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 Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial. Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project. 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) Web-based telemedicine for management of type 2 diabetes through glucose uploads: a randomized controlled trial. Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial Improved diabetes control in the elderly delays global cognitive decline Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. The Use of Telemedicine in the Management of Diabetes-Related Foot Ulceration: A Pilot Study Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project. An automated telemedicine system improves patient-reported well-being. Managing hypertension in urban underserved subjects using telemedicine--a clinical trial. Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project. Telemedicine improved diabetic management. Tele-Mum: A Feasibility Study for a Randomized Controlled Trial Exploring the Potential for Telemedicine in the Diabetes Care of Those with Gestational Diabetes. Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus 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 Telemedicine in the treatment of diabetic pregnancy. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Telemedicine for new neurological outpatients: putting a randomized controlled trial in the context of everyday practice. Telemedicine compared with standard care in type 2 diabetes mellitus: A randomized trial in an outpatient clinic Design, methods, and evaluation directions of a multi-access service for the management of diabetes mellitus patients. Accuracy of telemedicine in detecting uncontrolled hypertension and its impact on patient management. Glycemic Control and Health Disparities in Older Ethnically Diverse Underserved Adults With Diabetes Smart Care Based on Telemonitoring and Telemedicine for Type 2 Diabetes Care: Multi-Center Randomized Controlled Trial. Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus. Impact of remote management of diabetes via computer: the 360 study--a proof-of-concept randomized trial. The Informatics for Diabetes and Education Telemedicine (IDEATel) project. Effect of hospital-based telephone coaching on glycaemic control and adherence to management guidelines in type 2 diabetes, a randomised controlled trial. A comparison of diabetes education administered through telemedicine versus in person. Reliability of telemedicine for diagnosing and managing eye problems in accident and emergency departments Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial. Management of impacted third molars based on telemedicine: a pilot study. Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project The DiGEM trial protocol – a randomised controlled trial to determine the effect on glycaemic control of different strategies of blood glucose self-monitoring in people with type 2 diabetes [ISRCTN47464659] Telemedicine Experience for Chronic Care in COPD Real-time continuous glucose monitoring together with telemedical assistance improves glycemic control and glucose stability in pump-treated patients. Long-term Comparative Effectiveness of Telemedicine in Providing Diabetic Retinopathy Screening Examinations: A Randomized Clinical Trial. Diabetes telemonitoring reduces the risk of hypoglycaemia during Ramadan: a pilot randomized controlled study. A nurse‐led interdisciplinary approach to promote self‐management of type 2 diabetes: a process evaluation of post‐intervention experiences Effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes: a systematic review [Use of non-mydriatic retinography to determine the prevalence of diabetic retinopathy in diabetic patients]. Enhancing the effectiveness of diabetes self-management education: the diabetes literacy project. The effects of intermittent compared to continuous energy restriction on glycaemic control in type 2 diabetes; a pragmatic pilot trial. Pilot trial of telemedicine as a decision aid for patients with chronic wounds. The Association between Driving Distance and Glycemic Control in Rural Areas What we can really expect from telemedicine in intensive diabetes treatment: results from 3-year study on type 1 pregnant diabetic women. A nurse short message service by cellular phone in type-2 diabetic patients for six months. A Telemedicine System That Includes a Personal Assistant Improves Glycemic Control in Pump-Treated Patients with Type 1 Diabetes Telemedicine for the Medicare population: pediatric, obstetric, and clinician-indirect home interventions. Therapeutic education among adults with type 2 diabetes: effects of a three-day intervention on perceived competence, self-management behaviours and glycaemic control Research: Treatment A randomized crossover study to assess the effect of an oat-rich diet on glycaemic control, plasma lipids and postprandial glycaemia, inflammation and oxidative stress in Type 2 diabetes [Evaluation of telemedicine systems for impacted third molars diagnosis]. Training in flexible, intensive insulin management to enable dietary freedom in people with Type 1 diabetes: dose adjustment for normal eating (DAFNE) randomized controlled trial Impact of telemedicine on the practice of pediatric cardiology in community hospitals. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial Feasibility of using videoconferencing to provide diabetes education: a pilot study Lessened decline in physical activity and impairment of older adults with diabetes with telemedicine and pedometer use: results from the IDEATel study. A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients Telemedicine in the Management of Type 2 Diabetes Mellitus Strategies for the introduction and implementation of a guideline for the treatment of type 2 diabetics by general practitioners (GPs) of the Lazio region of Italy (IMPLEMEG study): Protocol for a cluster randomised controlled trial [ISRCTN80116232] Expert advice provided through telemedicine improves healing of chronic wounds: prospective cluster controlled study. Multimorbidity in a cohort of patients with type 2 diabetes Poor Cognitive Function and Risk of Severe Hypoglycemia in Type 2 Diabetes Evaluation of a telemedicine system for heart failure patients: feasibility, acceptance rate, satisfaction and changes in patient behavior: results from the CARME (CAtalan Remote Management Evaluation) study Effectiveness of a community pharmacist intervention in diabetes care: a randomized controlled trial. A novel telemonitoring device for improving diabetes control: protocol and results from a randomized clinical trial. Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. Improvement in diabetes control with a monitoring system based on a hand-held, touch-screen electronic diary Sustaining better diabetes care in remote indigenous Australian communities Glycaemic index of New Zealand foods. Family-based psychoeducation and Care Ambassador intervention to improve glycemic control in youth with type 1 diabetes: a randomized trial. Impact of population management with direct physician feedback on care of patients with type 2 diabetes. Using a Telemedicine System to Decrease Cardiovascular Disease Risk in an Underserved Population: Design, Use, and Interim Results [Pilot study of two different strategies to reinforce self care behaviors and treatment compliance among type 2 diabetes patients from low income strata]. Advice to follow a low-carbohydrate diet has a favourable impact on low-grade inflammation in type 2 diabetes compared with advice to follow a low-fat diet Effect of the diabetes outpatient intensive management programme on glycaemic control for type 2 diabetic patients. Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme. The impact of a social network based intervention on self-management behaviours among patients with type 2 diabetes living in socioeconomically deprived neighbourhoods: a mixed methods approach A randomized controlled trial of the effect of real-time telemedicine support on glycemic control in young adults with type 1 diabetes (ISRCTN 46889446). Effectiveness of a patient-centred, empowerment-based intervention programme among patients with poorly controlled type 2 diabetes: A randomised controlled trial. Impact of hypoglycaemia on patient-reported outcomes from a global, 24-country study of 27,585 people with type 1 and insulin-treated type 2 diabetes. Effects of intensive glucose lowering in the management of patients with type 2 diabetes mellitus in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. [Interventions to improve the management of diabetes mellitus in primary health care and outpatient community settings]. Barriers and strategies for oral medication adherence among children and adolescents with Type 2 diabetes. Designing and evaluating a web-based self-management site for patients with type 2 diabetes - systematic website development and study protocol The Diabeo Software Enabling Individualized Insulin Dose Adjustments Combined With Telemedicine Support Improves HbA1c in Poorly Controlled Type 1 Diabetic Patients A Randomized controlled trial of the effect of yoga and peer support on glycaemic outcomes in women with type 2 diabetes mellitus: a feasibility study Telemedical Interventional Monitoring in Heart Failure (TIM-HF), a randomized, controlled intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with heart failure: study design. A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective Culturally Competent Diabetes Education for Mexican Americans: The Starr County Study Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health centers: a pragmatic randomized comparative effectiveness trial.
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 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 BACKGROUND with increasing prevalence of diabetes in older people , it is important to underst and factors that affect their outcomes . The Informatics for Diabetes Education and Telemedicine ( IDEATel ) project is a demonstration project to evaluate the feasibility and effectiveness of telemedicine with diverse , medically underserved , older diabetes patients . Subjects were r and omised to telemedicine case management or usual care .  This intervention has been shown to result in improved medical outcomes and self-efficacy . Self-efficacy refers to one 's belief that (s)he can successfully engage in a behaviour . Self-efficacy has been shown to relate to behaviour change and glycaemic control in middle-aged individuals , but not studied in older individuals . OBJECTIVES to assess whether ( a ) diabetes self-efficacy relates to the primary medical outcome of glycaemic control , and to secondary outcomes ( blood pressure and cholesterol ) , and ( b ) whether , after an intervention , change in diabetes self-efficacy relates to change in these medical outcomes in a group of older , ethnically diverse individuals . METHODS three waves of longitudinal data from participants in IDEATel were analysed . RESULTS diabetes self-efficacy at baseline correlated with glycaemic control , blood pressure and cholesterol . An increase in diabetes self-efficacy over time was related to an improvement in glycaemic control ( P < 0.0001 ) , but not in blood pressure and lipid levels . The intervention was significantly related to improved self-efficacy over time ( P < 0.0001 ) , and both directly ( P = 0.022 ) and indirectly through self-efficacy ( P < 0.001 ) to improved glycaemic control . The mediation effect of self-efficacy was also significant ( P < 0.004 ) . CONCLUSIONS diabetes self-efficacy is a relevant construct for older diabetes patients . Thus , interventions that target enhanced self-efficacy may also result in improved glycaemic control 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 AIMS To evaluate the feasibility and effectiveness of a telemedicine system based on internet in the follow-up of patients with type 2 diabetes mellitus ( T2DM ) . METHODS A prospect i ve r and omized telemedicine study with two parallel groups was design ed . 114 patients diagnosed T2DM were r and omly divided into telemedicine group and traditional face-to-face visit group as control . 57 cases were included for each group . 108 patients completed the trial , in which 53 cases in telemedicine group and 55 cases in control group . Patients in telemedicine group were taught to use telemedicine software to upload their blood glucose and other metabolic information at home at least every 2 weeks , and the research ers gave proper advices according to patients ' key behaviors . The telemedicine interval is 3 months . RESULTS Compared to control group , telemedicine group exhibited better HbA1c and fasting blood glucose controlling ( P < 0.05 ) . Moreover , telemedicine intervention decreased hypoglycemia risk ( P = 0.044 ) , and contributed to levels of HbA1c less than 7 % which is the target of our study ( P = 0.049 ) . CONCLUSIONS Telemedicine system can provide a tighter glycemic control for the treatment of T2DM patients , especially in cases with difficulties to access to the medical centre 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 Compliance with continuous positive airway pressure ( CPAP ) therapy is essential in patients with obstructive sleep apnoea ( OSA ) , but adequate control is not always possible . This is clinical ly important because CPAP can reverse the morbidity and mortality associated with OSA . Telemedicine , with support provided via a web platform and video conferences , could represent a cost-effective alternative to st and ard care management . Aim To assess the telemedicine impact on treatment compliance , cost-effectiveness and improvement in quality of life ( QoL ) when compared with traditional face-to-face follow-up . Methods A r and omised controlled trial was performed to compare a telemedicine-based CPAP follow-up strategy with st and ard face-to-face management .  Consecutive OSA patients requiring CPAP treatment , with sufficient internet skills and who agreed to participate , were enrolled . They were followed-up at 1 , 3 and 6 months and answered surveys about sleep , CPAP side effects and lifestyle . We compared CPAP compliance , cost-effectiveness and QoL between the beginning and the end of the study . A Bayesian cost-effectiveness analysis with non-informative priors was performed . Results We r and omised 139 patients . At 6 months , we found similar levels of CPAP compliance , and improved daytime sleepiness , QoL , side effects and degree of satisfaction in both groups . Despite requiring more visits , the telemedicine group was more cost-effective : costs were lower and differences in effectiveness were not relevant . Conclusions A telemedicine-based strategy for the follow-up of CPAP treatment in patients with OSA was as effective as st and ard hospital-based care in terms of CPAP compliance and symptom improvement , with comparable side effects and satisfaction rates . The telemedicine-based strategy had lower total costs due to savings on transport and less lost productivity ( indirect costs ) . Trial register number NCT01716676 Objectives To examine whether improved diabetes control is related to better cognitive outcomes . Design R and omized control trial . Setting A r and omized trial of telemedicine vs. usual care in elderly persons with type 2 diabetes . Participants Participants were 2169 persons 55 years and older with type 2 diabetes from New York City and Upstate New York . InterventionThe diabetes case management intervention was implemented by a diabetes nurse , via a telemedicine unit in the participant ’s home , and in coordination with the primary care physician . Measurements Hemoglobin A1c ( HbA1c ) , systolic blood pressure ( SBP ) , and low density lipoprotein cholesterol ( LDL ) , were measured at a baseline visit and at up to 5 annual follow-up visits . Global cognition was measured at those visits with the Comprehensive Assessment and Referral Evaluation ( CARE ) . Result In mixed models the intervention was related to slower global cognitive decline in the intervention group ( p = 0.01 ) . Improvements in HbA1c ( p = 0.03 ) , but not SBP or LDL , mediated the effect of the intervention on cognitive decline . Conclusion Improved diabetes control in the elderly following existing guidelines through a telemedicine intervention was associated with less global cognitive decline . The main mediator of this effect seemed to be improvements in HbA1c BACKGROUND Health information technology has been proven to be a successful tool for the management of patients with multiple medical conditions . The purpose of this study was to examine the impact of an enhanced telemedicine system on glucose control and pregnancy outcomes in women with gestational diabetes mellitus ( GDM ) . SUBJECTS AND METHODS We used an Internet-based telemedicine system to also allow interactive voice response phone communication between patients and providers and to provide automated reminders to transmit data . Women with GDM were r and omized to either the telemedicine group ( n=40 ) or the control group ( n=40 ) and asked to monitor their blood glucose levels four times a day . Women in the intervention group transmitted those values via the telemedicine system , whereas women in the control group maintained paper logbooks , which were review ed at prenatal visits . Primary outcomes were infant birth weight and maternal glucose control . Data collection included blood glucose records , transmission rates for the intervention group , and chart review . RESULTS There were no significant differences between the two groups ( telemedicine vs. controls ) in regard to maternal blood glucose values or infant birth weight . However , adding telephone access and reminders increased transmission rates of data in the intervention group compared with the intervention group in our previous study ( 35.6±32.3 sets of data vs.17.4±16.9 sets of data ; P<0.01 ) . CONCLUSIONS Our enhanced telemedicine monitoring system increased system utilization and contact between women with GDM and their healthcare providers but did not impact upon pregnancy outcomes OBJECTIVE : To determine if the management of forefoot ulcerations through telemedicine is medically equivalent to ulcer care at a diabetes foot program . DESIGN : Nonr and omized comparison of forefoot ulcer healing rates SETTING : The Louisiana State University Health Sciences Center Diabetes Foot Program , Baton Rouge , LA , and Lallie Kemp Medical Center , Independence , LA PARTICIPANTS : Twenty consecutive patients with diabetes were treated for neuropathic forefoot ulcerations via telemedicine consultation and 120 consecutive patients with diabetes were treated face-to-face at a diabetes foot program . INTERVENTIONS : Management of forefoot ulcers by a certified wound care nurse trained in the use of a staged management approach algorithm and alternative off-loading methods , supported by real-time interactive telemedicine consultation . MAIN OUTCOME VARIABLES : Forefoot ulcer healing time in days , percentage of wounds healed in 12 weeks , and healing time ratio ( adjusted for age , gender , ulcer duration , location , size , crossover , and grade ) . RESULTS : No differences were found between the telemedicine and diabetes foot program groups in the average forefoot ulcer healing time ( 43.2 + 29.3 vs. and 45.5 + 43.4 days , P = .828 ) , the percent of forefoot ulcers healed in 12 weeks ( 75 % vs. 81 % , P = .546 ) and the adjusted healing time ratio ( 1.40 vs 1.00 , P = .104 ) . CONCLUSION : These data appear to support the effectiveness of real-time interactive telemedicine consultation in the management of diabetes-related forefoot ulceration OBJECTIVE The purpose of the study was to investigate the effect of comorbid depression on glycemic control and on response to a telemedicine case management intervention for elderly , ethnically diverse diabetic patients . RESEARCH DESIGN AND METHODS Medicare beneficiaries in underserved areas were participants ( n = 1,665 ) in the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project and r and omized to a telemedicine case management intervention or usual care .  