Diabetes Metab. 2011 Aug 31. Franc S, Daoudi A, Mounier S, Boucherie B, Dardari D, Laroye H, Neraud B, Requeda E, Canipel L, Charpentier G. Centre d'études et de recherche pour l'intensification du traitement du diabète (CERITD), 91100 Corbeil-Essonnes, France; Sud-Francilien Hospital, Department of Diabetes, 59, boulevard Henri-Dunant, 91100 Corbeil-Essonnes, France.

Health authorities currently have high expectations for telemedicine (TM), as it addresses several major challenges: to improve access to healthcare (especially for patients in underserved or remote areas); to overcome the scarcity of specialists faced with epidemic disease; and to reduce the costs of healthcare while improving quality. The aims of TM in the field of diabetes differ according to the type of diabetes. In type 1 diabetes (T1DM) associated with complex insulin regimens, the goal of TM is to help patients achieve better control of their blood glucose levels through accurate adjustment of insulin doses. In type 2 diabetes (T2DM), while therapeutic adjustments may be necessary, improvement in blood glucose control is based primarily on behavioural changes (reduced calorie and carbohydrate intakes, increased physical activity). Many TM studies focusing on management of blood glucose levels have been published, but most failed to demonstrate any superiority of TM vs traditional care. While previously published meta-analyses have shown a slight advantage at best for TM, these meta-analyses included a mix of studies of varying durations and different populations (both T1DM and T2DM patients, adults and children), and tested systems of inconsistent quality. Studies published to date on TM suggest two currently promising approaches. First, handheld communicating devices, such as smartphones, loaded with software to apply physicians' prescriptions, have been shown to improve glycaemic control. These systems provide immediate assistance to the patient (such as insulin-dose calculation and food choice optimization at meals), and all data stored in the smartphone can be transmitted to authorized caregivers, enabling remote monitoring and even teleconsultation.

These systems, initially developed for T1DM, appear to offer many possibilities for T2DM, too. Second, systems combining an interactive Internet system (or a mobile phone coupled to a remote server) with a system of communication between the healthcare provider and the patient by e-mail, texting or phone calls have also shown certain benefits for glycaemic control. These systems, primarily aimed at T2DM patients, generally provide motivational support as well. Although the individual benefits of these systems for glycaemic control are fewer than with smartphones, their widespread use should be of particular value for overcoming the relative shortage of doctors and reducing the health costs associated with a disease of such epidemic proportions

Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings

Laurence C. Baker1,*, Scott J. Johnson2, Dendy Macaulay3 and Howard Birnbaum4 + Author Affiliations 1Laurence C. Baker is chief of health services research, a professor of health research and policy, and a CHP/PCOR fellow at Stanford University, in California. 2Scott J. Johnson is a manager at Analysis Group, in Boston, Massachusetts. 3Dendy Macaulay is a manager at Analysis Group, in New York City. 4Howard Birnbaum is a principal at Analysis Group, in Boston.

Treatment of chronically ill people constitutes nearly four-fifths of US health care spending, but it is hampered by a fragmented delivery system and discontinuities of care. We examined the impact of a care coordination approach called the Health Buddy Program, which integrates a telehealth tool with care management for chronically ill Medicare beneficiaries. We evaluated the program’s impact on spending for patients of two clinics in the US Northwest who were exposed to the intervention, and we compared their experience with that of matched controls. We found significant savings among patients who used the Health Buddy telehealth program, which was associated with spending reductions of approximately 7.7–13.3 percent ($312–$542) per person per quarter.

These results suggest that carefully designed and implemented care management and telehealth programs can help reduce health care spending and that such programs merit continued attention by Medicare. Meanwhile, mortality differences in the treatment and control groups suggest that the intervention may have produced noticeable changes in health outcomes, but we leave it to future research to explore these effects fully.

An Exploratory Study of Patient Attitudes towards Symptom Reporting in a Primary Care Setting Benefits for Medical Consultation and Syndromic Surveillance?

Special Topic: Medinfo 2010 M. A. Johansen (1), G. Berntsen (1), N. Shrestha (2), J. G. Bellika (1, 3), J.-A. K. Johnsen (1, 2) (1) Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway; (2) Research Group Telemedicine, Department of Clinical Medicine, University of Tromsø, Tromsø, Norway; (3) Department of Computer Science, University of Tromsø, Tromsø, Norway Summary

Objectives: The aim of this study was to investigate people’s attitude towards providing symptom information electronically before a consultation. Specific areas investigated include a) attitudes and experiences with regards to acquisition of information related to symptoms, b) attitudes towards computer based communication of symptoms to the general practitioner and how they preferred to carry out such reporting, and c) attitudes towards storage, use and presentation of symptom-data in general, and particularly in a symptom based surveillance setting. Methods: Data was collected from 83 respondents by use of convenience sampling. Results: The respondents were familiar with using the Internet for health purposes, such as acquisition of information related to their symptoms prior to a consultation. The majority of respondents had a positive attitude towards providing information about their symptoms to the general practitioner’s office as soon as possible after falling ill. Over half of the respondents preferred to use e-mail or a web-interface to perform this task. Eighty four percent were willing to have their symptom data stored in their EPR and 76 percent agreed that the general practitioner might access the symptoms together with the prevalence of matching diseases in order to assist the diagnostic process during the next consultation. Conclusions: The results of this study support the applicability of electronically mediated pre-consultation systems both for improving primary care consultation and for use in symptom based surveillance, including real-time surveillance.
Health Buddy yields hundreds of dollars in quarterly savings for telehealth patients
Carefully designed and implemented care management and telehealth programs can help reduce health care spending, and thus merit continued attention by Medicare, a Stanford University research team concluded. Writing in the journal Health Affairs, the team published results from its study of two health clinics in the Northwest that adopted the Health Buddy telehealth program, which provides patients with handheld devices and monitors for home use as they respond to daily questions tailored to their diagnosis. Patient responses are uploaded to a Web-based application, viewable by care managers, that evaluates risks associated with patient responses. The team found “significant” spending reductions among Health Buddy users of about 7.7% to 13.3%— between $312 and $542—per person per quarter.

The effect of mobile phone text-message reminders on Kenyan health workers' adherence to malaria treatment guidelines: a cluster randomised trial

The Lancet, Volume 378, Issue 9793, Pages 795 - 803, 27 August 2011 doi:10.1016/S0140-6736(11)60783-6 Dr Dejan Zurovac PhD a b c, Raymond K Sudoi BSc a, Willis S Akhwale PhD d, Moses Ndiritu MD a, Davidson H Hamer MD c e, Alexander K Rowe MD f, Prof Robert W Snow FMedSci a b

Background: Health workers' malaria case-management practices often differ from national guidelines. We assessed whether text-message reminders sent to health workers' mobile phones could improve and maintain their adherence to treatment guidelines for outpatient paediatric malaria in Kenya.

Methods: From March 6, 2009, to May 31, 2010, we did a cluster-randomised controlled trial at 107 rural health facilities in 11 districts in coastal and western Kenya. With a computer-generated sequence, health facilities were randomly allocated to either the intervention group, in which all health workers received text messages on their personal mobile phones on malaria case-management for 6 months, or the control group, in which health workers did not receive any text messages. Health workers were not masked to the intervention, although patients were unaware of whether they were in an intervention or control facility. The primary outcome was correct management with artemether-lumefantrine, defined as a dichotomous composite indicator of treatment, dispensing, and counselling tasks concordant with Kenyan national guidelines. The primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, ISRCTN72328636.

Findings: 119 health workers received the intervention. Case-management practices were assessed for 2269 children who needed treatment (1157 in the intervention group and 1112 in the control group). Intention-to-treat analysis showed that correct artemether-lumefantrine management improved by 23•7 percentage-points (95% CI 7•6—40•0; p=0•004) immediately after intervention and by 24•5 percentage-points (8•1—41•0; p=0•003) 6 months later.

Interpretation: In resource-limited settings, malaria control programmes should consider use of text messaging to improve health workers' case-management practices.

Web-based management of diabetes through glucose uploads: has the time come for telemedicine?

Diabetes Res Clin Pract. 2009 Jan;83(1):9-17. Epub 2008 Dec 3. Azar M, Gabbay R. Source Division of Endocrinology, Diabetes and Metabolism, Pennsylvania State College of Medicine, Hershey, PA, USA.

This review focuses on the burgeoning use of web-based systems allowing patient-initiated glucometer uploads to facilitate provider treatment intensification. Studies in type 1 diabetes tended to show equivalent HbA1c improvements in both intervention and control groups without statistically significant difference.

In contrast, type 2 patients seemed to do better than controls with significant differences in HbA1c.

Patients were the beneficiaries of web-based diabetes management both through savings in time and cost.

Major obstacles to wider implementation are patient computer skills, adherence to the technology, architectural and technical design, and the need to reimburse providers for their care.

Change of Patients' Perceptions of Telemedicine After Brief Use

Telemedicine and e-Health. September 2011, 17(7): 530-535. doi:10.1089/tmj.2010.0208. Karlijn Cranen, Rianne Huis in't Veld, Maarten Ijzerman and Miriam Vollenbroek-Hutten. Roessingh Research and Development, Enschede, The Netherlands. Department of Health Technology and Services Research, University of Twente, Enschede, The Netherlands. Department of Biomedical Signals and Systems/Telemedicine, University of Twente, Enschede, The Netherlands.

Objective: This study aims to investigate whether patients' perceptions regarding a Web-based telemedicine service, for instruction and monitoring of an exercise program, change after brief use.

Materials and Methods: Thirty patients were allocated, matched on gender and age, to a control group (10) or an experimental group (20). After basic training, the experimental group was given a 15 min opportunity to use a Web-based telemedicine service. Patients' perceptions regarding the telemedicine service were measured using a questionnaire, based on the Technology Acceptance Model (TAM). This questionnaire was administered to both the control and experimental group before and after the experimental group's intervention. Both groups were compared with respect to any change in perceptions related to the Web-based telemedicine service.

Results: The experimental group showed a significantly greater change on the TAM constructs perceived usefulness [F(1,27)=3.40, p =0.08] and perceived ease of use [F(1,27)=5.37, p=0.03] than the control group, who showed no statistically significant change of perceptions. Patients within the experimental group became significantly more positive about the usefulness and ease-of-use of the Web-based telemedicine program after a brief period of use.

Conclusions: These findings show that brief use of a Web-based telemedicine service has a significant positive effect on patients' perceptions of this service. Therefore, as patients do not have prior experience with innovative telemedicine services, offering patients a risk-free way to explore and experiment with the service can increase the development of accurate perceptions and user needs. Ultimately, this will increase patients' acceptance of telemedicine. Future studies should investigate the effect of continued usage on patients' perceptions of telemedicine.

Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic

Eur J Heart Fail. 2011 Jul 6 Inglis SC, Clark RA, McAlister FA, Stewart S, Cleland JG. Preventative Health, Baker IDI Heart and Diabetes Institute and Faculty of Nursing, Midwifery and Health, University of Technology, Sydney, Australia.

AIMS: Telemonitoring (TM) and structured telephone support (STS) have the potential to deliver specialized management to more patients with chronic heart failure (CHF), but their efficacy is still to be proven. The aim of this meta-analysis was to review randomized controlled trials (RCTs) of TM or STS for all-cause mortality and all-cause and CHF-related hospitalizations in patients with CHF, as a non-invasive remote model of a specialized disease-management intervention.

METHODS AND RESULTS: We searched all relevant electronic databases and search engines, hand-searched bibliographies of relevant studies, systematic reviews, and meeting abstracts. Two reviewers independently extracted all data. Randomized controlled trials comparing TM or STS to usual care in patients with CHF were included. Studies that included intensified management with additional home or clinic-visits were excluded. Primary outcomes (mortality and hospitalizations) were analysed; secondary outcomes (cost, length of stay, and quality of life) were tabulated. Thirty RCTs of STS and TM were identified (25 peer-reviewed publications (n= 8323) and five abstracts (n= 1482)). Of the 25 peer-reviewed studies, 11 evaluated TM (2710 participants), 16 evaluated STS (5613 participants) with two testing both STS and TM in separate intervention arms compared with usual care. Telemonitoring reduced all-cause mortality {risk ratio (RR) 0.66 [95% confidence interval (CI) 0.54-0.81], P< 0.0001 }and STS showed a similar, but non-significant trend [RR 0.88 (95% CI 0.76-1.01), P= 0.08]. Both TM [RR 0.79 (95% CI 0.67-0.94), P= 0.008], and STS [RR 0.77 (95% CI 0.68-0.87), P< 0.0001] reduced CHF-related hospitalizations. Both interventions improved quality of life, reduced costs, and were acceptable to patients. Improvements in prescribing, patient-knowledge and self-care, and functional class were observed.

CONCLUSION: Telemonitoring and STS both appear effective interventions to improve outcomes in patients with CHF

Home blood pressure management and improved blood pressure control: results from a randomized controlled trial.

Arch Intern Med. 2011 Jul 11;171(13):1173-80. Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, Gentry PW, Rose C, Van Houtven C, Wang V, Goldstein MK, Oddone EZ. Health Services Research and Development, Durham Veterans Affairs Medical Center.

BACKGROUND: To determine which of 3 interventions was most effective in improving blood pressure (BP) control, we performed a 4-arm randomized trial with 18-month follow-up at the primary care clinics at a Veterans Affairs Medical Center.

METHODS: Eligible patients were randomized to either usual care or 1 of 3 telephone-based intervention groups: (1) nurse-administered behavioral management, (2) nurse- and physician-administered medication management, or (3) a combination of both. Of the 1551 eligible patients, 593 individuals were randomized; 48% were African American. The intervention telephone calls were triggered based on home BP values transmitted via telemonitoring devices. Behavioral management involved promotion of health behaviors. Medication management involved adjustment of medications by a study physician and nurse based on hypertension treatment guidelines.

RESULTS: The primary outcome was change in BP control measured at 6-month intervals over 18 months. Both the behavioral management and medication management alone showed significant improvements at 12 months-12.8% (95% confidence interval [CI], 1.6%-24.1%) and 12.5% (95% CI, 1.3%-23.6%), respectively-but not at 18 months. In subgroup analyses, among those with poor baseline BP control, systolic BP decreased in the combined intervention group by 14.8 mm Hg (95% CI, -21.8 to -7.8 mm Hg) at 12 months and 8.0 mm Hg (95% CI, -15.5 to -0.5 mm Hg) at 18 months, relative to usual care.

