Tele-Mum: A Feasibility Study for a Randomized Controlled Trial Exploring the Potential for Telemedicine in the Diabetes Care of Those with Gestational Diabetes. Feasibility of using videoconferencing to provide diabetes education: a pilot study Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus. Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes A comparison of diabetes education administered through telemedicine versus in person. Costs to Medicare of the Informatics for Diabetes Education and Telemedicine (IDEATel) Home Telemedicine Demonstration The use of TeleMedicine in the treatment of paediatric obesity: feasibility and acceptability. Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project. Sources of evidence for systematic reviews of interventions in diabetes. A Randomized Clinical Trial Comparing Behavior Modification and Individual Counseling in the Nutritional Therapy of Non-insulin-dependent Diabetes Mellitus: Comparison of the Effect on Blood Sugar, Body Weight, and Serum Lipids Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. An integrated wound-care pathway, supported by telemedicine, and competent wound management - Essential in follow-up care of adults with diabetic foot ulcers Assessment of two culturally competent Diabetes education methods: Individual versus Individual plus Group education in Canadian Portuguese adults with Type 2 Diabetes Impact of a Preconception Counseling Program for Teens With Type 1 Diabetes (READY-Girls) on Patient-Provider Interaction, Resource Utilization, and Cost The Use of Telemedicine in the Management of Diabetes-Related Foot Ulceration: A Pilot Study Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus. An empirical chart analysis of the suitability of telemedicine for hospice visits. Impact on psychosocial outcomes of a nationally available weight management program tailored for individuals with type 2 diabetes: Results of a randomized controlled trial. Telemedicine Experience for Chronic Care in COPD Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project. Design and participant characteristics of a randomized-controlled trial of telemedicine for smoking cessation among rural smokers. Evaluating the Costs and Benefits of Outpatient Diabetes Education and Nutrition Counseling Telemedicine for new neurological outpatients: putting a randomized controlled trial in the context of everyday practice. Seeing the forests and the trees—innovative approaches to exploring heterogeneity in systematic reviews of complex interventions to enhance health system decision-making: a protocol Nutrition during pregnancy: the effects of an educational intervention program in Greece. Longitudinal trends in quality of life after starting home parenteral nutrition: a randomised controlled study of telemedicine. Telemedicine for the Medicare population: pediatric, obstetric, and clinician-indirect home interventions. 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) Impact of remote management of diabetes via computer: the 360 study--a proof-of-concept randomized trial. Practical Telemedicine for Veterans with Persistently Poor Diabetes Control: A Randomized Pilot Trial. Pilot trial of telemedicine as a decision aid for patients with chronic wounds. Detection and remediation of medically urgent situations using telemedicine case management for older patients with diabetes mellitus Long-term Comparative Effectiveness of Telemedicine in Providing Diabetic Retinopathy Screening Examinations: A Randomized Clinical Trial. Integrated Tobacco Cessation Counseling in a Diabetes Self-management Training Program A randomized nutrition counseling intervention in pediatric leukemia patients receiving steroids results in reduced caloric intake A Randomized Study to Assess the Impact of Pharmacist Counseling of Employer-Based Health Plan Beneficiaries With Diabetes The impact of telemedicine on outcomes of chronic wounds in the home care setting. Managing hypertension in urban underserved subjects using telemedicine--a clinical trial. Comparing the effectiveness of telemedicine and traditional surveillance in providing diabetic retinopathy screening examinations: a randomized controlled trial. Comparative and Cost Effectiveness of Telemedicine Versus Telephone Counseling for Smoking Cessation Nutrition counseling impacts serum albumin levels. A Medical Nutrition Therapy Program Improves Perinatal Outcomes in Mexican Pregnant Women With Gestational Diabetes and Type 2 Diabetes Mellitus Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project. Real-time continuous glucose monitoring together with telemedical assistance improves glycemic control and glucose stability in pump-treated patients. Telemedicine improved diabetic management. Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project A Low-Intensity Mobile Health Intervention With and Without Health Counseling for Persons With Type 2 Diabetes, Part 1: Baseline and Short-Term Results From a Randomized Controlled Trial in the Norwegian Part of RENEWING HEALTH Organizational and Environmental Factors Affecting the Utilization of Telemedicine in Rural Home Healthcare 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 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 [Impact of a dietary counseling program on the gain weight speed of pregnant women attended in a primary care service]. Improved diabetes control in the elderly delays global cognitive decline Nutrition counseling increases weight gain among Brazilian children. Web-based telemedicine for management of type 2 diabetes through glucose uploads: a randomized controlled trial. Smart Care Based on Telemonitoring and Telemedicine for Type 2 Diabetes Care: Multi-Center Randomized Controlled Trial.