The data analyzed include baseline demographics ( age , sex , race/ethnicity , marital status , insulin use , years of education , years of diabetes , and pack-years smoked ) and measures of glycemic control ( HbA(1c ) [ A1C ] ) , comorbidity , diabetes symptom severity , functional disability and depression , and 1-year ( n = 1,578 ) A1C . The association between depression and glycemic control was analyzed cross-sectionally and prospect ively . RESULTS At baseline , there was a significant correlation between depression and A1C and a trend for depression to predict A1C when other factors were controlled . However , in prospect i ve analyses , depression did not predict change in A1C , either in the control or intervention group . CONCLUSIONS In this large sample of elderly diabetic patients , a weak relationship between depression and A1C was found , but depression did not prospect ively predict change in glycemic control . Thus , there is no evidence that depression should be used to exclude patients from interventions . Also , we should evaluate the impact of depression on outcomes other than glycemic control BACKGROUND Control of serum glucose levels is essential for the reduction of complications of diabetes . Telemedicine is one strategy through which serum glucose control can be improved . METHODS A total of 35 adult , insulin-treated patients with diabetes ( type 1 and type 2 ) were enrolled in the present study ( 63.0 + /- 10 years of age , 63 % female ) and r and omized to telemedicine monitoring ( including cordless , remote glucose monitor , and transmitter , n =  17  ) , or conventional follow-up ( n = 18 ) . Metabolic parameters were evaluated , and a quality of life question naire was administered both pre- and post-treatment . RESULTS Groups were similar at baseline in terms of demographic , quality of life , and metabolic parameters . Significant differences in post-treatment metabolic parameters were not observed , although serum glucose was marginally elevated in the control group compared to the telemedicine group ( 214 + /- 65 mg/dL vs. 171 + /- 77 mg/dL , P = 0.09 ) . On the other h and , being clinical ly symptom-free ( 71 % vs. 11 % , P = 0.003 ) , having no hypoglycemic events ( 82 % vs. 17 % , P = 0.0001 ) , and having no hyperglycemic events ( 65 % vs. 17 % , P = 0.004 ) were all significantly more frequently reported in the telemedicine group compared to the control group . Compared to the control group , the telemedicine group reported experiencing significantly less anxiety , treatment difficulty , depression , disease-associated life complications , and feelings of impotence or ineptitude and significantly greater improvement in personal control over glucose , weight , and overall diabetes . CONCLUSIONS Though post-treatment metabolic differences were not observed between treatment groups , the telemedicine group reported significantly greater post-treatment experiences of improved quality of life and sense of control over the disease . Thus patient satisfaction can be enhanced through the use of telemedicine 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 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 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 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 Detection and response to medically urgent situations in patients with diabetes mellitus can improve the process and outcomes of care and potentially decrease morbidity and mortality . We examined the detection and remediation of medically urgent situations among older patients receiving telemedicine case management for diabetes . Methods In the setting of a r and omized trial , 338 patients in the intervention group and living in upstate New York received a home telemedicine unit to transmit blood glucose and blood pressure values to a nurse case manager , videoconference with a nurse or dietitian every 4–6 weeks and access educational websites . The educators met with a supervising endocrinologist 4–5 times weekly and clinical recommendations were proposed to the primary care providers via mail , fax , or phone . Results Over a 36 month period , 67 medically urgent situations were identified and addressed ( 1.9 events/month ) . Some of these situations were potentially life-threatening , including major drug contraindications ( N = 24 ) , other medically urgent situations ( N = 19 ) , and medical urgent conditions ( ie , unstable angina ) ( N = 24 ) . Conclusion The interaction via telemedicine in rural upstate New York between patients with diabetes mellitus , a diabetes care team , and primary care providers can successfully identify and remediate medically urgent situations 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 Good diabetic control requires that treatment be continuously adapted to the patient behavior . We investigated whether the use of telemedicine could present an advantage to the management of the diabetic woman during pregnancy . A system completely automatic ( DIANET system ) was used . Twenty IDDM women participated in the study : 10 treated by telemedicine and 10 by conventional system , at times " entry " ( 9.5 weeks ) , " basal " ( 9.5 - 16.8 weeks ) , " 1st month " of investigation , and " end " ( near delivery ) . All women used intensified protocol s of insulin administration . The treatment with DIANET vs conventional showed a better metabolic control as estimated by profile of blood glucose absolute values ( at time " end " : values significantly lower before breakfast : 87 + /- 6 vs 104 + /- 4 mg , lunch : 85 + /- 5 vs 104 + /- 4 mg , and after dinner : 102 + /- 5 vs 124 + /- 6 mg ) . These results were associated with higher insulin doses in the DIANET vs conventional treatment , and a significant reduction of hypoglycemic reaction in both group . Our results suggest that telemedicine-DIANET is a practical way of providing specialist care in the pregnancy area OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model ( CCM ) . PARTICIPANTS AND METHODS As part of the CCM , 97 primary care physicians at 6 primary care practice s in Rochester , MN , referred 639 patients to an on-site diabetes educator between July 1 , 2001 , and December 31 , 2003 . On first referral , physicians were central ly r and omized to receive a telemedicine intervention ( specialty advice and evidence -based messages regarding medication management for cardiovascular risk ) or no intervention , keeping outcome assessors and data analysts blinded to group assignment . After each subsequent clinical encounter , endocrinologists review ed an abstract from the patient 's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail . Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes . Outcome measures included diabetes care processes ( diabetes test completion ) , outcomes ( metabolic and cardiovascular risk factors , estimated coronary artery disease risk ) , and patient costs ( payer perspective ) . RESULTS During the intervention , 951 ( 70 % ) of the 1361 endocrinology review s detected performance gaps and result ed in a message ; primary care physicians reported using 49 % of messages in patient care . With a mean of 21 months ' follow-up , the intervention , compared with control , did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease ( adjusted mean difference , -1 % ; 95 % confidence interval , -19 % to 17 % ) . The intervention group incurred lower costs ( P=.02 ) but not in diabetes-related costs . CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care In a retrospective review , the  telemedical management of 65 out patients from a r and omized controlled trial ( RCT ) of telemedicine for non-urgent referrals to a consultant neurologist was compared with the management of 76 patients seen face to face in the same trial , with that of 150 out patients seen in the neurology clinics of district general hospitals and with that of 102 neurological out patients seen by general physicians . Outcome measures were the numbers of investigations and of patient review s. The  telemedicine group did not differ significantly from the 150 patients seen face to face by neurologists in hospital clinics in terms of either the number of investigations or the number of review s they received . Patients from the RCT seen face to face had significantly fewer investigations but a similar number of review s to the other 150 patients seen face to face by neurologists ( the disparity in the number of investigations may explain the negative result for telemedicine in that RCT ) . Patients with neurological symptoms assessed by general physicians had significantly more investigations and were review ed significantly more often than all the other groups . Patients from the RCT seen by telemedicine were not managed significantly differently from those seen face to face by neurologists in hospital clinics but had significantly fewer investigations and follow-ups than those patients managed by general physicians . The results suggest that management of new neurological out patients by neurologists using telemedicine is similar to that by neurologists using a face-to-face consultation , and is more efficient than management by general physicians 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 Recent advances in information and communication technology allow the design and testing of new models of diabetes management , which are able to provide assistance to patients regardless of their distance from the health care providers . The M2DM project , funded by the European Commission , has the specific aim to investigate the potential of novel telemedicine services in diabetes management . A multi-access system based on the integration of Web access , telephone access through interactive voice response systems , and the use of palmtops and smart modems for data downloading has been implemented . The system is based on a technological platform that allows a tight integration between the access modalities through a middle layer called the multi-access organizer . Particular attention has been devoted to the design of the evaluation scheme for the system : A r and omized controlled study has been defined , with clinical , organizational , economic , usability , and users ' satisfaction outcomes . The evaluation of the system started in January 2002 . The system is currently used by 67 patients and seven health care providers in five medical centers across Europe . After 6 months of usage of the system no major technical problems have been encountered , and the majority of patients are using the Web and data downloading modalities with a satisfactory frequency . From a clinical viewpoint , the hemoglobin A1c ( HbA1c ) of both active patients and controls decreased , and the variance of HbA1c in active patients is significantly lower than the control ones . The M2DM system allows for the implementation of an easy-to-use , user-tailored telemedicine system for diabetes management . The first clinical results are encouraging and seem to substantiate the hypothesis of its clinical effectiveness This study was aim ed at assessing the diagnostic accuracy of telemedicine among hypertensive patients . This was a cross-sectional analysis of patients attending a hypertension clinic over a year-long study . Patients were seen both by telemedicine and in-person on the same day with order of the encounters r and omly determined . A telemedicine system , which utilized phone lines , was employed . For each type of encounter , whether telemedicine ( TM ) or in-person ( IP ) , clinical data on blood pressure ( BP ) control as well as physician ordering patterns were collected . Receiver Operator Characteristic ( ROC ) curves were used to assess the validity of TM as compared to IP in the assessment of uncontrolled hypertension .  Sixty-two patients participated result ing in 107-paired visits over the year-long study period . The mean age of the 62 participants was 67.1 + /- 11.4 years ; 56.6 % were men . ROC curves for detecting elevated mean blood pressure provided an area under the curve ( auc ) of 0.87 ( 95 % CI , 0.80 - 0.95 ) . ROC curves for the detection of uncontrolled systolic hypertension provided an auc of 0.86 ( 95 % CI , 0.78 - 0.93 ) . Telemedicine-determined BP differed slightly , but statistically significant ( p < 0.05 ) , from IP assessment s. Meanwhile , there was no difference in ordering diagnostic tests or therapeutics detectable between the two encounter types . Telemedicine proved to be a valid means for detecting uncontrolled BP among hypertensive patients 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 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 BACKGROUND Internet technology has been proven to be a successful tool for the management of patients with multiple medical conditions . The purpose of this study was to demonstrate the feasibility of monitoring glucose control in indigent women with gestational diabetes mellitus ( GDM ) over the Internet . METHODS Women with GDM were r and omized to either the Internet group ( n = 32 ) or the control group ( n = 25 ) . Patients in the Internet group were provided with computers and /or Internet access if needed . A website was established for documentation of glucose values and communication between the patient and the health care team . Women in the control group maintained paper logbooks , which were review ed at each prenatal visit . Maternal feelings of diabetes self-efficacy were assessed at study entry and again before delivery . RESULTS Women in the Internet group accessed the system and sent on average 21.8 ( + /- 16.9 ) sets of data . There was no difference between the two groups in regards either fasting or post-pr and ial blood glucose values , although more women in the Internet group received insulin therapy ( 31 % vs. 4 % ; P < 0.05 ) . There were also no significant differences in pregnancy and neonatal outcomes between the two groups . Women in the Internet group demonstrated significantly higher feelings of self-efficacy at the study 's end . CONCLUSIONS The benefit of monitoring blood glucose in indigent women with GDM via the Internet was limited by their infrequent use of the telemedicine system . Although system use was not associated with improved pregnancy outcomes , women in the telemedicine group did experience enhanced feelings of diabetes psychosocial self-efficacy BACKGROUND Previous studies have provided limited guidance regarding the clinical efficacy and cost-effectiveness of interventions using " telemedicine " models in the management of diabetes mellitus . We conducted a study to determine if routine clinical assessment s of diabetes patients could be effectively conducted via computer and telephone interaction with patients and still provide clinical results similar to traditional office care . SUBJECTS AND METHODS We enrolled 100 subjects with diabetes in this 12-month , r and omized , controlled , non-inferiority study . Subjects were r and omized ( 1:1 ratio ) to a control group ( CG ) or study group ( SG ) . Baseline characteristics were similar . CG subjects participated in quarterly office visits ; SG subjects participated in two office visits ( months 6 and 12 ) and two telemedicine interactions ( months 3 and 9 ) . Changes in clinical measurements ( hemoglobin A1c [ HbA1c ] , blood pressure , lipids , body mass index [ BMI ] , and body weight ) and clinician time requirements were assessed . RESULTS Seventy subjects completed the study ( CG , n=37 ; SG , n=33 ) . No significant between-group differences in HbA1c , blood pressure , lipids , or BMI were seen at 12 months . SG subjects showed significantly greater reductions in mean ( SD ) body weight compared with CG subjects : -5.2 ( 1.6 ) pounds versus -0.7 ( 1.5 ) pounds , respectively ( P=0.04 ) . Clinician time requirements for SG subjects were reduced by > 40 % . CONCLUSIONS Our study demonstrated that use of a telemedicine-based treatment protocol in diabetes patients is feasible and efficient and yields similar clinical outcomes compared with traditional , clinic-based protocol s. Telemedicine applications of computer software can potentially exp and access to care for patients and may reduce costs for patients , providers , and payers 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 BACKGROUND Failure to achieve treatment targets is common among people with type 2 diabetes . Cost-effective treatments are required to delay the onset and slow the progression of diabetes-related complications . AIMS This study aim ed to measure the effect of a 6-month telephone coaching intervention on glycaemic control , risk factor status and adherence to diabetes management practice s at the intervention 's conclusion ( 6 months ) and at 12 months . METHOD This r and omised controlled trial recruited 94 adults with type 2 diabetes and