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CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care . OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older , ethnically diverse , medically underserved patients with diabetes . DESIGN , Setting , and Patients A r and omized controlled trial was conducted , comparing telemedicine case management to usual care , with blinded outcome evaluation , in 1,665 Medicare recipients with diabetes , aged > /= 55 years , residing in federally design ated medically underserved areas of New York State . Interventions Home telemedicine unit with nurse case management versus usual care . Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c ( HgbA1c ) , low density lipoprotein ( LDL ) cholesterol , and blood pressure levels . RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints ( HgbA1c , p = 0.001 ; LDL , p < 0.001 ; systolic and diastolic blood pressure , p = 0.024 ; p < 0.001 ) . Estimated differences ( 95 % CI ) in year 5 were 0.29 ( 0.12 , 0.46)% for HgbA1c , 3.84 ( -0.08 , 7.77 ) mg/dL for LDL cholesterol , and 4.32 ( 1.93 , 6.72 ) mm Hg for systolic and 2.64 ( 1.53 , 3.74 ) mm Hg for diastolic blood pressure . There were 176 deaths in the intervention group and 169 in the usual care group ( hazard ratio 1.01 [ 0.82 , 1.24 ] ) . CONCLUSIONS Telemedicine case management result ed in net improvements in HgbA1c , LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries . Mortality was not different between the groups , although power was limited . Trial Registration http:// clinical trials.gov Identifier : NCT00271739 BACKGROUND Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness . METHODS The authors conducted a r and omized , controlled trial comparing telemedicine case management to usual care , with blinding of those obtaining outcome data , in 1,665 Medicare recipients with diabetes , aged 55 years or greater , and living in federally design ated medically underserved areas of New York State . The primary endpoints were HgbA1c , blood pressure , and low-density lipoprotein ( LDL ) cholesterol levels . RESULTS In the intervention group ( n = 844 ) , mean HgbA1c improved over one year from 7.35 % to 6.97 % and from 8.35 % to 7.42 % in the subgroup with baseline HgbA1c > or = 7 % ( n = 353 ) . In the usual care group ( n = 821 ) mean HgbA1c improved over one year from 7.42 % to 7.17 % . Adjusted net reductions ( one-year minus baseline mean values in each group , compared between groups ) favoring the intervention were as follows : HgbA1c , 0.18 % ( p = 0.006 ) , systolic and diastolic blood pressure , 3.4 ( p = 0.001 ) and 1.9 mm Hg ( p < 0.001 ) , and LDL cholesterol , 9.5 mg/dL ( p < 0.001 ) . In the subgroup with baseline HgbA1c > or = 7 % , net adjusted reduction in HgbA1c favoring the intervention group was 0.32 % ( p = 0.002 ) . Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York . CONCLUSION Telemedicine case management improved glycemic control , blood pressure levels , and total and LDL cholesterol levels at one year of follow-up Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures , as measured by Medicare cl aims , and to assess the costs of developing and implementing the telemedicine intervention . Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine ( IDEATel ) , a r and omized controlled trial comparing telemedicine case management of diabetes to usual care . Participants were aged 55 years or older , and resided in federally design ated medically underserved areas of New York State . Measurements We analyzed Medicare cl aims payments for each participant for up to 60 study months from date of r and omization , until their death , or until December 31 , 2006 ( whichever happened first ) . We also analyzed study expenditures for the telemedicine intervention over six budget years ( February 28 , 2000- February 27 , 2006 ) . Results Mean annual Medicare payments ( SE ) were similar in the usual care and telemedicine groups , $ 9040 ( $ 386 ) and $ 9669 ( $ 443 ) per participant , respectively ( p>0.05 ) . Sensitivity analyses , including stratification by censored status , adjustment by enrollment site , and semi-parametric weighting by probability of dropping-out , rendered similar results . Over six budget years 28 821 participant/months of telemedicine intervention were delivered , at an estimated cost of $ 622 per participant/month . Conclusion Telemedicine case management was not associated with a reduction in Medicare cl aims in this medically underserved population . The cost of implementing the telemedicine intervention was high , largely representing special purpose hardware and software costs required at the time . Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used BACKGROUND Telemedicine-based diabetes management improves outcomes versus clinic care but is seldom implemented by healthcare systems . In order to advance telemedicine-based management as a practical option for veterans with persistent poorly controlled diabetes mellitus ( PPDM ) despite clinic-based care , we evaluated a comprehensive telemedicine intervention that we specifically design ed for delivery using existing Veterans Health Administration ( VHA ) clinical staffing and equipment . MATERIAL S AND METHODS We conducted a 6-month r and omized trial among 50 veterans with PPDM ; all maintained hemoglobin A1c ( HbA1c ) levels continuously > 9.0 % for > 1 year despite clinic-based management . Participants received usual care or a telemedicine intervention combining telemonitoring , medication management , self-management support , and depression management ; existing VHA clinical staff delivered the intervention . Using linear mixed models , we examined HbA1c , diabetes self-care ( measured by the Self-Care Inventory-Revised question naire ) , depression , and blood pressure . RESULTS At baseline , the model-estimated common HbA1c intercept was 10.5 % . By 6 months , estimated HbA1c had improved by 1.3 % for intervention participants and 0.3 % for usual care ( estimated difference , -1.0 % , 95 % confidence interval [ CI ] , -2.0 % , 0.0 % ; p = 0.050 ) . Intervention participants ' diabetes self-care ( estimated difference , 7.0 ; 95 % CI , 0.1 , 14.0 ; p = 0.047 ) , systolic blood pressure ( -7.7 mm Hg ; 95 % CI , -14.8 , -0.6 ; p = 0.035 ) , and diastolic blood pressure ( -5.6 mm Hg ; 95 % CI , -9.9 , -1.2 ; p = 0.013 ) were improved versus usual care by 6 months . Depressive symptoms were similar between groups . CONCLUSIONS A comprehensive telemedicine intervention improved outcomes among veterans with PPDM despite clinic-based care . Because we specifically design ed this intervention with scalability in mind , it may represent a practical , real-world strategy to reduce the burden of poor diabetes control among veterans Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness . We conducted a r and omized controlled trial comparing telemedicine case management to usual care , with blinding of those obtaining outcome data , in 1,665 Medicare recipients with diabetes , aged 55 years or greater , and living in federally design ated medically underserved areas of New York State . In New York City , 98 % of participants were black or Hispanic , 69 % were Medicaid-eligible , and 93 % reported annual household income < or = $ 20,000 . In upstate New York , 91 % were white , 14 % Medicaid eligible , and 50 % reported annual household income < or = $ 20,000 . A baseline survey found that 95 % of participants in New York City and 67 % in upstate New York reported that they did not know how to use a computer . The primary endpoints were HgbA1c , blood pressure , and low density lipoprotein ( LDL ) cholesterol levels . In the intervention group ( N = 844 ) , mean HgbA1c improved over 1 year from 7.35 % to 6.97 % , and from 8.35 % to 7.42 % in the subgroup with baseline HgbA1c > or = 7 % ( N = 353 ) . In the usual care group ( N = 821 ) , mean HgbA1c improved over 1 year from 7.42 % to 7.17 % . Adjusted net reductions ( 1-year minus baseline mean values in each group , compared between groups ) favoring the intervention were as follows : HgbA1c , 0.18 % ( p = 0.006 ) , systolic and diastolic blood pressure , 3.4 ( p = 0.001 ) and 1.9 mmHg ( p < 0.001 ) , and LDL cholesterol , 9.5 mg/dl ( p < 0.001 ) . In the subgroup with baseline HgbA1c > or = 7 % , net adjusted reduction in HgbA1c favoring the intervention group was 0.32 % ( p = 0.002 ) . Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dl . The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York . A satisfaction survey of intervention group participants ( N = 346 respondents ) showed high levels of satisfaction with major intervention components . A satisfaction survey of participating primary care physicians ( N = 116 respondents ) showed positive perceptions for acceptability , impact on patients and communication .  Telemedicine case management  improved glycemic control , blood pressure levels , and total and LDL-cholesterol levels at 1 year of follow-up . Telemedicine is an effective method for translating modern approaches to disease management into effective care for underserved population Healthcare costs for heart failure are increasing . The need for a better care , however , has to be matched with a policy of cost containment . A way to improve the cost-effectiveness of heart failure care is the disease management approach , in which therapy , education and follow-up are tailored for each patient by a multidisciplinary team . Such a complex intervention can be facilitated by the use of telemedicine , which allows the remote control of considerable amounts of clinical data . In Italy , a few studies with telemedicine have been reported . A recent development in this field is represented by the ICAROS project ( Integrated Care vs Conventional Intervention in Cardiac Failure Patients : R and omized Open Label Study ) , whose aim is to improve the clinical and psychological care of heart failure patients employing advanced wireless telecommunication technology . So far , we r and omized 60 patients : 30 in usual ambulatory care , 30 in an intensive treatment group . The latter patients were instructed to use a portable computer to get in touch daily with the heart failure clinic and receive feedback instruction for the management of drug therapy and daily problems .  At the first year of follow-up , the treatment group showed good compliance to drug prescriptions , and could easily h and le the portable computer . The preliminary results of this ongoing study support the feasibility and appropriateness of new technologies for the management of heart failure , even in elderly patients in whom a limited expertise with these appliances could have been anticipated Information and telecommunication technologies are called to play a major role in the changes that healthcare systems have to face to cope with chronic disease . This paper reports a telemedicine experience for the home care of chronic patients suffering from chronic obstructive pulmonary disease ( COPD ) and an integrated system design ed to carry out this experience . To determine the impact on health , the chronic care telemedicine system was used during one year ( 2002 ) with 157 COPD patients in a clinical experiment ; endpoints were readmissions and mortality . Patients in the intervention group were followed up at their homes and could contact the care team at any time through the call center . The care team shared a unique electronic chronic patient record ( ECPR ) accessible through the web-based patient management module or the home visit units . Results suggest that integrated home telemedicine services can support health professionals caring for patients with chronic disease , and improve their health . We have found that simple telemedicine services ( ubiquitous access to ECPR , ECPR shared by care team , accessibility to case manager , problem reporting integrated in ECPR ) can increase the number of patients that were not readmitted ( 51 % intervention , 33 % control ) , are acceptable to professionals , and involve low installation and exploitation costs . Further research is needed to determine the role of telemonitoring and televisit services for this kind of Diabetes case management ( DCM ) may improve medical outcomes ( 1,2 ) . Case managers coordinate care and often provide a mix of interventions , e.g. , telephone outreach , education , reminders . However , the efficacy of DCM is unclear . Three systematic review s lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid , weight , or blood pressure benefits ( 3–5 ) . DCM studies typically target biomedical outcomes and ignore potential psychosocial effects . Yet , psychosocial variables ( e.g. , depression , anxiety , social support ) relate to hyperglycemia , complications , adherence , and quality of life ( 6–11 ) . Thus , a positive impact of DCM on these factors is important . Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction ( cluster visit ) ( 12 ) and quality of life ( dietitian-led DCM group ) ( 13 ) . Because barriers ( e.g. , distance , weather ) limit DCM access , telemedicine can be used . A review of telemedicine versus face-to-face trials concluded that , while feasible and acceptable , there is little evidence that telemedicine has clinical benefits ( 14 ) . Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients ( 15 ) . The intervention result ed in significant improvements in glycemic control , blood pressure , and total and LDL cholesterol ( 16 ) . The purpose of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project , funded by the Centers for Medicare and Medicaid Services , is to evaluate the feasibility and effectiveness of telemedicine with a diverse , medically underserved , elderly diabetic sample . The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes . A detailed description of the IDEATel study design has been previously reported ( 15,16 ) . Medicare recipients were recruited if they were aged ≥55 years , diagnosed with diabetes , and without moderate/severe impairments or comorbidities . Research nurses blinded to the groups BACKGROUND The incidence of gestational diabetes mellitus (GDM)--hyperglycemia with onset or first recognition during pregnancy -- is increasing and will have a significant impact on diabetes services . This study aim ed to determine the feasibility and acceptability of using telemedicine in the diabetes care of women with GDM and the possibility of replacing alternate ( one in every two ) diabetes review appointments with telemedicine . SUBJECTS AND METHODS A feasibility study for a r and omized controlled trial was conducted across two sites . Fifty women with GDM were r and omized to usual care ( n = 26 ) or usual care plus telemedicine ( n = 24 ) . Telemedicine entailed weekly blood pressure and weight measurements and transmission of these data , along with blood glucose readings , for review by the healthcare team . Patients were contacted about these results as necessary . Patients completed question naires to measure their satisfaction with telemedicine or blood glucose monitoring .  The intervention group and healthcare providers also took part in qualitative interviews . Analysis involved descriptive statistics for the satisfaction question naires and framework analysis for the qualitative interviews . RESULTS Eighty-nine percent of patients were satisfied with telemedicine and would use it again . Both HCPs and patients found the equipment easy to use and were positive about using it to replace alternate diabetes review appointments in the future . If used in this way , healthcare providers felt that protected time in which to perform the telemedicine review would be necessary . CONCLUSIONS Telemedicine may help meet the growing dem and on diabetes services due to increasing numbers of women being diagnosed with GDM INTRODUCTION Diabetic foot ulcers are a feared complication of diabetes . Care delivered via telemedicine is suggested to be a more integrated care pathway to manage diabetic foot ulcers than traditionally delivered healthcare . Our aim was to explore patients ' experiences with telemedicine follow-up care as compared to traditional care . METHODS Interpretive description was used as an analysis strategy . Data were collected using individual semi-structured interviews in the context of a larger ongoing clustered r and omized controlled trial . Twenty-four patients ( 13 in the intervention group ; 11 in the control group ) , aged 38 - 88 years were purposively recruited from the RCT in order to obtain a diverse sample in terms of group composition ( intervention vs. control ) , age , gender , marital status , setting , and comorbidities present . The control group received traditional care . RESULTS Three themes emerged from the interpretive analysis : competence of healthcare professionals , continuity of care , and easy access . This was independed of types of follow-up that had limited impact on the patients ' follow-up experiences . Competence of healthcare professionals and continuity of care were crucial , because they can either enhance or jeopardize wound care . If these two latter factors were absent , patients would lose confidence in the wound care process . If this happened , patients pointed out that the expert knowledge of a specialist clinic was essential to receive good care . When telemedicine functioned optimally , telemedicine was an advantage in the treatment , because the images quickly captured changes in the wound healing that immediately could be corrected . Easy access is important for patients , but the importance of accessibility appears to be primary when the other two factors were present . CONCLUSION The best wound care pathway for patients with diabetes foot ulcers is depended on a combination of competence and professional skills in wound management , and continuity of care . If telemedicine is functioning as intended , it can be an important additional tool OBJECTIVE To estimate the impacts on Medicare costs of providing a particular type of home telemedicine to eligible Medicare beneficiaries with type 2 diabetes . RESEARCH DESIGN AND METHODS Two cohorts of beneficiaries ( n = 1,665 and 504 , respectively ) living in two medically underserved areas of New York between 2000 and 2007 were r and omized to intensive nurse case management via televisits or usual care .  Medicare service use and costs covering a 6-year follow-up period were drawn from cl aims data . Impacts were estimated using regression analyses . RESULTS Informatics for Diabetes Education and Telemedicine ( IDEATel ) did not reduce Medicare costs in either site . Total costs were between 71 and 116 % higher for the treatment group than for the control group . CONCLUSIONS Although IDEATel had modest effects on clinical outcomes ( reported elsewhere ) , it did not reduce Medicare use or costs for health services . The intervention 's costs were excessive ( over $ 8,000 per person per year ) compared with programs with similar-sized clinical impacts Objectives . Adherence to diabetes self care is poor for Hispanic American and African-American patients . This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients . We also examined whether adherence mediated the effect of the intervention on glycemic control ( A1c ) . Design . The Informatics for Diabetes Education and Telemedicine project r and omized medically underserved Medicare patients ( n=1665 ) to telemedicine case management ( televideo educator visits , individualized goal - setting /problem solving ) or usual care .  