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 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 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 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 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 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 To assess the feasibility of conducting empirically supported family-based paediatric obesity group treatment via TeleMedicine .  Seventeen families were r and omly assigned to one of two conditions ( physician visit , TeleMedicine ) . Measures included feasibility , satisfaction and intervention outcome measures such as BMI percentile , and nutrition and activity behaviours . Measures were completed at baseline , post-treatment and at 1-year follow-up . Analyses indicate that both feasibility and satisfaction data regarding the TeleMedicine intervention were positive . Intervention outcome indicates no change in BMI percentile or nutrition and activity behaviours for either treatment group . A behavioural family-based weight loss intervention delivered via TeleMedicine was well received by both parents and providers . Due to the small sample size , null findings regarding intervention outcome should be interpreted with caution . Future research should focus on methods to increase the impact of this intervention on key outcome variables 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 AIMS To analyse the effect on systematic review s in diabetes interventions of including only trials that are indexed in medline , and to assess the impact of adding trials from other data bases and the grey literature . METHODS All systematic review s of diabetes interventions which included a meta- analysis of r and omized controlled trials , and were published since 1996 , were selected . The impact on the meta- analysis of including only those trials indexed in medline , and the effect of then adding trials from other sources , was assessed . Where possible this was measured quantitatively , by redoing the meta- analysis , otherwise a qualitative estimate was made . RESULTS Forty-four systematic review s met our inclusion criteria . There were 120 articles reporting trial data which were not indexed in medline . These came from 52 % of the review s. In 34 % of the review s , basing a meta- analysis on a search of only medline would miss trials that could affect the result . Sources of non- medline data which had the biggest effect on the meta-analyses were journal articles from central and embase ( mainly in Diabetes , Nutrition and Metabolism ) and unpublished data ( mainly from industry ) . The exceptions were journal articles on herbal medicine , mostly indexed in Chinese language data bases . CONCLUSIONS A search of only the medline data base is insufficient for systematic review s of diabetes , because in about 34 % of review s the missed trials could affect the results of the meta- analysis . It is recommended that central ( on the Cochrane Library ) also be search ed . Scanning meeting abstract s , and seeking unpublished data are also recommended if the intervention has only recently been introduced To determine whether a group behavior modification approach might be preferable to individual counseling in the nutritional therapy of non-insulin-dependent diabetes mellitus , 40 adults younger than 65 yr of age with diabetes mellitus who were not receiving insulin were r and omized to either a program of individualized dietary review and recommendations or a program of group meetings aim ed at controlling the signals leading to overeating and noncompliance with a diabetic dietary regimen . Statistically significant ( P < 0.05 ) decreases in body weight , sum skin-fold thickness , fasting serum glucose , and serum triglycerides but not LDL-C or HDL-C were observed . The individual counseling group had a greater amount of weight loss than the behavior modification group . There were no significant ( P < 0.05 ) differences between the two groups with respect to the biochemical outcome variables . Patient characteristics assessed at entry — namely anxiety , internal versus external locus of control and perceived disease severity , and compliance with advice — were significantly associated with weight loss in the behavior modification group while only the latter index was of value in the individual counseling group . Thus , our use of these programs does not identify a clear advantage of either approach in the nutritional therapy of non-insulin-dependent diabetic patients 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 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 examine the impact of two culturally competent diabetes education methods , individual counselling and individual counselling in conjunction with group education , on nutrition adherence and glycemic control in Portuguese Canadian adults with type 2 diabetes over a three-month period . Design . The Diabetes Education Centre is located in the urban multicultural city of Toronto , Ontario , Canada . We used a three-month r and omized controlled trial design . Eligible Portuguese-speaking adults with type 2 diabetes were r and omly assigned to receive either diabetes education counselling only ( control group ) or counselling in conjunction with group education ( intervention group ) . Of the 61 patients who completed the study , 36 were in the counselling only and 25 in the  counselling with group education intervention . We used a per- protocol analysis to examine the efficacy of the two educational approaches on nutrition adherence and glycemic control ; paired t-tests to compare results within groups and analysis of covariance ( ACOVA ) to compare outcomes between groups adjusting for baseline measures . The Theory of Planned Behaviour was used to describe the behavioural mechanisms that influenced nutrition adherence . Results . Attitudes , subjective norms , perceived behaviour control , and intentions towards nutrition adherence , self-reported nutrition adherence and glycemic control significantly improved in both groups , over the three-month study period . Yet , those receiving individual counselling with group education showed greater improvement in all measures with the exception of glycemic control , where no significant difference was found between the two groups at three months . Conclusions . Our study findings provide preliminary evidence that culturally competent group education in conjunction with individual counselling may be more efficacious in shaping eating behaviours than individual counselling alone for Canadian Portuguese adults with type 2 diabetes . However , larger longitudinal studies are needed to determine the most efficacious education method to sustain long-term nutrition adherence and glycemic control OBJECTIVE To evaluate the impact of a preconception counseling program tailored for teens with type 1 diabetes on cognitive , psychosocial , and behavioral outcomes and to assess its cost-effectiveness . RESEARCH DESIGN AND METHODS A total of 88 teens with type 1 diabetes from two sites were r and omized into the READY-Girls ( Reproductive-health Education and Awareness of Diabetes in Youth for Girls ) intervention ( IG ) ( n = 43 ) or st and ard care ( SC ) ( n = 45 ) groups . During three diabetes clinic visits , IG subjects viewed a two-part CD-ROM , read a book , and met with a nurse .  