an HbA1C > 7 % from the Diabetes Clinic of St Vincent 's Hospital Melbourne . People who were non-English speaking , cognitively impaired , severely hearing impaired or without telephone access were excluded . Participants were r and omised to receive usual care plus 6 months of telephone coaching focusing on achieving treatment targets and complication screening , or usual care only . The primary outcome was HbA1C at 6 months ; secondary outcomes included other physiological and monitoring measures . RESULTS Significant interaction effects were observed between group and time at 6 months , demonstrating improvement in HbA1C , fasting glucose , diastolic blood pressure and physical activity . The intervention 's effect on these parameters was not sustained at 12 months . Intervention group participants also improved compliance with foot examinations and pneumococcal vaccination by 6 months and retinal screening by 12 months . CONCLUSIONS Telephone coaching improved glycaemic control and adherence to complication screening in people with type 2 diabetes , for the duration of its delivery , but these effects were not maintained on withdrawal of the intervention . Strategies that assist patients to sustain these benefits are required OBJECTIVE To determine whether diabetes education can be provided as effectively through telemedicine technology as through in-person encounters with diabetes nurse and nutrition educators . RESEARCH DESIGN AND METHODS A total of 56 adults with diabetes were r and omized to receive  diabetes education in person ( control group ) or via telemedicine ( telemedicine group ) and were followed prospect ively . The education consisted of three consultative visits with diabetes nurse and nutrition educators . The in-person and telemedicine groups were compared using measures of glycemic control ( HbA(1c ) ) and question naires to assess patient satisfaction and psychosocial functioning as related to diabetes . Outcome measures were obtained at baseline , immediately after the completion of diabetes education , and 3 months after the third educational visit . RESULTS Patient satisfaction was high in the telemedicine group . Problem Areas in Diabetes scale scores improved significantly with diabetes education ( adjusted P < 0.05 , before vs. immediately after education and 3 months after education ) , and the attainment of behavior-change goals did not differ between groups . With diabetes education , HbA(1c ) improved from 8.6 + /- 1.8 % at baseline to 7.8 + /- 1.5 % immediately after education and 7.8 + /- 1.8 % 3 months after the third educational visit ( unadjusted P < 0.001 , P = 0.089 adjusted for BMI and age ) , with similar changes observed in the telemedicine and in-person groups . CONCLUSIONS Diabetes education via telemedicine and in person was equally effective in improving glycemic control , and both methods were well accepted by patients . Reduced diabetes-related stress was observed in both groups . These data suggest that telemedicine can be successfully used to provide diabetes education to patients Abstract Objectives To assess the accuracy and efficiency of telemedicine in diagnosing and managing eye problems presenting to accident and emergency departments . Design A controlled trial with a face-to-face and telemedicine phases , each involving 40 patients undergoing two consecutive consultations . In the face-to-face phase , both consultations were in person ; in the telemedicine phase , observer 1 used videoconferencing technology at 384 kbit/s ( separate nonslit lamp – torchlight and slit lamp examinations ) and observer 2 saw the patient face to face . Setting The accident and emergency department at Moorfields Eye Hospital . Participants In total , 80 consenting new patients presenting to the department . Main outcome measures ( 1 ) Agreement levels between the two observers for each phase ( judged by an independent masked investigator ) , ( 2 ) length of consultation , and ( 3 ) number of unnecessary recalls . Results Agreement rates were as follows . Face-to-face phase : total agreement ( 30/40=75 % ) , trivial disagreement ( 8/40=20 % ) , clinical ly important disagreement ( 2/40=5 % ) . Telemedicine phase ( torchlight ) : complete agreement ( 16/40=40 % ) , trivial disagreement ( 20/40=50 % ) , clinical ly important disagreement ( 4/40=10 % ) . Telemedicine phase ( slit lamp ) : total agreement ( 23/40=58 % ) , trivial disagreement ( 15/40=37 % ) , clinical ly important disagreement ( 2/40=5 % ) . Agreement levels in the telemedicine phase with torchlight examination were significantly lower ( χ2=10.07 , P=0.007 ) for any disagreement . Telemedicine consultations erred on the side of clinical caution and were no slower than face-to-face consultations ( mean 6 min for observer 1 in both phases ) . Recalls were more likely ( χ2=5.16 , P=0.02 ) after telemedicine consultations with torchlight only ( 9/40 ) compared with face-to-face consultations ( 2/40 ) . Although there were more significant disagreements using the telemedicine , in each case the telemedicine diagnosis and management erred on the side of safety ; hence , no patient would have suffered by wrong management because of the consultation using telemedicine . Conclusions Telemedicine was found to be an accurate , safe , and efficient method of diagnosing and managing these patients , especially if slit lamp images were used . Advice using telemedicine erred on the side of caution , which result ed in more recalls 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 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 PURPOSE The incorporation of new technologies into clinical daily practice is nowadays a fact in the field of medicine . Within these new technologies , telemedicine is turning out to be a working tool that is used with increasing frequency in medical centers . The systems of telemedicine have still not reached the same development in oral and maxillofacial surgery that they have reached in other medical specialties . This study describes the preliminary results of a store- and -forward telemedicine system ( SFTMS ) aim ed at the presurgical management of impacted third molar pathology . MATERIAL S AND METHODS A multicenter , longitudinal , descriptive , evaluative pilot study of an SFTMS aim ed at the presurgical management of patients with impacted third molar pathology was conducted at the Oral and Maxillofacial Surgery Unit of Virgen Macarena University Hospital ( Seville , Spain ) and 4 primary care areas located between 15 and 95 km from the hospital . The study was carried out between January and December 2009 . RESULTS Over a period of 12 months , 97 patients were enrolled in the study , from 102 teleconsultations received and evaluated within the same period . Patients managed through telemedicine were included on the surgical wait list on within a mean interval of 3.33 days ( 95 % confidence interval [ CI ] , 2 - 4.65 days ) since the visit to the primary care dentist , with only 1 visit to the hospital that was on the day of surgery . The mean waiting interval of patients managed through the conventional referral system was 28 days ( 95 % CI , 24.51 - 29.6 days ) , with at least 2 visits to the hospital before the final intervention . The on-the-day surgery cancellation rate of the series was 7.8 % ( 95 % CI , 3.8%-10.5 % ) because 8 patients did not have surgery on the scheduled day . The cancellation rate in the sample of patients managed through the conventional system was 8.85 % ( 95 % CI , 5.62%-11.81 % ; P < .005 ) . CONCLUSIONS The SFTMS was effective and accurate as a preoperative tool for impacted third molar pathology . It avoids unnecessary visits to the hospital and shortens waiting intervals . Further r and omized studies are needed , however , to establish real advantages , in clinical and economic terms , against the conventional presurgical management systems 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 do not yet know how to use blood glucose self-monitoring ( BGSM ) most effectively in the self-management of type 2 diabetes treated with oral medication . Training in monitoring may be most effective in improving glycaemic control and well being when results are linked to behavioural change . Methods / design DiGEM is a three arm r and omised parallel group trial set in UK general practice s. A total of 450 patients with type 2 diabetes managed with lifestyle or oral glucose lowering medication are included . The trial compares effectiveness of three strategies for monitoring glycaemic control over 12 months ( 1 ) a control group with three monthly HbA1c measurements ; interpreted with nurse-practitioner ; ( 2 ) A self-testing of blood glucose group ; interpreted with nurse- practitioner to inform adjustment of medication in addition to 1 ; ( 3 ) A self-monitoring of blood glucose group with personal use of results to interpret results in relation to lifestyle changes in addition to 1 and 2.The trial has an 80 % power at a 5 % level of significance to detect a difference in change in the primary outcome , HbA1c of 0.5 % between groups , allowing for an attrition rate of 10 % . Secondary outcome measures include health service costs , well-being , and the intervention effect in sub-groups defined by duration of diabetes , current management , health status at baseline and co-morbidity . A mediation analysis will explore the extent to which changes in beliefs about self-management of diabetes between experimental groups leads to changes in outcomes in accordance with the Common Sense Model of illness . The study is open and has recruited more than half the target sample . The trial is expected to report in 2007 . Discussion The DiGEM intervention and trial design address weaknesses of previous research by use of a sample size with power to detect a clinical ly significant change in HbA1c , recruitment from a well-characterised primary care population , definition of feasible monitoring and behaviour change strategies based on psychological theory and evidence , and measures along the hypothesised causal path from cognitions to behaviours and disease and well being related outcomes . The trial will provide evidence to support , focus or discourage use of specific BGSM strategies 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 BACKGROUND Real-time continuous glucose monitoring ( CGM ) has recently been incorporated into routine diabetes management because of the potential advantages it offers for glycemic control . The aim of our study was to evaluate the impact of the use of real-time CGM together with a telemedicine system in hemoglobin A1c and glucose variability in patients with type 1 diabetes treated with insulin pumps . METHODS Ten patients ( five women , 41.2 [ range , 21 - 62 ] years old , duration of diabetes 14.9 [ range , 3 - 52 ] years ) were included in this r and omized crossover study . Patients used the DIABTel telemedicine system throughout the study , and real-time CGM was used for 3 days every week during the intervention phase . At the end of the control phase , a blind 3-day CGM was performed . Glucose variability was evaluated using the Glucose Risk Index ( GRI ) , a comparative analysis of continuous glucose values over two consecutive hours . RESULTS Hemoglobin A1c decreased significantly ( 8.1 + /- 1.1 % vs. 7.3 + /- 0.8 % ; P = 0.007 ) after the intervention phase , while no changes were observed during the control phase . The mean number of daily capillary glucose readings was higher during the intervention phase ( 4.7 + /- 1.1 vs. 3.8 + /- 1.0 ; P < 0.01 ) , because of an increase in r and om analyses ( 1.22 + /- 0.3 vs. 0.58 + /- 0.1 ; P < 0.01 ) , and there was also a significant increase in the mean number of bolus doses per day ( 5.23 + /- 1.1 vs. 4.4 + /- 0.8 ; P < 0.05 ) . The GRI was higher during the control phase than during the experimental phase ( 9.6 vs. 6.25 ; P < 0.05 ) . CONCLUSIONS Real-time CGM in conjunction with the DIABTel system improves glycemic control and glucose stability in pump-treated patients with type 1 diabetes IMPORTANCE Minimal information exists regarding the long-term comparative effectiveness of telemedicine to provide diabetic retinopathy screening examinations . OBJECTIVE To compare telemedicine to traditional eye examinations in their ability to provide diabetic retinopathy screening examinations . DESIGN , SETTING , AND PARTICIPANTS From August 1 , 2006 , through September 31 , 2009 , 567 participants with diabetes were r and omized and followed up to 5 years of follow-up ( last date of patient follow-up occurred on August 6 , 2012 ) as part of a multicenter r and omized clinical trial with an intent to treat analysis . We assigned participants to telemedicine with a nonmydriatic camera in a primary care medical clinic ( n = 296 ) or traditional surveillance with an eye care professional ( n = 271 ) . Two years after enrollment , we offered telemedicine to all participants . MAIN OUTCOMES AND MEASURES Percentage of participants receiving annual diabetic retinopathy screening examinations , percentage of eyes with worsening diabetic retinopathy during the follow-up period using a vali date d scale from stage 0 ( none ) to stage 4 ( proliferative diabetic retinopathy ) , and percentage of telemedicine participants who would require referral to an eye care professional for follow-up care using a cutoff of moderate diabetic retinopathy or worse , the presence of macular edema , or an unable-to-determine result for retinopathy or macular edema . RESULTS The telemedicine group was more likely to receive a diabetic retinopathy screening examination when compared with the traditional surveillance group during the 6-month or less ( 94.6 % [ 280/296 ] vs 43.9 % [ 119/271 ] ; 95 % CI , 46.6%-54.8 % ; P < .001 ) and greater than 6-month through 18-month ( 53.0 % [ 157/296 ] vs 33.2 % [ 90/271 ] ; 95 % CI , 16.5%-23.1 % ; P < .001 ) time bins . After we offered telemedicine to both groups , we could not identify a difference between the groups in the percentage of diabetic retinopathy screening examinations . Diabetic retinopathy worsened by 2 stages or more in 35 ( 8.6 % ) of 409 participants ( 95 % CI , 5.8%-11.2 % ) and improved by 2 stages or more in 5 ( 1.2 % ) of 409 participants ( 95 % CI , 0.1%-2.3 % ) during the 4-year period . The percent of telemedicine participants requiring referral ranged from 19.2 % ( 52/271 ) to 27.9 % ( 58/208 ) . CONCLUSIONS AND RELEVANCE Telemedicine increased the percentage of diabetic retinopathy screening examinations , most participants did not require referral to an eye care professional , and diabetic retinopathy levels were generally stable during the study period . This finding suggests that primary care clinics can use telemedicine to screen for diabetic retinopathy and monitor for disease worsening over a long period . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01364129 AIM This pilot study evaluated the short-term benefits of a telemonitoring-supplemented focused diabetic education compared with education alone in participants with Type 2 diabetes who were fasting during Ramadan . METHODS In this pilot mixed- method study , we identified 37 participants and r and omly allocated them to either a telemonitoring group ( n = 18 ) or a group receiving Ramadan-focused pre-education only ( usual care ; n = 19 ) . The telemonitoring group received goal - setting and personalized feedback . RESULTS The telemonitoring group was less likely to experience hypoglycaemia than the usual care group ( odds ratio : 0.1273 ; 95 % confidence interval : 0.0267 - 0.6059 ) . No significant differences were noted in glycaemic control at the end of study . Participants viewed telemedicine as a more convenient alternative although technological barriers remain a concern . CONCLUSIONS The results of this study reinforce the need for monitoring as well as educational initiatives for Muslims with diabetes who fast during Ramadan . Telemonitoring offers an attractive option requiring further research . ( Clinical Trial Registry No. NCT02189135 ) RATIONALE , AIMS AND OBJECTIVES Self-management of type 2 diabetes through diet , exercise and for many medications , are vital in achieving and maintaining glycaemic control in type 2 diabetes . A number of interventions have been design ed to improve self-management , but the outcomes of these are rarely explored from a qualitative angle and even fewer through a process evaluation . METHOD A process evaluation was conducted using a qualitative design with participants r and omized to an intervention . Seventy-three people living with type 2 diabetes and hyperglycaemia for a minimum of 1 year , r and omized to one of two interventions ( n = 34 to an education intervention and n = 39 to an education and acceptance and commitment therapy intervention )  completed stage one of the process evaluation , immediately following the intervention through written feedback guided by open-ended questions . A purposive sample of 27 participants completed semi-structured interviews at 3 and 6 months post intervention . Interview data were transcribed and data analysed using a thematic analysis . RESULTS The majority of participants described an increase in knowledge around diabetes self-management and an increased sense of personal responsibility . Participants also described changes in self-management activities and reflected on the challenges in instigating and maintaining change to improve diabetes management . CONCLUSION The complexities of implementing change in daily life to improve glycaemic control indicate the need for ongoing support post intervention , which may increase and maintain the effectiveness of the intervention Executive summary Background As a chronic condition , the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications , an essential component of self‐management , has been shown to improve glycaemic control . However compliance with oral medication adherence remains poor . Educating people with Type 2 diabetes is an important strategy to enhance self‐management ability , including medication‐taking behaviour . Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes . Inclusion criteria Types of participants Studies involving adults over 18 years old with Type 2 diabetes , with or without co‐morbidities , currently taking oral hypoglycaemic medication without insulin treatment , and with aglycated haemoglobin ( HbA1c ) > 7.0 % prior to the intervention were considered . Aglycated haemoglobin ( HbA1c ) concentration of less than 7.0 % , is important in order to delay or prevent diabetes‐related complications . Participants could be from the primary , tertiary or acute care setting . Types of intervention The review focused on various forms of educational interventions delivered by healthcare professionals aim ed at improving participants ’ knowledge . Types of outcomes The review evaluated outcomes measuring oral hypoglycaemic adherence including HbA1c , fasting blood glucose levels and other relevant indicators . Types of studies Studies that were r and omized controlled trials ( RCTs ) or case‐control studies were considered . Search strategy A three‐stage search strategy was employed . Papers in English and between the years 1990‐2009 were search ed in the following data bases : CINAHL , Medline , Mosby 's Nursing Consult , PsycINFO , PubMed , ScienceDirect , Scopus , TRIP and Web of Science . Full text was retrieved when the titles and abstract s of studies fulfilled the inclusion criteria . Method ological quality Full papers were assessed for method ological quality independently by two review ers using critical appraisal checklists from the Joanna Briggs Institute ( JBI ) . A third review er was consulted whenever there were disagreements between the two review ers . Data collection / extraction Details of each study included in the review were extracted using st and ardized data extraction forms developed by JBI . Extraction was conducted independently by two review ers . Data synthesis Meta‐ analysis was not possible due to method ological and statistical heterogeneity of the included studies . Hence study findings are presented in narrative form . Results Seven studies included in the final review consisted of seven RCTs . Five studies concluded that the educational intervention was effective in promoting oral hypoglycaemic adherence compared to usual care . These included pharmacist‐led interventions , individual diabetes education provided by nurses and diabetes group education based on a self‐management approach . Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions . However , small sample s in some studies limited generalization of results . Conclusions Implication s for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence . Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence . Educational interventions focusing on self‐management strategies appear more likely to achieve positive outcomes . Implication s for research Further trials involving larger sample s and population s with poor glycaemic control are needed . The effects of educational interventions , influence of additional take‐home written material , the optimal interval length of follow‐up and duration of education sessions , and specific processes of individual or group education which have been identified as effective need further exploration OBJECTIVES To establish the prevalence and severity of diabetic retinopathy ( DR )  in a sample of patients from " Health Area 3 " in the Community of Madrid using non-mydriatic retinography and telemedicine . METHODS All patients who had their ocular fundus examined due to one of the following conditions were included in the sample : type 1 diabetes ( DM1 ) , type 2 non- insulin-dependent diabetes ( DM2NID ) , and type 2 insulin-dependent diabetes ( DM2ID ) . In all cases , 3-field retinographies were taken of both eyes to be evaluated for the presence of DR , and its severity , by an ophthalmologist at the hospital . RESULTS No DR was observed in 79 % of the patients examined , 9 % had a mild non-proliferative DR , 9 % had a moderate non-proliferative DR , and 1 % had a severe non-proliferative DR . The estimated prevalence of DR in " Health Area 3 " of the Community of Madrid was thus 21 % . In 12 % of the examinations the retinographies were considered " low quality " , thus requiring a second evaluation at hospital . CONCLUSIONS The use of non-mydriatic retinography and telemedicine is an adequate method for the screening of DR among the diabetic population Patient empowerment through self-management education is central to improving the quality of diabetes care and preventing Type 2 Diabetes .  Although national programs exist , there is no EU-wide strategy for diabetes self-management education , and patients with limited literacy face barriers to effective self-management . The Diabetes Literacy project , initiated with the support of the European Commission , aims to fill this gap . The project investigates the effectiveness of diabetes self-management education , targeting people with or at risk of Type 2 Diabetes in the 28 EU Member States , as part of a comprehensive EU-wide diabetes strategy . National diabetes strategies in the EU , US , Taiwan , and Israel are compared , and diabetes self-management programs inventorized . The costs of the diabetes care pathway are assessed on a per person basis at national level . A comparison is made of the (cost)-effectiveness of different methods for diabetes self-management support , and the moderating role of health literacy , organization of the health services , and implementation fidelity of education programs are considered . Web-based material s are developed and evaluated by r and omized trials to evaluate if interactive internet delivery can enhance self-management support for people with lower levels of health literacy . The 3-year project started in December 2012 . Several literature review s have been produced and protocol development and research design are in the final stages . Primary and secondary data collection and analysis take place in 2014 . The results will inform policy decisions on improving the prevention , treatment , and care for persons with diabetes across literacy levels AIMS Weight loss improves glycaemic control in type 2 diabetes mellitus ( T2DM ) . However , as achieving and maintaining weight loss is difficult , alternative strategies are needed . Our primary aim was to investigate the effects of intermittent energy restriction ( IER ) compared to continuous energy restriction ( CER ) on glycated haemoglobin A1c ( HbA1c ) . Secondary aims were to assess effects on weight loss , body composition , medication changes and subjective measures of appetite . Using a 2-day IER method , we expected equal improvements to HbA1c and weight in both groups . METHOD Sixty-three overweight or obese participants ( BMI 35.2±5kg/m2 ) with T2DM ( HbA1c 7.4±1.3 % ) ( 57mmol/mol ) were r and omised to a 2-day severe energy restriction ( 1670 - 2500kJ/day ) with 5days of habitual eating , compared to a moderate CER diet ( 5000 - 6500kJ/day ) for 12weeks . RESULTS At 12weeks HbA1c ( -0.7±0.9 % P<0.001 ) and percent body weight reduction ( -5.9±4 % P<0.001 ) was similar in both groups with no group by time interaction . Similar reductions were also seen for medication dosages , all measures of body composition and subjective reports of appetite . CONCLUSIONS In this pilot trial , 2days of IER compared with CER result ed in similar improvements in glycaemic control and weight reduction offering a suitable alternative treatment strategy The study goal was to evaluate the impact of the telemedicine consult on patients with chronic wounds . Thirty patients from long-term care skilled nursing facilities , referred to the ambulatory wound care program for wound assessment and preparation of management plans , were the subject of this prospect i ve , r and omized trial . To facilitate communication with a surgical wound care specialist , telemedicine feedback was provided prior to face-to-face consultation to 15 patients . The telemedicine consult included ( 1 ) wound assessment , ( 2 ) rationale for the suggested wound management with emphasis on wound risk projections , and ( 3 ) prevention and benefits of surgical intervention . This was communicated to the patient by the field wound care nurse . The telemedicine impact was measured by assessing the duration of the subsequent face-to-face consultation and patient satisfaction with further care decisions as well as by validation of a decisional conflict scale . The average duration of the face-to-face consultation was 50 + /- 12 minutes versus 35 + /- 6 ( p < 0.01 ) minutes for patients subjected to the telemedicine feedback preceding the direct contact with the specialist . The telemedicine consult was found to be a useful aid in increasing the satisfaction rate from care decisions ultimately made during the direct consult ( acceptance rate 93 % vs. 47 % in those subjected to treatment without the intermediate telemedicine consult , p < 0.01 ) . The decisional conflict as a state of uncertainty about the course of action to take was reduced in patients subjected to telemedicine decision aid . The average Decisional Conflict Scale score was 14 + /- 1.73 in patients subjected to telemedicine feedback as opposed to 35 + /- 4.26 ( p < 0.001 ) in no-telemedicine contact . The telemedicine consult preceding face-to-face evaluation improved patient satisfaction and underst and ing of their care as well as increased the perception of shared decision making regarding the wound care Background : In order to optimize care and improve outcomes in people with diabetes , adequate access to health care facilities and re sources for self-management is required . Methods : Data on 3369 individuals with type 2 diabetes who received education at 7 diabetes centers were collected prospect ively between June 2005 and January 2007 . The driving distances of subjects who were in good control [ hemoglobin A1c ( A1C ) > 7.0 % ] were compared with the driving distances of those who were not ( A1C > 7.0 % ) . The association between A1C and improvement in A1C with travel burden was tested . Results : The mean distance subjects traveled to visit their center was 13.3 miles . The results indicated that residing more than 10 miles from the diabetes management center [ odds ratio ( OR ) = 1.91 , p < .0001 ] , being younger ( OR = 0.99 , p = .00015 ) , and having a longer duration of diabetes ( OR = 1.03 , p = .0007 ) were significant contributors to a A1C > 7 % adjusted for individual- and community-level factors . In addition , those who lived within 10 miles of their center were 2.5 times more likely to have improved their A1C values between their first and last Office visits . Conclusion : Health care providers should be aware of travel burden as a potential barrier to glycemic control . In the future , it may be useful to minimize driving distance for individuals with diabetes , perhaps by improved public transportation , more diabetes center locations in rural areas , telemedicine , or home visits Existing st and ards of the management of the diabetic patients are not efficient enough , and further improvement is needed . The major objective of this paper is to present and discuss the therapeutic effectiveness of an intensive care telematic system design ed and applied for intensive treatment of pregnant type 1 diabetic women . The developed system operates automatically , every night transferring all the data recorded during the day in the patient 's glucometer memory to a central clinical unit . In order to assess the efficiency of the design ed and developed system , a 3-year r and omized prospect i ve clinical trial was conducted , using the study group and the control group , each consisting of 15 pregnant type 1 diabetic women . All patients were treated by the same diabetologist . In the presented analysis , two indices calculated weekly were used for the assessment of glycemic control : MBG represents mean blood glucose level , and the universal J-index is sensitive to the glycemic level and glycemic variations . The most important results from the study concern : ( a ) better glycemic control in the study group in comparison with the control group during the course of treatment , as assessed by the average differences of the MBG and J indices calculated weekly ( n = 24 ) ( deltaMBG = -3.2 + /- 4.3 mg/dL , p = 0.0016 , deltaJ = -1.4 + /- 2.3 , p = 0.0065 ) ; ( b ) much more similar results in glycemic control among members of the study group compared to each other , than among members of the control group compared to each other , as indicated by significantly lower variations of the applied glycemic control indices ( SDMBG : 11.9 vs. 18.7 mg/dL , p = 0.0498 ; SDJ : 6.5 vs. 10.9 , p = 0.0318 ) ; ( c ) the observed tendency of a better glycemic control for patients with a lower level of intelligence ( IQ < 100 ) supported by the telematic system in comparison with all other assessed groups of patients . The last result was not statistically significant ( p > 0.05 ) . This telematic intensive care system improved the effectiveness of diabetes treatment during pregnancy . It also allows the diabetologist 's strategy to be much more precise than if it were conducted without telematic support . This telematic system is inexpensive and simple in use AIM To investigate the effectiveness of a nurse short message service ( SMS ) by cellular phone and wire Internet on plasma glucose levels in people with diabetes for six months . BACKGROUND Blood glucose management system using telemedicine approaches may maintain the appropriate blood glucose levels in type-2 diabetic patients . DESIGN A control group pre-test-post-test design was used to assess the effectiveness of nurse 's education . METHODS Twenty-five patients were r and omly assigned to an intervention group and 26 to a control group . The intervention was applied for six months . The goal of the intervention was to keep blood glucose concentrations close to the normal range . Participants were requested to input their  blood glucose level , diet and exercise diary everyday in the website by cellular phone or wire Internet . The research er sends optimal recommendations to each patient using SMS by cellular phone and wire Internet weekly . RESULTS Glycosylated hemoglobin ( HbA(1)c ) decreased 1.15 % points at three months and 1.05 % points at six months compared with baseline in the intervention group . Patients in the intervention group had a decrease of two hours post meal glucose ( 2HPMG ) of 85.1 mg/dl at three months and 63.1 mg/dl at six months compared with baseline . CONCLUSION This web-based intervention using SMS of cellular phone improved HbA(1)c and 2HPMG for six months in type-2 diabetic patients . RELEVANCE TO CLINICAL PRACTICE An SMS of cellular phone intervention by a nurse can reduce HbA(1)c and 2HPMG for six months in type-2 diabetic patients Background : The DIABTel system , a Web-based telemedicine application , integrates a whole communication system ( glucometer , insulin pump , wireless h and -held assistant ) for medical remote advice . We sought to evaluate , in terms of glycemic control , the DIABTel system in a r and omized crossover clinical study . Methods : Ten patients with type 1 diabetes [ 5 women , age 40.6 ( 21–62 ) years , diabetes duration 14.7 ( 3–52 ) years ] were included . During the 4-week active phase , data sent by patients were analyzed by the physician and modifications of the basal rate and bolus were advised in the following 24 hours . During the control phase , patients sent glucose data without any feedback from the medical center . Results : The mean numbers of daily glucose values and bolus sent by patients during the active period were 4.46 ± 0.91 and 4.58 ± 0.89 , respectively . The personal digital assistant functionalities used more frequently by patients were ( times per week ) data visualization ( 8.1 ± 6.8 ) , data download from the insulin pump ( 6.8 ± 3.3 ) , and synchronization with the telemedicine server ( 8.5 ± 4.9 ) . After the experimental phase , serum fructosamine decreased significantly ( 393 ± 32 vs 366 ± 25 μmol/liter ; p < 0.05 ) and hemoglobin A1c ( HbA1c ) tended to decrease ( 8.0 ± 0.6 vs 7.78 ± 0.6 ; p = 0.073 ) , whereas no changes were observed during the control phase . The number of treatment modifications proposed and performed by the patients correlated with the change observed in HbA1c during the active phase ( r = −0.729 , p = 0.017 ) . Conclusions : The DIABTel system , a telemedicine system that includes a wireless personal assistant for remote treatment advising , allows better glycemic control in pump-treated patients with type 1 diabetes . To our knowledge , this is the first study that demonstrates improved glycemic control with the use of a telemedicine system that incorporates insulin delivery data 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 The purpose of this study was to evaluate the impact of a three-day therapeutic education programme on perceived competence , self-management behaviours ( i.e. physical activity , diet and medication ) and glycaemic control among adults with type 2 diabetes . A total of 120 participants were included in this r and omized , wait list control group trial . The results confirm that therapeutic education may be a powerful healthcare intervention to improve lifestyle and health status of people with type 2 diabetes . We observed that the education programme used in this study generated positive changes in glycaemic control and adherence to physical activity and diet after three months follow-up . Furthermore , the intervention positively impacted participants ’ perceived competence towards physical activity and diet . The latter finding is of particular importance , given that perceived competence has been found to be involved in long-term adherence to self-management behaviours Aims In the UK , lifestyle intervention is first-line management in Type 2 diabetes . It is unclear what type of diet is most efficacious for improving glycaemic control . This study investigated the effects of an oat-enriched diet on glycaemic control , postpr and ial glycaemia , inflammation and oxidative stress compared with st and ard dietary advice . Methods In a r and omized crossover design , 27 volunteers with Type 2 diabetes , managed on diet and lifestyle only , were observed for two consecutive 8-week periods following either the oat-enriched diet or re-enforced st and ard dietary advice . Volunteers attended at baseline ( habitual intake ) and 8 and 16 weeks . Measurements included basic clinical measurements and fasted and postpr and ial ( 3-h ) glucose and insulin in response to a healthy test meal . Markers of inflammation and oxidative stress , including high-sensitivity C-reactive protein , interleukin 6 , interleukin 18 , tumour necrosis factor-alpha , adiponectin , thiobarbituric acid reactive substances , oxygen