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Review

The Contribution of Teleconsultation and Videoconferencing to Diabetes Care: A Systematic Literature Review

Fenne Verhoeven¹, MSc; Lisette van Gemert-Pijnen¹, PhD; Karin Dijkstra³, MSc; Nicol Nijland², MSc; Erwin Seydel², PhD; Michaël Steehouder¹, PhD

¹Department of Technical and Professional Communication, Faculty of Behavioral Sciences, University of Twente, Enschede, The Netherlands
²Department of Psychology and Communication of Health, Faculty of Behavioral Sciences, University of Twente, Enschede, The Netherlands
³Department of Marketing Communication and Consumer Psychology, Faculty of Behavioral Sciences, University of Twente, Enschede, The Netherlands

ABSTRACT

(J Med Internet Res 2007;9(5):e37)
doi:10.2196/jmir.9.5.e37

KEYWORDS

Chronic diseases; diabetes mellitus; telemedicine; consultation; teleconsultation; videoconferencing

Diabetes mellitus (DM) is major chronic disease that demands teamwork from various caregivers for the delivery of high-quality care [1]. Consequently, an adequate communication structure is an important condition for optimal interaction and coordination among caregivers and between patients and caregivers [2]. Information and communication technology (ICT) is often seen as the solution for problems in the management of diabetes care because of its potential to enhance care coordination and support patient self-care [3]. It is expected that using ICT will reduce costs while maintaining high-quality health care and that ICT can respond to an increasing demand for care with a decreasing availability of personnel [4]. Previous reviews on diabetes care have found modest benefits of ICT-based care compared to conventional face-to-face care. However, these reviews focused primarily on the usability of technology and considered mainly one-sided interventions such as clinical improvements (glucose and diet) rather than looking at the multifaceted process of a diabetic patient, including relevant issues such as the influence of interactive technology on the process of care (patient-caregiver collaboration, care coordination, costs) and patient outcomes such as quality of life and self-care [2,4,5].

ICT-based care is more than just a technological intervention—it includes a way of thinking about how to deliver health care with the aid of ICT [6]. The most important modalities of ICT-based care are teleconsultation and videoconferencing [1]. Teleconsultation is a kind of telemonitoring including patient-caregiver communication (monitoring and delivering feedback) via email, phone, automated messaging systems, other equipment without face-to-face contact, or the Internet [7]. Videoconferencing involves real-time face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, videophone, etc) to connect caregivers and one or more patients simultaneously, usually for instruction [8].

The aim of this review is to obtain an overview of the existing empirical support for the alleged benefits of teleconsultation and videoconferencing on diabetes care. The benefits are evaluated by means of criteria for “good chronic care” [1,2]. The evaluation criteria are clinical outcomes, behavioral outcomes, and care coordination outcomes [1,2]. Clinical outcomes include metabolic control and of life. Behavioral outcomes include self-care and patient-caregiver interaction. Care coordination outcomes refer to cost-effectiveness, transparency of the care delivery process, equity of access to care, and usability of equipment to facilitate the care delivery process.

Our review is intended to inform social scientists and practitioners about the potential of technology to improve diabetes care. We provide an overview of what is currently known about the benefits and deficits of teleconsultation and videoconferencing and how practical and worthwhile these services are [9].

Literature Search

We collected publications (from May 2005 to December 2007) on empirical research on ICT-based interaction between caregivers and patients or groups of patients, or among caregivers or patients themselves, using the for systematic reviews developed by the Centre for Reviews and Dissemination [10]. The review was restricted to studies evaluating teleconsultation and/or videoconferencing developed for type 1, type 2, and/or gestational diabetes and to language publications published between 1994 and 2006.

No restrictions were imposed on the quality of study design because assessment studies dealing with ICT-based care are scarce [9], and, in practice, reviews have been constrained by the availability of data. In particular, behavioral or care coordination aspects were seldom the focus of reviews on diabetes care. Most reviews focused solely on clinical values in randomized controlled trials (RCTs). In light of a holistic approach, we wanted to provide a broad range of information in order to facilitate decisions about implementing new technology in health care. We excluded studies dealing with broader target groups than diabetics, studies not aimed at patient-caregiver interaction but solely reporting technical aspects of the equipment used, and those that strived for clinical improvements only. We included studies that covered clinical outcomes plus one or more other outcomes (behavioral, care coordination).