Program effectiveness was measured by knowledge , attitudes , intentions , and behaviors regarding diabetes , pregnancy , sexuality , and preconception counseling . Assessment s occurred at baseline , before and after viewing program material s , and at 9 months . Economic analyses included an assessment of re source utilization , direct medical costs , and a break-even cost analysis .  RESULTS Age range was 13.2–19.7 years ( mean ± SD 16.7 ± 1.7 years ) ; 6 % ( n = 5 ) were African American , and 24 % ( n = 21 ) were sexually active . Compared with baseline and SC subjects , IG subjects demonstrated a significant group-by-time interaction for benefit and knowledge of preconception counseling and reproductive health : increasing immediately after the first visit ( P < 0.001 ) and being sustained for 9 months ( P < 0.05 benefits ; P < 0.001 knowledge ) . For IG subjects , preconception counseling barriers decreased over time ( P < 0.001 ) , and intention and initiation of preconception counseling and reproductive health discussion s increased ( P < 0.001 ) . Costs of adverse reproductive outcomes are high . Direct medical costs of READY-Girls were low . CONCLUSIONS READY-Girls was beneficial and effects were sustained for at least 9 months . This low-cost self-instructional program can potentially empower young women with type 1 diabetes to make well-informed reproductive health choices , adding little time burden or cost to their diabetes management 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 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 Telehospice ( TH ) utilizes telemedicine technology to provide care at the end of life . A bistate project was launched in 1998 to study the use of home-based telemedicine for routine hospice care . Videophones were deployed for telenursing visits and evaluations by social workers . In order to determine what proportion of home hospice visits could be performed using currently available telemedicine technology , we review ed clinical records retrospectively for hospice nurse home visits . Clinical notes documenting home nursing visits were obtained from two large hospices , one based in Kansas , and the other in Michigan . Records were r and omly selected for patients who received hospice nurse visits during the month of January 2000 . The charts were review ed for patient demographic information , patient assessment s , teaching activities , and interventions . Five hundred ninety-seven nursing notes were analyzed using an 85-item coding instrument . After careful review of the records , the coders also made a subjective observation regarding the suitability of each visit for telemedicine . As part of this analysis , we found that 64.5 % of home hospice nursing visits could be performed by telemedicine . Using TH , it is possible to reduce the number of in-person visits , thereby significantly decreasing the cost of providing hospice care AIMS Type 2 diabetes mellitus ( T2DM ) can substantially decrease quality of life ( QOL ) . This study examined the effects on QOL-relevant psychosocial measures of a widely available commercial weight loss program enhanced for individuals with T2DM . METHODS A year-long multi-site r and omized clinical trial compared the Weight Watchers ( WW ) approach , supplemented with phone and email counseling with a certified diabetes educator ( CDE ) , to brief st and ard diabetes nutrition counseling and education ( St and ard Care ; SC ) . Participants were 400 women and 163 men ( N=279 WW ; 284 SC ) with T2DM [ mean ( ±SD ) HbA1c 8.32±1 % ; BMI = 37.1±5.7kg/m2 ; age=55.1 ± 9.1years ] . Psychosocial outcomes were assessed at baseline , month 6 , and month 12 using a diabetes specific psychosocial measure ( Diabetes Distress Scale [ DDS ] ) , Impact of Weight on Quality of Life-Lite scale ( IWQOL ) , a generic QOL measure ( SF-36 ) , and a depression screen ( PHQ-9 ) . RESULTS WW participants showed significantly greater improvements than did SC participants on all DDS subscales and total score and on IWQOL total score and physical function , sex life and work domains ( all ps<.05 ) . There was no significant treatment effect on SF-36 scores or PHQ-9 . CONCLUSIONS WW enhanced for individuals with T2DM was superior to SC in improving psychosocial outcomes most specific to T2DM and obesity . Available commercial WL programs , combined with scalable complementary program-specific diabetes counseling , may have benefits that extend to diabetes-related distress and weight-relevant QOL 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 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 INTRODUCTION In rural America cigarette smoking is prevalent , few cessation services are available , and healthcare providers lack the time and re sources to help smokers quit . This paper describes the design and participant characteristics of Connect2Quit ( C2Q ) , a r and omized control trial ( RCT ) that tests the effectiveness and cost-effectiveness of integrated telemedicine counseling delivered by 2-way webcams mounted on desktop computers in participant 's physician office examining rooms ( ITM ) versus quitline counseling delivered by telephone in participant 's homes ( Phone ) for helping rural smokers quit . METHODS / DESIGN C2Q was implemented in twenty primary care and safety net clinics .  Integrated telemedicine consisted of real-time video counseling , delivered to patients in their primary care physician 's ( PCP ) office . Phone counseling , was delivered to patients in their homes . All participants received educational material s and guidance in selecting cessation medications . RESULTS The 566 participants were predominantly Caucasian ( 92 % ) ; 9 % were Latino . Most ( 65 % ) earned < 200 % of Federal Poverty Level .  