radical antioxidant capacity , oxidized LDL and urinary isoprostanes , were also measured at fasting and in the postpr and ial period . Results There were no diet-related effects on glycaemic control or glycaemic or insulinaemic responses to the test meal . Total cholesterol ( 5.1 ± 1.0 vs. 4.9 ± 0.8 mmol/l , P = 0.019 ) concentrations declined following the oat-enriched diet compared with st and ard dietary advice . There was a postpr and ial decline in adiponectin concentration ( P = 0.009 ) , but no effect of dietary intervention . None of the measures of oxidative stress or inflammation were altered by the oat-enriched diet compared with st and ard dietary advice . Conclusion The oat-enriched diet had a modest impact on lipid lowering , but did not impact on oxidative stress or inflammation in these volunteers with Type 2 diabetes UNLABELLED BACKGROUND / AIM . In the last twenty years significant advances have been made in the fields of information and telecommunication technology in health care applications , with a positive impact on the health care practice . The need for remote diagnosis and planning of interventions is of special importance in military health care , and health management of immobile persons , and those with special needs . In cases such as these , availability of specialist health care is mainly limited by geographic and financial factors . The aim of this study was to investigate practical usability of telemedicine approaches in everyday management of oral surgery patients in terms of reliability of established diagnosis and indications for oral surgery treatment of the third molars . METHODS Our experimental r and omized study enrolled 432 r and omly selected patients of both genders , aged 20 to 87 years , undergoing panoramic radiography for some reason in the Centre for Dental Radiography in Bel grade . In addition to radiography , photographs of the face and mouth cavity were taken . These images were uploaded to the web server specially dedicated to the study purpose s , and then transmitted to teledentists , i.e. oral surgeons , who made remote diagnoses . Diagnostic agreement was determined by way of the Cohen 's kappa coefficient , and diagnostic sensitivity ( SE ) , specificity ( SP ) , and effectiveness ( EFF ) were also established . Statistical significance was determined and comparisons performed by using the z-test , and testing of non-parametric characteristics by using the McNemar 's chi2 test for p = 0.05 significance cut-off . RESULTS The results obtained by analyzed images and diagnostic assessment of the clinical diagnosis ( kappa = 0.99 , SE = 99 % , SP = 99 % , EFF = 99 % , for 95 % CI ) indicate an almost complete diagnostic agreement . The differences in diagnosis were not statistically significant . CONCLUSION Diagnostic assessment of the clinical diagnosis of impacted or semi-impacted third molars assisted by the telemedicine approach was equal to the real-time assessment of clinical diagnosis . Telemedicine , and teledentistry as its branch , represent the present and even more the future of this field of health care Objectives To evaluate whether a course teaching flexible intensive insulin treatment combining dietary freedom and insulin adjustment can improve both glycaemic control and quality of life in type 1 diabetes . Design R and omised design with participants either attending training immediately ( immediate DAFNE ) or acting as waiting list controls and attending “ delayed DAFNE ” training 6 months later . Setting Secondary care diabetes clinics in three English health districts . Participants 169 adults with type 1 diabetes and moderate or poor glycaemic control . Main outcome measures Glycated haemoglobin ( HbA1c ) , severe hypoglycaemia , impact of diabetes on quality of life ( ADDQoL ) . Results At 6 months , HbA1c was significantly better in immediate DAFNE patients ( mean 8.4 % ) than in delayed DAFNE patients ( 9.4 % ) ( t=6.1 , P < 0.0001 ) . The impact of diabetes on dietary freedom was significantly improved in immediate DAFNE patients compared with delayed DAFNE patients ( t= − 5.4 , P < 0.0001 ) , as was the impact of diabetes on overall quality of life ( t=2.9 , P < 0.01 ) . General wellbeing and treatment satisfaction were also significantly improved , but severe hypoglycaemia , weight , and lipids remained unchanged . Improvements in “ present quality of life ” did not reach significance at 6 months but were significant by 1 year . Conclusion Skills training promoting dietary freedom improved quality of life and glycaemic control in people with type 1 diabetes without worsening severe hypoglycaemia or cardiovascular risk . This approach has the potential to enable more people to adopt intensive insulin treatment and is worthy of further investigation BACKGROUND Tele-echocardiography has the potential to bring real-time diagnoses to neonatal facilities without in-house pediatric cardiologists . Many neonates in rural areas , smaller cities , and community hospitals do not have immediate access to pediatric sonographers or echocardiogram interpretation by pediatric cardiologists . This can result in suboptimal echocardiogram quality , delay in initiation of medical intervention , unnecessary patient transport , and increased medical expenditures . Telemedicine has been used with increased frequency to improve efficiency of pediatric cardiology care in hospitals that are not served by pediatric cardiologists . Initial reports suggest that telecardiology is accurate , improves patient care , is cost-effective , enhances echocardiogram quality , and prevents unnecessary transports of neonates in locations that are not served by pediatric cardiologists . OBJECTIVE We report the largest series to evaluate the impact of telemedicine on delivery of pediatric cardiac care in community hospitals . We hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from community hospitals is accurate , improves patient care , enhances sonographer proficiency , allows for more efficient physician time management , increases patient referrals , and does not result in increased utilization of echocardiography . METHODS Using desktop videoconferencing computers , pediatric cardiologists guided and interpreted pediatric echocardiograms from 2 community hospital nurseries 15 miles from a tertiary care center . Studies were transmitted in real-time using the H.320 videoconferencing protocol over 3 integrated services digital network lines ( 384 kilobits per second ) . This result ed in a frame rate of 23 to 30 frames per second . Sonographers who primarily scanned adult patients but had received additional training in echocardiography of infants performed the echocardiograms . Additional views were suggested as deemed necessary by the interpreting physician , and interpretations were made during the videoconference . The results of the echocardiogram and recommendations for patient care were communicated to the referring physician over the telemedicine system . Analyses of accuracy , patient treatment , echocardiogram quality , time to diagnosis , pediatric cardiologist practice time management , patient referral patterns , and echocardiography utilization were conducted prospect ively . RESULTS A total of 500 studies in 364 patients were transmitted during a 30-month period . The most common indication for echocardiography was to rule out congenital heart disease ( 208 of 500 studies ) . Signs and symptoms that prompted this concern included cyanosis , murmur , tachypnea , genetic syndrome , arrhythmia , abnormal fetal echocardiogram , and maternal diabetes . Other indications included suspected  patent ductus arteriosus ( PDA ; 182 of 500 studies ) , intracardiac clot or catheter position , persistent pulmonary hypertension , and hemodynamic instability . Cardiac diagnoses included complex congenital heart disease ( n = 16 ) , noncritical heart disease ( n = 107 ) , and PDA ( n = 86 ) . Additional diagnoses included persistent pulmonary hypertension ( n = 12 ) , septal hypertrophy ( n = 18 ) , right atrial mass/clot/vegetation ( n = 11 ) , and decreased cardiac function ( n = 6 ) . An umbilical venous catheter was visualized in the left atrium in 9 % ( 45 of 500 ) of all studies . No significant abnormalities were found in 244 studies . Major diagnoses were confirmed by subsequent review of videotape in all studies . Comparison of final videotape interpretation to initial telemedicine diagnosis result ed in 1 minor diagnostic change ( membranous versus inlet ventricular septal defect ) . Echocardiograms were performed in subsequent visits in 264 patients . The diagnosis was altered in 3 patients . Telemedicine had an immediate impact on patient care in 151 transmissions . The most common interventions were indomethacin treatment for PDA ( n = 76 ) , retraction of umbilical venous catheters from the left atrium ( n = 45 ) , inotropic or anticongestive therapy ( n = 19 ) , anticoagulation ( n = 8) , and prostagl and in infusion ( n = 8) . Nineteen patients were transported to our hospital because of the telemedicine diagnosis . Inpatient or outpatient cardiology follow-up was recommended in an additional 131 studies and did not result in any change in the initial management . The most common diagnoses in these patients were ventricular septal defect ( n = 56 ) , atrial septal defect ( n = 21 ) , septal hypertrophy ( n = 9 ) , intracardiac thrombosis ( n = 8) , and pulmonary valve stenosis ( n = 4 ) . We speculate that the immediate availability of an echocardiographic diagnosis likely prevented unnecessary transport in 14 cases . Recommendations for additional views or adjustment of echocardiography machine setting s were made in 95 % of transmissions . Real-time guidance was especially helpful in suprasternal notch and subcostal sagittal imaging . Depth , color Doppler sector size , and color Doppler scale were frequently adjusted from routine adult setting s during the teleconference . The average time from request for echocardiogram to completion of the videoconference was 28 + /- 14 minutes . This was significantly shorter than the waiting time ( 12 + /- 16 hours ) for the videotape to be delivered by courier . Telemedicine eliminated the need for consultation in 194 cases and allowed the cardiologist to delay the visit until the end of the day in an additional 26 cases . This result ed in average time savings of 4.2 person-hours/wk based on travel and consultation time . Utilization of echocardiography  was similar before ( 35 of 1000 births ) and after ( 33 of 1000 to 43 of 1000 ) telemedicine installation . The percentage of neonatal echocardiograms that were interpreted by our practice increased from 63 % to 81 % at 1 hospital and from 0 % to 100 % at the other hospital . CONCLUSION Real-time transmission of neonatal echocardiograms from community hospitals over 3 integrated services digital network lines is accurate and has the potential to improve patient care , enhance echocardiogram quality , aid sonographer education , and have a positive impact on referral patterns and time management without increasing the utilization of echocardiography Abstract Objectives : To evaluate whether a course teaching flexible intensive insulin treatment combining dietary freedom and insulin adjustment can improve both glycaemic control and quality of life in type 1 diabetes . Design : R and omised design with participants either attending training immediately ( immediate DAFNE ) or acting as waiting list controls and attending “ delayed DAFNE ” training 6 months later . Setting : Secondary care diabetes clinics in three English health districts . Participants : 169 adults with type 1 diabetes and moderate or poor glycaemic control . Main outcome measures : Glycated haemoglobin ( HbA1c ) , severe hypoglycaemia , impact of diabetes on quality of life ( ADDQoL ) . Results : At 6 months , HbA1c was significantly better in immediate DAFNE patients ( mean 8.4 % ) than in delayed DAFNE patients ( 9.4 % ) ( t=6.1 , P<0.0001 ) . The impact of diabetes on dietary freedom was significantly improved in immediate DAFNE patients compared with delayed DAFNE patients ( t=−5.4 , P<0.0001 ) , as was the impact of diabetes on overall quality of life ( t=2.9 , P<0.01 ) . General wellbeing and treatment satisfaction were also significantly improved , but severe hypoglycaemia , weight , and lipids remained unchanged . Improvements in “ present quality of life ” did not reach significance at 6 months but were significant by 1 year . Conclusion : Skills training promoting dietary freedom improved quality of life and glycaemic control in people with type 1 diabetes without worsening severe hypoglycaemia or cardiovascular risk . This approach has the potential to enable more people to adopt intensive insulin treatment and is worthy of further investigation We conducted a pilot study of the effectiveness of individual counselling sessions provided by a dietician through telemedicine for patients with diabetes . All participants received a single group education session via videoconference .  Those who were r and omized to the intervention also received two additional follow-up sessions , four and eight weeks later . Glycosylated haemoglobin and total cholesterol were measured at the start and again 16 weeks later . The patients completed diabetes quality -of-life and telemedicine patient satisfaction surveys . Thirty-two participants consented to participate . Complete data were collected on 13 intervention and 13 control patients . There was a 1 % fall in HbA1c in the intervention group from pre- to post- assessment , although this was not significant . The control group showed a significantly larger fall in HbA1c levels than the intervention group ( P = 0.043 ) . Total cholesterol decreased in both groups , although not significantly . All control and intervention group participants indicated that they would participate in videoconferencing nutritional counselling again . The results suggest that providing nutritional therapy via videoconferencing may be useful in assisting patients to manage their conditions 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 INTRODUCTION The implementation of telemedicine often introduces major organizational changes in the affected healthcare sector . The objective of this study was to examine the organizational changes through the perception of the healthcare professionals regarding the implementation of a telemedical intervention . We posed the following research question : What are the key organizational factors in the implementation of telemedicine in wound care ? METHODS In connection with a r and omized controlled trial of telemedical intervention for patients with diabetic foot ulcers in the region of Southern Denmark , we conducted an organizational analysis . The trial was design ed as a multidisciplinary assessment of outcomes using the Model of ASsessment of Telemedicine ( MAST ) . We conducted eight semi-structured interviews including individual interviews with leaders , and an IT specialist as well as focus group interviews with the clinical staff . A qualitative data analysis of the interviews was performed in order to analyze the healthcare professionals and leaders perception of the organizational changes caused by the implementation of the intervention . RESULTS The telemedical setup enhanced confidence among collaborators and improved the wound care skills of the visiting nurses from the municipality . The effect was related to the direct communication between visiting nurses and specialist doctors . Focus on the training of the visiting nurses was highlighted as a key factor in the success to securing implementation . Concerns regarding lack of multidisciplinary wound care teams , patient responsibility and lack of patient interaction with the physician were raised . Furthermore , the need for clinical guidelines in future implementation was underlined . CONCLUSIONS Several influential factors were demonstrated in the analysis including visiting nurses wound care training , focus on management , economy , periods with absence from work and clinical care . However , the technology used here could provide an additional option to offer patients after an individual assessment of their health condition Objective To explore a model of Internet‐based integrated management of diabetes , we established a remote diabetes medical service platform ( U‐Healthcare ) and evaluated its effectiveness and practicality . Material s and Methods In total , 212 patients with type 2 diabetes mellitus were r and omly assigned to 2 groups . Data from the intervention group were automatically transmitted through a glucometer ; furthermore , this group received information regarding medicines , diet , exercise and other management through U‐Healthcare . The control group received conventional medical treatment without any additional intervention . All patients were regularly followed up every 3 months for half a year . Results At the 3‐month follow‐up , fasting plasma glucose levels of the intervention group were significantly lower than those at the baseline as well as those of the control group . Triglyceride levels of the intervention group were much lower than those at the baseline . At the 6‐month follow‐up , 2‐hour postpr and ial plasma glucose levels of the intervention group significantly improved compared with those of the control group . HbA1c levels gradually decreased every 3 months in the intervention group , and the mean change in the levels was significantly greater in this group than in the control group ( from 1.27‐0.68 % ) . At the end of the study , more than 80 % of the patients in the intervention group adhered to blood glucose monitoring 2‐3 days per week , and their compliance degree was 72 % . Conclusions The Internet‐based U‐Healthcare system of integrated management in diabetes not only achieved better glycemic control , effectively improved HbA1c levels and decreased triglyceride levels but also enhanced patients ’ adherence to the medical team 's instructions Background Despite broad agreement on the necessity to improve quality of diabetic care through implementation of clinical guidelines , in Italy many people with diabetes still lack adequate care in general practice . In addition there is little evidence to support the choice of implementation strategies , especially in the Lazio region ( central Italy ) , where comparative studies among general practitioners ( GPs ) are uncommon . The primary objective of the study is to assess the effectiveness of different strategies for the implementation of an  evidence -based guideline for the management of  non-complicated type 2 diabetes mellitus ( DM ) among GPs of the Lazio region . Methods / Design Three-arm cluster-r and omised trial ( C- RCT ) . 