CONCLUSIONS: Overall intervention effects were moderate, but among individuals with poor BP control at baseline, the effects were larger. This study indicates the importance of identifying individuals most likely to benefit from potentially resource intensive programs.

Effectiveness of Home Telehealth in Comorbid Diabetes and Hypertension: A Randomized, Controlled Trial

TELEMEDICINE and e-HEALTH MAY 2011 Bonnie J. Wakefield, Ph.D., R.N.,1 John E. Holman, M.A.,1 Annette Ray, R.N.,1 Melody Scherubel, R.N.,1 Margaret R. Adams, ARNP, BC-ADM, C.D.E.,2 Stephen L. Hillis, Ph.D.,1,3 and Gary E. Rosenthal, M.D.1,4 1Department of Veterans Affairs (VA) Health Services Research and Development Center for Comprehensive Access & Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, Iowa. 2Iowa City Veterans Affairs Medical Center, Iowa City, Iowa. 3Department of Biostatistics, College of Public Health and 4Division of General Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa.

Background: Increased emphasis is being placed on the critical need to control hypertension (HTN) in patients with diabetes.

Objective: The objective of this study was to evaluate the efficacy of a nursemanaged home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN.

Design: A single-center, randomized, controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used.

Measurements: Primary outcomes were hemoglobin A1c and systolic blood pressure (SBP); secondary outcome was adherence.

Results: Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group, but 6 months after the intervention was withdrawn, the intervention groups were comparable with the control group. For SBP, the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months. Adherence improved over time for all groups, but there were no differences among the three groups.

Limitations: Subjects had relatively good baseline control for A1c and SBP; minorities and women were underrepresented.

Conclusions: Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention. Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness.

Telemonitoring in chronic obstructive airway disease and adult patients with cystic fibrosis.

J Telemed Telecare. 2011;17(3):127-32. Jarad NA, Sund ZM. Department of Respiratory Medicine, Level 4, Dolphin House, Bristol BS2 8HW, UK.

We compared the use of telemonitoring in patients with chronic obstructive pulmonary disease (COPD) and adult patients with cystic fibrosis (CF).

Seventy patients (51 CF and 19 COPD) were enrolled in two studies of six months' duration. Patients used a personal data assistant (PDA) attached to a spirometer to score symptoms and to perform daily spirometry. Criteria for diagnosis of exacerbations of COPD and CF were pre-defined. When exacerbations were detected, patients were offered treatment according to a pre-designed protocol.

Thirty-two (63%) CF patients and one (5%) COPD patient withdrew from the studies due to lack of adherence to daily recording. For those who remained in the study, COPD patients recorded more study days (139) than CF patients (113), P = 0.03. The median number of exacerbations detected during the study was greater in COPD than in CF patients, although this was not significant. The median number of device-detected exacerbations in the COPD group was significantly greater than in the CF group, P = 0.024. When compared to a parallel period in the previous year, the number of hospitalisations for COPD exacerbations was reduced, whereas the number of intravenous antibiotics in CF patients did not differ.

Adherence to telemonitoring was much greater for COPD than CF patients and the results appear to be more favourable for COPD patients than for CF patients.

Evaluation of a telemedicine system for heart failure patients: Feasibility, acceptance rate, satisfaction and changes in patient behavior Results from the CARME (CAtalan Remote Management Evaluation)

Eur J Cardiovasc Nurs. 2011 Mar 12 Domingo M, Lupón J, González B, Crespo E, López R, Ramos A, Urrutia A, Pera G, Verdú JM, Bayes-Genis A. Unitat d'Insuficiència Cardíaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Equipo de Atención Primaria Sant Roc, Institut Català de la Salut, Badalona, Barcelona, Spain; Unitat de Suport a la Recerca Metropolitana Nord, Institut d'Investigació en Atenció Primària Jordi Gol, Institut Català de la Salut, Spain.

BACKGROUND: Telemedicine can be useful for managing heart failure (HF), but patient acceptance of telemedicine and its impact on patient behavior are unclear.

AIMS: To assess a telemedicine program in a HF Unit.

METHODS AND RESULTS: This sub-analysis of the CARME study assessed the use of an interactive telemedicine platform. This prospective intervention study had a before/after design with HF patients randomized 1:1 into two groups: A) Motiva system (educational videos, motivational messages, and questionnaires); and B) Motiva system+telemonitoring of blood pressure, heart rate and weight. Of 211 patients screened, 44 were excluded, 62 did not consent to participate and 8 withdrew consent prior to installation of the system. The final study population included 97 patients. During 1year of follow-up, 22 patients voluntarily discontinued use of the system, 5 died (three after early discontinuation) and 5 withdrew consent before the last evaluation. A total of 15,017 questionnaires were sent to patients, with a median response rate of 88%. Satisfaction with the system and tools was high (median score 8.4/10), especially with the self-monitoring chart, scale and sphygmomanometer. Positive changes were observed in patient behavior, especially for blood pressure and weight control (p<0.001). After the study, 65% of the patients wished to continue with telemonitoring, particularly those in Group B (p=0.004).

CONCLUSION: Less than half of our patients participated in the telemedicine study. However, those who completed the study had confidence in the system, a high degree of satisfaction with the tools and positive behavioral changes.

Noninvasive remote telemonitoring for ambulatory patients with heart failure: effect on number of hospitalizations, days in hospital, and quality of life. CARME (CAtalan Remote Management Evaluation)

Rev Esp Cardiol. 2011 Apr;64(4):277-85. Domingo M, Lupón J, González B, Crespo E, López R, Ramos A, Urrutia A, Pera G, Verdú JM, Bayes-Genis A. Unitat d'Insuficiència Cardiaca, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.

INTRODUCTION AND OBJECTIVES: Multidisciplinary strategies for the management of heart failure (HF) improve outcomes. We aimed to evaluate the effectiveness of noninvasive home telemonitoring in ambulatory patients with HF already included in a structured multidisciplinary HF program.

METHODS: Prospective intervention study with before/after comparison design of an interactive telemedicine platform in HF patients, randomized 1:1 into two groups: A) Motiva System with educational videos, motivational messages, and questionnaires, and B) Motiva System + self monitoring of blood pressure, heart rate, and weight. Hospitalizations were compared over 12 months prior to and post study inclusion. Quality of life was evaluated using the generic EuroQoL visual analogue scale and the specific questionnaire Minnesota Living With Heart Failure Questionnaire.

RESULTS: There were 92 patients included (71% male; 66.3 ± 11.5 years; 71% ischemic aetiology). During real-time telemonitoring over 11.8 months (interquartile range 8.6-12), 14,730 questionnaires were administered with 89% median response rate. Hospitalizations for HF decreased by 67.8% (P = .010) and for other cardiac causes by 57.6% (P = .028). The number of days in hospital for HF decreased by 73.3% (P =.036), without statistically significant differences between groups, and for other cardiac causes by 82.9% (P =.008). The perception of quality of life improved significantly both for the generic scale (P < .001) and for the HF specific questionnaire (P=.005).

CONCLUSIONS: HF patients who used an interactive telehealth system with motivational support tools at home spent less time in hospital and felt their quality of life had significantly improved. No significant differences were observed between groups.

Patient preferences for a hospital-based rheumatology Interactive Health Communication Application and factors associated with these preferences.

Rheumatology (Oxford). 2011 May 6 van der Vaart R, Drossaert CH, Taal E, van de Laar MA. IBR Research Institute for Social Sciences and Technology, Department of Psychology, Health & Technology, University of Twente and Arthritis Centre Twente, Enschede, The Netherlands.

Objectives: To examine current disease-related Internet use and intentions to use various online support services on a hospital-based Interactive Health Communication Application (IHCA) of patients with rheumatic diseases. Furthermore, to examine which variables are associated with the intentions to use different services.

Methods: Questionnaires were sent to a random sample of 484 patients of a large hospital's rheumatology clinic: response was 47% (n = 227). Questions included socio-demographics, health characteristics, health literacy, patients' current disease-related Internet use and their intentions to use eight different support services: (i) information about disease and treatment; (ii) information about care and support; (iii) peer communication; (iv) e-consultation; (v) autonomous symptom monitoring; (vi) symptom monitoring with telemonitoring; (vii) self-management support; and (viii) access to their electronic medical records.

Results: Although most patients with Internet access had used it in relation to their disease (82%), Internet use was mainly limited to searching information. Many patients (45-68%), however, intended to use seven out of eight possible online services if offered on a hospital-based rheumatology IHCA. An exception was peer communication; only 11% intended to use this service. Of all the services, access to the electronic medical record was mostly preferred, followed by information provision. Demographics, health characteristics and health literacy did not show clear significant relationships with the reported intentions.

Conclusion: Results show that patients with rheumatic diseases are interested in online support from the hospital and that they intend to use an IHCA, if it is available. Clear associating variables with reported intentions to use the different services were not found.

A New Imaging and Data Transmitting Device for Telemonitoring of Diabetic Foot Syndrome Patients.

Diabetes Technol Ther. 2011 May 13 Foltynski P, Ladyzynski P, Migalska-Musial K, Sabalinska S, Ciechanowska A, Wojcicki J. Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences , Warsaw, Poland .

Background: Proper healing of ulcers and wounds on the feet of diabetes patients is important in order to prevent amputation. If the wound area reduction during the first 4 weeks of the treatment is not 40% or more, reevaluation of the treatment is necessary. The wound area evaluation is not complicated when the patient stays at a hospital, but when he or she goes home the physician does not have a tool allowing monitoring of the wound area.

Methods and Results: The aim of the present article is to present a new device able to take a wound picture and send it automatically to the database. This device, called the Patient's Module (PM), is also able to download data from the memories of blood pressure and blood glucose meters and send the data to the database. The PM is able to operate within the TeleDiaFoS system (developed earlier in collaboration with the Department and Clinic of Gastroenterology and Metabolic Diseases, Medical University of Warsaw, Warsaw, Poland) aimed at monitoring of treatment of patients with diabetic foot syndrome. The PM was tested on 10 type 2 diabetes patients during a 3-month period.

Conclusions: The study revealed that the PM can be used as a home telemonitoring device, and the analysis of the data sent from patient's home enables the assessment of wound healing progress, giving the physician the possibility for earlier change of the treatment if the wound area reduction is not satisfactory.

Telemonitoring Increases Patient Awareness of Health and Prompts Health-Related Action: Initial Evaluation of the TELE-ERA Study.

Telemed J E Health. 2011 May 25. Pecina JL, Vickers KS, Finnie DM, Hathaway JC, Hanson GJ, Takahashi PY. 1 Department of Family Medicine, Mayo Clinic , Rochester, Minnesota.

Introduction: Telemonitoring is being increasingly used for chronic disease monitoring. Understanding elderly patients' feelings and perspectives toward telemonitoring is important to minimize any barriers to implementation in this population.

Methods: Twenty Tele-Era Trial participants completed qualitative interviews assessing opinions about their telemonitoring experience. Participants also rated telemonitoring on burden, communication with clinicians, impact on medical condition knowledge, and confidence in using the monitor.

Results: On an average, participants rated telemonitoring as minimally burdensome, rated themselves confident in using the monitor, and positively rated telemonitoring for clinical communication. Qualitative analysis revealed a predominant theme that telemonitoring increases patient awareness of their health and also that telemonitoring prompts action.

Conclusion: Elderly patients find home telemonitoring to be an acceptable and satisfying experience that can increase their awareness of their health and provide a sense of safety in their home. Home telemonitoring can lead to earlier evaluation of decline in health status.

Automatic Identification of Apnea Through Acoustic Analysis for At-Home Screening.

Telemed J E Health. 2011 Jun 1. Nasu Y, Ashida N, Yamakawa M, Makimoto K, Tsuji M. 1 Department of Medical and Welfare Management, Koshien University , Takarazuka, Hyogo, Japan .

Objective: Although many studies have analyzed breathing sounds in the diagnosis of obstructive sleep apnea syndrome, the recording of snoring sounds at home is hampered by the various background noises of daily life. Recordings also frequently include talking during sleep, which may infringe the privacy of patients.

Materials and Methods: A recording system used a bone conduction microphone to record snoring sounds. This microphone reduced background noise. A simple system transmitted recorded breathing sound data for screening at a hospital as envelope data instead of complete sound recordings, thereby decreasing data volume and protecting privacy.

Results: In periods in which blood oxygen levels (SpO(2)) were drastically decreased, the probability of apnea as deduced from the envelope curve of breathing sounds was consistent with SpO(2) values.

Conclusions: This method provides a basis for telemonitoring of sleep apnea syndrome.

Integrating telecare for chronic disease management in the community: What needs to be done?

BMC Health Serv Res. 2011 May 27;11(1):131 May CR, Finch TL, Cornford J, Exley C, Gately C, Kirk S, Jenkings KN, Osbourne J, Robinson AL, Rogers A, Wilson R, Mair FS.

BACKGROUND: Telecare could greatly facilitate chronic disease management in the community, but despite government promotion and positive demonstrations its implementation has been limited. This study aimed to identify factors inhibiting the implementation and integration of telecare systems for chronic disease management in the community.

METHODS: Large scale comparative study employing qualitative data collection techniques: semi-structured interviews with key informants, task-groups, and workshops; framework analysis of qualitative data informed by Normalization Process Theory. Drawn from telecare services in community and domestic settings in England and Scotland, 221 participants were included, consisting of health professionals and managers; patients and carers; social care professionals and managers; and service suppliers and manufacturers.

RESULTS: Key barriers to telecare integration were uncertainties about coherent and sustainable service and business models; lack of coordination across social and primary care boundaries, lack of financial or other incentives to include telecare within primary care services; a lack of a sense of continuity with previous service provision and self-care work undertaken by patients; and general uncertainty about the adequacy of telecare systems. These problems led to poor integration of policy and practice.

CONCLUSION: Telecare services may offer a cost effective and safe form of care for some people living with chronic illness. Slow and uneven implementation and integration do not stem from problems of adoption. They result from incomplete understanding of the role of telecare systems and subsequent adaption and embeddedness to context, and uncertainties about the best way to develop, coordinate, and sustain services that assist with chronic disease management. Interventions are therefore needed that (i) reduce uncertainty about the ownership of implementation processes and that lock together health and social care agencies; and (ii) ensure user centred rather than biomedical/service-centred models of care.