The following electronic databases on medicine, psychology, and telemedicine were searched: Medline, ScienceDirect, ISI Web of Science, Telemedicine Information Exchange, PsycINFO, PiCarta, Google Scholar, and journal indexes (Diabetes Care, Effective Health Care, Journal of Medical Internet Research, Journal of Medical Informatics, Telemedicine and E-health, Telemedicine and Telecare). Keyword sets combined “diabetes” and one of the following: “telemedicine,” “telecare,” “telehealth,” “e-health,” “teleconsultation,” “telemonitoring,” or “videoconferencing.” We used “telemedicine” because the terms “e-health” and “electronic care” were hardly used in the literature before 2004. In addition to the databases, the reference lists of the identified publications were hand-searched. Citation was reviewed and designated as “in,” “out,” or “uncertain” based on the aforementioned restrictions. Sources designated as “in” or “uncertain” were obtained for further review. Two of the authors independently reviewed titles and abstracts of the identified publications to decide whether they should be examined in full detail.

Two authors completed data extraction forms developed by the Centre for Reviews and Dissemination [10] and recorded the following details: study design (evidence level and methods for measurement outcomes, patient selection, description of intervention and control groups), study population (type of diabetes, age group, number and recruitment of patients), and intervention details (care setting, technology used to support the care delivery process, duration of the intervention). Using the care levels previously mentioned (clinical, behavioral, and care coordination) [1,2], we developed a checklist to categorize the outcomes of the interventions (Table 1).

[view this table]

Table 1. Checklist to classify the outcome measures related to the levels of diabetes care

Five levels [10] were used to categorize the methodological approaches of the studies (Table 2). Two authors independently rated the study designs. In case of disagreement, consensus was reached by discussion.

[view this table]

Table 2. Checklist to categorize level of evidence of study design

Statistical Methods

A quality assessment was completed for all RCTs using the Jadad scale [11]. This scale contains questions about randomization, blinding, and withdrawals that are scored by a yes (1) or no (0). In total, five points can be awarded, with higher points indicating higher study quality.

Changes in HbA_1c values were calculated from baseline and follow-up means and standard deviations. Only studies researching effects on adults were included in the meta-analysis. When the deviation of the mean difference was not available in the papers, the authors were contacted. In case of no response or no availability of the requested information, we estimated the variance by using (1) reported confidence intervals, (2) reported P values, or (3) an imputation technique [12]. A random-effects model was used for pooling the included studies because clinical heterogeneity between studies was expected. The between-study heterogeneity was tested using the chi-square statistic. In one study, three intervention groups and one control group were studied. In meta-analyses, all three intervention groups were compared with the same usual care group, resulting in two extra comparisons.

Study Characteristics

We identified 852 potentially relevant publications, 39 of which were included after the selection procedure described in the previous section (Figure 1).

[view this figure]

Figure 1. Study selection process

Table 3 (teleconsultation) and Table 4 (videoconferencing) summarize the characteristics of the publications that were included. As can be seen, 22 interventions addressed teleconsultation [13-34], 13 addressed videoconferencing [35-47], and 4 addressed videoconferencing combined with teleconsultation [48-51]. The most frequently used methodological approach was observational (case series or before-after design), which was used in 19 studies; 11 studies were RCTs, and 6 were quasi-experimental. The other methodological approaches were used only incidentally (two cohort studies and one study based on expert interviews). Sample sizes included ≤ 20 (n = 9), ≤ 100 (n = 17), > 100 (n = 12), and one was not specified. Participants were selected by the research team [31,33,36,47,49,50], general practitioner [17,30,35,47], a specialist [15,17,22,24], or via convenience sampling [32,40].

Data were gathered via interviews, focus groups, log files, and nonstandardized questionnaires. Validated questionnaires were used in 12 of the 39 studies to measure usability of technology, quality of life, and self-care. The Telemedicine Satisfaction Questionnaire [14,25,41,47] was used for measuring usability of technology. Quality of life was measured with various questionnaires: the World Health Organization Quality of Life-BREF [14], SF-12 [17,25,30], SF-36 [36,38,41,44,48,49], Diabetes Quality of Life [25,30,36,41,44], Depression Scale CES-D [30], Problem Areas in Diabetes Scale [41], and the Visual Analog Scale [26]. The Diabetes Knowledge Assessment [36], Diabetes Treatment Satisfaction Questionnaire [41], and the Appraisal of Diabetes Scale [41] were used to measure self-care.