252 GPs were r and omised either to arm 1 ( comprising a training module and administration of the guideline ) , or to arm 2 ( administration of guideline without training ) , or to arm 3 ( control arm ) , continuing current practice . Arm 1 participants attended a two-day course with CME credits . Data collection will be performed using current information systems . Patients ' health data was also collected to describe diabetic population s cared for by GP participants . Process outcomes will be measured at the patient level and at the cluster level one year after the intervention . We will assess GPs ' adherence to guideline recommendations for diabetes management relative to : 1 ) pharmacological management of diabetes ; 2 ) pharmacological management of cardiovascular risk factors ( hypertension and dislypidaemia ) ; 3 ) measurement of glycosilated haemoglobin as the principal indicator of glycaemic control ; 4 ) micro- and macrovascular complications assessment tests . Outcomes will be expressed as proportions of patients cared for by GPs who will have prescriptions of drugs , requests for tests and for outpatient appointment visits . To estimate the efficiency of re source use associated with the intervention a cost-effectiveness analysis will be carried out . The design of the study is based on three Cochrane and one Health Technology Assessment systematic review s of guideline dissemination and implementation strategies Telemedicine is widely considered as an efficient approach to manage the growing problem of chronic wounds . However , to date , there is no convincing evidence to support the clinical efficacy of telemedicine in wound management . In this prospect i ve cluster controlled study , we tested the hypothesis that advice on wound management provided by a team of wound-care specialists through telemedicine would significantly improve the likelihood of wound healing compared with the best available conventional practice . A total of 90 chronic wound patients in home care met all study criteria and were included : 50 in the telemedicine group and 40 in the conventional group . Patients with pressure ulcers , surgical wounds , and cancer wounds were excluded . During the 1-year follow-up , complete wound healing was achieved in 35 patients ( 70 % ) in the telemedicine group compared with 18 patients ( 45 % ) in the conventional group . After adjusting for important covariates , offering advice on wound management through telemedicine was associated with significantly increased healing compared with the best available conventional practice ( telemedicine vs. conventional practice : adjusted hazard ratio 2.19 ; 95 % confidence interval : 1.15 - 4.17 ; P=0.017 ) . This study strongly supports the use of telemedicine to connect home-care nurses to a team of wound experts in order to improve the management of chronic wounds ABSTRACT Background : People with type 2 diabetes frequently have a variety of related and unrelated chronic conditions . These additional conditions have implication s for patient education , treatment burden and disease management . Objectives : The aim of this study was to examine the nature of multimorbidity , and its impact on GP visits , polypharmacy and glycaemic control as measured by HbA1c , in a cohort of patients with type 2 diabetes attending general practice in Irel and . Methods : A cohort of 424 patients with type 2 diabetes enrolled in a cluster r and omized controlled trial based in Irish general practice was examined . Patient data included : medical conditions , HbA1c , health service utilization , socio-economic status and number of prescribed medications . Results : 90 % of patients had at least one additional chronic condition and a quarter had four or more additional chronic conditions . 66 % of patients had hypertension ; 25 % had heart disease ; and 16 % had arthritis . General practitioner visits and polypharmacy increased significantly with increasing numbers of chronic conditions . When comparing patient self-report with medical records , patients who reported a higher proportion of their conditions had better glycaemic control with a significantly lower HbA1c score . Conclusion : There was a high prevalence of multimorbidity in these patients with type 2 diabetes and the results suggest that glycaemic control is related to patients ’ awareness of their chronic conditions . The variety of conditions emphasizes the complexity of illness management in this group and the importance of maintaining a generalist and multidisciplinary approach to their clinical care OBJECTIVE Self-management of type 2 diabetes including avoidance of hypoglycemia is complex , but the impact of cognition on safe self-management is not well understood . This study aim ed to assess the effect of baseline cognitive function and cognitive decline on subsequent risk of severe hypoglycemia and to assess the effect of different glycemic strategies on these relationships . RESEARCH DESIGN AND METHODS Prospect i ve cohort analysis of data from the ACCORD trial included 2,956 adults aged ≥55 years with type 2 diabetes and additional cardiovascular risk factors .  Cognitive tests ( Digit Symbol Substitution Test [ DSST ] , Rey Auditory Verbal Learning Test , Stroop Test , and Mini Mental Status Examination )  were conducted at baseline and 20 months . Study outcomes were incident confirmed severe hypoglycemia requiring medical assistance ( HMA ) and hypoglycemia requiring any assistance ( HAA ) . RESULTS After a median 3.25-year follow-up , a 5-point-poorer baseline score on the DSST was predictive of a first episode of HMA ( hazard ratio 1.13 [ 95 % CI 1.08–1.18 ] ) . Analyses of the other cognitive tests and of HAA were consistent with the DSST results . Cognitive decline over 20 months increased the risk of subsequent hypoglycemia to a greater extent in those with lower baseline cognitive function ( Pinteraction = 0.037 ) . R and omization to an intensive versus st and ard glycemic strategy had no impact on the relationship between cognitive function and the risk of severe hypoglycemia . CONCLUSIONS Poor cognitive function increases the risk of severe hypoglycemia in patients with type 2 diabetes . Clinicians should consider cognitive function in assessing and guiding their patients regarding safe diabetes self-management regardless of their glycemic targets Background : Telemedicine can be useful for managing heart failure ( HF ) , but patient acceptance of telemedicine and its impact on patient behavior are unclear . Aims : To assess a telemedicine program in a HF Unit . Methods and results : This sub- analysis of the CARME study assessed the use of an interactive telemedicine platform . This prospect i ve intervention study had a before/after design with HF patients r and omized 1:1 into two groups : A ) Motiva system ( educational videos , motivational messages , and question naires ) ; and B ) Motiva system + telemonitoring of blood pressure  , heart rate and weight .  Of 211 patients screened , 44 were excluded , 62 did not consent to participate and 8 withdrew consent prior to installation of the system . The final study population included 97 patients . During 1 year of follow-up , 22 patients voluntarily discontinued use of the system , 5 died ( three after early discontinuation ) and 5 withdrew consent before the last evaluation . A total of 15,017 question naires were sent to patients , with a median response rate of 88 % . Satisfaction with the system and tools was high ( median score 8.4/10 ) , especially with the self-monitoring chart , scale and sphygmomanometer . Positive changes were observed in patient behavior , especially for blood pressure and weight control ( p < 0.001 ) . After the study , 65 % of the patients wished to continue with telemonitoring , particularly those in Group B ( p = 0.004 ) . Conclusion : Less than half of our patients participated in the telemedicine study . However , those who completed the study had confidence in the system , a high degree of satisfaction with the tools and positive behavioral changes WHAT IS KNOWN AND OBJECTIVE There is little evidence from well- design ed r and omized controlled trials of the impact of community pharmacist intervention on the clinical management of patients with type 2 diabetes . It is also not known how sustainable any observed effects on glycaemic control are , over time . This study was initiated to address both these issues . METHODS A 6-month , r and omized , controlled parallel-group trial in 66 community pharmacies was conducted in Belgium . Patients were r and omly assigned to receive usual pharmacist care ( n = 135 ) or a predefined pharmacist intervention ( n = 153 ) . The intervention mainly focused on correct medication use , medication adherence and healthy lifestyle promotion . Primary outcome was glycaemic control , as measured by fasting plasma glucose and HbA1c . Sustainability of changes in glycaemic control was assessed by additional glucose measurements 18 months after the end of the study . RESULTS AND DISCUSSION The intervention significantly reduced HbA1c ( between-group difference : 0·5 % , P = 0.009 ) . The largest impact on HbA1c was observed when pharmacotherapy changes ( i.e. , type and /or dose of hypoglycaemic agents ) initiated by the physician were sustained with pharmaceutical care : HbA1c was reduced by 1·05 % in the intervention group , whose medication was changed , compared with a reduction of 0·02 % in the therapy-modification only , group . It was also found that the diabetes education program result ed in improved self-management and better knowledge of diabetes . Eighteen months after the end of the formal study period , the mean HbA1c of the intervention group did not differ significantly from the control group ( 7·4 % vs. 7·2 % ) . WHAT IS NEW AND CONCLUSION This study provides new evidence , from a r and omized controlled trial , of the beneficial  effect of community pharmacist intervention in the clinical management of type 2 diabetic patients . However , questions remain about the sustainability of the observed improvements BACKGROUND Telemedicine is one approach to managing patients with chronic illness . Several telephone-based monitoring studies of diabetes patients have shown improved glycosylated hemoglobin ( HbA1c ) , blood pressure ( BP ) , and low-density lipoprotein ( LDL ) levels . The purpose of this study was to evaluate an investigational in-home telemetry device for improving glucose and BP control over 6 months for patients with type 2 diabetes . The device was used to transmit weekly blood glucose , weight , and BP readings to a diabetes care manager . SUBJECTS AND METHODS We conducted a two-arm , parallel-comparison , single-blind , r and omized controlled trial among Kaiser Permanente Northern California members 18 - 75 years old with type 2 diabetes mellitus and entry HbA1c levels between 7.5 % and 10.0 % . Participants were r and omly assigned to either the telemonitoring arm or the usual care arm . RESULTS We observed very small , nonsignificant changes in fructosamine ( telemonitoring , -54.9 μmol ; usual care , -59.4 μmol ) and systolic BP ( telemonitoring , -6.3 mm Hg ; usual care , -3.2 mm Hg ) from baseline to 6 weeks in both groups . At 6 months , we observed no significant intergroup differences in change from baseline for HbA1c , fructosamine , or self-efficacy . However , LDL cholesterol in the telemonitoring arm decreased more than in the usual care arm ( -17.1 mg/dL versus -5.4 mg/dL ; P=0.045 ) . CONCLUSIONS Although HbA1c improved significantly over 6 months in both groups , the difference in improvement between the groups was not significant . This lack of significance may be due to the relatively healthy status of the volunteers in our study and to the high level of care provided by the care managers in the Santa Rosa , CA clinic . Further study in subgroups of less healthy diabetes patients is recommended Patients in a low-income community health center with Type 2 diabetes ( N = 81 ) taking a one-day education workshop  as part of their diabetes medical management were r and omly assigned either to education alone or to a combination of education and acceptance and commitment therapy ( ACT ) . Both groups were taught how to manage their diabetes , but those in the ACT condition also learned to apply acceptance and mindfulness skills to difficult diabetes-related thoughts and feelings . Compared with patients who received education alone , after 3 months those in the ACT condition were more likely to use these coping strategies , to report better diabetes self-care , and to have glycated hemoglobin ( HbA-sub(1C ) ) values in the target range . Mediational analyses indicated that changes in acceptance coping and self-management behavior mediated the impact of treatment on changes in HbA-sub(1C ) We conducted a six-month prospect i ve interventional crossover study examining a computerized diabetes monitoring system ( DMS ) that conveyed dietary information . The objectives were to compare glycaemic control between intervention and control periods , and to assess patients ' acceptance of the DMS . Nineteen patients were r and omized into two groups , each using the DMS for three months and serving as the control group for another three months . The patients recorded information about their meal portions and blood glucose readings in a h and -held electronic diary . After transmitting the data to the DMS through a telephone modem , the patients received immediate feedback about the carbohydrate , protein and fat content of the meal , as well as the calorie content . A significant improvement in glycaemic control was achieved during intervention compared with control periods ( mean HbA1C reduction of 0.825 % ) . The DMS was also highly acceptable : 95 % patients found it easy to operate while 63 % found it useful . The DMS was thus a feasible model of telemedicine in diabetes care and a larger study is warranted to examine its cost-effectiveness Abstract Problem : Inhabitants of Torres Strait Isl and s have the highest prevalence of diabetes in Australia and many preventable complications . In 1999 , a one year r and omised cluster trial showed improved diabetes care processes and reduced admissions to hospital when local indigenous health workers used registers , recall and reminder systems , and basic diabetes care plans , supported by a specialist outreach service . This study looked at whether those improvements were sustained two years after the end of the trial . Design : Three year follow up clinical audit of 21 primary healthcare centres , and review of admissions to hospital in the previous 12 months . Background and setting : Remote indigenous communities in far north east Australia , population about 9600 , including 921 people with diabetes . Key measures for improvement Number of people on registers , care processes ( regular measures of weight , blood pressure , haemoglobin A 1c , urinary protein concentration , and concentrations of serum lipids and creatinine ) , appropriate clinical interventions ( drug treatment and vaccinations ) , and intermediate patient outcome measures ( weight , blood pressure , and glycaemic control ) . Admissions to hospital . Strategies for change : Audit and feedback to clinicians and managers ; provision of clinical guidelines and a clear management structure ; workshops and training . Effects of change : The number of people on registers increased from 555 in 1999 to 921 in 2002 . Most care processes and clinical interventions improved . The proportion of people with good glycaemic control ( haemoglobin A 1c ≤ 7 % ) increased from 18 % to 25 % in line with increased use of insulin ( from 7 % to 16 % ) . The proportion of those with well controlled hypertension ( < 140/90 ) increased from 40 % to 64 % . The proportion admitted to hospital with a diabetes related condition fell from 25 % to 20 % . Mean weight increased from 87 kg to 91 kg . Lessons learnt : In remote setting s , appropriate management structures and clinical support for people with diabetes can lead to improvements in care processes , control of blood pressure , and preventable complications that result in admission to hospital . Control of weight and glycaemia are more difficult and requires more active community engagement . Priorities now include increasing the availability and affordability of good food , achieving weight loss , and increasing appropriate use of hypoglycaemic agents , including insulin AIM To determine the glycaemic index values to a range of foods that are unique to New Zeal and , and those that are grown and /or manufactured locally . METHODS We determined the glycaemic index of 28 carbohydrate foods in both healthy subjects and those with type 2 diabetes . Venous blood sample s were collected over two to three hours , and the incremental area under the blood glucose curve was used to calculate glycaemic index values . RESULTS AND CONCLUSIONS This study has identified the glycaemic index values for a range of New Zeal and foods which will be clinical ly useful in the nutritional management of individuals with diabetes mellitus . People with diabetes are recommended to choose foods with a low glycaemic index which is associated with optimal blood glucose control and lipid levels OBJECTIVE Youth with type 1 diabetes frequently do not achieve glycemic targets . We aim ed to improve glycemic control with a Care Ambassador ( CA ) and family-focused psychoeducational intervention . RESEARCH DESIGN AND METHODS In a 2-yr , r and omized , clinical trial , we compared three groups : ( i ) st and ard care , ( ii ) monthly outreach by a CA , and ( iii ) monthly outreach by a CA plus a quarterly clinic-based psychoeducational intervention . The psychoeducational intervention provided realistic expectations and problem-solving strategies related to family diabetes management . Data on diabetes management and A1c were collected , and participants completed surveys assessing parental involvement in management , diabetes-specific family conflict , and youth quality of life ( QOL ) . The primary outcome was A1c at 2 yr ; secondary outcomes included maintaining parent involvement and avoiding deterioration in glycemic