One out of three lacked home internet access , 40 % were not comfortable using computers , and only 4 % had been seen by a doctor via telemedicine in the past . Hypertension , chronic lung disease , and diabetes were highly prevalent . Participants  smoked nearly a pack a day and were highly motivated to quit . DISCUSSION C2Q is reaching a rural low-income population , with comorbid chronic diseases , that would benefit greatly from quitting smoking . ITM is a good delivery model , which integrates care by holding counseling sessions in the patient 's PCP office and keeps the primary care team up date d on patients ' progress . TRIAL REGISTRATION CLINICAL TRIALS REGISTRATION NCT00843505 The Board of Directors of the American Diabetes Association ( ADA ) recently endorsed a resolution recommending third-party payment for outpatient education and nutritional counseling . One of the major rationale s for the statement was that education and nutritional counseling will lead to reductions in health care costs . This article critically review s the 13 studies cited in support of the ADA Policy Statement . Among these studies , only 2 compared a treated group with a control group . Both of the studies with control groups failed to r and omly assign patients to treatment condition . Only 4 of the studies showed an accounting of program costs . Upon close inspection , it appears that some of the programs actually increased , rather than decreased , health care expenditures . Attrition from programs was reported in only a minority of cases , and was large when reported . The effect of the programs upon diabetes control was inconsistent across studies . It is suggested that the rationale for education and nutritional services be based on improved health status . In addition , the execution of a systematic experimental study to evaluate these services is urged 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 Background To improve quality of care and patient outcomes , health system decision-makers need to identify and implement effective interventions . An increasing number of systematic review s document the effects of quality improvement programs to assist decision-makers in developing new initiatives . However , limitations in the reporting of primary studies and current meta- analysis methods ( including approaches for exploring heterogeneity ) reduce the utility of existing syntheses for health system decision-makers . This study will explore the role of innovative meta- analysis approaches and the added value of enriched and up date d data for increasing the utility of systematic review s of complex interventions . Methods / Design We will use the data set from our recent systematic review of 142 r and omized trials of diabetes quality improvement programs  to evaluate novel approaches for exploring heterogeneity . These will include exploratory methods , such as multivariate meta-regression analyses and all-subsets combinatorial meta- analysis . We will then up date our systematic review to include new trials and enrich the data set by surveying authors of all included trials . In doing so , we will explore the impact of variables not , reported in previous publications , such as details of study context , on the effectiveness of the intervention . We will use innovative analytical methods on the enriched and up date d data set to identify key success factors in the implementation of  quality improvement interventions  for diabetes . Decision-makers will be involved throughout to help identify and prioritize variables to be explored and to aid in the interpretation and dissemination of results . Discussion This study will inform future systematic review s of complex interventions and describe the value of enriching and updating data for exploring heterogeneity in meta- analysis . It will also result in an up date d comprehensive systematic review of diabetes quality improvement interventions that will be useful to health system decision-makers in developing interventions to improve outcomes for people with diabetes . Systematic review registration PROSPERO registration no. An intervention program was undertaken to assess dietary habits and the impact of nutrition education among pregnant women in the rural county of Florina , northern Greece . Analysis of dietary habits , nutrient intake , hemoglobin , and serum vitamin concentrations in an intervention and control group indicated that the population was adequately nourished although nutrient intake was below recommended levels for pregnant women . Nutrition counseling was associated with improvements in dietary intake and significantly greater maternal weight gain ( p less than 0.05 ) . Mean birth weight was slightly higher in the intervention group but so was the incidence of low birth weight ( 4.5 % vs 3.9 % ) . The prematurity rate was marginally lower in the intervention group ( p less than 0.04 ) , as was the number of perinatal deaths ( 9 vs 11 ) . The results indicate that nutrition counseling during pregnancy can improve dietary intake and maternal weight gain but the mediating influence on low frequency pregnancy outcomes is indeterminate in a population that is not nutritionally at risk BACKGROUND AND AIMS This study defines and quantifies longitudinal changes in quality of life ( QoL ) at the time of first discharge home on home parenteral nutrition ( HPN ) and over the first year . METHODS Results were compared in patients in st and ard contact with a nutrition nurse specialist by telephone  , with results of those in contact via telemedicine in a r and omised controlled trial . Participants were recruited from nine UK HPN centres . Patients were r and omised to receive telemedicine upon initial discharge or after 1 year . The SF36 was the principal instrument chosen to determine QoL throughout the year on three predetermined occasions . EQ5D and hospital anxiety and depression scores were also recorded . RESULTS Thirty participants were recruited to the study from March 2001 to June 2003 . In all domains , QoL scores were significantly lower than normative data at discharge . QoL scores significantly improved over the first 6 months in physical functioning , physical role ( RP ) , vitality ( VT ) , social functioning ( SF ) , emotional-role ( RE ) domains , and mental component summary ( MCS ) . At 6 months RE , mental health ( MH ) and MCS were no longer significantly lower than normative data . There was no significant change in bodily pain ( BP ) , general health ( GH ) , MH , and physical component summary ( PCS ) . Opiate use significantly reduced SF36 domains RP , BP , VT , SF , MH , and MCS at 6 months and was associated with more subsequent inpatient episodes and central line reinsertions . Patients with an acute onset of intestinal failure had less pain and better GH scores at 6 months , and had less inpatient episodes after discharge than patients with a more chronic onset . Telemedicine had no impact on QoL or subsequent clinical outcome . CONCLUSIONS Aspects of QoL improve over the first 6 months of HPN . Opiate use and chronic diagnosis have a negative impact on some elements of QoL and clinical outcome variables 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 Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures , as measured by Medicare cl aims , and to assess the costs of developing and implementing the telemedicine intervention . Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine ( IDEATel ) , a r and omized controlled trial comparing telemedicine case management of diabetes to usual care . Participants were aged 55 years or older , and resided in federally design ated medically underserved areas of New York State . Measurements We analyzed Medicare cl aims payments for each participant for up to 60 study months from date of r and omization , until their death , or until December 31 , 2006 ( whichever happened first ) . We also analyzed study expenditures for the telemedicine intervention over six budget years ( February 28 , 2000- February 27 , 2006 ) . Results Mean annual Medicare payments ( SE ) were similar in the usual care and telemedicine groups , $ 9040 ( $ 386 ) and $ 9669 ( $ 443 ) per participant , respectively ( p>0.05 ) . Sensitivity analyses , including stratification by censored status , adjustment by enrollment site , and semi-parametric weighting by probability of dropping-out , rendered similar results . Over six budget years 28 821 participant/months of telemedicine intervention were delivered , at an estimated cost of $ 622 per participant/month . Conclusion Telemedicine case management was not associated with a reduction in Medicare cl aims in this medically underserved population . The cost of implementing the telemedicine intervention was high , largely representing special purpose hardware and software costs required at the time . Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used BACKGROUND 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 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 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 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 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 Purpose The purpose of this study was to evaluate the impact of a tobacco cessation intervention using motivational interviewing on smoking cessation rates during diabetes self-management training ( DSMT ) . Methods A r and omized controlled trial was conducted with subjects recruited from an ongoing type 2 diabetes adult education program at a large diabetes center . A total of 114 subjects were r and omized to intervention ( n = 57 ; face-to-face motivational interviewing plus telephone counseling and offering of medication ) or st and ard care ( n = 57 ) . Outcome measures included tobacco cessation rates , mean number of cigarettes smoked , A1C , weight , blood pressure , and lipids . Results Intensive intervention using motivational interviewing integrated into a st and ard DSMT program result ed in a trend toward greater abstinence at 3 months of follow-up in those receiving the intervention . However , this same trend was not observed at 6 months . The addition of this structured smoking cessation intervention did not negatively affect either diabetes education or other measures of diabetes management , including A1C values BACKGROUND Quality of life in survivors of pediatric acute lymphocytic leukemia ( ALL ) can be compromised by chronic diseases including increased risk of second cancers , cardiovascular disease , and diabetes . Overweight or obesity further increases these risks . Steroids are a component of chemotherapy for ALL , and weight gain is a common side effect . To impact behaviors associated with weight gain , we conducted a r and omized nutrition counseling intervention in ALL patients on treatment . PROCEDURE ALL patients on a steroid-based treatment regimen at the MD And erson Children 's Cancer Hospital were recruited and r and omized into control or intervention groups . The control group received st and ard care and nutrition education material s. The intervention group received monthly one-on-one nutrition counseling sessions , consisting of a baseline and 12 follow-up visits . Anthropometrics , dietary intake ( 3-day 24-hr dietary recalls ) and oxidative stress measures were collected at baseline , 6 months , and postintervention . Dietary recall data were analyzed using the Nutrition Data System for Research . RESULTS Twenty-two patients ( median age 11.5 years ) , all in the maintenance phase of treatment , were recruited . The intervention group ( n = 12 ) reported significantly lower calorie intake from baseline to 12-month follow-up and significant changes in glutamic acid and selenium intake ( P < 0.05 ) . Waist circumference was significantly associated with calorie , vitamin E , glutamic acid , and selenium intake . CONCLUSIONS A year-long dietary intervention was effective at reducing caloric intake in pediatric ALL patients receiving steroid-based chemotherapy  , indicating that this is a modality that can be built upon for obesity prevention and management Objective : To assess the impact of pharmacist counseling on empowering people with diabetes to better self-care .  Introduction : Community-based pharmacists can play a key role in educating and empowering people in such programs . Methods : A r and omized trial compared the effects of pharmacist counseling ( intervention group ) with printed material s ( control group ) in diabetic beneficiaries of several employer-based health care plans . All participants also received waiver of out-of-pocket expenses for diabetic-related medications and supplies . Clinical , humanistic , and cl aim outcomes were evaluated at baseline and at 1 year follow-up . Results : Sixty-seven beneficiaries participated in this study . The 0.50 % decrease from baseline in glycosylated hemoglobin ( A1c ) was statistically significant ( P = .0008 ) in the intervention group and the difference between the groups approached statistical significance ( P = .076 ) . Beneficiaries in both groups had greater cl aim costs for diabetic-related medications and supplies during the study year . Both groups also improved in ability to manage their diabetes with the counseling group showing a significantly better underst and ing of diabetes ( P = .0024 ) . Conclusion : There was a trend toward improvement in A1c in patients counseled by pharmacist with an increased utilization of diabetes-related medications and supplies . Counseling also improved diabetes knowledge and empowered patients to better diabetes management Since 1997 , more than 2,700 home care agencies have closed due to changes in reimbursement . With the implementation of a prospect i ve payment system , there is concern -- not only regarding the survival of the remaining home care agencies , but also whether adequate care can be provided to the patient . Chronic wound care is both prevalent and costly in home care . Factors contributing to cost include inconsistency of wound assessment and documentation and low usage of advanced wound products . These factors lead to lengthened healing time , more frequent visits by practitioners , and low healing rates . Involving a wound specialist can improve patient outcomes while decreasing cost . The authors examined the utilization of telemedicine in situations where wound specialists consulted with the home health nurse in the patient 's home regarding care of chronic wounds . During the two-way video visit , the wound specialist assessed the patient and the wounds and made recommendations for treatment . The wound specialist also collected outcome data during the visits . This data was then compared with like data collected as a baseline prior to the telemedicine intervention . Results revealed improved healing rates , decreased healing time , decreased number of home health visits , and a decreased number of hospitalizations related to wound complications .  Telemedicine was deemed a viable option for delivering quality , cost-effective care to chronic wound patients in the home care setting 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 OBJECTIVE To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities , including American Indian/Alaska Natives . SUBJECTS AND METHODS We conducted a multicenter , r and omized controlled trial and assigned diabetic participants to one of two groups : ( 1 ) telemedicine with a nonmydriatic camera or ( 2 ) traditional surveillance with an eye care provider . For those receiving telemedicine , the criteria for requiring follow-up with an eye care provider were ( 1 ) moderate nonproliferative diabetic retinopathy or higher , ( 2 ) presence of clinical ly significant macular edema , or ( 3 ) " unable to grade " result for diabetic retinopathy or macular edema . RESULTS The telemedicine group ( n=296 ) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group ( n=271 ) ( 94 % versus 56 % , p<0.001 ) . The overall prevalence of diabetic retinopathy at baseline was 21.4 % , and macular edema was present in 1.4 % of participants . In the telemedicine group , 20.5 % would require further evaluation with an eye care provider , and 86 % of these referrals were because of poor- quality digital images . CONCLUSIONS Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations , and most did not require follow-up with an eye care provider . Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider . Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations Background In rural America , cigarette smoking is prevalent and health care providers lack the time and re sources to help smokers quit . Telephone quitlines are important avenues for cessation services in rural areas , but they are poorly integrated with local health care re sources . Objective The intent of the study was to assess the comparative effectiveness and cost effectiveness of two models for delivering expert tobacco treatment at a distance : telemedicine counseling that was integrated into smokers ’ primary care clinics ( Integrated Telemedicine — ITM ) versus telephone counseling , similar to telephone quitline counseling , delivered to smokers in their homes ( Phone ) . Methods Smokers ( n=566 ) were recruited offline from 20 primary care and safety net clinics across Kansas . They were r and omly assigned to receive 4 sessions of ITM or 4 sessions of Phone counseling . Patients in ITM received real-time video counseling , similar to Skype , delivered by computer/webcams in clinic exam rooms . Three full-time equivalent trained counselors delivered the counseling . The counseling duration and content was the same in both groups and was available in Spanish or English . Both groups also received identical material s and assistance in selecting and obtaining cessation medications . The primary outcome was verified 7-day point prevalence smoking abstinence at month 12 , using an intent-to-treat analysis . Results There were no significant baseline differences between groups , and the trial achieved 88 % follow-up at 12 months . Verified abstinence at 12 months did not significantly differ between ITM or Phone ( 9.8 % , 27/280 vs 12 % , 34/286 ; P=.406 ) . Phone participants completed somewhat more counseling sessions than ITM ( mean 2.6 , SD 1.5 vs mean 2.4 , SD 1.5 ; P=.0837 ) ; however , participants in ITM were significantly more likely to use cessation medications than participants in Phone ( 55.9 % , 128/280 vs 46.1 % , 107/286 ; P=.03 ) . Compared to Phone participants , ITM participants were significantly more likely to recommend the program to a family member or friend ( P=.0075 ) . From the combined provider plus participant ( societal ) perspective , Phone was significantly less costly than ITM . Participants in ITM had to incur time and mileage costs to travel to clinics for ITM sessions . From the provider perspective , counseling costs were similar between ITM ( US $ 45.46 , SD 31.50 ) and Phone ( US $ 49.58 , SD 33.35 ) ; however , total provider costs varied widely depending on how the clinic space for delivering ITM was valued . Conclusions Findings did not support the superiority of ITM over telephone counseling for helping rural patients quit smoking . ITM  increased utilization of cessation pharmacotherapy and produced higher participant satisfaction , but Phone counseling was significantly less expensive . Future interventions could combine elements of both approaches to optimize pharmacotherapy utilization , counseling adherence , and satisfaction . Such an approach could commence with a telemedicine-delivered clinic office visit for pharmacotherapy guidance , and continue with telephone or real-time video counseling delivered via mobile phones to flexibly deliver behavioral support to patients where they most need it — in their homes and communities . Trial Registration Clinical trials.gov NCT00843505 ; http:// clinical trials.gov/ct2/show/NCT00843505 ( Archived by WebCite at http://www.webcitation.org/6YKSinVZ9 ) OBJECTIVE To determine the difference in the rate of change of serum albumin levels between protein-energy malnourished patients who receive intensive dietary counseling and patients who receive a special oral liquid nutritional supplement ( Nepro ;  Ross Products , Division Abbott Laboratories , Columbus , OH ) . DESIGN Participants with serum albumin values < or = 3.5 g/dL ( bromocresol green ) or 3.2 g/dL ( bromocresol purple ) and a Mini Nutrition Assessment ( MNA ) Malnutrition score < or = 23.5 were r and omized to the supplement group ( Nepro ) or the nonsupplement group with intensive dietary counseling .  