, and lipid control for the
      participants were: HbA1c 6.5-7.5% (48-58 mmol/L) , fasting blood glucose 6.5-7.5 mmol/l,
      diurnal blood pressure < 130/80 mmHg, LDL-cholesterol <100 mg/dL (<2.5 mmol/L) and start of
      medication with elevated urinary albumin/creatinine excretion ≥30 (μg/mg). The treatment
      algorithm was lifestyle adjustment plus antidiabetic drugs described elsewhere. When the
      goals were reached within 3 weeks, the videotelephone was disconnected and patients were
      encouraged to continue glycemic control at their general practitioner. However, the trial
      went on with a follow-up and evaluation after six month according to the 'intention-to-treat'
      principle to see if a difference in the initial care mattered significantly.

      A videotelephone in the telemedicine group was delivered and serviced by the Danish Tele
      Company. The trial included type 2 diabetes patients allocated from October 2011 until July
      2012 referred to the outpatient clinic from general practitioners. At entry, all patients
      were screened by albumin/creatinine excretion rate, blood pressure, and electrocardiogram,
      lipid profile, diabetic food control, and arteriosclerotic symptoms (angina pectoris,
      claudication, and fatigue). Diurnal blood pressure was measured by monitors. All measurements
      were repeated six months after inclusion in all participants
    

Intervention name(s): A videotelephone, TandBerg E20,; Behavioral motivation
Intervention type(s): Device; Behavioral
Intervention description(s): Optimization of medical care in diabetes
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: diabetes; telemedicine; glycemia; lipids; blood pressure