Impact of Home Blood Pressure Telemonitoring and Blood Pressure Control: A Meta-Analysis of Randomized Controlled Studies.

Am J Hypertens. 2011 Jun 9. doi: 10.1038/ajh.2011.100. Omboni S, Guarda A. Italian Institute of Telemedicine, Varese, Italy.

Background: Home blood pressure telemonitoring figures among the possible solutions that could help improve blood pressure control of hypertensive patients. To summarize the effectiveness of home blood pressure telemonitoring on blood pressure control from randomized, controlled studies.

Methods: Electronic databases were searched for publications in English, reporting on randomized trials of home blood pressure telemonitoring vs. usual care. Outcome measures were office or ambulatory blood pressure changes, rate of blood pressure control, and number of antihypertensive drugs used by patients. A random effects model was applied.

Results: Twelve studies met inclusion criteria. A high level of heterogeneity was found among studies for all the variables explored. Office blood pressure was reduced significantly more in patients randomized to home telemonitoring (systolic: 5.64 (95% confidence interval: 7.92, 3.36) mm Hg; diastolic: 2.78 (3.93, 1.62) mm Hg; 11 comparisons, n = 4,389). The effect on ambulatory blood pressure was smaller than on office blood pressure (systolic: 2.28 (4.32, 0.24); diastolic: 1.38 (3.55, +0.79) mm Hg; 3 comparisons, n = 655). The relative risk of blood pressure normalization (<140/90 mm Hg nondiabetics and <130/80 mm Hg diabetics) in the telemonitoring vs. the usual care group was 1.31 (1.06, 1.62) (5 comparisons, n = 2,432 subjects). Use of telemonitoring was associated with a significantly increased use of antihypertensive medications (+0.22 (+0.02, +0.43), 5 comparisons, n = 1,991).

Conclusions: Home blood pressure telemonitoring may represent a useful tool to improve blood pressure control. However, heterogeneity of published studies suggests that well designed, large-scale, randomized, controlled studies are still needed to demonstrate the clinical usefulness of this technique.

Telecare is a valuable tool for hypertension management, a systematic review and meta-analysis.

Blood Press Monit. 2011 Jun;16(3):149-55. Verberk WJ, Kessels AG, Thien T.

There is an increasing interest for using telecare(TC) in the management of hypertension. A systematic review to the use of blood pressure (BP) measurement in TC has been performed (Medline/PubMed, Embase, and Cochrane Library), selecting randomized clinical trials that compared TC with usual care (UC) for hypertension management (treatment and/or coaching). Nine randomized clinical trials were selected (n=2501, 61.4±0.6 years, 42±2.7% males). Overall there was a significant larger decrease in the TC group than in the UC group for systolic (5.2±1.5 mmHg; P<0.001) and diastolic BP (2.1±0.8 mmHg; P<0.01). When studies were separated for antihypertensive treatment modification during the study (yes or no), systolic BP decrease difference between the TC and UC groups (ΔTC-ΔUC) tended to be significantly lower (5.1±2.9 mmHg lower) with treatment modification compared with nontreatment modification in which the ΔTC-ΔUC was 8.6±2.4 mmHg, P=0.07. TC led to a greater decrease in systolic and diastolic BP than UC. The differences between TC and UC for systolic BP tend to become larger when no treatment modification is applied.

TC seems a valuable tool for hypertension management.

Home-based integrated care in patients with COPD with the use of e-health services

G. Kontopirgias, T. Vontetsianos, P. Giovas, A. Rigopoulou, G. Mpirmpa, P. Giaboutdakis, T. Katsaras (Athens, Greece)

Aim: The aim of the study was the evaluation of clinical usefulness of an advanced e-health system in home-based rehabilitation, follow up and home hospitalization of patients with advanced stages of COPD.

Methods: Eighteen subjects (mean FEV1 0.73 L) with at least four admissions for COPD in the previous 2 years were treated at home for 1 year, after an initial out-patient rehabilitation phase. The system consisted of a specially designed electronic health record (HER) and a compilation of advanced telemedicine devises (spirometer, oximetry, ECG) for the transmission of patients‘ examinations from their homes to the hospital. Through the system the patients were able to undergo home tele-visits, with a real time video connection by the members of the rehabilitation team in the hospital on a regular or on emergency basis.

Results: During the first year, hospital days fell from 17.5 to 4 per patient as compared to the previous year. This was due to both, reduction of the number of admissions (from 2.1 to 0.4), as well as in the length of stay. Patients had a significant improvement in their quality of life (using CRQ), exercise tolerance (6 min walk test) and emotional status score.

Conclusion: It seems that the adoption of such systems in today's clinical practice can offer hospital-quality services at home resulting in improvement in patients' quality of life and significant cost savings.

E-Health services for home monitoring and rehabilitation in COPD patients (preliminary report with 6 months follow up)

T. A. Vontetsianos, P. G. Giovas, A. N. Rigopoulou, G. M. Mpirmpa, P. A. Giaboudakis, T. M. Katsaras, S. K. Contos (Athens, Greece; New Haven, United States Of America)

Aim: The aim of the study was the evaluation of clinical usefulness of an advanced e-health system in home-based rehabilitation and follow up of patients with advanced stages of COPD
Methods: Eighteen subjects (mean FEV1 0.73 L) with at least four admissions for COPD in the previous 2 years were followed up for 6 months after an initial preparation phase. The system consisted of a specially designed electronic health record (HER) and a compilation of advanced telemedicine devices (spirometer, oximetry ect.) for the transmission of patients’ examinations from their homes to the hospital. Through the system the patients were able to undergo home tele-visits, with real time video connection by the members of the rehabilitation team in the hospital, about once a month on a regular or emergency basis
Results: During the first 6 months of the program, the number of hospital days fell to 6 per patient from 14 in the correspondent time of the previous year. This was due to both, reduction of the number of admissions, as well as in the length of stay. The patients had a significant improvement in their quality-of-life, exercise tolerance and emotional status scores.
Conclusions: It seems that the adoption of such systems in clinical practice in our days with the explosive evolutions in e-health technologies, can result in significant cost savings and improvement in patients’ quality of life.

Blood pressure telemonitoring is useful to achieve blood pressure control in inadequately treated patients with arterial hypertension.

J Hum Hypertens. 2011 Jan 13. Neumann CL, Menne J, Rieken EM, Fischer N, Weber MH, Haller H, Schulz EG. Center of Nephrology Goettingen, Goettingen, Germany.

Failing to reach blood pressure (BP) goals is one of the main problems in hypertension management. Especially in high-risk patients, intensive monitoring including frequently office visits or new techniques to monitor home BP is required. A total of 60 patients with uncontrolled hypertension were included and randomized into a group with telemetric BP monitoring (TBPM) (n=30) and a control group receiving standard care (n=30). During the 3-month study period, patients received in addition to their antihypertensive pre-treatment up to 2 × 300 mg irbesartan to achieve the required target BP. All patients were instructed to measure their BP once daily in the morning. In the TBPM group automatic alerts were generated by the central database server using pre-defined algorithms and patients were subsequently contacted by the physician. At baseline mean 24-h ambulant BP monitoring (ABPM) was 143.3±11.1/82.6±9.9 mm Hg in the TBPM group and 141.4±12.6/82.1±6.5 mm Hg in the standard care group. During treatment mean systolic BP showed a more intensive decrease in the TBPM vs control group (-17.0±11.1 mm Hg vs -9.8±13.7 mm Hg; P=0.032). Patients in the TBPM group had a more pronounced night dipping and a higher reduction of mean pulse pressure than controls (-8.1±5.9 mm Hg vs -2.8±7.4 mm Hg, P=0.004). After 3 months, TBPM-treated patients were given a higher mean daily dose of irbesartan (375±187 mg vs 222±147 mg in controls; P=<0.001).

We demonstrated that with TBPM a more effective and faster titration of the antihypertensive agent is possible. The alarm criteria chosen were useful to improve BP control

The outcomes of gestational diabetes mellitus after a telecare approach are not inferior to traditional outpatient clinic visits.

Int J Endocrinol. 2010;2010:386941. Pérez-Ferre N, Galindo M, Fernández MD, Velasco V, Runkle I, de la Cruz MJ, Martín Rojas-Marcos P, Del Valle L, Calle-Pascual AL. Endocrinology and Nutrition Department, Hospital Clínico Universitario San Carlos, 28040 Madrid, Spain.

Objective: To evaluate the feasibility of a telemedicine system based on Internet and a short message service in pregnancy and its influence on delivery and neonatal outcomes of women with gestational diabetes mellitus (GDM).

Methods: 100 women diagnosed of GDM were randomized into two parallel groups, a control group based on traditional face-to-face outpatient clinic visits and an intervention group, which was provided with a Telemedicine system for the transmission of capillary glucose data and short text messages with weekly professional feedback. 97 women completed the study (48/49, resp.).

Main Outcomes Measured: The percentage of women achieving HbA1c values <5.8%, normal vaginal delivery and having a large for-gestational-age newborn were evaluated.

Results: Despite a significant reduction in outpatient clinic visits in the experimental group, particularly in insulin-treated women (2.4 versus 4.6 hours per insulin-treated woman resp.; P < .001), no significant differences were found between the experimental and traditional groups regarding HbA1c levels (all women had HbA1c <5.8% during pregnancy), normal vaginal delivery (40.8% versus 54.2%, resp.; P > .05) and large-for-gestational-age newborns (6.1% versus 8.3%, resp.; P > .05).

Conclusions: The system significantly reduces the need for outpatient clinic visits and achieves similar pregnancy, delivery, and newborn outcomes.

Evaluation of Data Display for Patient-Oriented Electronic Record of Anticoagulant Therapy

Telemedicine and e-Health. September 2010, 16(7): 799-806. doi:10.1089/tmj.2010.0025. Noemi Bitterman, D.Sc.,1 Eyal Lerner, M.Sc.,1 and Haim Bitterman, M.D.2 1Department of Industrial Design, Faculty of Architecture and Town Planning, Carmel Medical Center, Technion, Israel Institute of Technology, Haifa, Israel. 2Faculty of Medicine, Carmel Medical Center, Technion, Israel Institute of Technology, Haifa, Israel.

Objective: Our aim was to evaluate visualization methods for specific tasks performed with personal healthcare e-record systems for lay adults and older patients. We investigated common visualization methods for data entry and follow-up of personal and clinical information for self-control of blood coagulation functions.

Methods: Twenty-five old (72.2+-5.5 years) and 25 young (30.4+-4.9 years) participants completed tasks based on common scenarios, on experimental Web sites with hidden tracking programs. Functional parameters (time, accuracy), subjective parameters (preference, satisfaction), and physiological parameters (heart rate, skin temperature, sweat, respiratory rate, and muscle tension) monitored with miniature sensors were used.

Results: Total time for data entry and information follow-up were significantly longer for older compared with younger participants, with no significant differences in accuracy (errors), in stress-related physiological parameters, in preferences, or in satisfaction between age group. The Menu display was the significantly preferred configuration for data entry in both age groups, based on functional, physiological, and subjective criteria (p<0.05, Duncan test). The Calendar configuration was significantly preferred for mixed tasks of follow-up and information retrieval, in both age groups, based on functional, physiological, and subjective criteria (p<0.05, Duncan test).

Conclusions: Our study supports equal capabilities of old and young people to use interactive healthcare systems for management of chronic diseases and further encourages using physiological, functional, and subjective methods for evaluating personal healthcare records.

Patient self-management support: novel strategies in hypertension and heart disease.

Cardiol Clin. 2010 Nov;28(4):655-63. Bosworth HB, Powers BJ, Oddone EZ. Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, HSR&D (152), Suite 600, 411 West Chapel Hill Street, Durham, NC 27701, USA; Division of General Internal Medicine, Department of Medicine, Duke University, 2424 Erwin Road, Hock Plaza, Durham, NC 27703, USA.

Cardiovascular diseases (CVDs) have become the leading cause of death and disability in most countries in the world. This article addresses how patient self-management is a crucial component of effective high-quality health care for hypertension and CVD. The patient must be a collaborator in this process, and methods of improving patients' ability and confidence for self-management are needed. Successful self-management programs have often supplemented the traditional patient-physician encounter by using nonphysician providers, remote patient encounters (telephone or Internet), group settings, and peer support for promoting self-management. Several factors need to be considered in self-management.

Given the health care system's inability to achieve several quality indicators using traditional office-based physician visits, further consideration is needed to determine the degree to which these interventions and programs can be integrated into primary care, their effectiveness in different groups, and their sustainability for improving chronic disease care.

Public health in an era of personal health records: opportunities for innovation and new partnerships.

J Med Internet Res. 2010 Aug 10;12(3):e33. Bonander J, Gates S. National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Atlanta, GA 30341, USA.

In the near future, citizens will be able to control and manage their own health information through electronic personal health record systems and tools. The clinical benefits of this innovation, such as cost savings, error reduction, and improved communication, have been discussed in the literature and public forums, as have issues related to privacy and confidentiality. Receiving little attention are the benefits these will have for public health. The benefits and potential for innovation are broad and speak directly to core public health functions such as health monitoring, outbreak management, empowerment, linking to services, and research. Coupled with this is a new relationship with citizens as key partners in protecting and promoting the public's health.

A systematic review of economic analyses of telehealth services using real time video communication.

BMC Health Serv Res. 2010 Aug 10;10:233. Wade VA, Karnon J, Elshaug AG, Hiller JE. Discipline of Public Health, The University of Adelaide, North Tce,, Adelaide, 5005, Australia.

BACKGROUND: Telehealth is the delivery of health care at a distance, using information and communication technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase access in health care delivery. This systematic review assesses the economic value of one type of telehealth delivery - synchronous or real time video communication - rather than examining a heterogeneous range of delivery modes as has been the case with previous reviews in this area.

METHODS: A systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in June 2009. Studies with patient outcome data and a non-telehealth comparator were included. Cost analyses, non-comparative studies and those where patient satisfaction was the only health outcome were excluded.

RESULTS: 36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of care was more important in determining the value of the service than the clinical discipline, the type of technology, or the date of the study.