Hispanic and African-American educators delivered the intervention in Spanish if needed . Main outcome measures . Annual assessment included A1c and self-reported adherence ( Summary of Diabetes Self-Care Activities scale ) . A simple model ( only time and group terms ) and a model with covariates ( e.g. , age ) were examined for baseline and 5 years of follow-up . SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c , by performing tests of the mediating path coefficients . Results . Over time , self-reported adherence improved for the treatment group compared to usual care ( p<0.001 ) . There was no significant interaction with racial/ethnic group membership , i.e. , all groups improved . However , minority subjects were consistently less adherent than whites . Also , greater comorbidity and diabetes symptoms predicted poorer adherence , greater duration of diabetes and more years of education predicted better adherence . Adherence was a significant mediator of A1c ( p<0.001 ) . Conclusions . A unique , tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care . However , African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention . The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity BACKGROUND We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure ( BP ) in underserved subjects with hypertension . METHODS A total of 241 patients with systolic BP ≥140 mm Hg were r and omized to usual care ( C ; n = 121 ) or telemedicine  ( T ; n = 120 ) . The T group reported BP , heart rate , weight , steps/day , and tobacco use twice weekly . The primary outcome was BP control at 6 months . RESULTS Average age was 59.6 years , average body mass index was 33.7 kg/m(2 ) , 79 % were female , 81 % were African American , 15 % were white , 53 % were at or below the federal poverty level , 18 % were smokers , and 32 % had diabetes . Six-month follow-up was achieved in 206 subjects ( C : 107 , T : 99 ) . Goal BP was achieved in 52.3 % in C and 54.5 % in T ( P = .43 ) . Systolic BP change ( C : -13.9 mm Hg , T : -18.2 ; P = .118 ) was similar in both groups . Subjects in the T group reported BP 7.7 ± 6.9 d/mo . Results were not affected by age , sex , ethnicity , education , or income . In nondiabetic T subjects , goal BP was achieved in 58.2 % compared with 45.2 % of diabetic T subjects ( P = .024 ) . Nondiabetic T subjects demonstrated a greater reduction in systolic BP ( T : -19 ± 20 mm Hg , C : -12 ± 19 mm Hg ; P = .037 ) . No difference in BP response between C and T was noted in patients with diabetes . CONCLUSION In hypertensive subjects , engagement in a system of care with or without telemedicine result ed in significant BP reduction . Telemedicine for nondiabetic patients result ed in a greater reduction in systolic BP compared with usual care . Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects Introduction Good metabolic control is important in type 2 diabetes mellitus to improve quality of life , work ability and life expectancy , and the use of telemedicine has proved efficient as an add-on to the usual treatment . However , few studies in type 2 diabetes patients have directly compared telemedicine with conventional outpatient treatment , and we wanted to evaluate whether telemedicine , compared with st and ard care , provides equivalent clinical outcomes . Methods Forty patients with type 2 diabetes mellitus allocated from October 2011–July 2012 were r and omized to either treatment at home by video conferences only or st and ard outpatient treatment . Primary outcomes were HbA1c and blood glucose levels and secondary outcomes were 24-hour blood pressure , cholesterol levels and albuminuria . The video-telephone was a broadb and solution installed and serviced by the Danish Telephone Company ( TDC ) . Results The improvements in the two treatments , given as changes in percentage of telemedicine vs st and ard , showed significant differences in HbA1c ( −15 vs −11 % ) , mean blood glucose ( −18 vs −13 % ) and in cholesterol ( −7 vs −6 % ) . No differences in LDL ( −4 vs −6 % ) , weight ( −1 vs 2 % ) , diastolic diurnal blood pressure ( −1 vs −7 % ) , and systolic diurnal blood pressure ( 0 vs −1 % ) were found . Nine consultations were missed in the st and ard outpatient group and none in the telemedicine group . Conclusions In the direct comparison of home video consultations vs st and ard outpatient treatment in type 2 diabetes mellitus , telemedicine was a safe and available option with favourable outcomes after six months treatment BACKGROUND This report is a supplement to an earlier evidence report ,  Telemedicine for the Medicare Population , which was intended to help policymakers weigh the evidence relevant to coverage of telemedicine services under Medicare . That report focused on telemedicine programs and clinical setting s that had been used with or were likely to be applied to Medicare beneficiaries . While we prepared that report , it became apparent that there are also telemedicine studies among non-Medicare beneficiaries -- e.g . , children and pregnant women -- that could inform policymakers and provide more comprehensive evidence of the state of the science regarding telemedicine applications . In addition , the first evidence report only partially included a class of telemedicine applications ( called self-monitoring/testing telemedicine ) in which the beneficiary used a home computer  or modern-driven telephone system  to either report information or access information and support from Internet re sources and indirectly interact with a clinician . Self-monitoring/testing applications in the first report required direct interaction with a clinician . The goal of this report is to systematic ally review the evidence in the clinical areas of pediatric and obstetric telemedicine as well as home-based telemedicine where there is indirect involvement of the health care professional . ( In this report , we will refer to the latter as clinician-indirect home telemedicine . ) Specifically , the report summarizes scientific evidence on the diagnostic accuracy , access , clinical outcomes , satisfaction , and cost-effectiveness of services provided by telemedicine technologies for these patient groups . It also identifies gaps in the evidence and makes recommendations for evaluating telemedicine services for these population s in the future . The evidence is clustered according to three categories of telemedicine service defined in our original report : store- and -forward , self-monitoring/testing , and clinician-interactive services . The three clinical practice areas review ed in this report are defined as follows . The term pediatric applies to any telemedicine study in which the sample consisted wholly or partially of persons aged 18 or younger , including studies with neonatal sample s. The term obstetric applies to any telemedicine study in which the sample consisted entirely of women seeking pregnancy-related care . The term clinician-indirect home telemedicine applies to home-based telemedicine ( called self-monitoring/testing in our original report ) where a telemedicine application used in the home has only indirect involvement by the health care professional . Interactive home telemedicine was applied in this report to all patient population s. KEY QUESTIONS The key questions that served as a guide for review ing the literature in the evaluation of pediatric , obstetric , and clinician-indirect  home telemedicine applications were derived by consensus among the evidence - review team based on the analytic framework established for the original evidence report . For the current report , the questions were applied to studies in all three practice areas as a whole group within each of the three categories of telemedicine services : store- and -forward ; self-monitoring/testing ; and clinician-interactive . The specific key questions were : 1 . Does telemedicine result in comparable diagnosis and appropriateness of recommendations for management ? 2 . Does the availability of telemedicine provide comparable access to care ? 3 . Does telemedicine result in comparable health outcomes ? 4 . Does telemedicine result in comparable patient or clinician satisfaction with care ? 5 . Does telemedicine result in comparable costs of care and /or cost-effectiveness ? METHODS We search ed for peer- review ed literature using several bibliographic data bases . In addition , we conducted h and search es of leading telemedicine journals and identified key papers from the reference lists of journal articles . For our original evidence report on telemedicine for the Medicare population , we design ed a search to find any publications about telemedicine and used it to search the MEDLINE , CINAHL , and HealthSTAR data bases for all years the data bases were available . Through this process , we captured studies of pediatric , obstetric , and clinician-indirect home telemedicine ; however , they were excluded from the original report since they were outside its scope . For this supplemental report , we review ed our original search results and identified studies relevant to this report . We identified additional studies from the reference lists of included papers and from h and search ing two peer- review ed telemedicine publications , the Journal of Telemedicine and Telecare and Telemedicine Journal . We critically appraised the included studies for each study area and key question and discussed the strengths and limitations of the most important studies at weekly meetings of the research team . We also developed recommendations for research to address telemedicine knowledge gaps . To match these gaps with the capabilities of specific research methods , we classified the telemedicine services according to the type of evidence that would be needed to determine whether the specific goals of covering such services had been met . We emphasized the relationship between the type and level of evidence found in the systematic review of effectiveness and the types of studies that might be funded to address the gaps in knowledge in this growing field of research . FINDINGS We identified a total of 28 eligible studies . In the new clinical areas , we found few studies in store- and -forward telemedicine . There is some evidence of comparable diagnosis and management decisions made using store- and -forward telemedicine from the areas of pediatric dental screening , pediatric ophthalmology , and neonatalogy . In self-monitoring/testing telemedicine for the areas of pediatrics , obstetrics , and clinician-indirect home telemedicine , there is evidence that access to care can be improved when patients and families have the opportunity to receive telehealth care at home rather than in-person care in a clinic or hospital . Access is particularly enhanced when the telehealth system enables timely communication between patients or families and care providers that allows self-management and necessary adjustments that may prevent hospitalization . There is some evidence that this form of telemedicine improves health outcomes , but the study sample sizes are usually small , and even when they are not , the treatment effects are small . There is also some evidence for the efficacy of clinician-interactive telemedicine , but the studies do not clearly define which technologies provide benefit or cost-efficiency . Some promising areas for diagnosis include emergency medicine , psychiatry , and cardiology . Most of the studies measuring access to care provide evidence that it is improved . Although none of these studies were r and omized controlled trials , they provide some evidence of access improvement over prior conditions . Clinician-interactive telemedicine was the only area for which any cost studies were found . The three cost studies did not adequately demonstrate that telemedicine reduces costs of care ( except comparing only selected costs ) . No study addressed cost-effectiveness . CONCLUSIONS This supplemental report covering the areas of pediatrics , obstetrics , and indirect-clinician home telemedicine echoes the findings of our initial report for the Medicare domain , which is that while the use of telemedicine is small but growing , the evidence for its efficacy is incomplete . Many of the studies are small and /or method ologically limited , so it can not be determined whether telemedicine is efficacious . Future studies should focus on the use of telemedicine in conditions where burden of illness and /or barriers to access for care are significant . Use of recent innovations in the design of r and omized controlled trials for emerging technologies would lead to higher quality studies . Journals publishing telemedicine evaluation studies must set high st and ards for method ologic quality so that evidence reports need not rely on studies with marginal method ologies Background Telemedicine is the use of telecommunications technology for medical diagnosis and patient care . From its beginnings telemedicine has been used in a variety of health care fields , although widespread interest among healthcare providers has only now become apparent with the development of more sophisticated technology . Objectives To assess the effects of telemedicine as an alternative to face-to-face patient care . Search methods We search ed the Effective Practice and Organisation of Care Group 's specialised register , The Cochrane Library , MEDLINE ( 1966-August 1999 ) , EMBASE ( to 1996 ) , CINAHL ( to August 1999 ) , Inspec ( to August 1996 ) , Healthstar ( 1983 - 1996 ) , OCLC , Sigle ( to 1999 ) , Assia , SCI ( 1981 - 1997 ) , SSCI ( 1981 - 1997 ) , DHSS- Data . We h and search ed the Journal of Telemedicine and Telecare ( 1995 - 1999 ) , Telemedicine Journal ( 1995 - 1999 ) and reference lists of articles . We also h and search ed conference proceedings and contacted experts in countries identified as having an interest in telemedicine . Selection criteria R and omised trials , controlled before and after studies and interrupted time series comparing telemedicine with face-to-face patient care .  The participants were qualified health professionals and patients receiving care through telemedicine .  Data collection and analysis Two review ers independently assessed trial quality and extracted data . Main results Seven trials involving more than 800 people were included . One trial was concerned with telemedicine in the emergency department , one with video-consultations between primary health care and the hospital out patients department , and the remainder were concerned with the provision of home care or patient self-monitoring of chronic disease . The studies appeared to be well conducted , although patient numbers were small in all but one . Although none of the studies showed any detrimental effects from the interventions , neither did they show unequivocal benefits and the findings did not constitute evidence of the safety of telemedicine . None of the studies included formal economic analysis . All the technological aspects of the interventions appear to have been reliable , and to have been well accepted by patients . Authors ' conclusions Establishing systems for patient care using telecommunications technologies is feasible , but there is little evidence of clinical benefits . The studies provided variable and inconclusive results for other outcomes such as psychological measures , and no analysable data about the cost effectiveness of telemedicine systems . The review demonstrates the need for further research and the fact that it is feasible to carry out r and omised trials of telemedicine applications . Policy makers should be cautious about recommending increased use and investment in unevaluated technologies BACKGROUND We examine the changes in waist circumference ( WC ) and body mass index ( BMI ) in older adults enrolled in a diabetes telemedicine program . The subjects were elderly Medicare beneficiaries participating in the rural ( upstate New York ) cohort of Informatics and Diabetes Education and Telemedicine , a r and omized , controlled trial using telemedicine to improve diabetes care in which the primary outcome was glycemic control . METHODS Ninety-two percent of the subjects had BMI > 25 kg/m(2 ) , and 65.8 % had a BMI > or = 30 kg/m(2 ) . Intervention subjects received home televisits with a dietitian or nurse educator every 4 - 6 weeks .  Blood glucose and blood pressure values  were review ed , and lifestyle and medication changes were recommended . Non-intervention subjects received usual care through their primary care physicians . Change in WC , BMI , diet , and exercise behaviors and knowledge were examined at baseline and 12 and 24 months . A mixed-effects path analysis was performed to examine direct and indirect effects . RESULTS The telemedicine participants increased diet and exercise knowledge over time ( P < 0.001 ) . It was estimated that women in the  telemedicine  group reduced their WC over the 2 years by 1.2 cm , whereas women in the usual care group increased their WC by almost 1 cm ( P = 0.02 ) . Path analysis demonstrated that the intervention , through improved diet and exercise knowledge , was related to the decrease in WC ( P = 0.006 ) and BMI ( P = 0.004 ) . CONCLUSIONS Diabetes case management using telemedicine improved self-reported diet and exercise knowledge , practice s , and behaviors , which in turn was associated with reductions in WC and BMI at 2 years OBJECTIVE To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities , including American Indian/Alaska Natives . SUBJECTS AND METHODS We conducted a multicenter , r and omized controlled trial and assigned diabetic participants to one of two groups : ( 1 ) telemedicine with a nonmydriatic camera or ( 2 ) traditional surveillance with an eye care provider . For those receiving telemedicine , the criteria for requiring follow-up with an eye care provider were ( 1 ) moderate nonproliferative diabetic retinopathy or higher , ( 2 ) presence of clinical ly significant macular edema , or ( 3 ) " unable to grade " result for diabetic retinopathy or macular edema . RESULTS The telemedicine group ( n=296 ) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group ( n=271 ) ( 94 % versus 56 % , p<0.001 ) . The overall prevalence of diabetic retinopathy at baseline was 21.4 % , and macular edema was present in 1.4 % of participants . In the telemedicine group , 20.5 % would require further evaluation with an eye care provider , and 86 % of these referrals were because of poor- quality digital images . CONCLUSIONS Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations , and most did not require follow-up with an eye care provider . Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider . Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations BACKGROUND This study was performed to determine the effectiveness of the Smart Care service on glucose control based on telemedicine and telemonitoring compared with conventional treatment in patients with type 2 diabetes . MATERIAL S AND METHODS This 24-week prospect i ve multi-center r and omized controlled trial involved 338 adult patients with type 2 diabetes at four university hospitals in South Korea . The patients were r and omly assigned to a control group ( group A , n = 113 ) , a telemonitoring group ( group B , n = 113 ) , or a telemedicine group ( group C , n = 112 ) . Patients in the telemonitoring group visited the outpatient clinic regularly , accompanied by an additional telemonitoring service that included remote glucose monitoring with automated patient decision support by text . Remote glucose monitoring was identical in the telemedicine group , but assessment by outpatient visits was replaced by video conferencing with an endocrinologist . RESULTS The adjusted net reductions in HbA1c concentration after 24 weeks were similar in the conventional , telemonitoring , and telemedicine groups ( -0.66 % ± 1.03 % vs. -0.66 % ± 1.09 % vs. -0.81 % ± 1.05 % ; p > 0.05 for each pairwise comparison ) . Fasting glucose concentrations were lower in the telemonitoring and telemedicine groups than in the conventional group . Rates of hypoglycemia were lower in the telemedicine group than in the other two groups , and compliance with medication was better in the telemonitoring and telemedicine than in the conventional group . No serious adverse events were associated with telemedicine . CONCLUSIONS Telehealthcare was as effective as conventional care at improving glycemia in patients with type 2 diabetes without serious adverse effects A r and omized controlled trial was conducted to assess the efficacy of a telemedicine service for the diagnosis of essential hypertension . The telemedicine service consisted of using an automatic home blood pressure monitor connected to an ordinary telephone line for the transmission of the data to a central computer . After use of the home monitor for a week , the results were converted to a report form and faxed to the patient 's physician . The gold st and ard for assessment of true hypertension status was 24 h ambulatory blood pressure monitoring . A total of 74 patients from outpatient clinics were r and omized into either the  telemedicine service  or  usual care . Use of the telemedicine service significantly improved the detection of essential hypertension compared with usual care : in the telemedicine group , 64 % of patients with essential hypertension were diagnosed ; in the usual care group , 26 % of patients with essential hypertension were diagnosed . Furthermore , diagnosis occurred earlier in the telemedicine group than in patients receiving usual care .  