control . RESULTS We studied 153 youth ( 56 % female , median age 12.9 yr ) with type 1 diabetes ( mean A1c 8.4 ± 1.4 % ) . There were no differences in A1c across treatment groups . Among youth with suboptimal baseline A1c ≥ 8 % , more youth in the psychoeducation group maintained or improved their A1c and maintained or increased parent involvement than youth in the other two groups combined ( 77 vs. 52 % , p = 0.03 ; 36 vs. 11 % , p = 0.01 , respectively ) without negative impact on youth QOL or increased diabetes-specific family conflict . CONCLUSIONS No differences in A1c were detected among the three groups at 2 yr . The psychoeducational intervention was effective in maintaining or improving A1c and parent involvement in youth with suboptimal baseline glycemic control OBJECTIVE Population -level strategies may improve primary care for diabetes . We design ed a controlled study to assess the impact of population management versus usual care on metabolic risk factor testing and management in patients with type 2 diabetes . We also identified potential patient-related barriers to effective diabetes management . RESEARCH DESIGN AND METHODS We used novel clinical software to rank 910 patients in a diabetes registry at a single primary care clinic and thereby identify the 149 patients with the highest HbA(1c ) and cholesterol levels . After review of the medical records of these 149 patients , evidence -based guideline recommendations regarding metabolic testing and management were sent via e-mail to each intervention patient 's primary care provider ( PCP ) . Over a 3-month follow-up period , we assessed changes in the evidence -based management of intervention patients compared with a matched cohort of control patients receiving usual care  at a second primary care clinic affiliated with the same academic medical center . RESULTS In the intervention cohort , PCPs followed testing recommendations more often ( 78 % ) than therapeutic change recommendations ( 36 % , P = 0.001 ) . Compared with the usual care control cohort , population management result ed in a greater overall proportion of evidence -based guideline practice s being followed ( 59 vs. 45 % , P = 0.02 ) . Most intervention patients ( 62 % ) had potential barriers to effective care , including depression ( 35 % ) , substance abuse ( 26 % ) , and prior nonadherence to care plans ( 18 % ) . CONCLUSIONS Population management with clinical recommendations sent to PCPs had a modest but statistically significant impact on the evidence -based management of diabetes compared with usual care . Depression and substance abuse are prevalent patient-level adherence barriers in patients with poor metabolic control Cardiovascular disease is the leading cause of morbidity and mortality in the USA . Disease management programs , while successful , are intensive and expensive . Follow-up is often inadequate , incomplete , and inconsistent . To address these problems , we developed an Internet- Telemedicine system . Patients send/receive data to/from their care provider via the Internet . The system optimizes function and minimizes cost ( all hardware is off the shelf and FDA approved ) . We are currently using this Telemedicine system in a prospect i ve , r and omized clinical trial , to reduce CVD risk in medically underserved population s. Over an 8-month time interval , we found very high rates of usage of the Telemedicine system  ( 92 % ) . This rate of self-monitoring greatly exceeded the self-monitoring rate in controls ( 48 % ) . The patient-entered Telemedicine blood pressure values were similar to the meter recorded values and to the office values UNLABELLED Long term diabetes self-management behaviors , and strict glycemic control are difficult to achieve in clinical practice . OBJECTIVE Asesss two different reinforcement strategies for diabetes selfcare management , psychological distress and glycemic control in a one year follow up study . METHODS 70 consecutive type 2 diabetic patients , were recruited and r and omly assigned to three study groups . Subjects in the control group ( CG ) continued with their normal treatment schedule . The second group received a reinforcement course at 6 months ( RCG ) and in the third group , patients were contacted monthly by phone ( PHCG ) to promote self-management attitudes and address problems as they arose . A battery of questions and laboratory work-up were obtained at baseline and at one year follow-up . RESULTS At one year follow-up , the three groups significantly increased their diabetes-related knowledge . Both experimental groups displayed improved treatment compliance and had better adherence to the recommended meal plan ( p=0.06 and 0.003 ) . In addition , the PHCG significantly increased ( p<0.0001 ) their adherence to pharmacological treatment . No significant differences were observed in glycemic control , prevalence of depression or diabetes related distress . CONCLUSIONS Follow-up patient reinforcement strategies improve strategic diabetes self-care management behaviors . Further studies are needed to demonstrate the positive impact of these benefits on diabetes related outcomes Abstract Background . Inflammation may play an important role in type 2 diabetes . It has been proposed that dietary strategies can modulate inflammatory activity . Methods . We investigated the effects of diet on inflammation in type 2 diabetes by comparing a traditional low-fat diet ( LFD ) with a low-carbohydrate diet ( LCD ) .  Patients with type 2 diabetes were r and omized to follow either LFD aim ing for 55–60 energy per cent ( E% ) from carbohydrates ( n = 30 ) or LCD aim ing for 20 E% from carbohydrates ( n = 29 ) . Plasma was collected at baseline and after 6 months . C-reactive protein ( CRP ) , interleukin-1 receptor antagonist ( IL-1Ra ) , IL-6 , tumour necrosis factor receptor ( TNFR ) 1 and TNFR2 were determined . Results . Both LFD and LCD led to similar reductions in body weight , while beneficial effects on glycaemic control were observed in the LCD group only . After 6 months , the levels of IL-1Ra and IL-6 were significantly lower in the LCD group than in the LFD group , 978 ( 664–1385 ) versus 1216 ( 974–1822 ) pg/mL and 2.15 ( 1.65–4.27 ) versus 3.39 ( 2.25–4.79 ) pg/mL , both P < 0.05 . Conclusions . To conclude , advice to follow LCD or LFD had similar effects on weight reduction while effects on inflammation differed . Only LCD was found significantly to improve the sub clinical inflammatory state in type 2 diabetes . Trial registration : Clinical Trials.gov identifier : NCT01005498 AIM The purpose of this study was to examine the effect of the diabetes outpatient intensive management programme ( DOIMP ) on glycaemic control over a 12 week follow-up period for type 2 diabetic patients in Korea . BACKGROUND Diabetic complications can be prevented if the glycaemic status of diabetes patients is maintained within a nearly normal range . Patient education is critical in controlling blood glucose levels of patients with diabetes within the optimal range . METHODS DOIMP was composed of multidisciplinary education , complication monitoring and telephone counselling .  Twenty-five patients in the intervention group participated in the DOIMP and 24 patients in the control group were briefed on the conventional description of diabetes mellitus by diabetes education nurses . RESULTS Patients in the intervention group had a mean decrease of 2.3 % , which those in the control group having a mean decrease 0.4 % in glycosylated haemoglobin ( HbA(1)c ) . There was no difference between the two groups in the change in fasting blood glucose ( FBG ) and two-hour postpr and ial blood glucose ( 2-h PBG ) . The proportion of the patients with HbA(1)c < 7 % was higher in the intervention group than in the control group at the post-test compare with the pretest . CONCLUSION DOIMP can reduce HbA(1)c in type 2 diabetes patients . RELEVANCE TO CLINICAL PRACTICE These findings indicated that DOIMP could be effective in glycaemic control in type 2 diabetes patients AIMS To assess the impact of a French adaptation of the Staged Diabetes Management ( SDM ) programme on glycaemic control of people with Type 2 diabetes in primary care . Secondary endpoints were blood pressure , blood lipids , healthcare costs and quality of life . METHODS Prospect i ve , r and omized controlled study , of 1 years ' duration . General practitioners ( GPs ) were recruited in four separate districts of a French region . They enrolled consecutive patients with Type 2 diabetes . GPs in the intervention group were educated in the SDM programme . GPs in the control group were asked to provide usual care .  Healthcare costs were collected by medical departments of the Health Insurance systems . Quality of life was assessed with the Duke Health Profile . RESULTS Three hundred and forty patients enrolled by 57 GPs completed the study , 192 in the intervention group and 148 in the control group . Patients in the intervention group were managed more adequately in accordance with the guidelines ( P < 0.05 for nine out of 10 items ) . HbA(1c ) decreased by 0.31 % in the intervention group and increased by 0.56 % in the control group , result ing in a difference of 0.87 % by the end of the study ( P = 0.001 ) . Blood pressure and blood lipids did not differ between groups . Occurrence of major complications was low and identical in both groups . Incremental costs during the study in the intervention group were 35 euros per patient per month , and this was not significantly different in comparison with the control group . Quality of life was not affected by the intervention . CONCLUSIONS Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting , without significantly increasing healthcare costs Aims : This paper aims to explore the effect of the social network based intervention Powerful Together with Diabetes on diabetes self-management among socioeconomically deprived patients . This 10-month group intervention targeting patients and significant others aim ed to improve self-management by stimulating social support and diminishing social influences that hinder self-management . Methods : This intervention was evaluated in a quasi-experimental study using a mixed methods approach . Of 131 socioeconomically deprived patients with suboptimal glycaemic control , 69 were assigned to the  intervention  group and 62 to the  control group ( st and ard diabetes education ) . 27 qualitative in-depth interviews with the participants and 24 with their group leaders were held to study the subjective impact of the intervention . Further , self-management behaviours ( medication adherence , diet and physical activity ) were assessed at baseline , 10 and 16 months . Data were analysed using framework analyses and a linear mixture model . Results : Qualitative data showed that the intervention group had a better underst and ing of the way self-management influences diabetes . The intervention group showed more complex self-management behaviours , such as planning ahead , seeking adequate food and physical activity alternatives , and consistently taking their diabetes into consideration when making choices . In participants with complete follow-up data , we found a significant increase in physical activity in the intervention group ( 3.78 vs. 4.83 days ) and no changes in medication adherence and diet . Conclusions : This study indicates that an intensive support group and simultaneously involving significant others might improve diabetes self-management behaviours among socioeconomically deprived patients . More studies are needed to justify further implementation of the intervention . This study is registered in the Dutch Trial Register NTR1886 . http://www.trialregister.nl/trialreg/admin/ rct OBJECTIVE To determine whether a system of telemedicine support can improve glycemic control in type 1 diabetes . RESEARCH DESIGN AND METHODS A 9-month r and omized trial compared glucose self-monitoring real-time result transmission and feedback of results for the previous 24 h in the control group with real-time graphical phone-based feedback for the previous 2 weeks together with nurse-initiated support using a web-based graphical analysis of glucose self-monitoring results in the intervention group .  All patients aged 18 - 30 years with HbA(1c ) ( A1C ) levels of 8 - 11 % were eligible for inclusion . RESULTS A total of 93 patients ( 55 men ) with mean diabetes duration ( means + /- SD ) 12.1 + /- 6.7 years were recruited from a young adult clinic . In total , the intervention and control groups transmitted 29,765 and 21,400 results , respectively . The corresponding median blood glucose levels were 8.9 mmol/l ( interquartile range 5.4 - 13.5 ) and 10.3 mmol/l ( 6.5 - 14.4 ) ( P < 0.0001 ) . There was a reduction in A1C in the intervention group after 9 months from 9.2 + /- 1.1 to 8.6 + /- 1.4 % ( difference 0.6 % [ 95 % CI 0.3 - 1.0 ] ) and a reduction in A1C in the control group from 9.3 + /- 1.5 to 8.9 + /- 1.4 % ( difference 0.4 % [ 0.03 - 0.7 ] ) . This difference in change in A1C between groups was not statistically significant ( 0.2 % [ -0.2 to 0.7 , P = 0.3 ) . CONCLUSIONS Real-time telemedicine transmission and feedback of information about blood glucose results with nurse support is feasible and acceptable to patients , but to significantly improve glycemic control , access to real-time decision support for medication dosing and changes in diet and exercise may be required BACKGROUND Despite extensive efforts and advances in evidence -based diabetes management , poor glycaemic control still remains a challenge in many countries . There is a paucity of research addressing the needs of patients with poorly controlled type 2 diabetes , or exploring the effectiveness of empowerment-based interventions in this vulnerable population . OBJECTIVES To evaluate the effectiveness of a patient-centred , empowerment-based programme on  glycaemic control and self-management behaviours among patients with poorly controlled type 2 diabetes . DESIGN A prospect i ve multi-centre , single-blind , r and omised controlled trial . SETTING S AND PARTICIPANTS Adult patients with poorly controlled type 2 diabetes [ Haemoglobin A1c ( HbA1c ) ≥7.5 % in the recent six months ] were recruited from two tertiary hospitals in Xi'an city , China . METHODS A total of 242 eligible patients were recruited and r and omly assigned to the intervention or attentional control groups after baseline measurement . Participants in the intervention group received a 6-week patient-centred , empowerment-based self-management programme , which is theoretically grounded on the principles of the Empowerment Process Model- setting personally meaningful goals , taking action towards goals and reflecting on the impact of action plans . Those in the attentional control group received health education classes and post-discharge follow-up . Outcome measures included glycaemic control ( measured by HbA1c ) and self-management behaviours . Data were collected at baseline , and at 8th and 20th week after enrolment . Intervention effect were analysed using the generalised estimating equation model on the basis of the intention-to-treat principle . RESULTS Compared with the attention control group , the intervention group showed a non-significant HbA1c reduction of 0 . 476 % ( Cohen 's d effect size=0.31 , p=0.162 ) . The intervention group exhibited significant improvements in general diet management at the 8th-week ( β=0.740 ; p=0.013 ) , specific diet management at 8th-week ( β=0.646 ; p=0.022 ) and 20th-week ( β=0.517 ; p=0.043 ) , and blood glucose self-monitoring at both the 8th- ( β=0.793 ; p=0.009 ) and 20th-week ( β=0.739 ; p=0.017 ) follow-ups . No intervention-related adverse events were observed . CONCLUSIONS Findings indicate that the patient-centred , empowerment-based self-management intervention program did not induce a significant HbA1c reduction . Whereas this intervention yields improvements in diet management and blood glucose self-monitoring among patients with poorly controlled type 2 diabetes AIMS Data on the impact of hypoglycaemia on patients ' daily lives and diabetes self-management , particularly in developing countries , are lacking . The aim of this study was to assess fear of , and responses to , hypoglycaemia experienced by patients globally . MATERIAL S AND METHODS This non-interventional , multicentre , 4-week prospect i ve study using self- assessment question naires and patient diaries consisted of 27,585 patients , ≥18years , with type 1 diabetes ( n=8022 ) or type 2 diabetes ( n=19,563 ) treated with insulin for > 12months , at 2004 sites in 24 countries worldwide . RESULTS Increased blood glucose monitoring ( 69.7 % ) and seeking medical assistance ( 62.0 % ) were the most common responses in the 4weeks following hypoglycaemic events for patients with type 1 diabetes and type 2 diabetes , respectively . Approximately 44 % of patients with type 1 diabetes or type 2 diabetes increased calorie intake in response to a hypoglycaemic episode . Following hypoglycaemia , 3.9 % ( type 1 diabetes ) and 6.2 % ( type 2 diabetes ) of patients took leave from work or study . Regional differences in fear of , and responses to , hypoglycaemia were evident - in particular , a lower level of hypoglycaemic fear and utilisation of healthcare re sources in Northern Europe and Canada . CONCLUSIONS Hypoglycaemia has a major impact on patients and their behaviour . These global data for the first time reveal regional variations in response to hypoglycaemia and highlight the importance of patient education and management strategies The Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) trial was design ed to test whether treatment targeting nearly normal glycemic control reduces the risk of cardiovascular events in type 2 diabetes mellitus . This aim was based on consistent epidemiological evidence that higher glucose and hemoglobin A1c ( HbA1c ) levels are associated with greater cardiovascular risk , together with inconclusive results from smaller and shorter interventional studies .1 All 10 251 participants in ACCORD were r and omized to either a st and ard treatment strategy that targeted HbA1c levels between 7 % and 7.9 % or an intensive strategy that sought to attain an HbA1c < 6.0 %  . With each strategy , investigators could prescribe any antihyperglycemic agent approved by regulatory authorities . The median HbA1c with the st and ard strategy was 7.5 % ; the intensive strategy achieved a median HbA1c