CONCLUSION: Delivery of health services by real time video communication was cost-effective for home care and access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for local delivery of services between hospitals and primary care.

Mobile Real-Time Data Acquisition System for Application in Preventive Medicine

Telemedicine and e-Health. May 2010, 16(4): 504-509. Sebastian Neubert, Dagmar Arndt, Kerstin Thurow, Regina Stoll

In this article, the development of a system for online monitoring of a subject's physiological parameters and subjective workload regardless of location has been presented, which allows for studies on occupational health. In the sector of occupational health, modern acquisition systems are needed. Such systems can be used by the subject during usual daily routines without being influenced by the presence of an examiner. Moreover, the system's influence on the subject should be reduced to a minimum to receive reliable data from the examination. The acquisition system is based on a mobile handheld (or smart phone), which allows both management of the communication process and input of several dialog data (e.g., questionnaires). A sensor electronics module permits the acquisition of different physiological parameters and their online transmission to the handheld via Bluetooth. The mobile handheld and the sensor electronics module constitute a wireless personal area network. The handheld allows the first analysis, the synchronization of the data, and the continuous data transfer to a communication server by the integrated mobile radio standards of the handheld. The communication server stores the incoming data of several subjects in an application-dependent database and allows access from all over the world via a Web-based management system. The developed system permits one examiner to monitor the physiological parameters and the subjective workload of several subjects in different locations at the same time. Thereby the subjects can move almost freely in any area covered by the mobile network. The mobile handheld allows the popping-up of the questionnaires at flexible time intervals. This electronic input of the dialog data, in comparison to the manual documentation on papers, is more comfortable to the subject as well as to the examiner for an analysis. A Web-based management application facilitates a continuous remote monitoring of the physiological and the subjective data of the subject.

Goal Setting Using Telemedicine in Rural Underserved Older Adults with Diabetes: Experiences from the Informatics for Diabetes Education and Telemedicine Project

Telemedicine and e-Health. May 2010, 16(4): 405-416. Susan P. West, Carina Lagua, Paula M. Trief, Roberto Izquierdo, Ruth S. Weinstock.

Objective: To describe the use of telemedicine for setting goals for behavior change and examine the success in achieving these goals in rural underserved older adults with diabetes.

Materials and Methods: Medicare beneficiaries with diabetes living in rural upstate New York who were enrolled in the telemedicine intervention of the Informatics for Diabetes Education and Telemedicine (IDEATel) project (nhttp://www.liebertonline.com/na101/home/literatum/publisher/mal/journals/entities/2009.gif=http://www.liebertonline.com/na101/home/literatum/publisher/mal/journals/entities/2009.gif610) participated in home televisits with nurse and dietitian educators every 4–6 weeks for 2–6 years. Behavior change goals related to nutrition, physical activity, monitoring, diabetes health maintenance, and/or use of the home telemedicine unit were established at the conclusion of each televisit and assessed at the next visit.

Results: Collaborative goal setting was employed during 18,355 televisits (mean of 33 goal-setting televisits/participant). The most common goals were related to monitoring, followed by diabetes health maintenance, nutrition, exercise, and use of the telemedicine equipment. Overall, 68% of behavioral goals were rated as “improved” or “met.” The greatest success was achieved for goals related to proper insulin injection technique and daily foot care. These elderly participants had the most difficulty achieving goals related to use of the computer. No gender differences in goal achievement were observed.

Conclusion: Televisits can be successfully used to collaboratively establish behavior change goals to help improve diabetes self-management in underserved elderly rural adults.

Remote Health Monitoring Using Mobile Phones and Web Services

Telemedicine and e-Health. June 2010, 16(5): 603-607. Sparsh Agarwal, Chiew Tong Lau

Diabetes and hypertension have become very common perhaps because of increasingly busy lifestyles, unhealthy eating habits, and a highly competitive workplace. The rapid advancement of mobile communication technologies offers innumerable opportunities for the development of software and hardware applications for remote monitoring of such chronic diseases. This study describes a remote health-monitoring service that provides an end-to-end solution, that is, (1) it collects blood pressure readings from the patient through a mobile phone; (2) it provides these data to doctors through a Web interface; and (3) it enables doctors to manage the chronic condition by providing feedback to the patients remotely. This article also aims at understanding the requirements and expectations of doctors and hospitals from such a remote health-monitoring service.

Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial.

Lancet. 2010 Jul 7. McManus RJ, Mant J, Bray EP, Holder R, Jones MI, Greenfield S, Kaambwa B, Banting M, Bryan S, Little P, Williams B, Hobbs FR. Primary Care Clinical Sciences, University of Birmingham and National Institute for Health Research (NIHR) National School for Primary Care Research, Birmingham, UK.

BACKGROUND: Control of blood pressure is a key component of cardiovascular disease prevention, but is difficult to achieve and until recently has been the sole preserve of health professionals. This study assessed whether self-management by people with poorly controlled hypertension resulted in better blood pressure control compared with usual care. METHODS: This randomised controlled trial was undertaken in 24 general practices in the UK. Patients aged 35-85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension. Participants were randomly assigned in a 1:1 ratio to self-management, consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs, combined with telemonitoring of home blood pressure measurements or to usual care. Randomisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex, baseline systolic blood pressure, and presence or absence of diabetes or chronic kidney disease. Neither participants nor investigators were masked to group assignment. The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point (6 months and 12 months). All randomised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis, without imputation for missing data. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN17585681. FINDINGS: 527 participants were randomly assigned to self-management (n=263) or control (n=264), of whom 480 (91%; self-management, n=234; control, n=246) were included in the primary analysis. Mean systolic blood pressure decreased by 12.9 mm Hg (95% CI 10.4-15.5) from baseline to 6 months in the self-management group and by 9.2 mm Hg (6.7-11.8) in the control group (difference between groups 3.7 mm Hg, 0.8-6.6; p=0.013). From baseline to 12 months, systolic blood pressure decreased by 17.6 mm Hg (14.9-20.3) in the self-management group and by 12.2 mm Hg (9.5-14.9) in the control group (difference between groups 5.4 mm Hg, 2.4-8.5; p=0.0004). Frequency of most side-effects did not differ between groups, apart from leg swelling (self-management, 74 patients [32%]; control, 55 patients [22%]; p=0.022). INTERPRETATION: Self-management of hypertension in combination with telemonitoring of blood pressure measurements represents an important new addition to control of hypertension in primary care.

Cell Phone-Based Interactive Self-Care System Improves Asthma Control.

Eur Respir J. 2010 Jun 18 Liu WT, Huang CD, Wang CH, Lee KY, Lin SM, Kuo HP. Chang Gung Memorial Hospital, Chang Gung University College of Medicine Taipei, Taiwan.

The self-management of asthma can improve clinical outcomes. Recently, cellular phones have been widely used as an efficient, instant personal communication tool. This study investigated whether the self-care system will achieve better asthma control through a cell phone-based interactive program. This was a prospective, controlled study in the outpatient clinics.

From 120 consecutive patients with moderate to severe persistent asthma, 89 were eventually recruited for the study, with 43 in the cell phone group (with a cell phone-based interactive asthma self-care system). In the cell phone group, the mean PEFR significantly increased at 4 (378.2+/-9.3 L.min(-1), n=43, p=0.020), 5 (378.2+/-9.2 L.min(-1), n=43, p=0.008), and 6 months (382.7+/-8.6 L.min(-1), n=43, p=0.001) compared to the control group. The predicted FEV1 value significantly increased at 6 months (65.2+/-3.2%, n=43, p<0.05). Patients in the cell phone group had better QOL in terms of SF-12((R)) PCS after 3 months and fewer episodes of exacerbation and unscheduled visits than the control group. Patients in the cell phone group significantly increased their mean daily dose of either systemic or inhaled corticosteroids than in the control group.

The cell phone-based interactive self-care system provides a convenient and practical self-monitoring and self-management of asthma, and improves asthma control.

Implementation of Telemedicine and Stroke Network in Thrombolytic Administration: Comparison Between Walk-in and Referred Patients.

Neurocrit Care. 2010 Apr 22. Dharmasaroja PA, Muengtaweepongsa S, Kommarkg U. Division of Neurology, Faculty of Medicine, Thammasat University, Klong 1, Klong Luang, Pathumthani, 12120, Thailand

BACKGROUND: The purpose of this study was to evaluate the efficacy and safety of implementation of telemedicine and the Thammasat Stroke Network model in treating acute ischemic stroke patients with intravenous thrombolysis.

METHODS: Telemedicine (telephone consultation and tele-radiology) has been used in acute ischemic stroke management since June, 2007. The Thammasat Stroke Network (TSN) was effectively organized in March, 2008. Thammasat Hospital served as a "hub" hospital, with 25 "spoke" hospitals in the TSN. The main outcome measures included favorable outcome of the patients treated with intravenous tissue plasminogen activator (tPA) at 3 months and symptomatic intracerebral hemorrhage by comparison between walk-in patients and the patients who were referred by the TSN.

RESULTS: There were 14 patients (14 out of 170 acute ischemic stroke patients, 8%) and 110 patients (110 out of 406 patients, 27%) receiving tPA, before and after implementation of TSN, respectively. Walk-in patients (66 patients) had significant shorter onset-to-treatment duration as compared with referred patients (58 patients) (130 vs. 170 min, P < 0.0001). However, there was no significant difference in favorable outcome (48 vs. 42%, P = 0.538) and rate of symptomatic intracerebral hemorrhage (3 vs. 2%, P = 0.637).

CONCLUSION: Implementation of telemedicine and TSN markedly increased tPA administrations, without compromising favorable and safety outcomes.

TECNOB: study design of a randomized controlled trial of a multidisciplinary telecare intervention for obese patients with type-2 diabetes.

BMC Public Health. 2010 Apr 23;10(1):204. Castelnuovo G, Manzoni GM, Cuzziol P, Cesa GL, Tuzzi C, Villa V, Liuzzi A, Petroni ML, Molinari E.

BACKGROUND: Obesity is one of the most important medical and public health problems of our time: it increases the risk of many health complications such as hypertension, coronary heart disease and type 2 diabetes, needs long-lasting treatment for effective results and involves high public and private costs. Therefore, it is imperative that enduring and low-cost clinical programs for obesity and related co-morbidities are developed and evaluated.

METHODS: TECNOB (TEChnology for OBesity) is a comprehensive two-phase stepped down program enhanced by telemedicine for the long-term treatment of obese people with type 2 diabetes seeking intervention for weight loss. Its core features are the hospital-based intensive treatment (1-month), that consists of diet therapy, physical training and psychological counseling, and the continuity of care at home using new information and communication technologies (ICT) such as internet and mobile phones. The effectiveness of the TECNOB program compared with usual care (hospital-based treatment only) will be evaluated in a randomized controlled trial (RCT) with a 12-month follow-up. The primary outcome is weight in kilograms. Secondary outcome measures are energy expenditure measured using an electronic armband, glycated hemoglobin, binge eating, self-efficacy in eating and weight control, body satisfaction, healthy habit formation, disordered eating-related behaviors and cognitions, psychopathological symptoms and weight-related quality of life. Furthermore, the study will explore what behavioral and psychological variables are predictive of treatment success among those we have considered.

DISCUSSION: The TECNOB study aims to inform the evidence-based knowledge of how telemedicine may enhance the effectiveness of clinical interventions for weight loss and related type-2 diabetes, and which type of obese patients may benefit the most from such interventions. Broadly, the study aims also to have a effect on the theoretical model behind the traditional health care service, in favor of a change towards a new 'health care everywhere' approach

The Heart of the Matter. About Good Nursing and Telecare.

Health Care Anal. 2010 Jan 10. Pols J. Department of General Practice, Section of Medical Ethics, Academic Medical Centre (AMC) Amsterdam, Postbox 22700, 1100 DE, Amsterdam, The Netherlands,

Nurses and ethicists worry that the implementation of care at a distance or telecare will impoverish patient care by taking out 'the heart' of the clinical work. This means that telecare is feared to induce the neglect of patients, and to possibly hinder the development of a personal relation between nurse and patient.

This study aims to analyse whether these worries are warranted by analysing Dutch care practices using telemonitoring in care for chronic patients in the Netherlands. How do clinical practices of nursing change when telecare devices are introduced and what this means for notions and norms of good nursing?

The paper concludes that at this point the practices studied do not warrant the fear of negligence and compromised relations. Quite the contrary; in the practices studied, telecare lead to more frequent and more specialised contacts between nurses and patients.

The paper concludes by reflecting on the ethical implications of these changes.

Managing Heart Failure Patients After Formal Homecare

Telemedicine and e-Health. December 2009, 15(10): 983-991. doi:10.1089/tmj.2009.0064. Kathryn Dansky, Ph.D., and Joseph Vasey, Ph.D. Department of Health Policy and Administration, Pennsylvania State University, University Park, Pennsylvania

The aim of this study was to determine whether using a teleheath system after discharge from formal home health services would improve clinical outcomes and self-management behaviors.

Patients were recruited from 10 home health agencies (HHAs) across the United States. All patients used the Health Buddy telehealth system during formal home health services. Patients were randomly assigned to either the telehealth group or the control group upon discharge from the HHA. Patients in the telehealth group used the Health Buddy for an additional 180 days; patients in the control group received no further telehealth or home health services.

Results show that patients who continued using telehealth beyond the formal episode of care showed greater improvements in respiratory status and activities of daily living. None of the patients who used telehealth during this stage had any hospitalizations or Emergency Department (ED) events, while 28.3% of the control group patients required hospitalization and 26.1% had at least one ED visit. Telehealth patients were more likely to report that they measured their weights daily, and were more likely to report an increase in diuretic dose following sudden weight gain, ankle swelling, or shortness of breath.

We conclude that patients with heart failure may benefit from continued use of telehealth following formal home health services. Results of this study will inform managers and clinicians who are responsible for integrating telehealth into chronic disease protocols.

Tertiary Teledermatology: A Systematic Review

Telemedicine and e-Health. doi:10.1089/tmj.2009.0020 Job P. van der Heijden, M.Sc., Phyllis I. Spuls, M.D., Ph.D., Frans P. Voorbraak, Ph.D., Nicolet F. de Keizer, Ph.D., Leonard Witkamp, M.D., Ph.D., and Jan D. Bos, M.D., Ph.D. Department of Dermatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.