Specificity and positive predictive value were similar in the two groups OBJECTIVE The Informatics for Diabetes Education and Telemedicine ( IDEATel ) project r and omized ethnically diverse underserved older adults with diabetes to a telemedicine intervention or usual care .  Intervention participants had lower A1C levels over 5 years . New analyses were performed to help better underst and this difference . RESEARCH DESIGN AND METHODS IDEATel r and omized Medicare beneficiaries with diabetes ( n = 1,665 ) to receive home video visits with a diabetes educator and upload glucose levels every 4–6 weeks or usual care ( 2000–2007 ) . Annual measurements included BMI , A1C ( primary outcome ) , and completion of question naires . Mixed-model analyses were performed using r and om effects to adjust for clustering within primary care physicians . RESULTS At baseline , A1C levels  ( mean ± SD ) were 7.02 ± 1.25 % in non-Hispanic whites ( n = 821 ) , 7.58 ± 1.78 % in non-Hispanic blacks ( n = 248 ) , and 7.79 ± 1.68 % in Hispanics ( n = 585 ) . Over time , lower A1C levels were associated with more glucose uploads ( P = 0.02 ) and female sex ( P = 0.002 ) . Blacks , Hispanics , and insulin-users had higher A1C levels than non-Hispanic whites ( P < 0.0001 ) . BMI was not associated with A1C levels . Blacks and Hispanics had significantly fewer uploads than non-Hispanic whites over time . Hispanics had the highest baseline A1C levels and showed the greatest improvement in the intervention , but , unlike non-Hispanic whites , Hispanics did not achieve A1C levels < 7.0 % at 5 years . CONCLUSIONS Racial/ethnic disparities were observed in this cohort of underserved older adults with diabetes . The IDEATel telemedicine intervention was associated with improvement in glycemic control , particularly in Hispanics , who had the highest baseline A1C levels , suggesting that telemedicine has the potential to help reduce disparities in diabetes management Effective control of diabetes is known to delay or prevent the end-organ complications of this disease . Can telemedicine improve a patient 's ability to self-manage diabetes  ? Twenty-eight patients entered a study comparing home telemedicine consultation with st and ard outpatient care . A nurse case manager contacted the telemedicine group once a week under the direction of a primary care physician , who contacted the telemedicine group once a month . Laboratory studies and total body weight were measured at the beginning and at the end of the 3-month study . The hemoglobin A1c ( HbA1c ) and total body weight improved significantly in the intervention ( telemedicine ) group , as shown by a 16 % reduction in mean HbA1c level ( from 9.5 to 8.2 % ) and a 4 % mean weight reduction ( from 214.3 to 206.7 pounds ) . Based on our experience , we present a functionally based telemedicine classification system to improve the application of electronic medicine in future studies OBJECTIVE to examine the effects of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) telemedicine intervention and pedometer use on physical activity ( PA ) and impairment in older adults with diabetes . DESIGN r and omised clinical trial . Subjects ethnically diverse medically underserved Medicare beneficiaries with diabetes ( n= 1,650 ) . METHODS participants received home videovisits with a diabetes educator every 4 - 6 weeks or usual care . All received a pedometer . Annual measurements included hemoglobin A1c , Comprehensive Assessment and Referral Evaluation Activities of Daily Living , Diabetes Self-Care Activities , Charlson Comorbidity Index , Luben Social Support and pedometer use . Mixed model analyses were performed using r and om effects to adjust for clustering within primary care physicians . RESULTS in the telemedicine group compared with the usual care group , the rate of decline in PA ( P= 0.0128 ) and physical impairment ( PI ) ( P= 0.0370 ) was significantly less over time . Significant mean endpoint differences were observed for PA ( P= 0.003 ) . Pedometer use was significantly associated with PA ( P= 0.0006 ) and PI ( P < 0.0001 ) . Baseline characteristics associated with greater PA included having fewer comorbid conditions ( P= 0.0054 ) , less depression ( P < 0.0001 ) , more social networking ( P < 0.0001 ) , lower BMI ( P < 0.0001 ) , male gender ( P < 0.0001 ) and lower hemoglobin A1c level ( P= 0.0045 ) . Similar predictors were observed for PI , except duration of diabetes also predicted increased impairment ( P < 0.0001 ) . Significant indirect effects were observed through use of the pedometer on reduced decline in PA ( P= 0.0024 , 0.0013 ) and PI ( P= 0.0024 , P < 0.0001 ) . CONCLUSIONS this telemedicine intervention reduced rates of decline in PA and impairment in older adults with diabetes . Pedometers may be a helpful inexpensive adjunct to diabetes initiatives delivered remotely with emerging technologies . Clinical Trials.gov identifier NCT 00271739 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 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 Background — Secondary prevention by risk factor modification improves patient outcomes , yet it is often not achieved in clinical practice . Reasons for failure stem from challenges of prioritizing risk factor reduction and engaging patients in changing their behaviors . We hypothesize that a novel telemedicine intervention with tailored patient education could improve cardiovascular risk factors . Methods — To evaluate this intervention , we propose enrolling 450 patients with a recent myocardial infa rct ion and hypertension into a 3-arm r and omized , controlled trial . The first arm ( n=150 ) will receive home blood pressure ( BP ) monitors plus a nurse-delivered , telephone-based tailored patient education intervention and will be enrolled into HealthVault , a Microsoft electronic health record platform . The second arm ( n=150 ) will also receive BP monitors plus a tailored patient education intervention and be enrolled in HeartVault . However , the patient education intervention will be delivered by a Web-based program and will cover topics identical to those in the nurse-delivered intervention . Both arms will be compared with a control group receiving st and ard care ( n=150 ) . All participants will have an in-person assessment at baseline and at completion of the study , including st and ardized measurements of BP , LDL cholesterol , and glycosylated hemoglobin ( in diabetic subjects ) . The study design will allow assessment of a telephone-based , nurse-administered disease management program versus st and ard care . The main outcome of interest is the reduction in systolic BP in each intervention group compared with the control group at 12 months . Secondary outcomes assessed will include reductions in LDL cholesterol , body weight , and glycosylated hemoglobin , as well as adherence to evidence -based therapies and improvement in health behaviors . Conclusion — If successful in optimizing BP control , managing other coronary heart disease risk factors , and demonstrating a lower cost , the Web-based disease management tool has the potential to enhance coronary artery disease management , quality of care , and ultimately , patient outcomes . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00901277 Introduction . Disease management modules ( DMM ) , including education , tracking , support , and medical care , have improved health for patients with asthma and diabetes . For rural patients , novel ways of delivery are needed to access clinical expertise from urban or academic specialists . Telemedicine ( telephone and televideo ) could be instrumental in this process , though no r and omized , controlled trials have assessed their effectiveness . Methods . Self-report and structured psychiatric interviews  were used to screen potential depressed subjects . Subjects were r and omized to : 1 ) usual care with a DMM using telephone and self-report question naires ; or 2 ) a DMM using telephone , question naires , and monthly televideo psychiatric consultation emphasizing primary care physician  ( PCP ) skill development . Subjects ' depressive symptoms , health status , and satisfaction with care were tabulated at three , six , and 12 months after study entry . Results . There was significant clinical improvement for depression in both groups , with a trend toward significance in the more intensive module . Satisfaction and retention was superior in the more intensive group . There was no overall change in health functioning in either group . Conclusions . Intensive modules using telepsychiatric educational interventions toward PCPs may be superior , but the most critical ingredient may be administrative tracking of patients , prompted intervention by PCPs , and ( when necessary ) new ideas by a specialist Background Patients with depression use more health services than patients without depression . However , when depression symptoms respond to treatment , use of health services declines . Most depression quality improvement studies increase total cost in the short run , which if unevenly distributed across stakeholders , could compromise buy-in and sustainability . The objective of this budget impact analysis was to examine patterns of utilization and cost associated with telemedicine-based collaborative care , an intervention that targets patients treated in small rural primary care clinics . Methods Patients with depression were recruited from VA Community-based Outpatient Clinics , and 395 patients were enrolled and r and omized to telemedicine-based collaborative care or usual care . Dependent variables representing utilization and cost were collected from administrative data . Independent variables representing clinical casemix were collected from self-report at baseline . Results There were no significant group differences in the total number or cost of primary care encounters . However , as intended , patients in the intervention group had significantly greater depression-related primary care encounters ( marginal effect=0.34 , P=0.004 ) and cost ( marginal effect=$61.4 , P=0.013 ) to adjust antidepressant therapy for nonresponders . There were no significant group differences in total mental health encounters or cost . However , as intended , the intervention group had significantly higher depression-related mental health costs ( marginal effect=$107.55 , P=0.03 ) due to referrals of treatment-resistant patients . Unexpectedly , patients in the intervention group had significantly greater specialty physical health encounters ( marginal effect = 0.42 , P=0.001 ) and cost ( marginal effect = $ 490.6 , P=0.003 ) , but not depression-related encounters or cost . Overall , intervention patients had a significantly greater total outpatient cost compared with usual care ( marginal effect=$599.28 , P=0.012 ) . Conclusions Results suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers . Thus , there is no disincentive for mental health providers to offer telemedicine-based collaborative care or for primary care providers to refer patients to telemedicine-based collaborative care In 1987 we established a  realtime echocardiography service  by  telemedicine  from the paediatric cardiology department of a tertiary-care hospital in Halifax . The service was initially provided to a single regional hospital but was exp and ed to six regional hospitals in the three Canadian Maritime Provinces . The system used a dialup broadb and video-transmission service provided by the telephone companies . Records of all transmissions were kept prospect ively and review ed to January 1997 . A total of 324 transmissions were made . During 1995- 96 there were 135 studies : 69 51 were urgent examinations of newborn children and 30 22 were urgent examinations of older children ; repeat studies and postoperative checks usually for pericardial effusion accounted for the other 36 studies 27 . The images were of broadcast quality except in five cases where problems with transmission or poor sedation occurred . A comparison of 26 transmitted studies with repeat , in person ' studies showed no important discrepancies in diagnosis . During the two-year study period , the cost of the network equipment leasing costs and telecommunications costs was C 90,000 . Use of the telemedicine network saved unnecessary patient transfer in 31 cases . The cost of the transportation avoided was C 100,000-C 118,000 . This review confirms our preliminary findings that broadb and echocardiography transmission provides a service comparable in availability and accuracy to that provided in our paediatric cardiology division Recent advances in telecommunications technology are leading to new developments in postacute and rehabilitative care . For about $ 400 per patient and a telephone hookup , physicians and therapists can provide ongoing , direct care to patients at remote clinics or in their homes . The lack of large-scale r and omized controlled trials demonstrating clinical and cost effectiveness in rehabilitation and telemedicine has precluded many payers from reimbursing for services . Guidelines for best use do not currently exist , yet the benefits for payers , providers , and patients could be substantial . Telerehabilitation could become an important modality to MCOs seeking to extend the continuum of postacute care to non clinical setting Recent advances in information and communication technology allow the design and testing of new models of diabetes management , which are able to provide assistance to patients regardless of their distance from the health care providers . The M2DM project , funded by the European Commission , has the specific aim to investigate the potential of novel telemedicine services in diabetes management . A multi-access system based on the integration of Web access , telephone access through interactive voice response systems , and the use of palmtops and smart modems for data downloading has been implemented . The system is based on a technological platform that allows a tight integration between the access modalities through a middle layer called the multi-access organizer . Particular attention has been devoted to the design of the evaluation scheme for the system : A r and omized controlled study has been defined , with clinical , organizational , economic , usability , and users ' satisfaction outcomes . The evaluation of the system started in January 2002 . The system is currently used by 67 patients and seven health care providers in five medical centers across Europe . After 6 months of usage of the system no major technical problems have been encountered , and the majority of patients are using the Web and data downloading modalities with a satisfactory frequency . From a clinical viewpoint , the hemoglobin A1c ( HbA1c ) of both active patients and controls decreased , and the variance of HbA1c in active patients is significantly lower than the control ones . The M2DM system allows for the implementation of an easy-to-use , user-tailored telemedicine system for diabetes management . The first clinical results are encouraging and seem to substantiate the hypothesis of its clinical effectiveness 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 We conducted a r and omized , controlled pilot trial to evaluate the feasibility of providing subspecialty care via telemedicine for patients with Parkinson 's disease residing in a remote community located approximately 130 miles from an academic movement disorders clinic . Study participants were r and omized to receive telemedicine care with a movement disorder specialist at the University of Rochester or to receive their usual care .  Participants in the telemedicine group received three telemedicine visits over six months . Feasibility , as measured by the completion of telemedicine visits , was the primary outcome measure . Secondary measures were quality of life , patient satisfaction , and clinical outcomes .  Ten participants residing in the community were r and omized to receive telemedicine care ( n = 6 ) or their usual care ( n = 4 ) . Four nursing home patients were assigned to telemedicine . Those receiving telemedicine completed 97 % ( 29 of 30 ) of their telemedicine visits as scheduled . At the study 's conclusion , 13 of 14 study participants opted to receive specialty care via telemedicine . Compared with usual care , those r and omized to telemedicine had significant improvements in quality of life ( 3.4 point improvement vs. 10.3 point worsening on the Parkinson 's Disease Question naire 39 ; P = 0.04 ) and motor performance ( 0.3 point improvement vs. 6.5 point worsening on the Unified Parkinson 's Disease Rating Scale , motor subscale ; P = 0.03 ) . Relative to baseline , nursing home patients experienced trends toward improvement in quality of life and patient satisfaction . Providing subspecialty care via telemedicine for individuals with Parkinson 's disease living remotely is feasible 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 BACKGROUND In 2015 , India had an estimated 69.2 million people with diabetes and a national prevalence of 8.7 % . Evidence is mounting for the benefits of telemedicine in diabetes care , but remains limited on mobile-health ( m-Health ) interventions . INTRODUCTION This study assessed the impact of an m-Health diabetes platform on clinical outcomes , patient-reported outcomes , patient and provider satisfaction , and app usage . MATERIAL S AND METHODS This open-label , two-arm parallel study enrolled 91 people at 3 sites in India , aged 18 - 65 , with type 2 diabetes , and an A1c between 7.5 % and 12.5 % ( 58 - 113 mmol/mol ) . Participants were r and omly assigned 1:1 to m-Health or usual care and observed for 6 months . All received free visits , laboratory tests , transportation fees , and strips and lancets . Intervention participants received the m-Health app and a mobile phone data stipend . RESULTS A1c change was previously reported as statistically significant . Significantly more participants in intervention than control had improved medication adherence ( 39.0 % vs. 12.8 % ; p = 0.03 ) and increased frequency of blood glucose ( BG ) self-testing ( 39.0 % vs. 10.3 % ; p = 0.01 ) at 6 months from baseline . No other outcomes were significantly different . Among m-Health users , 75 % of participants actively used the app at week 24 . Participants entered 29,668 medications and 2,575 BG readings , sent 497 messages , and received 890 messages . Most participants ( 80 % ) were satisfied with all aspects of the app and all seven providers rated the software very acceptable . DISCUSSION Participants assigned to m-Health had increased medication adherence and frequency of BG testing compared with usual care participants . CONCLUSIONS This tool could be an effective way to exp and access to quality chronic disease care and improve outcomes BACKGROUND Dementia is a common but frequently undiagnosed problem in aging . Barriers to early diagnosis include a lack of routine screening for dementia and a lack of access to specialty consultative services . We conducted a pilot study to see if telemedicine could provide reliable , accurate geriatric consultative services to evaluate patients for dementia who were residing at remote sites . METHODS This was a prospect i ve cohort study that compared the