Table 3 and Table 4 present the improvements found in the studies, per outcome (clinical values, quality of life, patient-caregiver interaction, self-care, usability, cost reduction, transparency, and equity). Most of the studies reported improvements in usability of technology (n = 26; 15 teleconsultation and 11 videoconferencing), followed by clinical improvements (n = 21; 15 teleconsultation and 6 videoconferencing), cost reduction (n = 16; 5 teleconsultation and 11 videoconferencing), self-care (n = 14; 10 teleconsultation and 4 videoconferencing), and patient-caregiver interaction (n = 13; 10 teleconsultation and 3 videoconferencing). A minority of the studies reported improvements in quality of life (n = 6, 3 teleconsultation and 3 videoconferencing), transparency of care delivery guidelines (n = 5, 3 teleconsultation and 2 videoconferencing), and equity in access to health care (n = 4; all videoconferencing).

The findings summarized in Table 3 and Table 4 were extracted from publications that varied in study design and data gathering methods, and the reported findings were often not substantiated with evidence, as can be seen in the tables. In the light of the purpose of our review, we took this heterogeneity in study characteristics into account.

To get insight into the contribution of teleconsultation and videoconferencing to diabetes care, the results of these interventions were presented separately, describing care setting and intervention and clinical, behavioral, and care coordination outcomes. Improvements were reported and explained.

[view this table]

Table 3. Overview of teleconsultation interventions (see Multimedia Appendix for full tables containing inclusion criteria and data gathering methods)

[view this table]

Table 4. Overview of videoconferencing and combined interventions

Studies on the Effects of Teleconsultation

Settings and Interventions

Interventions took place in secondary care settings [13,15,17,19,22,23,25,34] and in primary care [24,28,30-32] (see Table 3). To improve the reliability of monitoring, clinical data such as HbA_1c and insulin dose were usually sent and analyzed automatically (18/22 studies). In most settings, glucose meters, palmtops, and/or cell phones were used to send data (n = 15). To enhance disease control, feedback was given via computer-generated reminders whenever values were alarming [13,14,20,21,26,27,32]. In some cases, caregivers provided personal feedback to instruct patients in case of alarming values [15,17,22,24,25,30,33,34].

Inclusion of patients in the intervention groups included such criteria as being diagnosed with type 1 [13,15,18,19,22,23,25,28] or type 2 diabetes [24,26,30,32,33], being compliant with therapy [13,22,24], being motivated to take part in the intervention [14,15] having a caregiver taking part in the intervention [17,24,31,33,34], living in the region [17,21,30,32], demographics such as being younger than 30 years [19,22] and being economically disadvantaged [17,22,28,30,32], having insulin problems [15,19,25], and poor metabolic control (HbA_1c> 8%) [19,22-25,31]. As well, certain conditions needed to be met, such as being able to handle the technique [15,17,18,20,26,30], having followed a structured diabetes education program [15], and having access to the Internet [14,20,26] or a (cell) phone [14,17,20,21,26,30].

Though teleconsultation is generally assumed as the solution for better disease management and care coordination of diabetic patients, the preference for this kind of technology compared to other options has not been clearly stated. Teleconsultation is supposed to be cost-effective, to deliver continuous care, and to foster time-efficient communication between patients and caregivers [13,14,16,17,19,21,23,31]. Most teleconsultation interventions (n = 18) were aimed at improving clinical values, investigating usability of technology (n = 15), intensifying interaction by means of information exchange, either among caregivers or between patient and caregivers (n = 14), and enhancing self-care (n = 12).

Effects of Teleconsultation at Clinical Level

HbA_1c levels were measured in eight RCTs [14,15,19,22,25,27,30,31], but only six were suitable for meta-analysis. One trial studied only children [22] and was therefore not included in the meta-analyses. Another trial [14] reported that the variance of HbA_1c values was significantly lower in the experimental group compared to the control group. This study was excluded because using an imputation technique was unadvisable as data provided by the author differed from the published data. Changes in HbA_1c values were calculated from baseline and follow-up means and standard deviations. The Jadad quality score of the trials was either 2 or 3 (Table 5).