Telemedicine is becoming widely used in healthcare. Dermatology, because of its visual character, is especially suitable for telemedicine applications. Most common is teledermatology between general practitioners and dermatologists (secondary teledermatology). Another form of the teledermatology process is communication among dermatologists (tertiary teledermatology). The objective of this systematic review is to give an overview of studies on tertiary teledermatology with emphasis on the categories of use. A systematic literature search on tertiary teledermatology studies used all databases of the Cochrane Library, MEDLINE (1966–November 2007) and EMBASE (1980–November 2007). Categories of use were identified for all included articles and the modalities of tertiary teledermatology were extracted, together with technology, the setting the outcome measures, and their results. The search resulted in 1,377 publications, of which 11 were included. Four categories of use were found: getting an expert opinion from a specialized, often academic dermatologist (6/11); resident training (2/11); continuing medical education (4/11); and second opinion from a nonspecialized dermatologist (2/11). Three modalities were found: a teledermatology consultation application (7/11), a Web site (2/11), and an e-mail list (1/11). The majority (7/11) used store-and-forward, and 3/11 used store-and-forward and real-time. Outcome measures mentioned were learning effect (6), costs (5), diagnostic accuracy (1), validity (2) and reliability (2), patient and physician satisfaction (1), and efficiency improvement (3).

Tertiary teledermatology's main category of use is getting an expert opinion from a specialized, often academic dermatologist. Tertiary teledermatology research is still in early development. Future research should focus on identifying the scale of tertiary teledermatology and on what modality of teledermatology is most suited for what purpose in communication among dermatologists.

Telemedicine for Recently Discharged Older Patients

Telemedicine and e-Health. 10.1089/tmj.2009.0058. Lavoisier Cardozo, M.D., F.A.C.P., and Joel Steinberg, M.D. Division of Geriatric Medicine and The Geriatric Center of Excellence, Wayne State University, School of Medicine and The Detroit Medical Center, Detroit, Michigan.

Congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension are common causes of hospitalization in the elderly. Short-term postdischarge clinical outcomes regarding compliance, symptom control, readmission, functional status, and mortality rates are in need of improvement. This observational study documents the results of a home-based case-managed telemedicine (CMTM) program delivered over a 2-month period postdischarge. A population of 851, predominantly elderly (over age 60), recently discharged patients were enrolled in the program. They received a nurse visit up to 3 times/week and home telemedicine monitoring (weight, blood pressure, pulse rate, blood glucose, and oximeter recordings) on a daily basis. Patient education was provided by the nurse and reinforced through telemedicine. Compliance rates, quality of life parameters, patient satisfaction with telemedicine, and data regarding nine quality of care measures (QCM), hospital readmission, and mortality rates were documented. Patient demographics and outcomes of care were analyzed. There were 68% females and 56% African Americans. The readmission rate was 13% and mortality 2%. Treatment goals were met in 67%, patient compliance rate was 77%, and the average improvement in the nine QCM indicators was 66%.

A majority of patients showed improved quality of health perception, better disease understanding, and high satisfaction rates with telemedicine. This is one of the larger observational studies in a predominantly elderly patient population enrolled in a CMTM program, to date. This model of care was well accepted by the elderly and produced excellent short-term clinical outcomes.

Internet-Based Self-management Plus Education Compared With Usual Care in Asthma

Annals of Internal Medicine 151(2):110-120, 21 July 2009 Victor van der Meer, MD; Moira J. Bakker, RN; Wilbert B. van den Hout, PhD; Klaus F. Rabe, MD, PhD; Peter J. Sterk, MD, PhD; Job Kievit, MD, PhD; Willem J.J. Assendelft, MD, PhD; and Jacob K. Sont, PhD, for the SMASHING (Self-Management in Asthma Supported by Hospitals, ICT, Nurses and General Practitioners) Study Group

Background: The Internet may support patient self-management of chronic conditions, such as asthma.

Objective: To evaluate the effectiveness of Internet-based asthma self-management.

Design: Randomized, controlled trial.

Setting: 37 general practices and 1 academic outpatient department in the Netherlands.

Patients: 200 adults with asthma who were treated with inhaled corticosteroids for 3 months or more during the previous year and had access to the Internet.

Measurements: Asthma-related quality of life at 12 months (minimal clinically significant difference of 0.5 on the 7-point scale), asthma control, symptom-free days, lung function, and exacerbations.

Intervention: Participants were randomly assigned by using a computer-generated permuted block scheme to Internet-based self-management (n = 101) or usual care (n = 99). The Internet-based self-management program included weekly asthma control monitoring and treatment advice, online and group education, and remote Web communications.

Results: Asthma-related quality of life improved by 0.56 and 0.18 points in the Internet and usual care groups, respectively (adjusted between-group difference, 0.38 [95% CI, 0.20 to 0.56]). An improvement of 0.5 point or more occurred in 54% and 27% of Internet and usual care patients, respectively (adjusted relative risk, 2.00 [CI, 1.38 to 3.04]). Asthma control improved more in the Internet group than in the usual care group (adjusted difference, –0.47 [CI, –0.64 to –0.30]). At 12 months, 63% of Internet patients and 52% of usual care patients reported symptom-free days in the previous 2 weeks (adjusted absolute difference, 10.9% [CI, 0.05% to 21.3%]). Prebronchodilator FEV1 changed with 0.24 L and –0.01 L for Internet and usual care patients, respectively (adjusted difference, 0.25 L [CI, 0.03 to 0.46 L]). Exacerbations did not differ between groups.

Limitation: The study was unblinded and lasted only 12 months.

Conclusion: Internet-based self-management resulted in improvements in asthma control and lung function but did not reduce exacerbations, and improvement in asthma-related quality of life was slightly less than clinically significant.

Home hospitalization unit: an alternative to standard inpatient hospitalization from the emergency department.

Eur J Emerg Med. 2009 Jun;16(3):121-3. Salazar A, Estrada C, Porta R, Lolo M, Tomas S, Alvarez M. Hospital Mutua De Terrassa, Terrassa, Spain.

OBJECTIVE: To assess the characteristics of the patients admitted to a home hospitalization unit (HHU) after a first emergency department (ED) visit.

METHODS: This was a descriptive, retrospective study. The setting of the study was the ED of a 500-bed teaching hospital, which treats 125 000 emergency visits per year. HHU admits patients from the ED when hospitalization is imminent. Participants were all patients attending our ED from 1 January 2005 to 31 December 2005 and finally admitted to HHU. Variables were age, sex, diagnostic, mean length of stay, and readmission rate.

RESULTS: A cohort composed of 250 patients admitted to HHU directly from the ED was identified. Mean age was 75 years. One hundred and fifty-eight were males (63%). The most common diagnoses were acute exacerbation of chronic obstructive pulmonary disease (127 of 250 patients, 50.8%), acute exacerbation of chronic heart failure (32 of 250 patients, 12.8%), pneumonia (24 of 250 patients, 9.6%), urinary tract infection (20 of 250 patients, 8%), and leg deep venous thrombosis (14 of 250 patients, 5.6%). Mean length of stay was 8 days. Readmission rate was 9%.

CONCLUSION: A HHU proved to be effective and safe for acutely ill individuals who required hospitalization.

Home blood pressure monitoring: a new standard method for monitoring hypertension control in treated patients.

Nat Clin Pract Cardiovasc Med. 2008 Dec;5 (12):762-3. Pickering TG. Behavioral Cardiovascular Health and Hypertension Program, Columbia Presbyterian Medical Center, New York, NY 10032, USA.

Inadequate blood pressure (BP) control in patients with treated hypertension can be influenced by patient behavior, the inaccuracy of BP measurement in the clinical setting, and the fact that no single class of medication is universally effective. Home BP monitoring (HBPM) enables accurate measurement of BP and has been recommended (by multiple societies and associations) for the diagnosis of hypertension and the evaluation of antihypertensive treatment.

Although HBPM is thought to improve BP control as a result of patients' increased adherence to their medication, this improvement is limited. Green et al. have shown that HBPM in combination with regular internet correspondence with a medical professional is a highly effective therapeutic strategy for BP control, possibly because this strategy is associated with an increase in number of prescriptions. This strategy should, therefore, be routinely used in the management of patients with hypertension.

Remote daily real-time monitoring in patients with COPD - A feasibility study using a novel device.

Respir Med. 2009 Apr 15. Sund ZM, Powell T, Greenwood R, Jarad NA. Department Respiratory Medicine, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK.

New technologies have allowed remote real-time electronic recording of symptoms and spirometry. The feasibility of utilising this technology in COPD patients has not been investigated. This is a feasibility study. The primary objective is to determine whether the use of an electronic diary with a portable spirometer can be performed by COPD patients with a moderate to severe disease. Secondary objectives are to investigate the value of this method in early detection of acute exacerbations of COPD (AECOPD). In this 6-month study, 18 patients recorded daily their symptom score and spirometry. Data was sent on real time. AECOPD which was defined according to pre-set criteria were noted. Spirometry values and scores for health-related quality of life were compared between the start and the end of the study. Hospitalisation rate due to AECOPD was compared with a parallel period in the previous year. On average, patients were able to record 77% of their total study days. The system detected 73% of AECOPD. In further 27% of AECOPD patients sought treatment although the change in symptoms did not meet AECOPD definition. The number of COPD-related hospitalisations significantly reduced compared to the previous year. There was a significant increase in FEV(1) and FVC from the start to the end of the study. The remote monitoring device used in this study can be used in COPD patients. AECOPD was detected early in the majority of cases. Hospitalisation rate due to AECOPD was reduced and FEV(1) and FVC values increased during the study.

Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project.

Age Ageing. 2009 Mar;38(2):219-25 Trief PM, Teresi JA, Eimicke JP, Shea S, Weinstock RS. Department of Psychiatry, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY 13210, USA.

BACKGROUND: with increasing prevalence of diabetes in older people, it is important to understand 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 randomised 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.

Office spirometry can improve the diagnosis of obstructive airway disease in primary care setting.

Respir Med. 2009 Feb 4. Averame G, Bonavia M, Ferri P, Moretti AM, Fogliani V, Cricelli C, Canonica GW, Grassi C, Paggiaro PL, Rossi A; on behalf of the “Alliance Project” Study Group. MedicaLink s.r.l., Genova, Italy.

INTRODUCTION: Spirometry may reveal pre-clinical abnormal airway function in asymptomatic subjects and allow a better definition of severity in clinically diagnosed asthma and COPD. The hypothesis of this study was that telespirometry might increase the diagnostic accuracy of asthma and COPD.

METHODS: In the Italian "Alliance" study, 638 general practitioners (GPs) were trained to perform telespirometry and were asked to enrol the following categories of subjects: (a) current or ex-smokers without respiratory symptoms; (b) subjects with respiratory symptoms but without a pre-existing diagnosis of asthma or COPD; (c) subjects with a pre-existing clinical diagnosis of asthma; and (d) subjects with a pre-existing clinical diagnosis of COPD. Subjects completed a case report form (CRF) and performed telespirometry in the GP's office. Traces were sent by telephone to a Telespirometry Central Office, where they were interpreted by a pulmonary specialist, according to appropriately defined criteria. The results were returned in real time to the GP.

RESULTS: Overall, 9312 subjects were recruited and 7262 (78%) performed an acceptable telespirometric examination and the CRF. In the asymptomatic group, 340/1437 (24%) of the telespirometries were abnormal (147 with moderate-to-severe airway obstruction, i.e. FEV(1) <80% of predicted). Among symptomatic subjects, 1433/3725 (38%) had abnormal telespirometries (682 with moderate-to-severe obstruction). Of the asthmatic subjects, 336/1285 (26%) had moderate-to-severe airway obstruction, while telespirometry was normal in 184/815 (23%) of the COPD group.

CONCLUSION: Telespirometry, performed in a GP's office, can aid the diagnosis of obstructive airway diseases and could help GPs to better manage airway obstruction.

Substitutive Hospital at Home for older persons: effects on costs.

Am J Manag Care. 2009 Jan;15(1):49-56. Frick KD, Burton LC, Clark R, Mader SI, Naughton WB, Burl JB, Greenough WB, Steinwachs DM, Leff B. Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA.

OBJECTIVE: To compare the cost of substitutive Hospital at Home care versus traditional inpatient care for older patients with community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, exacerbation of congestive heart failure, or cellulitis.

STUDY DESIGN: Prospective nonrandomized clinical trial involving 455 community-dwelling older patients in 3 Medicare managed care health systems and at a Department of Veterans Affairs medical center.

METHODS: Costs were analyzed across all patients, within each of the separate health systems, and by condition. Generalized linear models controlling for confounders and using a log link and gamma family specification were used to make inferences about the statistical significance of cost differences. t Tests were used to make inferences regarding differences in follow-up utilization.

RESULTS: The costs of the Hospital at Home intervention were significantly lower than those of usual acute hospital care (mean [SD], $5081 [$4427] vs $7480 [$8113]; P <.001). Laboratory and procedure expenditures were lower across all study sites and at each site individually. There were minimal significant differences in health service utilization between the study groups during the 8 weeks after the index hospitalization. As-treated analysis results were consistent with Hospital at Home costs being lower.

CONCLUSIONS: Total costs seem to be lower when substitutive Hospital at Home care is available for patients with congestive heart failure or chronic obstructive pulmonary disease. This result may be related to the study-based requirement for continuous nursing input. Savings may be possible, particularly for care of conditions that typically use substantial laboratory tests and procedures in traditional acute settings.

Home blood pressure telemonitoring improves hypertension control in general practice. The TeleBPCare study.

J Hypertens. 2009 Jan;27(1):198-203. Parati G, Omboni S, Albini F, Piantoni L, Giuliano A, Revera M, Illyes M, Mancia G; TeleBPCare Study Group. Department of Cardiology, San Luca Hospital, Instituto Auxologico Italiano, Milan, Italy.

BACKGROUND: Self blood pressure monitoring at home may improve blood pressure control and patients' compliance with treatment, but its implementation in daily practice faces difficulties. Teletransmission facilities may offer a more efficient approach to long-term home blood pressure monitoring.