diagnostic reliability of telemedicine to an in-person examination for dementia . Eligible subjects were residents of a Washington State Veterans ' Home , age 60 years or older , with no prior diagnosis of dementia . Eligible subjects were screened for dementia using the 7-Minute Screen . Veterans who screened positive and consented to participate in the study received an in-person neuropsychiatric evaluation at baseline , and then both telemedicine and in-person examinations for dementia conducted by experienced geriatric psychiatrists . The accuracy of the telemedicine diagnosis was estimated by comparing it to the diagnosis from the clinical examination . Three geriatric psychiatrists who were blinded to the results of the clinical examination conducted the telemedicine and in-person examinations . We also assessed attitudes of the subjects and geriatric psychiatrists towards the telemedicine sessions . RESULTS Eighteen of 85 subjects screened were ' positive ' for dementia on the 7 Minute Screen . Of these , 16 consented to participate in the telemedicine study . Twelve of the 16 subjects were subsequently diagnosed with dementia by the telemedicine examination . The telemedicine diagnoses were in 100 % agreement with the diagnoses from the in-person clinical examinations . Moreover , the subjects reported a high degree of satisfaction with the telemedicine experience and that they would like to have further care through telemedicine in the future . The geriatric psychiatrists reported technical difficulties with the audio-visual quality of telemedicine in the initial phases of the project that resolved as familiarity with the telemedicine equipment increased . None of these problems had an adverse impact on the diagnostic accuracy of telemedicine . CONCLUSIONS We found that telemedicine was as accurate as an in-person clinical examination in establishing the diagnosis of dementia . In addition , subjects reported a high degree of satisfaction with telemedicine and a willingness to participate in telemedicine clinical care in the future . Given the large increase in the aging population and the shortage of geriatric psychiatrists nationally , it appears that telemedicine may be a promising means to exp and the availability of geriatric psychiatric consultation to remote areas UNLABELLED BACKGROUND / AIM . In the last twenty years significant advances have been made in the fields of information and telecommunication technology in health care applications , with a positive impact on the health care practice . The need for remote diagnosis and planning of interventions is of special importance in military health care , and health management of immobile persons , and those with special needs . In cases such as these , availability of specialist health care is mainly limited by geographic and financial factors . The aim of this study was to investigate practical usability of telemedicine approaches in everyday management of oral surgery patients in terms of reliability of established diagnosis and indications for oral surgery treatment of the third molars . METHODS Our experimental r and omized study enrolled 432 r and omly selected patients of both genders , aged 20 to 87 years , undergoing panoramic radiography for some reason in the Centre for Dental Radiography in Bel grade . In addition to radiography , photographs of the face and mouth cavity were taken . These images were uploaded to the web server specially dedicated to the study purpose s , and then transmitted to teledentists , i.e. oral surgeons , who made remote diagnoses . Diagnostic agreement was determined by way of the Cohen 's kappa coefficient , and diagnostic sensitivity ( SE ) , specificity ( SP ) , and effectiveness ( EFF ) were also established . Statistical significance was determined and comparisons performed by using the z-test , and testing of non-parametric characteristics by using the McNemar 's chi2 test for p = 0.05 significance cut-off . RESULTS The results obtained by analyzed images and diagnostic assessment of the clinical diagnosis ( kappa = 0.99 , SE = 99 % , SP = 99 % , EFF = 99 % , for 95 % CI ) indicate an almost complete diagnostic agreement . The differences in diagnosis were not statistically significant . CONCLUSION Diagnostic assessment of the clinical diagnosis of impacted or semi-impacted third molars assisted by the telemedicine approach was equal to the real-time assessment of clinical diagnosis . Telemedicine , and teledentistry as its branch , represent the present and even more the future of this field of health care BACKGROUND Over the past several years , there has been a resurgence of interest in telemedicine . Despite this renewed interest , some health care providers remain skeptical regarding the effectiveness of telemedicine for the delivery of health care . OBJECTIVE The objective of this prospect i ve , crossover study was to determine if there was any difference between care delivered using video conferencing-based telemedicine technology and that given by a traditional face-to-face encounter in a pulmonary medicine clinic . METHODS Two pulmonologists sequentially examined 40 individuals via video conferencing-based telemedicine technology and by the traditional face-to-face method .  Two additional pulmonologists , in a blinded fashion , compared the results for consistency in the history , examination with focus on auscultation of the lungs , diagnostic impression , and evaluation and treatment plans . RESULTS Evaluation of patients by telemedicine was as effective as the traditional mode . The telemedicine physician and the physician examining the patient in the traditional manner were able to elicit the same key complaints and hear the same adventitious sounds on auscultation of the lungs . CONCLUSION Telemedicine can enable the provision of high- quality care in a pulmonary clinic setting 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 In remote areas , telemedicine services can improve the quality of access to specialist medical care and dermatology is well suited to the use of this technology . There is no published work on teledermatology services in Australia . Our purpose was to investigate the reliability of dermatological diagnoses obtained using a store and forward telemedicine system , which is being developed to offer specialist consultative services to patients in remote areas of Western Australia . We report on a small prospect i ve non‐r and omized pilot study conducted at Royal Perth Hospital , Western Australia which compared diagnoses reached following telemedicine consultations with diagnoses reached following traditional face‐to‐face consultations . In 25 out of 30 consultations , identical diagnoses were reached . In the remaining five cases , the preferred diagnosis and first differential diagnosis were reversed in order of preference . We feel this system is sufficiently promising to trial more extensively in the field OBJECTIVE The purpose of the study was to investigate the effect of comorbid depression on glycemic control and on response to a telemedicine case management intervention for elderly , ethnically diverse diabetic patients . RESEARCH DESIGN AND METHODS Medicare beneficiaries in underserved areas were participants ( n = 1,665 ) in the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project and r and omized to a telemedicine case management intervention or usual care .  The data analyzed include baseline demographics ( age , sex , race/ethnicity , marital status , insulin use , years of education , years of diabetes , and pack-years smoked ) and measures of glycemic control ( HbA(1c ) [ A1C ] ) , comorbidity , diabetes symptom severity , functional disability and depression , and 1-year ( n = 1,578 ) A1C . The association between depression and glycemic control was analyzed cross-sectionally and prospect ively . RESULTS At baseline , there was a significant correlation between depression and A1C and a trend for depression to predict A1C when other factors were controlled . However , in prospect i ve analyses , depression did not predict change in A1C , either in the control or intervention group . CONCLUSIONS In this large sample of elderly diabetic patients , a weak relationship between depression and A1C was found , but depression did not prospect ively predict change in glycemic control . Thus , there is no evidence that depression should be used to exclude patients from interventions . Also , we should evaluate the impact of depression on outcomes other than glycemic control BACKGROUND Tele-echocardiography has the potential to bring real-time diagnoses to neonatal facilities without in-house pediatric cardiologists . Many neonates in rural areas , smaller cities , and community hospitals do not have immediate access to pediatric sonographers or echocardiogram interpretation by pediatric cardiologists . This can result in suboptimal echocardiogram quality , delay in initiation of medical intervention , unnecessary patient transport , and increased medical expenditures . Telemedicine has been used with increased frequency to improve efficiency of pediatric cardiology care in hospitals that are not served by pediatric cardiologists . Initial reports suggest that telecardiology is accurate , improves patient care , is cost-effective , enhances echocardiogram quality , and prevents unnecessary transports of neonates in locations that are not served by pediatric cardiologists . OBJECTIVE We report the largest series to evaluate the impact of telemedicine on delivery of pediatric cardiac care in community hospitals . We hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from community hospitals is accurate , improves patient care , enhances sonographer proficiency , allows for more efficient physician time management , increases patient referrals , and does not result in increased utilization of echocardiography . METHODS Using desktop videoconferencing computers , pediatric cardiologists guided and interpreted pediatric echocardiograms from 2 community hospital nurseries 15 miles from a tertiary care center . Studies were transmitted in real-time using the H.320 videoconferencing protocol over 3 integrated services digital network lines ( 384 kilobits per second ) . This result ed in a frame rate of 23 to 30 frames per second . Sonographers who primarily scanned adult patients but had received additional training in echocardiography of infants performed the echocardiograms . Additional views were suggested as deemed necessary by the interpreting physician , and interpretations were made during the videoconference . The results of the echocardiogram and recommendations for patient care were communicated to the referring physician over the telemedicine system . Analyses of accuracy , patient treatment , echocardiogram quality , time to diagnosis , pediatric cardiologist practice time management , patient referral patterns , and echocardiography utilization were conducted prospect ively . RESULTS A total of 500 studies in 364 patients were transmitted during a 30-month period . The most common indication for echocardiography was to rule out congenital heart disease ( 208 of 500 studies ) . Signs and symptoms that prompted this concern included cyanosis , murmur , tachypnea , genetic syndrome , arrhythmia , abnormal fetal echocardiogram , and maternal diabetes . Other indications included suspected  patent ductus arteriosus ( PDA ; 182 of 500 studies ) , intracardiac clot or catheter position , persistent pulmonary hypertension , and hemodynamic instability . Cardiac diagnoses included complex congenital heart disease ( n = 16 ) , noncritical heart disease ( n = 107 ) , and PDA ( n = 86 ) . Additional diagnoses included persistent pulmonary hypertension ( n = 12 ) , septal hypertrophy ( n = 18 ) , right atrial mass/clot/vegetation ( n = 11 ) , and decreased cardiac function ( n = 6 ) . An umbilical venous catheter was visualized in the left atrium in 9 % ( 45 of 500 ) of all studies . No significant abnormalities were found in 244 studies . Major diagnoses were confirmed by subsequent review of videotape in all studies . Comparison of final videotape interpretation to initial telemedicine diagnosis result ed in 1 minor diagnostic change ( membranous versus inlet ventricular septal defect ) . Echocardiograms were performed in subsequent visits in 264 patients . The diagnosis was altered in 3 patients . Telemedicine had an immediate impact on patient care in 151 transmissions . The most common interventions were indomethacin treatment for PDA ( n = 76 ) , retraction of umbilical venous catheters from the left atrium ( n = 45 ) , inotropic or anticongestive therapy ( n = 19 ) , anticoagulation ( n = 8) , and prostagl and in infusion ( n = 8) . Nineteen patients were transported to our hospital because of the telemedicine diagnosis . Inpatient or outpatient cardiology follow-up was recommended in an additional 131 studies and did not result in any change in the initial management . The most common diagnoses in these patients were ventricular septal defect ( n = 56 ) , atrial septal defect ( n = 21 ) , septal hypertrophy ( n = 9 ) , intracardiac thrombosis ( n = 8) , and pulmonary valve stenosis ( n = 4 ) . We speculate that the immediate availability of an echocardiographic diagnosis likely prevented unnecessary transport in 14 cases . Recommendations for additional views or adjustment of echocardiography machine setting s were made in 95 % of transmissions . Real-time guidance was especially helpful in suprasternal notch and subcostal sagittal imaging . Depth , color Doppler sector size , and color Doppler scale were frequently adjusted from routine adult setting s during the teleconference . The average time from request for echocardiogram to completion of the videoconference was 28 + /- 14 minutes . This was significantly shorter than the waiting time ( 12 + /- 16 hours ) for the videotape to be delivered by courier . Telemedicine eliminated the need for consultation in 194 cases and allowed the cardiologist to delay the visit until the end of the day in an additional 26 cases . This result ed in average time savings of 4.2 person-hours/wk based on travel and consultation time . Utilization of echocardiography  was similar before ( 35 of 1000 births ) and after ( 33 of 1000 to 43 of 1000 ) telemedicine installation . The percentage of neonatal echocardiograms that were interpreted by our practice increased from 63 % to 81 % at 1 hospital and from 0 % to 100 % at the other hospital . CONCLUSION Real-time transmission of neonatal echocardiograms from community hospitals over 3 integrated services digital network lines is accurate and has the potential to improve patient care , enhance echocardiogram quality , aid sonographer education , and have a positive impact on referral patterns and time management without increasing the utilization of echocardiography BACKGROUND Current diabetes management guidelines offer blueprints for providers , yet type 2 diabetes control is often poor in disadvantaged population s. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems .  Group visits offer promise for delivering care to diabetic patients , as visits are lengthier and can be more frequent , more organized , and more educational . OBJECTIVE To evaluate the effect of group visits on clinical outcomes , concordance with 10 American Diabetes Association ( ADA ) guidelines [ American Diabetes Association , Diabetes Care , 28:S4–36 , 2004 ] and 3 United States Preventive Services Task Force ( USPSTF ) cancer screens [ U.S. Preventive Services Task Force , http://www.ahrq.gov/clinic/uspstf/re source .htm , 2003 ] . RESEARCH DESIGN AND METHODS A 12-month r and omized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient – physician dyad . Clinical outcomes ( HbA1c , blood pressure [ BP ] , lipid profiles ) were assessed at 6 and 12 months and quality of care measures ( adherence to 10 ADA guidelines and 3 USPSTF cancer screens ) at 12 months . RESULTS At both measurement points , HbA1c , BP , and lipid levels did not differ significantly for patients attending group visits versus those in usual care . At 12 months , however , patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators ( p < .0001 ) and higher screening rates for cancers of the breast ( 80 vs. 68 % , p = .006 ) and cervix ( 80 vs 68 % , p = .019 ) . CONCLUSIONS Group visits can improve the quality of care for diabetic patients , but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes 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 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 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 BACKGROUND Only 31 % of Americans with hypertension have their blood pressure ( BP ) under effective control . We describe a study that tests 3 different interventions in a r and omized controlled trial using home BP telemedicine monitoring . METHODS A sample of hypertensive patients with poor BP control at baseline ( N = 600 ) are r and omized to 1 of 4 arms : ( 1 ) control group -- a group of hypertensive patients who receive usual care ; ( 2 ) nurse-administered tailored behavioral intervention ; ( 3 ) nurse-administered medication management according to a hypertension decision support system ; ( 4 ) combination of the 2 interventions . The interventions are triggered based on home BP values transmitted via telemonitoring devices over st and ard telephone lines . The tailored behavioral intervention involves promoting adherence with medication and health behaviors . Patients r and omized to the medication management or the combined arm have their hypertension regimen changed by the study team using a vali date d hypertension decision support system based on evidence -based hypertension treatment guidelines and individualized to patients ' comorbid illnesses . The primary outcome is BP control : < or = 140/90 mm Hg ( nondiabetic ) and < or = 130/80 mm Hg ( diabetics ) measured at 6-month intervals over 18 months ( 4 total measurements ) . CONCLUSIONS Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care , testing novel interventions in patients ' homes may improve access , quality , and outcomes Background Evidence -based practice s design ed for large urban clinics are not necessarily portable into smaller isolated clinics . Implementing practice -based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists . Objective The purpose of the Telemedicine Enhanced Antidepressant Management ( TEAM ) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists . Design Matched sites were r and omized to the intervention or usual care . Participants Small VA Community-based outpatient clinics with no on-site psychiatrists , but access to telepsychiatrists .  In 2003–2004 , 395 primary care patients with PHQ9 depression severity scores ≥12 were enrolled , and followed for 12 months . Patients with serious mental illness and current substance dependence were excluded .  Measures Medication adherence , treatment response , remission , health status , health-related quality of life , and treatment satisfaction . Results The sample comprised mostly elderly , white , males with substantial physical and behavioral health comorbidity . At baseline , subjects had moderate depression severity (  Hopkins Symptom Checklist , SCL-20 = 1.8 ) , 3.7 prior depression episodes , and 67 % had received prior depression treatment . Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 ( odds ratio [ OR ] = 2.1 , p = .04 ) and 12 months ( OR = 2.7 , p = .01 ) . Intervention patients were more likely to respond by 6 months ( OR = 2.0 , p = .02 ) , and remit by 12 months ( OR = 2.4 , p = .02 ) . Intervention patients reported larger gains in mental health status and health-related quality of life , and reported higher satisfaction . Conclusions Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies Background Addressing the increasing prevalence , and associated disease burden , of diabetes is a priority of health services internationally . Interventions to support patients to effectively self-manage their condition have the potential to reduce the risk of costly and debilitating complications . The utilisation of mobile phones to deliver self-management support allows for patient-centred care at the frequency and intensity that patients desire from outside the clinic environment . Self-Management Support for Blood Glucose ( SMS4BG ) is a novel text message-based intervention for supporting people with diabetes to improve self-management behaviours and achieve better glycaemic control and is tailored to individual patient preferences , demographics , clinical characteristics , and culture . This study aims to assess whether SMS4BG can improve glycaemic control in adults with poorly controlled diabetes . This paper outlines the rationale and methods of the trial . Methods / design A two-arm , parallel , r and omised controlled trial will be conducted across New Zeal and health districts . One thous and participants will be r and omised at a 1:1 ratio to receive SMS4BG , a theoretically based and individually tailored automated text message-based diabetes self-management support programme ( intervention ) in addition to usual care , or usual care alone ( control ) . The primary outcome is change in glycaemic control ( HbA1c ) at 9 months . Secondary outcomes include glycaemic control at 3 and 6 months , self-efficacy , self-care behaviours , diabetes distress , health-related quality of life , perceived social support , and illness perceptions . Cost information and healthcare utilisation will also be collected as well as intervention satisfaction and interaction . Discussion This study will provide information on the effectiveness of a text message-based self-management support tool for people with diabetes . If found to be effective it has the potential to provide individualised support to people with diabetes across New Zeal and ( and internationally ) , thus extending care outside the clinic environment . Trial registration Australian New Zeal and Clinical Trials Registry : ACTRN12614001232628 Background : Increasingly various technologies are being tested to deliver behavioral health care . Delivering services via videoconferencing shows promise . Given that the patient-provider relationship is a strong predictor of patient adherence to medical regimens , addressing relationship quality when services are not delivered face-to-face is critical . To that end , we compared the therapeutic alliance when behavioral health care was delivered to youth with poorly controlled type 1 diabetes mellitus ( T1DM ) and their caregivers in-clinic with the same services delivered via  Internet-based videoconferencing  ( i.e. , Skype ™ ) . Methods : Seventy-one adolescents with poorly controlled T1DM ( hemoglobin A1c ≤9 % ) and one of their caregivers received up to 10 sessions of a family-based behavioral health intervention previously shown to improve adherence to diabetes regimens and family functioning ; 32 were r and omized to the Skype condition . Youth and caregivers completed the working alliance inventory ( WAI ) , a 36-item measure of therapeutic alliance , at the end of treatment . Additionally , the number of behavioral health sessions completed was tracked . Results : No significant differences in WAI scores were found for those receiving behavioral health care via Skype versus in-clinic . Youth WAI goal and total scores were significantly associated with the number of sessions completed for those in the clinic group . Conclusion : Behavioral health can be delivered to youth with T1DM via Internet-based videoconferencing without significantly impacting the therapeutic relationship . Thus , for those adolescents with T1DM who require specialized behavioral health care that targets T1DM management , Internet-based teleconferencing represents a viable alternative to clinic-based care BACKGROUND Telemedicine is one approach to managing patients with chronic illness . Several telephone-based monitoring studies of diabetes patients have shown improved glycosylated hemoglobin ( HbA1c ) , blood pressure ( BP ) , and low-density lipoprotein ( LDL ) levels . The purpose of this study was to evaluate an investigational in-home telemetry device for improving glucose and BP control over 6 months for patients with type 2 diabetes . The device was used to transmit weekly blood glucose , weight , and BP readings to a diabetes care manager . SUBJECTS AND METHODS We conducted a two-arm , parallel-comparison , single-blind , r and omized controlled trial among Kaiser Permanente Northern California members 18 - 75 years old with type 2 diabetes mellitus and entry HbA1c levels between 7.5 % and 10.0 % . Participants were r and omly assigned to either the telemonitoring arm or the usual care arm . RESULTS We observed very small , nonsignificant changes in fructosamine ( telemonitoring , -54.9 μmol ; usual care , -59.4 μmol ) and systolic BP ( telemonitoring , -6.3 mm Hg ; usual care , -3.2 mm Hg ) from baseline to 6 weeks in both groups . At 6 months , we observed no significant intergroup differences in change from baseline for HbA1c , fructosamine , or self-efficacy . However , LDL cholesterol in the telemonitoring arm decreased more than in the usual care arm ( -17.1 mg/dL versus -5.4 mg/dL ; P=0.045 ) . CONCLUSIONS Although HbA1c improved significantly over 6 months in both groups , the difference in improvement between the groups was not significant . This lack of significance may be due to the relatively healthy status of the volunteers in our study and to the high level of care provided by the care managers in the Santa Rosa , CA clinic . Further study in subgroups of less healthy diabetes patients is recommended Good diabetic control requires that treatment be continuously adapted to the patient behavior . We investigated whether the use of telemedicine could present an advantage to the management of the diabetic woman during pregnancy . A system completely automatic ( DIANET system ) was used . Twenty IDDM women participated in the study : 10 treated by telemedicine and 10 by conventional system , at times " entry " ( 9.5 weeks ) , " basal " ( 9.5 - 16.8 weeks ) , " 1st month " of investigation , and " end " ( near delivery ) . All women used intensified protocol s of insulin administration . The treatment with DIANET vs conventional showed a better metabolic control as estimated by profile of blood glucose absolute values ( at time " end " : values significantly lower before breakfast : 87 + /- 6 vs 104 + /- 4 mg , lunch : 85 + /- 5 vs 104 + /- 4 mg , and after dinner : 102 + /- 5 vs 124 + /- 6 mg ) . These results were associated with higher insulin doses in the DIANET vs conventional treatment , and a significant reduction of hypoglycemic reaction in both group . Our results suggest that telemedicine-DIANET is a practical way of providing specialist care in the pregnancy area Background Chinese American patients with Major Depressive Disorder ( MDD ) tend to underutilize mental health services and are more likely to seek help in primary care setting s than from mental health specialists . Our team has reported that Culturally Sensitive Collaborative Treatment ( CSCT ) is effective in improving recognition and treatment engagement of depressed Chinese Americans in primary care . The current study builds on this prior research by incorporating telemedicine technology into the CSCT model . Methods / Design We propose a r and omized controlled trial to evaluate the acceptability and effectiveness of a  telepsychiatry-based culturally sensitive collaborative treatment ( T-CSCT ) intervention targeted toward Chinese Americans . Patients meeting the study 's eligibility criteria will receive either treatment as usual or the intervention under investigation . The six-month intervention involves : 1 ) an initial psychiatric interview using a culturally sensitive protocol via videoconference ; 2 ) eight scheduled phone visits with a care manager assigned to the patient , who will monitor the patient 's progress , as well as medication side effects and dosage if applicable ; and 3 ) collaboration between the patient 's PCP , psychiatrist , and care manager . Outcome measures include depressive symptom severity as well as patient and PCP satisfaction with the telepsychiatry-based care management service .  Discussion The study investigates the T-CSCT model , which we believe will increase the feasibility and practicality of the CSCT model by adopting telemedicine technology . We anticipate that this model will exp and access to culturally competent psychiatrists fluent in patients ' native language s to improve treatment of depressed minority patients in primary care setting s . Trial Registration This project tested the importance of enhanced information transfer of home monitoring results to health care providers . The study tested whether computer-assisted communication of medical information between the chronic care patient and the physician can result in health care benefit . The information tools were constructed/adapted as a test of this hypothesis for diabetes mellitus . Patients connected a glucometer to an intelligent modem weekly for six to nine months . Graphical and mathematical tools extracted and emphasized the information content of the home monitoring data arriving at the central site . Data smoothing , trend analysis , and calculation of quality control statistics were incorporated into a graphical time series oriented report that was used by the health care provider during an outpatient visit . The integrated home monitoring system was tested on 20 patients with diabetes in a double cross-over design over a 15-month period . A significant improvement in serum glucose control as measured by glycated hemoglobin was shown in the study group , but not in the control group 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 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 Control of serum glucose levels is essential for the reduction of complications of diabetes . Telemedicine is one strategy through which serum glucose control can be improved . METHODS A total of 35 adult , insulin-treated patients with diabetes ( type 1 and type 2 ) were enrolled in the present study ( 63.0 + /- 10 years of age , 63 % female ) and r and omized to telemedicine monitoring ( including cordless , remote glucose monitor , and transmitter , n =  17  ) , or conventional follow-up ( n = 18 ) . Metabolic parameters were evaluated , and a quality of life question naire was administered both pre- and post-treatment . RESULTS Groups were similar at baseline in terms of demographic , quality of life , and metabolic parameters . Significant differences in post-treatment metabolic parameters were not observed , although serum glucose was marginally elevated in the control group compared to the telemedicine group ( 214 + /- 65 mg/dL vs. 171 + /- 77 mg/dL , P = 0.09 ) . On the other h and , being clinical ly symptom-free ( 71 % vs. 11 % , P = 0.003 ) , having no hypoglycemic events ( 82 % vs. 17 % , P = 0.0001 ) , and having no hyperglycemic events ( 65 % vs. 17 % , P = 0.004 ) were all significantly more frequently reported in the telemedicine group compared to the control group . Compared to the control group , the telemedicine group reported experiencing significantly less anxiety , treatment difficulty , depression , disease-associated life complications , and feelings of impotence or ineptitude and significantly greater improvement in personal control over glucose , weight , and overall diabetes . CONCLUSIONS Though post-treatment metabolic differences were not observed between treatment groups , the telemedicine group reported significantly greater post-treatment experiences of improved quality of life and sense of control over the disease . Thus patient satisfaction can be enhanced through the use of telemedicine OBJECTIVE Echocardiography is an important tool in the diagnosis and management of critically ill neonates . The authors hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from underserved areas would improve management , prevent unnecessary transports , enhance sonographer proficiency , and result in monetary savings . MATERIAL S AND METHODS Using personal computers capable of real-time transmission of echocardiograms over three integrated services digital network ( ISDN ) telephone lines , pediatric cardiologists interpreted echocardiograms , suggested views to sonographers , and made recommendations to neonatologists 200 miles away . Analyses of accuracy , management , echocardiogram quality , time , and costs were carried out prospect ively . RESULTS Sixty studies were transmitted over 7 months . Indications for echocardiography  were suspected congenital heart disease ( n = 29 ) , suspected patent ductus arteriosus ( PDA ) ( n = 27 ) , and hemodynamic instability ( n = 4 ) . Diagnoses were critical congenital heart disease ( n = 4 ) , noncritical heart disease ( n = 8) , PDA ( n = 21 ) , ventricular dysfunction ( n = 5 ) , persistent pulmonary hypertension ( n = 3 ) , and normal ( n = 19 ) . Videotape review confirmed all telemedicine interpretations . The echocardiogram led to immediate change in management in 25 cases ( 42 % ) , and echocardiogram quality was improved in 53 studies ( 88 % ) . Time from request to completion of echocardiography was 43+/-30 min . Monetary savings from five avoided transports exceeded all expenses . CONCLUSION Live transmission of neonatal echocardiograms over three ISDN lines is diagnostic , improves patient care and echocardiography quality , and is cost effective INTRODUCTION The implementation of telemedicine often introduces major organizational changes in the affected healthcare sector . The objective of this study was to examine the organizational changes through the perception of the healthcare professionals regarding the implementation of a telemedical intervention . We posed the following research question : What are the key organizational factors in the implementation of telemedicine in wound care ? METHODS In connection with a r and omized controlled trial of telemedical intervention for patients with diabetic foot ulcers in the region of Southern Denmark , we conducted an organizational analysis . The trial was design ed as a multidisciplinary assessment of outcomes using the Model of ASsessment of Telemedicine ( MAST ) . We conducted eight semi-structured interviews including individual interviews with leaders , and an IT specialist as well as focus group interviews with the clinical staff . A qualitative data analysis of the interviews was performed in order to analyze the healthcare professionals and leaders perception of the organizational changes caused by the implementation of the intervention . RESULTS The telemedical setup enhanced confidence among collaborators and improved the wound care skills of the visiting nurses from the municipality . The effect was related to the direct communication between visiting nurses and specialist doctors . Focus on the training of the visiting nurses was highlighted as a key factor in the success to securing implementation . Concerns regarding lack of multidisciplinary wound care teams , patient responsibility and lack of patient interaction with the physician were raised . Furthermore , the need for clinical guidelines in future implementation was underlined . CONCLUSIONS Several influential factors were demonstrated in the analysis including visiting nurses wound care training , focus on management , economy , periods with absence from work and clinical care . However , the technology used here could provide an additional option to offer patients after an individual assessment of their health condition Background and Purpose — In acute stroke care , rapid but careful evaluation of patients is m and atory but requires an experienced stroke neurologist . Telemedicine offers the possibility of bringing such expertise quickly to more patients . This study tested for the first time whether remote video examination is feasible and reliable when applied in emergency stroke care using the National Institutes of Health Stroke Scale ( NIHSS ) . Methods — We used a novel multimedia telesupport system for transfer of real-time video sequences and audio data . The remote examiner could direct the set-top camera and zoom from distant overviews to close-ups from the personal computer in his office . Acute stroke patients admitted to our stroke unit were examined on admission in the emergency room . St and ardized examination was performed by use of the NIHSS ( German version ) via telemedicine and compared with bedside application . Results — In this pilot study , 41 patients were examined .  Total examination time was 11.4 minutes on average ( range , 8 to 18 minutes ) . None of the examinations had to be stopped or interrupted for technical reasons , although minor problems ( brightness , audio quality ) with influence on the examination process occurred in 2 sessions . Unweighted & kgr ; coefficients ranged from 0.44 to 0.89 ; weighted & kgr ; coefficients , from 0.85 to 0.99 . Conclusions — Remote examination of acute stroke patients  with a computer-based telesupport system is feasible and reliable when applied in the emergency room ; interrater agreement was good to excellent in all items . For more widespread use , some problems that emerge from details like brightness , optimal camera position , and audio quality should be solved Adults with type 2 diabetes mellitus often struggle with their antihyperglycemic medication regimens . To improve medication management , providers must ensure that their patients underst and potential benefits , harms , and burdens of available options and elicit patients ' preferences and barriers to taking medications . Patients who are actively involved in treatment decision making tend to be more satisfied with their health care , be more adherent to treatment , and have improved clinical outcomes ( 13 ) . Such discussion s , however , can be too time-consuming for clinic visits . For inner-city low-income African American and Latino adults , low health literacy and limited English proficiency are often additional barriers ( 4 ) that reduce the exchange of information and decrease patient participation during primary care visits ( 58 ) . This contributes to less optimal treatment decisions and lower patient satisfaction , leading to poor medication adherence and outcomes ( 3 , 911 ) . There is therefore an urgent need for cost-effective approaches to enable low-re source health systems to help these high-risk population s gain information and decision support so that they can more actively participate in and improve satisfaction with their treatment decision making . Since 2000 , the REACH ( Racial and Ethnic Approaches to Community Health 2010 ) Detroit Partnership , a coalition of community , health system , and academic partners , has used community-based participatory research principles to guide development , implementation , and evaluation of interventions to meet this need among African American and Latino adults with diabetes in Detroit , Michigan . These interventions have built on evidence that community health workers ( CHWs ) are effective in improving diabetes outcomes , particularly among racial and ethnic minority communities ( 12 ) . CHW interventions train community members to work as bridges between their ethnic , cultural , or geographic communities and health care providers ( 13 ) . Two cohorts of participants in our previous CHW-led diabetes self-management support interventions  improved hemoglobin A1c ( HbA1c ) levels and diabetes distress compared with usual care ( 14 , 15 ) . An important next step in increasing the potential effect of CHWs and other lay health care workers is to develop and test effective tools they can use to better present evidence -based information to patients and to help patients make better self-management decisions ( 16 ) . Little is known about the effectiveness of different approaches for nontraditional care providers , such as CHWs , to deliver health information to ethnic minority and low-literacy population s ( 17 ) . By definition , CHWs and other lay workers do not have medical expertise and thus rely on effectively sharing printed educational and support material