PATIENTS Forty-one hemodialysis patients 18 years and older who had been on dialysis for at least 6 months . INTERVENTION Participants were r and omly assigned to supplement ( 26 ) or nonsupplement ( 14 ) groups . MAIN OUTCOME MEASURES Albumin levels . STATISTICAL ANALYSES PERFORMED Analysis of variance and chi2 tests , linear regression . RESULTS After adjustment for demographic and clinical characteristics , the rate of change in serum albumin level was significantly greater among patients r and omized to dietary counseling alone than among those who received oral supplements . These preliminary results suggest that intensive nutritional counseling may be of greater benefit than nutritional supplements alone in the management of protein-energy malnutrition in patients on hemodialysis . These preliminary findings should be confirmed by a larger full-scale trial Diabetes in pregnancy is a major public health problem in Mexico .  Nutrition therapy is an important component of treatment . Intensive nutrition intervention has not been implemented for Mexican pregnant women with diabetes . Its effect on different types of diabetes mellitus has not been studied . Purpose The authors assessed the effect of a medical nutrition therapy ( MNT ) program on perinatal complications in Mexico City . Methods Quasi-experimental design with a historical control . Women were assigned to a MNT program ( n = 88 ) and were followed up with every 2 weeks until delivery ( 2004 - 2007 ) . The control group ( n = 86 ) was selected from medical charts ( 2001 - 2003 ) and the same inclusion criteria were used . In each group , 55 % of women had type 2 diabetes mellitus and 45 % had gestational diabetes . The MNT program included a moderate intake of carbohydrate ( 40%-45 % of total energy ) and reduction in energy intake , capillary glucose self-monitoring , and education . The control group received usual hospital routine care . Statistical analysis included descriptive statistics , chi-square , and multivariate logistic regression ( OR , 95 % CI ) as indicated . Results Women in the MNT program had a lower risk of preeclampsia , fewer maternal hospitalization , and neonatal deaths in both types of diabetes . Low birth weight was less frequent only in women with gestational diabetes receiving MNT , while neonatal intensive care unit admissions were lower only in women with type 2 diabetes . Conclusions An intensive MNT program , including counseling , education , and capillary glucose self-monitoring , has a positive effect over preeclampsia , maternal hospitalization , and neonatal death in women with diabetes in pregnancy . MNT guidelines should be implemented in Mexican health care facilities treating diabetes in pregnancy 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 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 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 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 Self-management support for people with type 2 diabetes is essential in diabetes care . Thus , mobile health technology with or without low-intensity theory-based health counseling could become an important tool for promoting self-management . Objectives The aim was to evaluate whether the introduction of technology-supported self-management using the Few Touch Application ( FTA ) diabetes diary with or without health counseling improved glycated hemoglobin ( HbA1c ) levels , self-management , behavioral change , and health-related quality of life , and to describe the sociodemographic , clinical , and lifestyle characteristics of the participants after 4 months . Methods A 3-armed r and omized controlled trial was conducted in Norway during 2011 - 2013 . In the 2 intervention groups , participants were given a mobile phone for 1 year , which provided access to the FTA diary , a self-help tool that recorded 5 elements : blood glucose , food habits , physical activity , personal goal setting , and a look-up system for diabetes information . One of the intervention groups was also offered theory-based health counseling with a specialist diabetes nurse by telephone for 4 months from baseline . Both intervention groups and the  control group were provided usual care according to the national guidelines . Adults with type 2 diabetes and HbA1c ≥7.1 % were included ( N=151 ) . There were 3 assessment points : baseline , 4 months , and 1 year . We report the short-term findings after 4 months . HbA1c was the primary outcome and the secondary outcomes were self-management ( Health Education Impact Question naire , heiQ ) , behavioral change ( diet and physical activity ) , and health-related quality of life ( SF-36 question naire ) . The data were analyzed using univariate methods ( ANOVA ) , multivariate linear , and logistic regression . Results Data were analyzed from 124 individuals ( attrition rate was 18 % ) . The groups were well balanced at baseline . There were no differences in HbA1c between groups after 4 months , but there was a decline in all groups . There were changes in self-management measured using the health service navigation item in the heiQ , with improvements in the FTA group compared to the control group ( P=.01 ) and in the FTA with health counseling group compared with both other groups ( P=.04 ) . This may indicate an improvement in the ability of patients to communicate health needs to their health care providers . Furthermore , the FTA group reported higher scores for skill and technique acquisition at relieving symptoms compared to the control group ( P=.02 ) . There were no significant changes in any of the domains of the SF-36 . Conclusions The primary outcome , HbA1c , did not differ between groups after 4 months . Both of the intervention groups had significantly better scores than the control group for health service navigation and the FTA group also exhibited improved skill and technique acquisition ABSTRACT In the last five years , home health agencies have become increasingly interested in telemedicine as a potential means to meet the future healthcare needs of their aged and chronically ill clientele . This case study examines the organizational and environmental conditions that affected the implementation of a telemedicine program in one rural home healthcare organization . Several factors restricted the utilization of telemedicine , including Medicare 's Prospect i ve Payment System and corresponding documentation ( Outcome Assessment and Information Set ) , the organization controlling grant funding for the program , and several environmental factors . Findings suggest that in rural communities , older homecare patients may have less opportunity to benefit from telemedicine . The study demonstrates the importance of environmental and organizational factors when implementing a telemedicine program . Recommendations are offered for home healthcare organizations considering development of telemedicine programs CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care . OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older , ethnically diverse , medically underserved patients with diabetes . DESIGN , Setting , and Patients A r and omized controlled trial was conducted , comparing telemedicine case management to usual care , with blinded outcome evaluation , in 1,665 Medicare recipients with diabetes , aged > /= 55 years , residing in federally design ated medically underserved areas of New York State . Interventions Home telemedicine unit with nurse case management versus usual care . Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c ( HgbA1c ) , low density lipoprotein ( LDL ) cholesterol , and blood pressure levels . RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints ( HgbA1c , p = 0.001 ; LDL , p < 0.001 ; systolic and diastolic blood pressure , p = 0.024 ; p < 0.001 ) . Estimated differences ( 95 % CI ) in year 5 were 0.29 ( 0.12 , 0.46)% for HgbA1c , 3.84 ( -0.08 , 7.77 ) mg/dL for LDL cholesterol , and 4.32 ( 1.93 , 6.72 ) mm Hg for systolic and 2.64 ( 1.53 , 3.74 ) mm Hg for diastolic blood pressure . There were 176 deaths in the intervention group and 169 in the usual care group ( hazard ratio 1.01 [ 0.82 , 1.24 ] ) . CONCLUSIONS Telemedicine case management result ed in net improvements in HgbA1c , LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries . Mortality was not different between the groups , although power was limited . Trial Registration http:// clinical trials.gov Identifier : NCT00271739 Background : Telemedicine 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 PURPOSE to evaluate the impact of dietary counseling on controlling weight gain in pregnant women , who were served in a public health service facility . METHODS the study was conducted at a known health unit located in the metropolitan region of the city of Porto Alegre , in Rio Gr and e do Sul , Brazil . Three hundred and fifteen pregnant women between the 10th and 29th week of gestation were r and omized to Control and Intervention Groups . The Intervention Group received dietary counseling according to nutritional status , and pregnant women in the Control Group were instructed to follow the routine of the health service facility . Weight and height were measured , and the body mass index ( BMI ) was calculated . The pre-gestational nutritional status was determined according to the following BMI criteria : low weight ( < 18.5 kg/m² ) , eutrophy ( 18.5 to 24.9 kg/m² ) , overweight ( 25.0 to 29.9 kg/m² ) , and obesity ( > 30 kg/m² ) . The nutritional status during pregnancy was determined according to the BMI curve for gestational age adopted by the Health Ministry of Brazil . Data were analyzed by the relative risk and respective 95 % confidence interval , and by the Student 's t-test and χ2 test . Statistical significance was set at p<0.05 . RESULTS the assessment of nutritional status before pregnancy showed that 28.0 % of the women were overweight and 4.1 % were underweight . In the first and last interview during pregnancy , the rates of prevalence of excessive weight were 36.2 and 46.0 % , respectively . The intervention proved to be effective in reducing the rate of weekly weight gain of pregnant women with excess weight ( 342.2 versus 420.2 ; p=0.015 ) and the prevalence of clinical complications ( 9.2 versus 24.85 ; p<0.001 ) . CONCLUSIONS dietary counseling was effective in decreasing the weight gain of pregnant women who were overweight and reducing clinical complications , such as gestational diabetes , preeclampsia , infant low weight , and prematurity in the Intervention Group 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 To assess the impact on child growth of the nutrition-counseling component of the Integrated Management of Childhood Illnesses ( IMCI ) strategy , a r and omized trial was implemented . All 28 government health centers in a Southern Brazil city were paired according to baseline nutritional indicators . One center from each pair was r and omly selected and its doctors received 20-h training in nutrition counseling .  Thirty-three doctors were included and 12 - 13 patients < 18 mo of age from each doctor were recruited . The study included testing the knowledge of doctors , observing consultations and visiting the children at home 8 , 45 and 180 d after the initial consultation . Maternal knowledge , practice s and adherence to nutritional recommendations were assessed , and anthropometric measurements were taken . Day-long dietary intake was evaluated on a sub sample of children . Doctors in the intervention group had better knowledge of child nutrition and improved assessment and counseling practice s. Maternal recall of recommendations was higher in the intervention than in the control group , as was satisfaction with the consultation . Reported use of recommended foods was also increased . Daily fat intake was higher in the intervention than in the control group ; mean daily intakes of energy and zinc also tended to improve . Children 12 mo of age or older had improved weight gain and a positive but nonsignificant improvement in length .  Nutrition-counseling training  improved doctors ' performances , maternal practice s and the diets and weight gain of children . The r and omized design with blind outcome evaluation strongly supports a causal link . These results should be replicated in other setting 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 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
Results Telemedicine programs that include a nutritional component show similar effect in diabetes management as those programs that do not .
Furthermore , subgroup analysis reveals that nutritional intervention via SMS such as email and text messages is at least as equally effective in reducing HbA1c when compared to personal nutritional counseling with a practitioner over videoconference or telephone .
Conclusion The inclusion of nutritional counseling as part of a telemedicine program does not make a significant difference to diabetes outcomes .
Incorporating nutritional counseling into telemedicine programs via SMS is at least as effective as counseling via telephone or videoconference
Background A growing number of studies and review s have documented the impact of telemedicine on diabetes management .
However , no meta- analysis has assessed whether including nutritional counseling as part of a telemedicine program has a significant impact on diabetes outcomes or what kind of nutritional counseling is most effective .