METHODS: Twelve general practitioners screened 391 consecutive uncontrolled mild-moderate hypertensive patients (80% treated), 329 of whom (58 +/- 11 years, 54% men) were randomized to either usual care on the basis of office blood pressure (group A, n = 113) or to integrated care on the basis of teletransmitted home blood pressure (group B, n = 216). Twenty-four-hour ambulatory blood pressure monitoring was performed at baseline and after 6 months, during which treatment was optimized according to either office (group A) or home (group B) blood pressure values. We compared differences between groups in the rate of daytime ambulatory blood pressure normalization (<130/80 mmHg), need of treatment changes during follow-up, quality of life scores, and healthcare costs.

RESULTS: Baseline office blood pressures were 149 +/- 12/89 +/- 9 and 148 +/- 13/89 +/- 7 mmHg in groups A (n = 111) and B (n = 187) respectively, the corresponding daytime values being 140 +/- 11/84 +/- 8 and 139 +/- 11/84 +/- 8 mmHg. The percentage of daytime blood pressure normalization was higher in group B (62%) than in group A (50%) (P < 0.05). There were less frequent treatment changes in group B than in group A (9 vs. 14%, P < 0.05). Quality of life tended to be higher and costs lower in group B.

CONCLUSION: Patients' management based on home blood pressure teletransmission led to a better control of ambulatory blood pressure than with usual care, with a more regular treatment regimen.

Impact of disease management on utilization and adherence with drugs and tests: the case of diabetes treatment in the Florida: a Healthy State (FAHS) program.

Diabetes Care. 2008 Sep;31(9):1717-22. Thiebaud P, Demand M, Wolf SA, Alipuria LL, Ye Q, Gutierrez PR. Pfizer Health Solutions, New York, New York, USA.

OBJECTIVE: The purpose of this study was to evaluate the effect of telephonic care management within a diabetes disease management program on adherence to treatment with hypoglycemic agents, ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), statins, and recommended laboratory tests in a Medicaid population.

RESEARCH DESIGN AND METHODS: A total of 2,598 patients with diabetes enrolled for at least 2 years in Florida: A Healthy State (FAHS), a large Medicaid disease management program, who received individualized telephonic care management were selected if they were eligible for at least 12 months before and 12 months after beginning care management. Patients were matched one-to-one on all baseline characteristics to 2,598 control patients. The impact of care management on utilization and adherence rates for diabetes-related medications and tests was analyzed with the difference-in-difference estimator.

RESULTS: Changes in utilization were evaluated separately for those who were characterized as adherent to treatment at baseline ("users") and those who were not ("nonusers"). Both groups achieved significant improvement in adherence between baseline and follow-up. Nonusers increased their overall hypoglycemic use by 0.7 script (P < 0.001), by 0.7 script for ACEIs and statins (both P < 0.001), by 0.8 test for A1C (P < 0.001), and by 0.7 test for lipids (P < 0.001). Users increased hypoglycemic use by 1.5 scripts (P < 0.001) and insulin use by 0.9 script (P < 0.001).

CONCLUSIONS: The FAHS telephonic care management intervention effectively induced Medicaid patients with diabetes to begin treatment and improved adherence to oral hypoglycemic agents and recommended tests. It also substantially improved adherence among baseline insulin users.

The value of provider-to-provider telehealth.

Telemed J E Health. 2008 Jun;14(5):446-53 Pan E, Cusack C, Hook J, Vincent A, Kaelber DC, Bates DW, Middleton B. Division of General Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachussetts, USA.

Telehealth has great potential to improve access to care, but its adoption in routine healthcare has been slow. The lack of clarity about the value of telehealth implementations has been one reason cited for this slow adoption. The Center for Information Technology Leadership has examined the value of telehealth encounters in which there is a provider both with the patient and at a distance from the patient.

We considered three models of telehealth: store-and-forward, real-time video, and hybrid systems. Evidence from the literature was extrapolated using a computer simulation, which found that the hybrid model was the most cost effective. The simulation predicted savings of $4.3 billion per year if hybrid telehealth systems were implemented in emergency rooms, prisons, nursing home facilities, and physician offices across the United States.

We also conducted a sensitivity analysis to determine which factors most influence costs and savings. Payers, providers, and policymakers should work together to remove the barriers to the adoption of telehealth so that this cost savings can be realized in the U.S. healthcare system.

Patients' perceptions of a home telecare system.

Int J Med Inform. 2008 Jul;77(7):486-98. Rahimpour M, Lovell NH, Celler BG, McCormick J. Graduate School of Biomedical Engineering, University of New South Wales, Sydney, NSW 2052, Australia.

GOAL: To identify any major factors that could affect patients' perceptions of a Home Telecare Management System (HTMS) and use the findings to contribute to development of a theoretical framework for patient acceptance of HTMS.

MATERIALS AND METHODS: Ten Focus Group Interviews (FGIs) were conducted with patients suffering from congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or both, from seven different ethnic groups in Sydney. Six key discussion points were used to conduct the FGIs. The participants were shown a video demonstrating the HTMS and its operation, followed by the demonstration of an HTMS prototype. The participants, who had no prior experience with the HTMS, were then asked questions to access their perceptions in potentially real situations. The discussions were audio-taped and content analysis performed.

RESULTS: Four major themes and 16 sub-themes were identified. The themes were: intention to use the HTMS, the impact of the HTMS on patients' health management, concerns associated with using the HTMS, and the impact of the HTMS on healthcare services.

CONCLUSION: Most participants perceived the system as a useful and convenient mode of health care delivery, expressed positive attitudes toward the HTMS and expressed intent to use the system. However, there were concerns centred on the issues of cost, ease of use, clinical support, low self-efficacy and anxiety related to the use of the HTMS. The findings of this study suggest that HTMS self-efficacy and anxiety are likely to be important constructs in patients' acceptance of home telecare. Therefore, we propose these two factors be included in future HTMS acceptance models. Also it is suggested that in order to develop training programs for patients to use HTMS, tailored training components should aim to reduce 'HTMS anxiety' and improve 'HTMS self-efficacy'. Participants agreed that the HTMS would save cost and time by reducing hospital admissions, emergency department and medical practitioner visits and associated travel. Participants generally agreed that the HTMS could inform patients of their health conditions, thus promoting active participation in their health management and empowering them to perform better self-care. Also, they agreed that the HTMS could improve their health management by their doctors by providing more accurate and up-to-date information, to help them make better decisions. They suggested that the HTMS could have a preventative role in terms of providing early warning when their health conditions were deteriorating, which could lead to on-time appropriate interventions. The latter may result in reducing the use of emergency services and hospital admissions.

The use of telecare for people with chronic obstructive pulmonary disease: implications for management.

J Nurs Manag. 2008 Mar;16(2):173-80. Horton K. Centre for Research in Nursing and Midwifery Education, Division of Health and Social Care, Faculty of Health and Medical Sciences, University of Surrey, Surrey, UK

AIM: To evaluate the telecare service offered by Home Care teams to patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND: The use of telecare aims to support older people in remaining independent at home, reducing hospital admissions and improving the quality of life for older people and their informal carers. In the redesign of managed care for people with COPD using telecare, an evaluation of the implementation process is necessary.

METHOD: A focus group with Home Care teams and social care staff was conducted. Six case studies identified by nursing staff were used to examine key issues relating to telecare implementation.

FINDINGS: The experience and expectation in telecare, the usability of equipment, and changes in practice can impact on COPD care. Case studies highlight that the rapid access to care, an increased sense of personal safety and security, and the continuity of care are perceived as benefits. However, the equipment was perceived as not 'user friendly' and bulky.

CONCLUSION: It is important that any service redesign to include telecare is evaluated and targeted at its specific role.

IMPLICATIONS FOR NURSING MANAGEMENT: Partnership working has to be negotiated, and leadership roles include addressing tensions and motivation within the team.

Effectiveness of telecare in elderly populations-a comparison of three settings.

Telemed J E Health. 2008 Mar;14(2):164-9. Onor ML, Trevisiol M, Urciuoli O, Misan S, Bertossi F, Tirone G, Aguglia E, Pascolo-Fabrici E. Department of Clinical, Morphological and Technological Sciences, U.C.O. of Clinical Psychiatry, University of Trieste, Italy

The primary aim of this study was to assess the level of satisfaction with 3 types of formal care systems of the elderly: (1) a day care center, (2) a nursing home, and (3) telecare service in a group of oldest frail elderly, and to describe the characteristics of the population using the services. The study involved a population of 162 oldest elderly using 3 different types of formal care services. Study participants were asked to complete a questionnaire, investigating socio-demographic characteristics and degree of overall satisfaction with the service, as well as eliciting possible suggestions for improvement.

In our study, nearly all subjects using the telecare service were satisfied or very satisfied (98.5%), as compared to 75.3% of those residing in a nursing home, and 76.5% of those attending the day care center. This result confirms the findings of previous studies on elderly subjects satisfaction with telecare services. Telecare, therefore, seems to be the service achieving the greatest levels of satisfaction, a service that can also be used by low-income subjects, by whom it is also perceived as a source of social support.

Electronic Alerts Versus On-Demand Decision Support to Improve Dyslipidemia Treatment

A Cluster Randomized Controlled Trial Circulation. 2008;117:371-378 Jacobus T. van Wyk, MD, PhD, MSc, BComm; Marc A.M. van Wijk, MD, PhD; Miriam C.J.M. Sturkenboom, PharmD, PhD, MSc; Mees Mosseveld, MSc; Peter W. Moorman, MD, PhD; Johan van der Lei, MD, PhD From the Departments of Medical Informatics and Epidemiology and Biostatistics, ErasmusMC University Medical Center Rotterdam, Rotterdam, the Netherlands.

Background — Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system. However, randomized trials comparing these methods in a clinical setting are lacking. We studied the effect of both alerting and on-demand decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners.

Methods and Results — In a clustered randomized trial design, 38 Dutch general practices (77 physicians) and 87 886 of their patients (39 433 men 18 to 70 years of age and 48 453 women 18 to 75 years of age) who used the ELIAS electronic health record participated. Each practice was assigned to receive alerts, on-demand support, or no intervention. We measured the percentage of patients screened and treated after 12 months of follow-up. In the alerting group, 65% of the patients requiring screening were screened (relative risk versus control=1.76; 95% confidence interval, 1.41 to 2.20) compared with 35% of patients in the on-demand group (relative risk versus control=1.28; 95% confidence interval, 0.98 to 1.68) and 25% of patients in the control group. In the alerting group, 66% of patients requiring treatment were treated (relative risk versus control=1.40; 95% confidence interval, 1.15 to 1.70) compared with 40% of patients (relative risk versus control=1.19; 95% confidence interval, 0.94 to 1.50) in the on-demand group and 36% of patients in the control group.

Conclusion — The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners

Delivering expert cardiac support in the community.

Paynter M. Emergency Care, Bridgwater Community Hospital. Br J Community Nurs. 2007 Oct;12(10):460-2.

This article outlines how cardiac problems can be assessed in the primary care environment, improving patient care and helping alleviate some of the operational and financial burdens on secondary and emergency care providers. It examines the approach that Bridgwater Community Hospital took in monitoring and managing cardiac conditions within primary care.

By opting for a cardiac telemedicine service, clinicians get fast, expert interpretation of ECG results, enabling them to deliver timely and more effective, preventative care, as well as delivering clear cost benefits across the trust, and ensuring healthcare resources are optimized.

Self-measurement and self-titration in hypertension a pilot telemedicine study

Am J Hypertens. 2007 Dec;20(12):1314-20.
Bobrie G, Postel-Vinay N, Delonca J, Corvol P; SETHI Investigators.
Department of Hypertension, Hôpital Européen Georges Pompidou, Paris, France.

BACKGROUND: Because of poor patient compliance and clinical inertia, hypertension control rates remain poor. Home blood-pressure measurements (HBPM) improve compliance of patients and achievement of blood pressure (BP) targets. However, few studies have evaluated self-BP management by patients.

METHODS: In a multicenter, prospective, single-group, open-label pilot study of 111 patients whose hypertension was uncontrolled despite monotherapy, we studied satisfaction with, and feasibility of, HBPM and self-titration of antihypertensive treatment using telemedicine for compliance, efficacy, and safety. After education (protocol, action plan, and use of the HBPM device), patients performed a sequence of HBPM every 2 weeks for 8 weeks. Following a stepwise approach, treatment was increased by the patient at weeks 4 and 6 if average HBPM values exceeded predefined limits. For each titration, the patient informed the Core Center by telemedicine, but BP values were transferred automatically.

RESULTS: Overall, 80% of patients were satisfied (58%) or very satisfied (23%) with the program (95% confidence interval, 73% to 87%). Regarding compliance, 78% of patients fully complied with self-measurement, and just over 71% titrated their treatment adequately. Physicians were satisfied (52%) or very satisfied (22%) with the program. Between the first and final visits (at week 8), office systolic/diastolic BP (mean +/- SD) decreased significantly from 151 +/- 9/91 +/- 6 to 143 +/- 13/84 +/- 11 mmHg. During the trial, HBPM (mean +/- SD) decreased significantly from 149 +/- 13/86 +/- 12 to 138 +/- 16/81 +/- 10 mmHg. No significant safety issues were reported.

CONCLUSIONS: This innovative approach to the management of hypertension, combining self-measurement and self-titration, is feasible, well-accepted by both patients and physicians, and safe.

A national survey of telemedicine in the Republic of Ireland.

J Telemed Telecare. 2007;13(7):348-51.
Maher L, Craig A, Menezes G.
Division of Radiation Therapy, School of Medicine, Trinity College, Dublin, Ireland.

We conducted a national survey of hospitals in the Republic of Ireland to assess their use of telemedicine. Information was sought from 187 hospitals and replies were received from 157, a response rate of 84%. Activity was identified in a total of 40 hospitals (25% of the respondents). The main disciplines using telemedicine were radiology, pathology, neurosurgery, oncology and paediatrics, and the main applications were teleradiology (25 hospitals), videoconferencing (16) and telepathology (5). Dublin, the capital city, was found to act as a centre for telemedicine activity for the whole country. A number of regional networks had developed in the east, but the pattern of development in the west was very different where there were mainly isolated links. One fully operational national network was found but this was only used for consultation in one discipline (neurosurgery). It appears that the development of telemedicine in the Republic of Ireland has been unplanned. A national telemedicine strategy might lead to an integrated national network in the future, which could help to provide more equitable access to health care.