s with patients as part of their coaching and counseling efforts . Decision aids can increase satisfaction with treatment decisions and result in treatments that better reflect patients ' preferences ( 18 , 19 ) . There is also evidence that tailored health messages are more effective than generic group messages ( 20 , 21 ) , including for patients with diabetes ( 22 , 23 ) . Tailoring individualizes information and behavior change strategies to reach each person based on characteristics unique to that person derived from an individual assessment and related to the outcome of interest ( 24 ) . Software programs that are being developed to automatically embed tailored content into portable e-health Web applications show promise in improving health behaviors and outcomes ( 25 , 26 ) . To date , however , most e-health applications have been design ed for use by patients with relatively high literacy and the skills to navigate them ( 27 ) . Do more sophisticated , tailored , interactive e-health tools increase the effectiveness of CHW outreach with underserved patients compared with reliance on printed educational material s alone ? We addressed this question by developing and evaluating a personally tailored , interactive diabetes medication decision aid ( iDecide [ in English ] or iDecido [ in Spanish ] ) design ed for CHWs to deliver on tablet computers with 3 G wireless access to African American and Latino adults with diabetes and low health literacy . We then evaluated the effectiveness of iDecide in improving key diabetes outcomes compared with CHW delivery of the same evidence -based information , without tailoring , through print consumer booklets developed by the Agency for Healthcare Research and Quality ( AHRQ ) . Methods Setting This study was developed and implemented by using community-based participatory research principles ( 28 ) in partnership with the REACH Detroit Partnership and the Community Health and Social Services Center ( CHASS ) , a federally qualified health center in Southwest Detroit serving more than 13000 patients with 47099 visits in 2012 ( 29 ) . The University of Michigan and CHASS institutional review boards approved the study . Content of AHRQ Consumer Guides The AHRQ guides ( Pills for Type 2 Diabetes and Premixed Insulin for Type 2 Diabetes ) ( 30 , 31 ) provide information on diabetes and summarize the effectiveness of currently available medication classes  ( oral and insulin ) on HbA1c . They also provide information on administration methods , costs , medication adverse effects , risks for diabetes complications , suggested questions to discuss with health care providers , and prompts to make notes of any questions for the doctor . The booklets include pictures of patients and tables and graphs summarizing information . Content of iDecide The development process and content of the iDecide program have been described in detail elsewhere ( 32 ) . Briefly , we used community-based participatory research and user-centered design ( 33 , 34 ) principles to iteratively develop and refine the iDecide tool . iDecide is available in English and Spanish , can be delivered via tablet computers , and enables navigation by the CHW and participant to selectively explore issues most important to the participant . The iDecide program is organized into 4 main sections and includes the same content as the AHRQ consumer guides . However , its information is presented in a more graphical style suited to patients with low literacy . Table 1 summarizes key differences between the presentation of information in iDecide and the printed material s. The first section illustrates , through animations , how diabetes affects the way glucose is processed in the body and how different medication classes , foods , and physical activity affect blood glucose . The second section includes pictographs showing participants ' own risk for diabetes complications ( tailored according to their baseline HbA1c ) and enabling participants to explore how their risk for different complications changes with their HbA1c levels . In the third section , participants review their current diabetes medications and barriers to taking the medications they had reported on the baseline survey . This section includes an interactive issue card approach to help elicit patient preferences and priorities about different medication characteristics ( for example , cost , adverse effects , effects on weight , and dosing schedules ) ( 22 , 35 ) . The fourth section prompts participants to set goals and develop specific action plans to address identified barriers or other concerns and identify specific questions and concerns to discuss with their doctor about their medications or making lifestyle changes . Personal information from the baseline assessment is interwoven throughout the program ( high-depth tailoring within sentences ) . Motivational interviewingbased , tailored discussion prompts encourage autonomy-supportive CHWpatient interactions at key points with open-ended questions and values exploration to help participants discover their motivation , overcome barriers to change , and develop an action plan ( 36 ) . Table 1 . Comparison of Content and Mode of Delivery Between the iDecide Study Group and the Printed Material s Group Recruitment and R and omization From September 2011 to August 2012 , potentially eligible participants were identified from a computer-generated list of CHASS patients with physician-diagnosed type 2 diabetes . Inclusion criteria required a HbA1c value greater than 7.5 % in the previous 6 months or expressed concerns about current diabetes medications during the screening assessment . Exclusion criteria were age younger than 21 years , terminal health conditions , self-reported alcohol or drug abuse , and conditions ( such as blindness and dementia ) that would impede meaningful participation . Pregnant women and individuals who reported that they could not be contacted by telephone were also excluded . Introductory letters were sent in timed batches . Research staff then telephoned patients and screened them for eligibility . Interested eligible patients met with research staff , who facilitated completion of written informed consent , administered baseline surveys in English or Spanish , and measured HbA1c and blood pressure . Participants received a stipend of $ 20 after each assessment . Within 1 to 14 days , participants were scheduled for a visit with a CHW ( at home , the clinic , or another agreed-upon place ) . At the beginning of the CHW visits , participants were registered into the iDecide program and r and omly assigned by the computer program , through use of a r and om-sequence algorithm , into 1 of 2 study groups . There were no differences between the steps to participate in either study group . Patients , research staff , and CHWs were blinded to r and omization results through completion of all baseline measures up to the start of the intervention . Data assessors remained blinded to group assignment throughout the study . CHW Intervention for Both Study Groups All participants received an initial one-on-one , face-to-face session with a CHW and a copy of the printed material s to take home . The iDecide sessions lasted approximately 2 hours , and the sessions using printed material s lasted Background Antiretroviral therapy has changed the natural history of human immunodeficiency virus ( HIV ) infection in developed countries , where it has become a chronic disease . This clinical scenario requires a new approach to simplify follow-up appointments and facilitate access to healthcare professionals . Methodology We developed a new internet-based home care model covering the entire management of chronic HIV-infected patients . This was called Virtual Hospital . We report the results of a prospect i ve r and omised study performed over two years , comparing st and ard care received by HIV-infected patients with Virtual Hospital care . HIV-infected patients with access to a computer and broadb and were r and omised to be monitored either through Virtual Hospital ( Arm I ) or through st and ard care at the day hospital ( Arm II ) . After one year of follow up , patients switched their care to the other arm . Virtual Hospital offered four main services : Virtual Consultations , Telepharmacy , Virtual Library and Virtual Community . A technical and clinical evaluation of Virtual Hospital was carried out . Findings Of the 83 r and omised patients , 42 were monitored during the first year through Virtual Hospital  ( Arm I ) and 41 through st and ard care  ( Arm II ) . Baseline characteristics of patients were similar in the two arms . The level of technical satisfaction with the virtual system was high : 85 % of patients considered that Virtual Hospital improved their access to clinical data and they felt comfortable with the videoconference system . Neither clinical parameters [ level of CD4 + T lymphocytes , proportion of patients with an undetectable level of viral load ( p = 0.21 ) and compliance levels > 90 % ( p = 0.58 ) ] nor the evaluation of quality of life or psychological question naires changed significantly between the two types of care . Conclusions Virtual Hospital is a feasible and safe tool for the multidisciplinary home care of chronic HIV patients . Telemedicine should be considered as an appropriate support service for the management of chronic HIV infection . Trial Registration Clinical -Trials.gov : NCT01117675 BACKGROUND AND OBJECTIVE Telemedicine , care provided by electronic communication , may serve as an alternative or extension to traditional outpatient visits . This pilot study determined the effects of telemedicine on health-care utilization and health status of chronic obstructive pulmonary disease ( COPD ) patients . METHODS One hundred and one patients were r and omized , 52 patients received telemedicine care and 49 had traditional outpatient visits . The primary outcome was COPD -specific health status , measured with the Clinical COPD Question naire ( CCQ ) . Secondary outcomes included St. George 's Respiratory Question naire ( SGRQ ) and the Short Form-36 ( SF-36 ) and re source use in primary and secondary care . RESULTS The mean age of the participants was 68 ± 9 years and the mean per cent of predicted forced expiratory volume in 1 s was 40.4 ± 12.5 . The CCQ total score deteriorated by 0.14 ± 0.13 in the telemedicine group , and improved by -0.03 ± 0.14 in the control group ( difference 0.17 ± 0.19 , 95 % confidence interval ( CI ) : -0.21 - 0.55 , P = 0.38 ) . The CCQ symptom domain showed a significant and clinical ly relevant difference in favour of the control group , 0.52 ± 0.24 ( 95 % CI : 0.04 - 0.10 , P = 0.03 ) . Similar results were found for the SGRQ , whereas results for SF-36 were inconsistent . Patients in the control group had significantly fewer visits to the pulmonologist in comparison to patients in the telemedicine group ( P = 0.05 ) . The same trend , although not significant , was found for exacerbations after 6 months . CONCLUSIONS This telemedicine model of initiated phone calls by a health-care provider had a negative effect on health status and re source use in primary and secondary care , in comparison with usual care and therefore can not be recommended in COPD patients in its current form Background : In order to optimize care and improve outcomes in people with diabetes , adequate access to health care facilities and re sources for self-management is required . Methods : Data on 3369 individuals with type 2 diabetes who received education at 7 diabetes centers were collected prospect ively between June 2005 and January 2007 . The driving distances of subjects who were in good control [ hemoglobin A1c ( A1C ) > 7.0 % ] were compared with the driving distances of those who were not ( A1C > 7.0 % ) . The association between A1C and improvement in A1C with travel burden was tested . Results : The mean distance subjects traveled to visit their center was 13.3 miles . The results indicated that residing more than 10 miles from the diabetes management center [ odds ratio ( OR ) = 1.91 , p < .0001 ] , being younger ( OR = 0.99 , p = .00015 ) , and having a longer duration of diabetes ( OR = 1.03 , p = .0007 ) were significant contributors to a A1C > 7 % adjusted for individual- and community-level factors . In addition , those who lived within 10 miles of their center were 2.5 times more likely to have improved their A1C values between their first and last Office visits . Conclusion : Health care providers should be aware of travel burden as a potential barrier to glycemic control . In the future , it may be useful to minimize driving distance for individuals with diabetes , perhaps by improved public transportation , more diabetes center locations in rural areas , telemedicine , or home visits BACKGROUND Health system reform is directed towards better management of diabetes . However , change can be difficult , and patients ' perspectives are a key aspect of implementing change . OBJECTIVE This study investigated patients ' perceptions and experiences  of  type 2 diabetes ( T2DM )  , self-care and engagement with GP-led integrated diabetes care . DESIGN Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care .  Normalization process theory was used to orientate the thematic analysis , to explain the work of implementing change . SETTING Two specialist GP-based complex diabetes services in primary care in Brisbane , Australia . PARTICIPANTS Intervention group patients ( n = 30 ) in a r and omized controlled trial to evaluate a model of GP-led integrated care for complex T2DM . MAIN OUTCOME MEASURES Participants ' experiences and perceptions of diabetes management and a GP-led model  of care . RESULTS Three themes were identified : sensibility of change , ' diabetic life ' and diabetes care alliance . The imperative of change made sense , but some participants experienced dissonance between this rational view and their lived reality . Diabetes invaded life , revealing incongruities between participants ' values and living with diabetes . They appreciated a flexible and personalized approach to care . DISCUSSION Participants responded to advice in ways that seemed rational within the complexities of their life context . Their diabetes partnerships with health professionals coupled providers ' biomedical expertise with patients ' context ual expertise . CONCLUSIONS Learning to manage relationships with various health professionals adds to patients ' diabetes-related work . Providers need to adopt a flexible , interactive approach and foster trust , to enable better diabetes care An Internet-based store- and -retrieval telemedicine system to communicate between patients and their healthcare provider was tested . The system requires no specialized equipment , is Web-based , and allows frequent surveillance of the health status of the patients with heart failure ( HF ) . Thirty six patients were recruited to evaluate a Web-based telemedicine system for reducing care encounters . Eighteen patients were r and omized to the telemedicine arm ( group T ) , and 18 were given usual clinical care ( group C ) in our HF center . Patients in group T reported three times weekly via a secure Internet site for telemedicine intervention . We studied patients with HF with New York Heart Association ( NYHA ) class 2 to 4 with hospitalization within past 6 months . Mean age was 56.1 + /- 12.6 years ( 66.7 % male ; 66.7 % Caucasian , 27.8 % African American , and 5.6 % Hispanic ) .  Mean ejection fraction ( EF ) was 23.9 % + /- 17.6 % in group T and 26.6 % + /- 16.4 % in group C. Over an 8-month period , unscheduled ( group T-3 ; group C-5 ) , and scheduled clinic visits ( group T-11 , group C-7 ) were similar ( p = NS ) ; one group T patient was transplanted , one group C patient died . Total hospital days were lower with group T ( 44 days ) compared to group C ( 133 days ) , p < 0.05 . An Internet-based telemedicine system was able to closely monitor patients with HF . Surveillance through Internet-based telemedicine result ed in less hospitalization compared to control patients . This system may be helpful in reducing the cost of HF patient care Objectives To identify barriers to deployment of four articulated Integrated Care Services supported by Information Technologies in three European sites . The four services covered the entire spectrum of severity of illness . The project targeted chronic patients with obstructive pulmonary disease , cardiac failure and /or type II diabetes mellitus . Setting One health care sector in Spain ( Barcelona ) ( n = 11.382 ) ; six municipalities in Norway ( Trondheim ) ( n = 450 ) ; and one hospital in Greece ( Athens ) ( n = 388 ) . Method The four services were : ( i ) Home-based long-term maintenance of rehabilitation effects ( n = 337 ) ; ( ii ) Enhanced Care for frail patients , n = 1340 ) ; ( iii ) Home Hospitalization and Early Discharge ( n = 2404 ) ; and Support for remote diagnosis ( forced spirometry testing ) in primary care ( Support ) ( n = 8139 ) . Both r and omized controlled trials and pragmatic study design s were combined . Two technological approaches were compared . The Model for Assessment of Telemedicine applications was adopted . Results The project demonstrated : ( i ) Sustainability of training effects over time in chronic patients with obstructive pulmonary disease ( p < 0.01 ) ; ( ii ) Enhanced care and fewer hospitalizations in chronic respiratory patients ( p < 0.05 ) ; ( iii ) Reduced in-hospital days for all types of patients ( p < 0.001 ) in Home Hospitalization/Early Discharge ; and ( iv ) Increased quality of testing ( p < 0.01 ) for patients with respiratory symptoms in Support , with marked differences among sites . Conclusions The four integrated care services showed high potential to enhance health outcomes with cost-containment . Change management , technological approach and legal issues were major factors modulating the success of the deployment . The project generated a business plan to foster service sustainability and health innovation . Deployment strategies require site-specific adaptations 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 BACKGROUND Telemedicine holds great potential to improve access to care and to reduce barriers to treatment for military population s with posttraumatic stress disorder ( PTSD ) . This study sought to integrate the use of telemedicine mental health treatment services by a community healthcare provider to military population s residing in a rural location and to compare the equivalency of cognitive behavioral therapy ( CBT ) administered via telemedicine and traditional face-to-face therapy . SUBJECTS AND METHODS Study subjects were men or women 18 years of age or older who had served in Operation Enduring Freedom ( OEF ) and /or Operation Iraqi Freedom ( OIF ) and were diagnosed with PTSD . The 18 study subjects were r and omized and provided 10 weekly therapy sessions of CBT . Pre- and post-intervention assessment s were conducted using the Clinician Administered PTSD Scale ( CAPS ) , Hamilton Anxiety Rating Scale ( HAM-A ) , Montgomery-Asberg Depression Rating Scale ( MADRS ) , Life Events Checklist , and SF-36v2 ® ( Quality Metric , Lincoln , RI ) Health Survey . RESULTS The CAPS , HAM-A , and MADRS each demonstrated lower scores , signifying improvement , and 69 % of subjects experienced a clinical ly significant change in the CAPS . Patient satisfaction results indicated greater satisfaction for telemedicine as opposed to traditional face-to-face treatment . CONCLUSIONS Findings reveal a trend expressing the equivalence of telemedicine and face-to-face therapy when treating OEF/OIF veterans with PTSD among rural population s by a community provider . It further demonstrates the successful collaboration between a community healthcare provider and the military healthcare system Telemedicine is widely considered as an efficient approach to manage the growing problem of chronic wounds . However , to date , there is no convincing evidence to support the clinical efficacy of telemedicine in wound management . In this prospect i ve cluster controlled study , we tested the hypothesis that advice on wound management provided by a team of wound-care specialists through telemedicine would significantly improve the likelihood of wound healing compared with the best available conventional practice . A total of 90 chronic wound patients in home care met all study criteria and were included : 50 in the telemedicine group and 40 in the conventional group . Patients with pressure ulcers , surgical wounds , and cancer wounds were excluded . During the 1-year follow-up , complete wound healing was achieved in 35 patients ( 70 % ) in the telemedicine group compared with 18 patients ( 45 % ) in the conventional group . After adjusting for important covariates , offering advice on wound management through telemedicine was associated with significantly increased healing compared with the best available conventional practice ( telemedicine vs. conventional practice : adjusted hazard ratio 2.19 ; 95 % confidence interval : 1.15 - 4.17 ; P=0.017 ) . This study strongly supports the use of telemedicine to connect home-care nurses to a team of wound experts in order to improve the management of chronic wounds OBJECTIVE Practice -based collaborative care is a complex evidence -based practice that is difficult to implement in smaller primary care practice s that lack on-site mental health staff . Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care setting s. The objective of this multisite r and omized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice -based and telemedicine-based collaborative care . METHOD From 2007 to 2009 , patients at federally qualified health centers serving medically underserved population s were screened for depression , and 364 patients who screened positive were enrolled and followed for 18 months . Those assigned to practice -based collaborative care received evidence -based care from an on-site primary care provider and a nurse care manager . Those assigned to telemedicine-based collaborative care received evidence -based care from an on-site primary care provider and an off-site team : a nurse care manager and a pharmacist by telephone , and a psychologist and a psychiatrist via videoconferencing . The primary clinical outcome measures were treatment response , remission , and change in depression severity . RESULTS Significant group main effects were observed for both response ( odds ratio=7.74 , 95 % CI=3.94 - 15.20 ) and remission ( odds ratio=12.69 , 95 % CI=4.81 - 33.46 ) , and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist , with greater reductions in severity over time for patients in the telemedicine-based group . Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group . CONCLUSIONS Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice -based collaborative care with locally available staff OBJECTIVE To determine patient perceptions of joint teleconsultations ( JTC )  , with particular reference to reasons underlying , and factors contributing to , patient satisfaction and dissatisfaction with this mode of health delivery . BACKGROUND Telemedicine has been welcomed as one way of improving health-care delivery , by improving patient access to secondary care and specialist services hence widening patient choice , particularly for patients outside major conurbations . However , a recent systematic review found currently available data on patient satisfaction with telemedicine to be method ologically flawed . Qualitative evaluations offer the opportunity to eluci date the details of patient satisfaction with this mode of health-care delivery . DESIGN Qualitative study using semi-structured interviews . SETTING AND PARTICIPANTS Purposive sample of 28 participants of a major r and omized controlled trial ( Virtual Outreach study ) of JTC conducted in one urban and one rural area in Britain . INTERVENTION Joint teleconferenced consultations with the patient , patient 's general practitioner ( GP ) , and a hospital specialist . The patient and GP were sited in the local practice , while the hospital specialist was in the hospital outpatient department , and the two parties were connected by an ISDN2 link and video-conferencing software . MAIN OUTCOME MEASURES  Patient experiences of JTC  , with particular reference to reasons underlying , and factors contributing to , overall satisfaction or dissatisfaction . RESULTS Two major themes were identified : customer care and doctor-patient interaction . Patients appreciated the customer care aspects of JTC , particularly the enhanced convenience , reduced costs and improved punctuality associated with JTC . However , there were divergent views about the doctor-patient interactions with some patients expressing a sense of alienation arising from the use of technology , and problems with doctor-patient communication . CONCLUSIONS These data add significantly to the existing literature on patient satisfaction with telemedicine , by elucidating the factors underlying overall satisfaction scores and hence have implication s for future service delivery and implementation of telemedicine 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 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 To evaluate group visits in the management of underinsured patients with uncontrolled type 2 diabetes , 120 eligible patients enrolled were r and omly assigned to receive care in groups or continue usual care .  Feasibility , acceptability , and concordance with American Diabetes Association st and ards of care ( Diab Camre . 25[suppl 1]:533 - 549 ) were evaluated . Patients who received care in groups exhibited improvement in American Diabetes Association st and ards of care ( p < .001 ) , improved sense of trust in physician ( p = .02 ) , and tended to report better coordination of care ( p = .07 ) , better community orientation ( p = .09 ) , and more culturally competent care ( p = .09 ) . Group visits offer a promising model for delivering health care to these patients 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 OBJECTIVE To demonstrate that Diabeo software enabling individualized insulin dose adjustments combined with telemedicine support significantly improves HbA1c in poorly controlled type 1 diabetic patients . RESEARCH DESIGN AND METHODS In a six-month open-label parallel-group , multicenter study , adult patients ( n = 180 ) with type 1 diabetes ( > 1 year ) , on a basal-bolus insulin regimen ( > 6 months ) , with HbA1c ≥8 % , were r and omized to usual quarterly follow-up ( G1 ) , home use of a smartphone recommending insulin doses with quarterly visits ( G2 ) , or use of the smartphone with short teleconsultations every 2 weeks but no visit until point end ( G3 ) . RESULTS Six-month mean HbA1c in G3 ( 8.41 ± 1.04 % ) was lower than in G1 ( 9.10 ± 1.16 % ; P = 0.0019 ) . G2 displayed intermediate results ( 8.63 ± 1.07 % ) . The Diabeo system gave a 0.91 % ( 0.60 ; 1.21 ) improvement in HbA1c over controls and a 0.67 % ( 0.35 ; 0.99 ) reduction when used without teleconsultation . There was no difference in the frequency of hypoglycemic episodes or in medical time spent for hospital or telephone consultations . However , patients in G1 and G2 spent nearly 5 h more than G3 patients attending hospital visits . CONCLUSIONS The Diabeo system gives a substantial improvement to metabolic control in chronic , poorly controlled type 1 diabetic patients without requiring more medical time and at a lower overall cost for the patient than usual care OBJECTIVES A 6-month pilot teleconsultative project linking Georgetown University Medical Center ( GUMC ) in Washington , DC , and City Hospital in Martinsburg , West Virginia , 90 miles away , was design ed to assess the effectiveness of  telemedicine on the clinical decision-making process for patients with urolithiasis . METHODS The telemedicine system design ed and tested for this project was based on a PC-based platform . Videoconferencing and review of the  patient 's imaging studies  were performed over an Integrated Service Digital Network ( ISDN ) with 3 Basic Rate ( BRI ) ISDN lines providing a 336-kilobytes/s b and width through an Inverse Multiplexor ( IMUX ) . Treatment options were recorded for the clinical trial group and a simulated study group by the consulting urologist after the initial telephone consultation , after the telemedicine consultation , and after examination of those patients transferred to GUMC . RESULTS A total of 32 telemedicine consultations were performed : 14 in the clinical trial group and 18 in the simulated study group . The recommendation of the consulting urologist at the tertiary center was altered in 12 patients ( 37.5 % ) after the telemedicine consultation compared with the recommended treatment after the initial telephone consultation . CONCLUSIONS In the evaluation of patients with urolithiasis , this telemedicine application enhanced the clinical decision-making process by allowing for improved quality of care through immediate access and effective transfer of information between the referring urologist , the patient , and the stone center specialist Background and Purpose — Telemedicine techniques can be used to address the rural – metropolitan disparity in acute stroke care . The Stroke Team Remote Evaluation Using a Digital Observation Camera ( STRokE DOC ) trial reported more accurate decision making for telemedicine consultations compared with telephone-only and that the California-based research network facilitated a high rate of thrombolysis use , improved data collection , low risk of complications , low technical complications , and favorable assessment times . The main objective of the STRokE DOC Arizona TIME ( The Initial Mayo Clinic Experience ) trial was to determine the feasibility of establishing , de novo , a single-hub , multirural spoke hospital telestroke research network across a large geographical area in Arizona by replicating the STRokE DOC protocol . Methods — Methods included prospect i ve , single-hub , 2-spoke , r and omized , blinded , controlled trial of a 2-way , site-independent , audiovisual telemedicine system design ed for remote examination of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis .  The primary outcome measure was whether the decision to give thrombolysis was correct . Secondary outcomes were rate of thrombolytic use , 90-day functional outcomes , incidence of intracerebral hemorrhages , and technical observations . Results — From December 2007 to October 2008 , 54 patients were assessed , 27 of whom were r and omized to each arm . Mean National Institutes of Health Stroke Scale score at presentation was 7.3 ( SD 6.2 ) points . No consultations were aborted ; however , technical problems ( 74 % ) were prevalent in the telemedicine arm . Overall , the correct treatment decision was established in 87 % of the consultations . Both modalities , telephone ( 89 % correct ) and telemedicine ( 85 % correct ) , performed well . Intravenous thrombolytic treatment was used in 30 % of the telemedicine and telephone consultations . Good functional outcomes at 90 days were not significantly different . There were no statistically significant differences in mortality ( 4 % in telemedicine and 11 % in telephone ) or rates of intracerebral hemorrhage ( 4 % in telemedicine and 0 % in telephone ) . Conclusions — It is feasible to extend the original STRokE DOC trial protocol to a new state and establish an operational single-hub , multispoke rural hospital telestroke research network in Arizona . The trial was not design ed to have sufficient power to detect a difference between the 2 consultative modes : telemedicine and telephone-only . Whether by telemedicine or telephone consultative modalities , there were appropriate treatment decisions , high rates of thrombolysis use , improved data collection , low rates of intracerebral hemorrhage , and equally favorable time requirements . The learning curve was steep for the hub and spoke personnel of the new telestroke network , as reflected by frequent technical problems . Overall , the results support the effectiveness of highly organized and structured stroke telemedicine networks for extending expert stroke care into rural remote communities lacking sufficient neurological expertise BACKGROUND AND PURPOSE Telemedicine can disseminate vascular neurology expertise and optimize recombinant tissue plasminogen activator ( rt-PA ) use for acute ischemic stroke in rural underserved communities . The purpose of this study was to prospect ively assess whether telemedicine or telephone was superior for decision-making . METHODS The study design is a pooled analysis of two identically design ed r and omized controlled trials conducted in a multistate hub and spoke telestroke network setting with acute stroke syndrome patients , comparing telemedicine versus telephone-only consultations . From each trial , common data elements were pooled to assess , principally , for correctness of thrombolysis decision-making . Secondary outcomes included rt-PA use rate , 90-day functional outcome , post-thrombolysis intracranial hemorrhage , and data completeness . RESULTS Two hundred seventy-six pooled patients were evaluated .  Correct thrombolysis eligibility decisions were made more often with telemedicine ( 96 % telemedicine , 83 % telephone ; odds ratio [ OR ] 4.2 ; 95 % confidence interval [ CI ] 1.69 - 10.46 ; p=0.002 ) . Intravenous rt-PA usage was 26 % ( 29 % telemedicine , 24 % telephone ; OR 1.27 ; 95 % CI 0.71 - 2.25 ; p=0.41 ) . Ninety-day outcomes were not different for Barthel Index , modified Rankin Scale , or mortality . There was no difference in post-thrombolysis intracranial hemorrhage ( 8 % telemedicine , 6 % telephone ; p>0.999 ) . CONCLUSIONS This pooled analysis supports the hypothesis that stroke telemedicine consultations , compared with telephone-only , result in more accurate decision-making . Together with high rt-PA utilization rate , low post-rt-PA intracranial hemorrhage rate , and acceptable patient outcome , the results confirm that telemedicine is a viable consultative tool for acute stroke . The replication of the hub and spoke network infrastructure supports the generalizability of telemedicine when used in broader setting OBJECTIVE This multi-site r and omized trial evaluates the quality of life ( QOL ) benefits of an imagery-based group intervention titled ' Envision the Rhythms of Life'(ERL ) . METHODS Breast cancer survivors > 6 weeks post-treatment were r and omized to attend five weekly 4-h group sessions at a community center with therapist present ( live delivery ( LD ) , n = 48 ) , therapist streamed via telemedicine ( telemedicine delivery ( TD ) , n = 23 ) , or to a waitlist control ( WL ) group ( n = 47 ) . Weekly individual phone calls to encourage at-home practice began at session one and continued until the 3-month follow-up . Seven self-report measures of QOL were examined at baseline , 1-month and 3-month post-treatments including health-related and breast cancer-specific QOL , fatigue , cognitive function , spirituality , distress , and sleep . RESULTS The Bonferroni method was used to correct for multiple comparisons , and alpha was adjusted to 0.01 . Linear multilevel modeling analyses revealed less fatigue , cognitive dysfunction , and sleep disturbance for LD and TD compared with WL across the follow-up ( p 's < 0.01 ) . Changes in fatigue , cognitive dysfunction , sleep disturbance , and health-related and breast cancer-related QOL were clinical ly significant . There were no differences between LD and TD . CONCLUSIONS Both the live and telemedicine delivered ERL intervention result ed in improvements in multiple QOL domains for breast cancer survivors compared with WL . Further , there were no significant differences between LD and TD , suggesting telemedicine delivered ERL intervention may represent an effective and viable option for cancer survivors in remote areas Background Diabetes and hypertension are devastating , deadly , and costly conditions that are very common in seniors . Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications . However , blood pressure ( BP ) must be lowered carefully because seniors are also susceptible to low BP and attendant harms . Achieving “ optimal BP control ” ( ie , avoiding both undertreatment and overtreatment ) is the ultimate therapeutic goal in such patients . Regular BP monitoring is required to achieve this goal . BP monitoring at home is cheap , convenient , widely used , and guideline endorsed . However , major barriers prevent proper use . These may be overcome through use of BP telemonitoring — the secure teletransmission of BP readings to a health portal , where BP data are summarized for provider and patient use , with or without protocol ized case management . Objective To examine the incremental effectiveness , safety , cost-effectiveness , usability , and acceptability of home BP telemonitoring , used with or without protocol ized case management , compared with “ enhanced usual care ” in community-dwelling seniors with diabetes and hypertension . Methods A 300-patient , 3-arm , pragmatic r and omized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors ’ residences in greater Edmonton . Consenting patients will be r and omized to usual care , home BP telemonitoring alone , or home BP telemonitoring plus protocol ized pharmacist case management . Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data . In both telemonitored arms , providers will receive telemonitored BP data summaries . In the case management arm , pharmacist case managers will be responsible for review ing teletransmitted data and initiating guideline -concordant and protocol ized changes in BP management . Results Outcomes will be ascertained at 6 and 12 months . Within- study -arm change scores will be calculated and compared between study arms . These include : ( 1 ) clinical outcomes : proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range ( 110 - 129 mmHg in patients 65 - 79 years and 110 - 139 mmHg in those ≥80 years : primary outcome ) ; additional ambulatory and home BP outcomes ; A1c and lipid profile ; medications , cognition , health care use , cardiovascular events , and mortality . ( 2 ) Safety outcomes : number of serious episodes of hypotension , syncope , falls , and electrolyte disturbances ( requiring third party assistance or medical attention ) . ( 3 ) Humanistic outcomes : quality of life , satisfaction , and medication adherence . ( 4 ) Economic outcomes : incremental costs , incremental cost-utility , and cost per mmHg change in BP of telemonitoring ± case management compared with usual care ( health payor and societal perspectives ) . ( 5 ) Intervention usability and acceptability to patients and providers . Conclusion The potential benefits of telemonitoring remain largely unstudied and unproven in seniors . This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes . Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada . Trial Registration Clinical trials.gov NCT02721667 ; https:// clinical trials.gov/ct2/show/NCT02721667 ( Archived by Webcite at http://www.webcitation.org/6i8tB20Mc PURPOSE The Women to Women Diabetes Project tested the use of telecommunication technology to deliver diabetes education and social support to rural women with diabetes . The aims were to ( 1 ) test the effects of the computer intervention in providing support , information , and education on selected outcomes , and ( 2 ) evaluate the women 's attitudes toward and satisfaction with the intervention and the support provided . METHODS Thirty women were r and omized into computer and noncomputer groups and participated for 10 months . For 5 months , one group participated in a self-help support and educational group via the computer ; the other group continued to use their usual modes of support and communication .  Psychosocial well-being scales were administered and attitudes were surveyed . RESULTS Improving health and higher educational levels positively influenced measures of social support and quality of life .  