of 6.4%.2 However , the intensive strategy was stopped after a median follow-up of 3.4 years , ≈60 % of that planned , because of 22 % higher all-cause mortality.2  Participants previously using the intensive strategy were switched to the st and ard strategy and continued in the trial . The cardiovascular and microvascular effects after the full 5 years of follow-up will soon be reported . Meanwhile , debate continues as to why there was higher mortality with intensive treatment and the clinical implication s. Several analyses of the data obtained during r and omized treatment have shed light on these issues . As expected , various factors such as age and presence of comorbidities were associated with higher risk of death during r and omized treatment.3 After adjustment for these factors , 3 baseline characteristics emerged as independent predictors of excess risk with the intensive strategy . Notably , a baseline HbA1c value > 8.5 % predicted 64 % higher risk . History of taking aspirin ( perhaps indicating perceived high UNLABELLED This review should be cited as : Renders CM , Valk GD , Griffin S. Wagner EH , Eijk JThM van , Assendelft WJJ . Interventions to improve the management of  diabetes mellitus  in primary care , outpatient and community setting s ( Cochrane Review ) . In : The Cochrane Library , Issue 2 , 2001 . Oxford : Up date Software . A substantive amendment to this systematic review was last made on 29 June 2000 . Cochrane review s are regularly checked and up date d if necessary . BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care . Different systems have been proposed to manage diabetes care . OBJECTIVES To assess the effects of different interventions , targeted at health professionals or the structure in which they deliver care , on the management of patients with diabetes in primary care , outpatient and community setting s. SEARCH STRATEGY We search ed the Cochrane Effective Practice and Organisation of Care Group specialised register , the Cochrane Controlled Trials Register ( Issue 4 1999 ) , MEDLINE ( 1966 - 1999 ) , EMBASE ( 1980 - 1999 ) , Cinahl ( 1982 - 1999 ) , and reference lists of articles . SELECTION CRITERIA R and omised trials ( RCTs ) , controlled clinical trials ( CCTs ) , controlled before and after studies ( CBAs ) and interrupted time series ( ITS ) analyses of professional , financial and organisational strategies aim ed at improving care for people with Type 1 or Type 2 diabetes . The participants were health care professionals , including physicians , nurses and pharmacists . The outcomes included objective ly measured health professional performance or patient outcomes , and self-report measures with known validity and reliability . DATA COLLECTION AND ANALYSIS Two review ers independently extracted data and assessed study quality . MAIN RESULTS Forty-one studies were included involving more than 200 practice s and 48,000 patients . Twenty-seven studies were RCTs , 12 were CBAs , and two were ITS . The studies were heterogeneous in terms of interventions , participants , setting s and outcomes . The method ological quality of the studies was often poor . In all studies the intervention strategy was multifaceted . In 12 studies the interventions were targeted at health professionals , in nine they were targeted at the organization of care , and 20 studies targeted both . In 15 studies patient education was added to the professional and organisational interventions . A combination of professional interventions improved process outcomes . The effect on patient outcomes remained less clear as these were rarely assessed . Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes . Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes . REVIEW ERS ' CONCLUSION : Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .  Organisational interventions that improve regular prompted recall and review of patients  ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management . The addition of patient-oriented interventions can lead to improved patient health outcomes . Nurses can play an important role in patient-oriented interventions , through patient education or facilitating adherence to treatment AIMS Examine barriers for taking  glucose-lowering oral medications  , associated baseline characteristics , strategies used , and the adherence impact in the Treatment Options for Type 2 Diabetes in Adolescents and Youth ( TODAY ) study . METHODS We studied youth prescribed oral diabetes medications over two years ( N = 611 , 583 , and 525 at 6 , 12 , and 24 months ) . Clinicians documented barriers ( e.g. forgetting , routines , other concerns ) in the sub sample that reported missed doses ( N = 423 [ 69.2 % ] , 422 [ 72.4 % ] , and 414 [ 78.9 % ] at 6 , 12 , and 24 months , respectively ) . Adherence strategies were also assessed ( e.g. family , schedule , reminder device ) using st and ard questions . Logistic regression was used to analyze associations with medication adherence . RESULTS Those missing doses were not different from the total sample ( 61.5 % female , 13.9 ± 2.0 years , > 80 % racial/ethnic minorities ) . No baseline demographic or clinical predictors of barriers to medication adherence were identified . Among those for whom barriers were assessed , " forgetting " with no reason named ( 39.3 % ) and disruptions to mealtime , sleep , and schedule ( 21.9 % ) accounted for the largest proportion of responses . Family support was the primary adherence strategy identified by most youth ( ≥50 % ) , followed by pairing the medication regimen with daily routines ( > 40 % ) ; the latter strategy was associated with significantly higher adherence rates ( p = 0.009 ) . CONCLUSIONS Family supported medication adherence was common in this mid-adolescent cohort , but self-management strategies were also in evidence . Findings are similar to those reported among youth with other serious chronic diseases . Prospect i ve studies of multi-component family support and self-management interventions for improving medication adherence are warranted . TRIAL REGISTRATION Clinical Trials.gov NCT00081328 Background Given that patients provide the majority of their own diabetes care , patient self-management training has increasingly become recognized as an important strategy with which to improve quality of care . However , participation in self management programs is low . In addition , the efficacy of current behavioural interventions wanes over time , reducing the impact of self-management interventions on patient health . Web-based interventions have the potential to bridge the gaps in diabetes care and self-management . Methods Our objective is to improve self-efficacy , quality of life , self-care , blood pressure , cholesterol and glycemic control and promote exercise in people with type 2 diabetes through the rigorous development and use of a web-based patient self-management intervention . This study consists of five phases : ( 1 ) intervention development ; ( 2 ) feasibility testing ; ( 3 ) usability testing ; ( 4 ) intervention refinement ; and ( 5 ) intervention evaluation using mixed methods . We will employ evidence -based strategies and tools , using a theoretical framework of self-efficacy , then elicit user feedback through focus groups and individual user testing sessions . Using iterative re design the intervention will be refined . Once finalized , the impact of the website on patient self-efficacy , quality of life , self-care , HbA1c , LDL-cholesterol , blood pressure and weight will be assessed through a non-r and omized observational cohort study using repeated measures modeling and individual interviews . Discussion Increasing use of the World Wide Web by consumers for health information and ongoing revolutions in social media are strong indicators that users are primed to welcome a new era of technology in health care . However , their full potential is hindered by limited knowledge regarding their effectiveness , poor usability , and high attrition rates . Our development and research agenda aims to address these limitations by improving usability , identifying characteristics associated with website use and attrition , and developing strategies to sustain patient use in order to maximize clinical outcomes OBJECTIVE To demonstrate that Diabeo software enabling individualized insulin dose adjustments combined with telemedicine support significantly improves HbA1c in poorly controlled type 1 diabetic patients . RESEARCH DESIGN AND METHODS In a six-month open-label parallel-group , multicenter study , adult patients ( n = 180 ) with type 1 diabetes ( > 1 year ) , on a basal-bolus insulin regimen ( > 6 months ) , with HbA1c ≥8 % , were r and omized to usual quarterly follow-up ( G1 ) , home use of a smartphone recommending insulin doses with quarterly visits ( G2 ) , or use of the smartphone with short teleconsultations every 2 weeks but no visit until point end ( G3 ) . RESULTS Six-month mean HbA1c in G3 ( 8.41 ± 1.04 % ) was lower than in G1 ( 9.10 ± 1.16 % ; P = 0.0019 ) . G2 displayed intermediate results ( 8.63 ± 1.07 % ) . The Diabeo system gave a 0.91 % ( 0.60 ; 1.21 ) improvement in HbA1c over controls and a 0.67 % ( 0.35 ; 0.99 ) reduction when used without teleconsultation . There was no difference in the frequency of hypoglycemic episodes or in medical time spent for hospital or telephone consultations . However , patients in G1 and G2 spent nearly 5 h more than G3 patients attending hospital visits . CONCLUSIONS The Diabeo system gives a substantial improvement to metabolic control in chronic , poorly controlled type 1 diabetic patients without requiring more medical time and at a lower overall cost for the patient than usual care Background Type two diabetes is a complex and dem and ing chronic disease and its impact in a state ( Kerala ) which leads India in terms of the number of people with Diabetes is profound . Though the male to female ratio among the people with diabetes is roughly equal , women are uniquely and more severely affected . Management of type two Diabetes requires considerable dexterity on the part of the patient to manage drugs , diet and exercise . Therefore , in a low middle-income country like India it is necessary to look at low cost interventions that can empower the patient and build on available re sources to help manage diabetes . Hence , we studied the feasibility and effect of two low cost interventions ; yoga and peer support on glycaemic and other outcomes among women with type two diabetes . Methods An open label parallel three armed r and omized control trial was conducted among 124 recruited women with Diabetes for three months . Block r and omization with a block length of six was carried out with each group having at least 41 women . In the Yoga arm , sessions by an instructor , consisting of a group of postures coordinated with breathing were conducted for an hour , two days a week . In the peer support arm each peer mentor after training visited 13–14 women with diabetes every week followed by a phone call . The meeting was about applying disease management or prevention plans in daily life . Results There was a trend in decline of fasting plasma glucose in the peer and yoga group and of glycosylated haemoglobin ( HbA1c ) in the yoga group only , though not significant . A significant decrease was observed in diastolic blood pressure and hip circumference in the yoga group . The process indicated that most ( 80 % ) of the women in the yoga group attended classes regularly and 90 % of the women in the peer group reported that peer mentoring was useful . Conclusion The effect of yoga and peer support on glycaemic outcomes was incremental . Longer term studies are necessary to ascertain the benefits shown by this feasibility study .Trial registration CTRI/2011/12/002227 date d 14/12/2011 AIMS Remote patient management ( telemonitoring ) may help to detect early signs of cardiac decompensation , allowing optimization of and adherence to treatments in chronic heart failure ( CHF ) . Two meta-analyses have suggested that telemedicine in CHF can reduce mortality by 30 - 35 % . The aim of the TIM-HF study was to investigate the impact of telemedical management on mortality in ambulatory CHF patients . Methods CHF patients [ New York Heart Association ( NYHA ) II/III , left ventricular ejection fraction (LVEF)≤35 % ] with a history of cardiac decompensation with hospitalization in the past or therapy with intravenous diuretics in the prior 24 months ( no decompensation required if LVEF≤25 % ) were r and omized 1:1 to an intervention group of daily remote device monitoring ( electrocardiogram , blood pressure , body weight ) coupled with medical telephone support or to usual care led by the patients ' local physician . In the intervention group , 24/7 physician-led medical support was provided by two central telemedical centres . A clinical event committee blinded to treatment allocation assessed cause of death and reason for hospitalization . The primary endpoint was total mortality . The first secondary endpoint was a composite of cardiovascular mortality or hospitalization due to heart failure . Other secondary endpoints included cardiovascular mortality , all-cause and cause-specific hospitalizations ( all time to first event ) as well as days lost due to heart failure hospitalization or cardiovascular death ( in % of follow-up time ) , and changes in quality of life and NYHA class . Overall , 710 CHF patients were recruited . The mean follow-up was 21.5±7.2 months , with a minimum of 12 months . Perspective The study will provide important prospect i ve outcome data on the impact of telemedical management in patients with CHF A r and omized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology  compared with conventional outpatient dermatology care for patients from urban and rural areas . One urban and one rural health centre were linked to a regional hospital in Northern Irel and by ISDN at 128 kbit/s . Over two years , 274 patients required a hospital outpatient dermatology referral - 126 patients ( 46 % ) were r and omized to a telemedicine consultation and 148 ( 54 % ) to a conventional hospital outpatient consultation .  Of those seen by telemedicine , 61 % were registered with an urban practice , compared with 71 % of those seen conventionally . The clinical outcomes of the two types of consultation were similar - almost half the patients were managed after a single consultation with the dermatologist . The observed marginal cost per patient of the initial  realtime teledermatology consultation  was 52.85 for those in urban areas and 59.93 per patient for those from rural areas . The observed marginal cost of the initial conventional consultation  was 47.13 for urban patients and 48.77 for rural patients . The total observed costs of teledermatology  were higher than the costs of conventional care in both urban and rural areas , mainly because of the fixed equipment costs . Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal , while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation PURPOSE Few culturally competent health programs have been design ed for Mexican Americans , a group that bears a disproportionate burden of Type 2 diabetes . In Starr County , a Texas-Mexico border community , investigators design ed and tested a culturally competent intervention aim ed at improving the health of this target population . The purpose of this article is to describe the development process of this diabetes education and support group intervention . METHODS The development stages were ( 1 ) community assessment , ( 2 ) intervention design , ( 3 ) selection or development of outcomes , ( 4 ) pilot testing , and ( 5 ) a r and omized clinical investigation . RESULTS Focus group participants identified knowledge deficits regarding diabetes and self-management strategies , and suggested characteristics of an effective intervention for Mexican Americans . Outcome measures included metabolic control indicators , a newly developed knowledge instrument , and an existing health belief instrument . Preliminary analyses indicated that the intervention was successful in significantly improving metabolic control in the target population . CONCLUSIONS Developing successful diabetes interventions for minority groups requires a number of stages , careful planning , assessment of cultural characteristics of the target population , and a systematic approach to implementation OBJECTIVE Practice -based collaborative care is a complex evidence -based practice that is difficult to implement in smaller primary care practice s that lack on-site mental health staff . Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care setting s. The objective of this multisite r and omized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice -based and telemedicine-based collaborative care . METHOD From 2007 to 2009 , patients at federally qualified health centers serving medically underserved population s were screened for depression , and 364 patients who screened positive were enrolled and followed for 18 months . Those assigned to practice -based collaborative care received evidence -based care from an on-site primary care provider and a nurse care manager . Those assigned to telemedicine-based collaborative care received evidence -based care from an on-site primary care provider and an off-site team : a nurse care manager and a pharmacist by telephone , and a psychologist and a psychiatrist via videoconferencing . The primary clinical outcome measures were treatment response , remission , and change in depression severity . RESULTS Significant group main effects were observed for both response ( odds ratio=7.74 , 95 % CI=3.94 - 15.20 ) and remission ( odds ratio=12.69 , 95 % CI=4.81 - 33.46 ) , and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist , with greater reductions in severity over time for patients in the telemedicine-based group . Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group . CONCLUSIONS Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice -based collaborative care with locally available staff
The review indicates that most telemedicine strategies can be useful , either as an adjunct or to replace usual care , leading to clinical ly meaningful reduction in HbA1c
The effects of telemedicine strategies on the management of diabetes is not clear .
This study aim ed to investigate the impact of different telemedicine strategies on glycaemic control management of type 2 diabetes patients .