Hypertension Intervention Nurse Telemedicine Study (HINTS): testing a multifactorial tailored behavioral/educational and a medication management intervention for blood pressure control.

Am Heart J. 2007 Jun;153(6):918-24.
Bosworth HB, Olsen MK, McCant F, Harrelson M, Gentry P, Rose C, Goldstein MK, Hoffman BB, Powers B, Oddone EZ.
Center for Health Services Research in Primary Care, Durham VAMC, Durham, NC 27705, USA.

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 randomized controlled trial using home BP telemedicine monitoring.

METHODS: A sample of hypertensive patients with poor BP control at baseline (N = 600) are randomized 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 standard telephone lines. The tailored behavioral intervention involves promoting adherence with medication and health behaviors. Patients randomized to the medication management or the combined arm have their hypertension regimen changed by the study team using a validated 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

Telecardiology for patients with acute or chronic cardiac complaints: The 'SHL' experience in Israel and Germany.

Int J Med Inform. 2006 Jun 7 Roth A, Korb H, Gadot R, Kalter E. Tel Aviv Sourasky Medical Center, Department of Cardiology, Tel Aviv, Israel.

OBJECTIVE: To assess the impact of a telemedicine program in which electrocardiogram (EKG), body weight and/or blood pressure are measured at home and medically trained personnel judge the transmitted data and council the patients by telephone.

METHOD: We systematically studied the outcome and cost-effectiveness of the cardiac programs carried out by Shahal (SHL) during the past 19 years.

RESULT: Most patients (85%) with acute complaints resembling coronary artery disease, could be reassured, representing a savings of about euro 677.000 per 10,000 members/yr in Israel in 1989, and a marked reduction in patient delay to 44min (median). In chronic heart failure a 66% reduction in hospitalisation days was observed, together with an improvement in quality of life. A large Healthcare Insurance Company in Germany (Taunus BKK) has calculated that it can save at least euro 5 million per year with the use of such services.

CONCLUSION: Disease management with concomitant telemedicine for coronary artery disease and chronic heart failure is safe and effective and has a huge potential for cost savings, improvements in quality of life and in prognosis of heart disease.

Efficacy of telephone and mail intervention in patient compliance with antihypertensive drugs in hypertension. ETECUM-HTA study.

Blood Press. 2005;14(3):151-8.
Contreras EM, Garcia OV, Claros NM, Guillen VG, de la Figuera von Wichmann M, Martinez JJ, Fernandez R.
Centro de Salud la Orden, Huelva, Spain.

OBJECTIVE: To study the efficacy of telephone and mail intervention in therapeutic compliance among patients with mild to moderate hypertension.

DESIGN: A prospective controlled multicenter clinical trial.

SETTING: Eighty-five primary care centers in Spain, with a duration of 6 months.

PATIENTS: A total of 636 patients with newly diagnosed or uncontrolled hypertension were included. Interventions. The patients were randomized and distributed between the following groups: (i) control (CG) - under routine clinical management; (ii) mail intervention (MIG) - received a mailed message reinforcing compliance and reminding of the visits (15 days, 2 and 4 months); (iii) telephone intervention (TIG) - received a telephone call at 15 days, then at 7 and 15 weeks.

MAIN OUTCOME MEASURE: Five visits were scheduled, with the measurement of blood pressure and counting of tablets. Compliers were defined as subjects showing 80-110% drug consumption. Calculations were made of mean percentage compliance (MPC) and compliers, mean blood pressure and percentage controlled subjects.

RESULTS: Five hundred and thirty-eight patients completed the study (261 males); 85.5% were compliers (CI = 82.5-88.5; n = 460). The MPC was 95.1+/-19.6% (CI = 93.28-96.92). The CG consisted of 182 individuals, MIG = 172 and TIG = 184. Compliers represented 69.2% of the CG (CI 62.5-75.9%), 91.3% (CI = 87.1-95.5) of the MIG (p = 0.0001) and 96.2% of the TIG (CI 93.5-98.9%); the final MPC was 89.6%+/-15 in CG, 96.6%+/-12 in MIG and 99.1+/-26.8 in TIG (p = 0.0001). The percentage of controlled subjects was 47.2% in CG (CI = 40-54.4), 61.3% in MIG (CI = 54.1-68.5%) and 63.3% in TIG (CI = 56.4-70.2%) (p<0.05).

CONCLUSIONS: TIG and MIG are effective measures for improving patient compliance in hypertension.

Daily usage and efficiency of remote home monitoring in hypertensive patients over a one-year period.

J Telemed Telecare. 2005;11 Suppl 1:34-6. Port K, Palm K, Viigimaa M. Curonia Research, Tallinn, Estonia.

We evaluated daily self-monitored blood pressure (BP) data collected over one year using remote home monitoring. Fifty treated, moderately hypertensive subjects (26 males, mean age 50 years; 17 females, mean age 54 years; seven exclusions) were recruited for the study in which semi-automatic arm-cuff BP measurement devices were used. The daily self-monitoring regimen had two phases of usage: one of initial enthusiasm (the first one to two months) followed by a phase of lower usage (89% versus 64%, P<0.01). Monitoring was missed more often (P < 0.01) during weekends (7.3 instances per patient) compared with workdays (5.0). Lack of motivation was not considered to be a major barrier. Approximately half of the study population was willing to continue the trial at the end of the one-year study. The occurrence of extreme BP values dropped significantly after the initial study month (P = 0.02). In conclusion, routine remote BP monitoring is capable of collecting consistent and accurate data, with sufficient sensitivity to reveal trends.

Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the TEN-HMS study.

J Am Coll Cardiol. 2005 May 17;45(10):1654-64 Cleland JG, Louis AA, Rigby AS, Janssens U, Balk AH; TEN-HMS Investigators. Department of Cardiology, University of Hull, Kingston Upon Hull, United Kingdom.

OBJECTIVES: We sought to identify whether home telemonitoring (HTM) improves outcomes compared with nurse telephone support (NTS) and usual care (UC) for patients with heart failure who are at high risk of hospitalization or death.

BACKGROUND: Heart failure is associated with a high rate of hospitalization and poor prognosis. Telemonitoring could help implement and maintain effective therapy and detect worsening heart failure and its cause promptly to prevent medical crises.

METHODS: Patients with a recent admission for heart failure and left ventricular ejection fraction (LVEF) <40% were assigned randomly to HTM, NTS, or UC in a 2:2:1 ratio. HTM consisted of twice-daily patient self-measurement of weight, blood pressure, heart rate, and rhythm with automated devices linked to a cardiology center. The NTS consisted of specialist nurses who were available to patients by telephone. Primary care physicians delivered UC. The primary end point was days dead or hospitalized with NTS versus HTM at 240 days.

RESULTS: Of 426 patients randomly assigned, 48% were aged >70 years, mean LVEF was 25% (SD, 8) and median plasma N-terminal pro-brain natriuretic peptide was 3,070 pg/ml (interquartile range 1,285 to 6,749 pg/ml). During 240 days of follow-up, 19.5%, 15.9%, and 12.7% of days were lost as the result of death or hospitalization for UC, NTS, and HTM, respectively (no significant difference). The number of admissions and mortality were similar among patients randomly assigned to NTS or HTM, but the mean duration of admissions was reduced by 6 days (95% confidence interval 1 to 11) with HTM. Patients randomly assigned to receive UC had higher one-year mortality (45%) than patients assigned to receive NTS (27%) or HTM (29%) (p = 0.032).

CONCLUSIONS: Further investigation and refinement of the application of HTM are warranted because it may be a valuable role for the management of selected patients with heart failure.

The use of a telematic connection for the follow-up of hypertensive patients improves the cardiovascular prognosis.

J Hypertens. 2005 Jul;23(7):1417-1423. De Luca N, Izzo R, Iaccarino G, Malini PL, Morisco C, Rozza F, Iovino GL, Rao MA, Bodenizza C, Lanni F, Guerrera L, Arcucci O, Trimarco B.

BACKGROUND: Inadequate blood pressure (BP) control could be due to incorrect management of hypertensives caused by the lack of interaction between general practitioners (GP) and hypertension specialists.

OBJECTIVES: To test the effectiveness on BP and total cardiovascular risk (TCVR) control of an internet-based digital network connecting specialists and GPs.

METHODS: We created a network among the Hypertension Clinic, Federico II University (Naples, Italy), 23 hospital-based hypertension clinics and 60 GPs from the area (CampaniaSalute Network, CS). Randomized GPs enrolled in CS could update online records of patients (n = 1979). As a control, we included 2045 patients referred to the specialist clinics by GPs from outside the network. All patients completed a 2-year follow-up.

RESULTS: CS provided a larger reduction in BP [systolic/diastolic BP (SBP/DBP): 7.3 +/- 0.4/5.4 +/- 0.3 versus 4.1 +/- 0.4/3.1 +/- 0.26 mmHg, CS versus control; P < 0.001 for both] and percentage of patients with BP < 140/90 mmHg (CS versus control: baseline, 33 versus 34%, NS; end of follow-up, 51 versus 47%, chi = 13.371; P < 0.001). A European Society of Hypertension-European Society of Cardiology (ESH/ESC) TCVR score was calculated [from 1 (average) to 5 (very high TCVR)]. The CS group showed a reduction in the mean TCVR score (CS: from 3.5 +/- 0.02 to 3.2 +/- 0, P < 0.01, ANOVA; control group: 3.5 +/- 0.03 to 3.4 +/- 0.03, NS) and, accordingly, fatal and non-fatal major cardiovascular events (MACE) were less frequent (2.9 versus 4.3%; chi = 5.047, P < 0.02). CS predicts fewer MACE in multiple binary regression analysis (beta:-7.27, P < 0.008) reducing the risk for MACE compared to control [odds ratio (OR): 0.838; 95% confidence interval (CI): 0.73-0.96].

CONCLUSION: Our results support the idea that telemedicine can achieve better control of BP and TCVR.

Improving asthma control through telemedicine: a study of short-message service.

Telemed J E Health. 2005 Spring;11(1):28-35.
Ostojic V, Cvoriscec B, Ostojic SB, Reznikoff D, Stipic-Markovic A, Tudjman Z. Division of Clinical Immunology and Pulmonology, Department for Internal Diseases, General Hospital "Sveti Duh," Zagreb, Croatia.

Home peak expiratory flow (PEF) measurement is recommended by asthma guidelines. In a 16-week randomized controlled study on 16 subjects with asthma (24.6 6.5 years old, asthma duration small ze, Cyrillic 6 months), we examined Global System for Mobile Communications (GSM) mobile telephone short-message service (SMS) as a novel means of telemedicine in PEF monitoring.

All subjects received asthma education, self-management plan, and standard treatment. All measured PEF three times daily and kept a symptom diary. In the study group, therapy was adjusted weekly by an asthma specialist according to PEF values received daily from the patients. There was no significant difference between the groups in absolute PEF, but PEF variability was significantly smaller in the study group (16.12 6.93% vs. 27.24 10.01%, p = 0.049). forced expiratory flow in 1 second (FEV(1); % predicted) in the study group was slightly but significantly increased (81.25 17.31 vs. 77.63 14.80, p = 0.014) and in the control group, unchanged (78.25 = 21.09 vs. 78.88 = 22.02, p = 0.497). Mean FEV1 was similar in the two groups both before and after the study.

Controls had significantly higher scores for cough (1.85 0.43 vs. 1.42 0.28, p < 0.05) and night symptoms (1.22 0.23 vs. 0.85 0.32, p < 0.05). There was no significant difference between the groups in daily consumption of inhaled medicine, forced vital capacity, or compliance. Per patient, per week, the additional cost of follow-up by SMS was 1.67 (equivalent to approximately $1.30 per 1 Euro), and SMS transmission required 11.5 minutes.

Although a study group of 40 patients is needed for the follow-up study to achieve the power of 80% within the 95% confidence interval, we conclude that SMS is a convenient, reliable, affordable, and secure means of telemedicine that may improve asthma control when added to a written action plan and standard follow-up.

Feasibility of Collecting Diary Data From Asthma Patients Through Mobile Phones and SMS: Evaluation From a Pilot Study

J Med Internet Res 2004 (Dec 2); 6(4):e42 Jacob Anhoej, Claus Moeldrup

Background: Self-management of asthma may improve asthma outcomes. The Internet has been suggested as a tool for the monitoring and self-management of asthma. However, in a recent study we found that a Web interface had some disadvantages and that users stopped using the application after a short while.

Objective: The primary objective of this study was to evaluate, from a user perspective, the feasibility of using short message service (SMS) for asthma diary data collection through mobile phones. The secondary objective was to investigate patient compliance with an SMS diary, as measured by response rates over time.

Methods: The study included quantitative response rate data, based on SMS collection, and qualitative data from a traditional focus group setting. In a period of 2 months, the participants received 4 SMS messages each day, including a medication reminder, a request to enter peak flow, data on sleep loss, and medication dosage. Participants were asked to reply to a minimum of 3 of the messages per day. Diary inputs were collected in a database and the response rate per patient was expressed as the number of diary inputs (SMS replies) divided by diary requests (product of number of days in the study and the number of diary questions per day) for each participant. After the study period, the participants were invited to a focus group interview addressing the participants' attitudes to their disease, their experience with the SMS asthma diary, and their future expectations from the SMS asthma diary. Results: Twelve patients with asthma (6 males, 6 females) participated in the data collection study. The median age was 38.5 (range: 13 - 57) years. The median response rate per patient was 0.69 (range: 0.03 - 0.98), ie, half the participants reported more than about two thirds of the requested diary data. Furthermore, response rates were relatively steady during the study period with no signs of decreasing usage over time. From the subsequent focus group interview with 9 users we learned that, in general, the participants were enthusiastic about the SMS diary - it became an integrated part of their everyday life. However, the participants wished for a simpler diary with only one SMS message to respond to and a system with a Web interface for system customization and graphical display of diary data history.

Conclusion: This study suggests that SMS collection of asthma diary data is feasible, and that SMS may be a tool for supporting the self-management of asthma (and possibly other chronic diseases) in motivated and self-efficacious patients because mobile phones are a part of people's everyday lives and enable active requests for data wherever the patient is. The combination of SMS data collection and a traditional Web page for data display and system customization may be a better and more usable tool for patients than the use of Web-based asthma diaries which suffer from high attrition rates.