Women who were married or who reported greater support had higher scores on the Personal Re source Question naire . The women expressed positive effects of the computer-based support group on their lives . CONCLUSIONS The intervention was enthusiastically accepted , and could be conducted effectively in isolated rural areas Abstract Purpose : Although self-measurement of home blood pressure ( HBP ) is common in Japan and HBP telemonitoring via the Internet is possible , whether telemonitoring improves HBP control better than conventional practice remains unclear . Furthermore , hypertension care with online communication using telemonitored HBP is feasible , whereas the efficacy and safety of such telemedicine have not been established . We aim to compare traditional care , care with office visits using HBP telemonitoring , and antihypertensive telemedicine based on HBP telemonitoring . Methods and design : In total , 444 patients with uncontrolled hypertension will be recruited and r and omly assigned to three groups : ( 1 ) control : usual care with office visits and HBP self-report , ( 2 ) telemonitoring : weekly assessment of transmitted HBP by physicians and treatment adjustment upon office visits , or ( 3 ) telemedicine : online communication instead of office visits to adjust medication using telemonitored HBP . Primary outcome is the time to control of HBP , and secondary outcomes include achieved HBP levels , adherence , treatment intensity , adverse events , patient satisfaction and cost-effectiveness . Discussion : Hypertension care with telemonitoring and telemedicine are expected to require shorter time to achieve HBP control compared to usual care . Combining HBP telemonitoring with telemedicine may lower the hurdles for starting and persisting to hypertension treatment and eventually reduce cardiovascular events Background Compliance with continuous positive airway pressure ( CPAP ) therapy is essential in patients with obstructive sleep apnoea ( OSA ) , but adequate control is not always possible . This is clinical ly important because CPAP can reverse the morbidity and mortality associated with OSA . Telemedicine , with support provided via a web platform and video conferences , could represent a cost-effective alternative to st and ard care management . Aim To assess the telemedicine impact on treatment compliance , cost-effectiveness and improvement in quality of life ( QoL ) when compared with traditional face-to-face follow-up . Methods A r and omised controlled trial was performed to compare a telemedicine-based CPAP follow-up strategy with st and ard face-to-face management .  Consecutive OSA patients requiring CPAP treatment , with sufficient internet skills and who agreed to participate , were enrolled . They were followed-up at 1 , 3 and 6 months and answered surveys about sleep , CPAP side effects and lifestyle . We compared CPAP compliance , cost-effectiveness and QoL between the beginning and the end of the study . A Bayesian cost-effectiveness analysis with non-informative priors was performed . Results We r and omised 139 patients . At 6 months , we found similar levels of CPAP compliance , and improved daytime sleepiness , QoL , side effects and degree of satisfaction in both groups . Despite requiring more visits , the telemedicine group was more cost-effective : costs were lower and differences in effectiveness were not relevant . Conclusions A telemedicine-based strategy for the follow-up of CPAP treatment in patients with OSA was as effective as st and ard hospital-based care in terms of CPAP compliance and symptom improvement , with comparable side effects and satisfaction rates . The telemedicine-based strategy had lower total costs due to savings on transport and less lost productivity ( indirect costs ) . Trial register number NCT01716676 PURPOSE To determine if modem transmission of blood glucose data by patients with gestational diabetes could provide faster communication of results , increased clinic work-flow efficiency , and equivalent accuracy . Participant and health care provider satisfaction with the technique was also assessed . DATA SOURCES Participants were r and omized to the modem group , which used the Acculink Modem to report blood glucose data , or to the control group , which used the telephone to report the data .  Telephone consultation time , clinic visit time , and accuracy of data were measured . Participants and health care providers completed satisfaction question naires . CONCLUSIONS No significant differences in telephone consultation time , clinic work-flow efficiency , or accuracy were found between the groups . However , both the modem group and clinic staff were highly satisfied with telemedicine transmission of blood glucose data . IMPLICATION S FOR PRACTICE Telemedicine is a convenient method for monitoring patients with gestational diabetes mellitus . As a result of this study , modem transmission was instituted in our clinic for insulin pump patients interested in using modem technology Background Depression is up to two to three times as common in people with long-term conditions . It negatively affects medical management of disease and self-care behaviors , and leads to poorer quality of life and high costs in primary care . Screening and treatment of depression is increasingly prioritized , but despite initiatives to improve access and quality of care , depression remains under-detected and under-treated , especially in people with long-term conditions .  Collaborative care is known to positively affect the process and outcome of care for people with depression and long-term conditions , but its effectiveness outside the USA is still relatively unknown . Furthermore , collaborative care has yet to be tested in setting s that resemble more naturalistic setting s that include patient choice and the usual care providers . The aim of this study was to test the effectiveness of a collaborative-care intervention , for people with depression and diabetes/coronary heart disease in National Health Service ( NHS ) primary care , in which low-intensity psychological treatment services are delivered by the usual care provider - Increasing Access to Psychological Therapies ( IAPT ) services . The study also aim ed to evaluate the cost-effectiveness of the intervention over 6 months , and to assess qualitatively the extent to which collaborative care was implemented in the intervention general practice s. Methods This is a cluster r and omized controlled trial of 30 general practice s allocated to either collaborative care or usual care . Fifteen patients per practice will be recruited after a screening exercise to detect patients with recognized depression ( ≥10 on the nine-symptom Patient Health Question naire ; PHQ-9 ) . Patients in the collaborative-care arm with recognized depression will be offered a choice of evidence -based low-intensity psychological treatments based on cognitive and behavioral approaches . Patients will be case managed by psychological well-being practitioners employed by IAPT in partnership with a practice nurse and /or general practitioner . The primary outcome will be change in depressive symptoms at 6 months on the 90-item Symptoms Checklist ( SCL-90 ) . Secondary outcomes include change in health status , self-care behaviors , and self-efficacy . A qualitative process evaluation will be undertaken with patients and health practitioners to gauge the extent to which the collaborative-care model is implemented , and to explore sustainability beyond the clinical trial . Discussion COINCIDE will assess whether collaborative care can improve patient-centered outcomes , and evaluate access to and quality of care of co-morbid depression of varying intensity in people with diabetes/coronary heart disease . Additionally , by working with usual care providers such as IAPT , and by identifying and evaluating interventions that are effective and appropriate for routine use in the NHS , the COINCIDE trial offers opportunities to address translational gaps between research and implementation . Trial Registration NumberIS RCT N80309252Trial The efficacy of telemedicine technology was tested for equivalence of nursing assessment with chronic congestive heart failure ( CHF ) home care patients ( N = 28 ) . The equivalence of nurses ' physical assessment findings was estimated using an innovative two-way , telemedicine audiovisual system . Nurses were r and omly assigned to a method of client assessment : on-site ( real time ) or telemedicine ( monitor time ) . Each assessment was performed within 10 minutes of each other . Assessment variables compared were auscultation of lung sounds , heart sounds , rate and rhythm , blood pressure , weight , edema , respiratory effort , and client 's face , lip , and nail color . Eighteen physiological parameters were analyzed , using either the Wilcoxon signed ranks test or the McNemar test . Results indicate few significant differences between the assessment s of the real time and monitor time nurses . The monitor nurse was more likely to cl aim abnormality than the real nurse was when assessing the color of nails ( p = .048 ) . The real nurse picked up ankle edema ( p = .024 ) , pedal edema ( p = .099 ) , and inspiratory wheeze ( p = .01 ) more frequently than did the monitor nurse . Kappa coefficients to determine the extent of agreement between nurse 's assessment s were significant . Nurses ' comments were favorable , but they recommended altering the interview to elicit symptoms not easily observed by the monitor nurse such as diaphoresis . Exit interviews of the elderly patients revealed a favorable reaction to using the telemedicine monitor , citing a quick connection to a nurse and response to their concerns and questions . Both nurses and patients reported the need to have real nurse home visits along with telemedicine visits OBJECTIVE : Evaluate the effectiveness of telemedicine ( TM ) with digital cameras in treating wounds in a home care setting . DESIGN : R and omized controlled study . PARTICIPANTS AND SETTING : One hundred three subjects with 160 pressure ulcers ( PrUs ) or nonhealing surgical wounds referred to a metropolitan Visiting Nurse Agency . INTERVENTIONS : Subjects were r and omly assigned to 1 of 3 groups . Group A ( n = 40 ) : weekly visits with TM and wound care specialist ( WCS ) consults ; group B ( n = 28 ) : weekly visits with weekly consults with WCSs ; and group C ( n = 35 ) : usual and customary care . MAIN OUTCOME MEASURES : Outcome measures were time to heal , costs , length of stay ( LOS ) , nursing visits , wound status , and change in size . RESULTS : There was a similar distribution of subject characteristics in all 3 groups , but group A had disproportionally larger and more numerous PrUs and larger nonhealing surgical wounds . Group A had increased time to heal , LOS , costs , and visits compared with groups B and C ; wound status was similar in all groups . CONCLUSIONS : Uneven distribution of severity and type of wounds among groups , with greatest percentage of large wounds in TM group . Larger wounds consume more re sources . TM is a useful communication tool in wound management but with limited power when r and omization does not include wound size or type . Two important benchmarks were established for home care . First , it took 51 days , on average , to heal or improve PrUs and 34 days to heal or improve surgical wounds regardless of group . Second , nearly 90 % of wounds improved or healed The objective of this study was to compare continuous positive airway pressure ( CPAP ) use , functional status , and client satisfaction in obstructive sleep apnea syndrome ( OSAS ) patients r and omized to either telemedicine support or traditional care . In our university-affiliated sleep disorders center , patients with OSAS who were initiating CPAP therapy were r and omized to receive telemedicine support vs traditional follow-up care for 30 days . The telemedicine group received a “ Health Buddy ” computer that provided daily Internet-based informational support and feedback for problems experienced with CPAP use . At 30 days , there were no significant differences in the hours of CPAP use between groups receiving traditional care ( M=4.22 , SD±2.05 ) and telemedicine support ( M=4.29 , SD±2.15 ) , p=0.87 , or in the proportion of nights with CPAP use between the traditional ( M=50%±33.8 ) and telemedicine groups ( M=47%±34.2 ) , p=0.61 . No significant differences were found between groups in functional status ( M=2.27±4.56 vs M=2.03±3.88 , respectively , p=0.76 ) or client satisfaction ( M=28.0±3.51 vs M=28.5±3.05 , p=0.43 ) . Patients in the telemedicine and traditional groups had similar CPAP use , functional status , and client satisfaction . The data suggest that telemedicine support as provided by our model compares favorably with traditional care . As a provider-extender , telemedicine support for patients initiating use of CPAP may allow for greater practice efficiency while maintaining quality of care Objective To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions . Design Cluster r and omised controlled trial . Setting 36 general practice s in the north west of Engl and . Participants 387 patients with a record of diabetes or heart disease , or both , who had depressive symptoms ( ≥10 on patient health question aire-9 ( PHQ-9 ) ) for at least two weeks . Mean age was 58.5 ( SD 11.7 ) . Participants reported a mean of 6.2 ( SD 3.0 ) long term conditions other than diabetes or heart disease ; 240 ( 62 % ) were men ; 360 ( 90 % ) completed the trial .  Interventions Collaborative care included patient preference for behavioural activation , cognitive restructuring , grade d exposure , and /or lifestyle advice , management of drug treatment , and prevention of relapse . Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service ; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse . Usual care was st and ard clinical practice provided by general practitioners and practice nurses . Main outcome measures The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale ( SCL-D13 ) at four months after baseline assessment . Secondary outcomes included anxiety symptoms ( generalised anxiety disorder 7 ) , self management ( health education impact question naire ) , disability ( Sheehan disability scale ) , and global quality of life ( WHOQOL-BREF ) . Results 19 general practice s were r and omised to collaborative care and 20 to usual care ; three practice s withdrew from the trial before patients were recruited . 191 patients were recruited from practice s allocated to collaborative care , and 196 from practice s allocated to usual care . After adjustment for baseline depression score , mean depressive scores were 0.23 SCL-D13 points lower ( 95 % confidence interval −0.41 to −0.05 ) in the collaborative care arm , equal to an adjusted st and ardised effect size of 0.30 . Patients in the intervention arm also reported being better self managers , rated their care as more patient centred , and were more satisfied with their care . There were no significant differences between groups in quality of life , disease specific quality of life , self efficacy , disability , and social support . Conclusions Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity . The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine setting s with a deprived population with high levels of mental and physical multimorbidity . Trial registration IS RCT N80309252 PURPOSE The incorporation of new technologies into clinical daily practice is nowadays a fact in the field of medicine . Within these new technologies , telemedicine is turning out to be a working tool that is used with increasing frequency in medical centers . The systems of telemedicine have still not reached the same development in oral and maxillofacial surgery that they have reached in other medical specialties . This study describes the preliminary results of a store- and -forward telemedicine system ( SFTMS ) aim ed at the presurgical management of impacted third molar pathology . MATERIAL S AND METHODS A multicenter , longitudinal , descriptive , evaluative pilot study of an SFTMS aim ed at the presurgical management of patients with impacted third molar pathology was conducted at the Oral and Maxillofacial Surgery Unit of Virgen Macarena University Hospital ( Seville , Spain ) and 4 primary care areas located between 15 and 95 km from the hospital . The study was carried out between January and December 2009 . RESULTS Over a period of 12 months , 97 patients were enrolled in the study , from 102 teleconsultations received and evaluated within the same period . Patients managed through telemedicine were included on the surgical wait list on within a mean interval of 3.33 days ( 95 % confidence interval [ CI ] , 2 - 4.65 days ) since the visit to the primary care dentist , with only 1 visit to the hospital that was on the day of surgery . The mean waiting interval of patients managed through the conventional referral system was 28 days ( 95 % CI , 24.51 - 29.6 days ) , with at least 2 visits to the hospital before the final intervention . The on-the-day surgery cancellation rate of the series was 7.8 % ( 95 % CI , 3.8%-10.5 % ) because 8 patients did not have surgery on the scheduled day . The cancellation rate in the sample of patients managed through the conventional system was 8.85 % ( 95 % CI , 5.62%-11.81 % ; P < .005 ) . CONCLUSIONS The SFTMS was effective and accurate as a preoperative tool for impacted third molar pathology . It avoids unnecessary visits to the hospital and shortens waiting intervals . Further r and omized studies are needed , however , to establish real advantages , in clinical and economic terms , against the conventional presurgical management systems STUDY OBJECTIVES Obstructive sleep apnea ( OSA ) has been associated with hypertension , which is one of the intermediary mechanisms leading to increased cardiovascular morbidity . This study aim ed at evaluating the effects of a combination of continuous positive airway pressure ( CPAP ) and telemedicine support on blood pressure ( BP ) reduction in high cardiovascular risk OSA patients . DESIGN A multi-center r and omized controlled trial that compared st and ard CPAP care and CPAP care and a telemedicine intervention . SETTING Sleep clinics in France . PATIENTS OR PARTICIPANTS 107 adult ( 18 - 65 years old ) OSA patients ( AHI > 15 events/h ) with a high cardiovascular risk ( cardiovascular SCORE > 5 % or secondary prevention ) . INTERVENTIONS Patients were r and omized to either  st and ard care CPAP ( n = 53 ) or CPAP and telemedicine ( n = 54 ) . Patients assigned to telemedicine were equipped with a smartphone for uploading  BP measurements , CPAP adherence , sleepiness , and quality of life data  ; in return , they received pictograms containing health-related messages . MEASUREMENTS The main outcome was home self-measured BP and secondary outcomes were cardiovascular risk evolution , objective physical activity , CPAP adherence , sleepiness and quality of life . RESULTS Self-measured BP did not improve in either group ( telemedicine or st and ard care ) . Patients in primary prevention showed greater BP reduction with CPAP treatment than those in secondary prevention . CONCLUSIONS CPAP treatment supported by telemedicine alone did not improve blood pressure and cardiovascular risk in high cardiovascular risk OSA patients . This study emphasizes the need for diet and physical activity training programs in addition to CPAP when aim ing at decreasing cardiometabolic risk factors in these patients . CLINICAL TRIALS REGISTRATION Clinical Trials.gov identifier : NCT01226641
Telemedicine had no convincing effect on quality of life , mortality or hypoglycemia .
INTERPRETATION : Compared with usual care , the addition of telemedicine , especially systems that allowed medication adjustments with or without text messaging or a Web portal , improved HbA1C but not other clinical ly relevant outcomes among patients with diabetes
BACKGROUND : Telemedicine , the use of telecommunications to deliver health services , expertise and information , is a promising but unproven tool for improving the quality of  diabetes care  .
We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care .