THE IMPACT OF TELEMEDICINE ON PATIENTS' COST SAVINGS: SOME PRELIMINARY FINDINGS

Telemed J E Health. 2003 Winter;9(4):361-7. Bynum AB, Irwin CA, Cranford CO, Denny GS. Rural Hospital Program, and Program Development, Arkansas Area Health Education Center (AHEC) Program, Little Rock, Arkansas, USA.

This study evaluated patients' cost savings in a telehealth project at the University of Arkansas for Medical Sciences' (UAMS) during 1998-2002. Differences in patients' cost savings from telemedicine were assessed by gender, age, ethnicity, education, occupation, annual household income, health insurance status, and household and community size. Variables examined for patients' cost savings included travel distance for medical care, missed days at work, and family expenses. The study population consisted of self-selected telemedicine patients in rural Arkansas (N = 410 consults).

Results suggest that without telemedicine, 94% of patients would travel greater than 70 miles for medical care; 84% would miss one day of work; and 74% would spend $75-$150 for additional family expenses. With telemedicine, 92% of patients saved $32 in fuel costs; 84% saved $100 in wages; and 74% saved $75-$150 in family expenses. Patients living alone (p < 0.001) and in smaller rural communities (p = 0.002) were significantly more likely to miss one day of work without telemedicine than patients with larger households and those residing in larger rural communities. Females (p = 0.040) and patients with a annual household income over $25,000 (p = 0.005) were significantly more likely to have family expenses over $150 without telemedicine than males and patients with a household income of $25,000 or less.

HOME TELEMONITORING FOR PATIENTS WITH SEVERE RESPIRATORY ILLNESS: THE ITALIAN EXPERIENCE

J Telemed Telecare 2003;9(2):67-71 Maiolo C; Mohamed EI; Fiorani CM; De Lorenzo A Division of Respiratory Diseases, A & C Cartoni Hospital, Rocca Priora, Rome

We investigated the feasibility of telemonitoring services for patients with severe respiratory illness. In the first phase of the study, patients were observed and treated using face-to-face medical visits for 12 months. In the second phase of the study, the patients were monitored at home for 12 months, during which time determinations of arterial oxygen saturation and heart rate were performed twice a week, and the data were automatically transmitted to the hospital's processing centre via a normal telephone line. Thirty patients on long-term oxygen therapy were enrolled in the study; 23 completed the 12 months of home telemonitoring.

The numbers of hospital admissions and of acute home exacerbations during the telemonitoring phase of the study decreased by 50% and 55%, respectively, in comparison with the first phase. Estimates of hospitalization costs for the patients during the second phase were approximately 17% lower than those for the first phase. Patients were satisfied with the quality of the personal telemonitoring process in 96% of cases.

We believe that telemedicine can enable the provision of high-quality home care for patients with severe respiratory illness

TELEMEDICINE IMPROVES DIAGNOSIS OF ESSENTIAL HYPERTENSION COMPARED WITH USUAL CARE

Author(s): Mary A M Rogers ; Debra A Buchan ; David Small ; Christine M Stewart ; Barbara E Krenzer Source: Journal of Telemedicine and Telecare Volume: 8 Number: 6 Page: 344 – 349

A randomized 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 standard for assessment of true hypertension status was 24 h ambulatory blood pressure monitoring. A total of 74 patients from outpatient clinics were randomized 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

CAN A DISEASE SELF-MANAGEMENT PROGRAM REDUCE HEALTH CARE COSTS? THE CASE OF OLDER WOMEN WITH HEART DISEASE

Med Care 2003 Jun;41(6):706-15
Wheeler JR Department of Health management and Policy, School of Public Health, University of Michigan, Ann Arbor 48109, USA.

BACKGROUND: There is increasing interest in the potential for chronic disease self-management interventions to provide health benefits while reducing health care costs.

OBJECTIVES: To assess the impact of a heart disease management program on use of hospital services; to estimate associated hospital cost savings; and to compare potential cost savings with the cost of delivering the program.

RESEARCH DESIGN: Randomized, controlled study design. Data were collected from hospital billing records during a 36 month period. Multivariate models were used to compare health care use with cost between treatment and control groups. Estimated differences were then compared with the program costs to determine cost-effectiveness.

SUBJECTS: Participants were recruited from 6 hospital sites. Screening criteria included: female, 60 years or older, diagnosed cardiac disease, and seen by a physician approximately every 6 months. The study included 233 women in the intervention group and 219 in the control group. The "Women Take PRIDE" program utilizes a self-regulation process for addressing a problematic area of the heart regimen recommended by each woman's physician. It is tailored to the unique needs of older women.

MEASURES: Hospital admissions, in-patient days, emergency department visits.

RESULTS: Program participants experienced 46% fewer in-patient days (P <0.05) and 49% lower in-patient costs (P <0.10) than women in the control group. No significant differences in emergency department utilization were found. Hospital cost savings exceeded program costs by a ratio of nearly 5-to-1.

CONCLUSIONS: A heart disease self-management program can reduce health care utilization and potentially yield monetary benefits to a health plan.

CHILDREN'S MEDICAL SERVICES PEDIATRIC DIABETES TELEHEALTH PROJECT: COST AVOIDANCE DATA

Authors: Dubault, R., Molinari, S., Sloyer, P., and Wood, B.M. In: Telemedicine Journal and e-Health 9 (Suppl 1): S1:35-6.

Abstract: Hypothesis: Cost savings can be realized by providing telehealth clinical services to children with diabetes. For each of the years being analyzed (1999 - 2001), all paid Medicaid claims for the sample population were reviewed for cost savings potential. Three areas were identified as the main targets for cost reductions: transportation, Emergency Room (ER) visits, and inpatient hospitalizations. The analysis revealed savings on transportation claims from Daytona Beach to Gainesville or Orlando where pediatric endocrinology experts were located, inpatient hospitalizations for diabetes and other endocrine disorders, and emergency room visits for diabetes and other endocrine disorders. In analyzing these claims for the target population in each of the calendar years included, it was determined that the total potential for cost savings to Florida Medicaid through the use of telemedicine for CMS eligible children with diabetes in the Daytona Beach area over this three-year span totaled $158,225.22. The total cost of the equipment and line charges for the CMS Network Pediatric Diabetes Telemedicine Project is $68,635. Thus, across the three years, the state of Florida could have realized a net potential savings of $89,590.22. Conclusion: Telehealth is an efficient and cost effective way of providing clinical services to children with diabetes. (Abstract from The American Telemedicine Association Eighth Annual Meeting & Exposition, April 27 - 30, 2003, Orlando, Florida)

UNDERSERVED POPULATIONS: CHILDHOOD ASTHMA AND LIFE IN PHILLY TOWN

Highlights From the ATSP Telehealth Conference 2002: Briefings on Telemedicine Activity in the US and Abroad During the Past 12 Months September 9-12, 2002, Teleconference

Connecting public health centers to state-supported teaching hospitals could lower the number of days that children with asthma miss school and could make better use of the children's insurance program in Pennsylvania.

Many poor children with asthma have severely impeded access to quality healthcare due to limits on transportation and other resources. Dr. Mitchell noted that asthma is now the number-one cause of hospitalization among children under the age of 15 in the United States, and asthma is considered the factor responsible for 10 million lost school days annually.

But a flare-up of the chronic respiratory disease does not mean that children must miss school, Dr. Mitchell said. "Seventy percent of asthma hospitalizations for children could be cared for in alternate settings with close nurse observation." He described a school-based setting equipped with a fiber-optics communication network that would allow a healthcare professional to monitor asthmatic children 1-2 times per week. Pennsylvania's CHIP program could pay for some or part of the program, Dr. Mitchell said. In fiscal 1999, $40.7 million in federal funding for the federal-state program was returned to federal coffers unspent, he said.

To put his estimated half-million dollar program into place, Dr. Mitchell proposed that $175,000 be used to connect public health clinics to state hospitals and determine billing and other communication costs. An additional $176,000 would be spent to acquire telemedicine equipment; $77,000 to determine physician scheduling, reimbursement policy, and procedures; and $73,000 to pay doctors for their services. In contrast, national expenditures for hospitalizations of asthmatic patients under age 18 run an estimated $3.2 billion per year.

TELECARE OF DIABETIC PATIENTS WITH INTENSIFIED INSULIN THERAPY. A RANDOMIZED CLINICAL TRIAL

Stud Health Technol Inform 2000;77:327-32
Biermann E; Dietrich W; Standl E
Institute for Diabetes Research, Kolnerplatz 1, 80804 Munchen, Germany.

BACKGROUND: Patients with insulin dependent diabetes require frequent advice if their metabolic control is suboptimal. A telemedical system for transmission of self monitoring blood glucose values from the patients' home to the diabetes center with a combined modem-interface is described. Data are processed by PC and advice is given by telephone. The study focuses on metabolic outcome, fiscal and administrative aspects.

METHODS: A prospective, randomized trial with 46 patients with intensified insulin therapy was conducted, 30 patients used telecare and 16 conventional care.

RESULTS: HbA1c, as a parameter of metabolic control, dropped from 8.3% to 7.3% in the telecare group and from 8.0% to 6.8% in the conventional group after 8 months of observation. There was no significant difference between the two groups. Time expenditure for telemanagement, compared to conventional advice, was moderately higher, but there was a substantial amount of time on the patients side that could be saved mainly by reduction of to travel time and work stoppage. Setting up an optimal telemanagement scenario a cost analysis was done. This yields a cost saving of about 650 EURO per year.

CONCLUSION: Telemanagement of insulin-requiring diabetic patients is a cost and time saving procedure for the patients and results in metabolic control comparable to conventional outpatient management.

TELEHEALTH FOR OLDER PATIENTS: THE HONG KONG EXPERIENCE

Author(s): Elsie Hui ; Jean Woo Source: Journal of Telemedicine and Telecare Volume: 8 Number: 6 Supplement: 3 Page: 39 – 41

We studied the feasibility, acceptability and cost-effectiveness of using telemedicine to provide geriatric services to residents of nursing homes. A local 200-bed nursing home supported by the community geriatric assessment team (CGAT) participated in a one-year study, during which videoconferencing was used to replace conventional outreach or clinic-based geriatric care. The feasibility of telemedicine was evaluated by participating specialists in a total of 1001 consultations. Other outcome measures included productivity gains, utilization of hospital emergency and inpatient services, and user satisfaction.

Telemedicine was adequate for patient care in 60-99% of cases in seven different disciplines. The CGAT was able serve more patients and see them earlier and more frequently. Telemedicine was cheaper than conventional care, and well accepted by health-care professionals as well as clients. Substantial savings were achieved in the study period through a 9% reduction in visits to the hospital emergency department and 11% fewer hospital bed-days. Telemedicine was a feasible means of care delivery to a nursing home and resulted in enhanced productivity and cost-savings. Linking more such institutions to care providers would further increase cost-effectiveness

HOSPITALIZATION REDUCTION BY AN ASTHMA TELE-MEDICINE SYSTEM

Kokubu F, Nakajima S, Ito K, Makino S, Kitamura S, Fukuchi Y, Mano K, Sano Y, Inoue H, Morita Y, Fukuda K, Akiyama K, Adachi M, Miyamoto T.
First Department of Internal Medicine, School of Medicine, Showa University.
Arerugi 2000 Jan;49(1):19-31

We examined an effectiveness of a new asthma telemedicine system in reducing hospitalizations using a multi-site randomized control study. In this program, a nurse under physician supervision monitors the patient's airway status at home and provides instructions to individuals via the telephone, helping them manage exacerbations as well as reinforcing proper use of a zone-controlled management plan.

Patients with a high risk for hospitalization were screened based on the numbers of emergency room visits and hospitalizations found in a previous study and randomly assigned to either the telemedicine or control group. After a six-month study period, an 83% reduction in hospitalization was demonstrated in the telemedicine group versus the control group, with a P value of 0.01. Improvement of peak expiratory flow and symptoms were also shown in the study group.

We conclude that the key success factors in home asthma management for poorly controlled asthma patients are early detection of exacerbations through daily peak flow monitoring, compliance with prescribed daily prophylactic anti-inflammatory steroid medications, and immediate action as specified by a zone-controlled action plan upon the first signs of deterioration.

AN EVALUATION OF THE WEST SURREY TELEMEDICINE MONITORING PROJECT

Author(s): Jeremy Dale ; Sarah Connor ; Kim Tolley Source: Journal of Telemedicine and Telecare Volume: 9 Number: 3 Supplement: 1 Page: 39 – 41

We conducted a three-month pilot study of a home monitoring service for patients with chronic obstructive pulmonary disease. Fifty-five patients were recruited. They transmitted physiological data to a monitoring centre once a day.

During the period of the study, 36 escalations were reported to have occurred. Of these, 29 (81%) were managed at home; the other 7 (19%) resulted in acute admission after emergency telephone calls.

Although only a small number of patients were involved for a relatively short period of time, there was evidence of a substantial (approximately 50%) decrease in rates of hospital admission. The service was highly acceptable to the patients.

TELESPIROMETRY: NOVEL SYSTEM FOR HOME MONITORING OF ASTHMATIC PATIENTS

Bruderman I, Abboud S.
Meir Hospital, Kfar Saba, Israel.
Telemed J 1997 Summer;3(2):127-33

OBJECTIVES: To describe a newly developed telespirometry system consisting of a portable spirometer that transmits the lung ventilatory values by telephone from the patient's home to a remote monitoring center and to assess the ability of the telespirometry system to detect early signs of asthmatic deterioration.

METHODS: Thirty-nine patients with moderate to severe asthma were monitored with the telespirometry system. The lung function testing and transmission of the spirometric data by telephone from the patient's home to a remote monitoring center were performed according to the patient's judgment. All previous transmissions of the spirometric data were analyzed retrospectively to detect early signs of asthmatic deterioration, which resulted in dispatch of the mobile intensive care unit (MICU) to the patient's home.

RESULTS: In 19 patients (49%), analysis of the spirometric data detected early signs of asthmatic deterioration. Analysis of the spirometric data correlated with decisions to dispatch the MICU in 22 of 39 (56%) patients. In patients with severe asthma, the decision was made during oral communication between the patient and the operator and was based on clinical impression rather than functional results.

CONCLUSION: Home monitoring of asthmatic patients with the telespirometry system may improve the management of the disease and the quality of life and reduce costly hospitalizations.