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. 2007 Dec 14;9(5):e37. doi: 10.2196/jmir.9.5.e37

Table 3.

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

Reference, Country, Year, and Duration of Intervention Care Setting and Intervention Study Design Reported Findings (Improvements) *
[13]

  • Italy/Spain/Norway

  • 2002

  • 18 months, follow-up planned (duration unknown)

 Secondary care.
Blood glucose meter to send clinical data and lifestyle data (every 7 to 10 days) via telecommunication system (Internet / telephone line). Daily computer-generated feedback is provided, and, if necessary, messages from physician (specialist in hospital) to advise patients. No details provided about feedback system and frequency of feedback.

  • Observational studies without control group: n = 32

  • Four conditions:

  1. Verification phase: clinical evaluation (n = 3)

  2. Pilot clinical validation (n = 12)

  3. Demonstration phase: Intranet (n = 6)

  4. Demonstration phase: Internet (n = 11)
[14]

  • Italy/Spain/Germany

  • 2003

  • 12 months, follow-up unknown

 Integrated care.
Reflectometer and palmtop to transmit clinical data via multi-access system (Web access, telephone, interactive voice) to each agent involved in the care process: nurses, case managers, and specialists. Computer-generated feedback is provided via SMS or email to patient and caregiver and educational messages are automatically sent to patients. Frequency of feedback not specified.

  • Experimental studies (RCT): n = 106

  • Two conditions:

  1. Intervention: n = 56 (subset randomized patients not reported)

  2. Control (usual care): n = 50 (subset randomized not reported)

  • Randomization method not described; no details about comparability of group (except same clinical treatment)

 a) Decreased HbA1c in (I: 8.31 to 7.59, P < .05; C: 8.86 to 7.95, P < .05 after 6 months). NSD between groups. Patients randomized decreased HbA1c (I: 8.24 to 7.44, P < .05; C: 8.83 to 7.78, P < .05, after 6 months). NSD.
[15]

  • Germany

  • 2002

  • 4-8 months, follow-up unknown

 Secondary care.
Blood glucose meter to send clinical data via modem and telephone line to physician in diabetes center. Personal feedback for proper dose adjustment by diabetes specialist via telephone advice. Frequency of feedback not specified.

  • Experimental studies (RCT): n = 43

  • Two conditions:

  1. Intervention: n = 27

  2. Control (usual care): n = 16

  • Randomization by lots (2:1 in favor of telecare).

  • Fairly good matching of groups

 a) Decreased HbA1c (I: 8.3 to 6.9 after 4 months, n = 27; to 7.1 after 8 months, n = 11; C: 8.0 to 7.0 after 4 months, n = 16, to 6.8 after 8 months, n = 10). NSD between groups.
e) System appeared easy to use; patients’ feeling of security increased through availability of BG data and the possibility of consulting a caregiver within minimal time, without the need to travel to the diabetes center.
f) Cost and time savings in I (saving in consultation time although intensified contacts with caregiver); on caregiver’s side patient’s time significantly increased.
[16]

  • Netherlands

  • 1999

  • 12 months, follow-up unknown

 Primary/secondary care.
Electronic communication network linking the physicians’ computer-based patient records (GPs and interns in hospital) to enable electronic data interchange. System provides computer-generated prompts for physicians to deliver feedback (messages). Frequency of feedback not specified.

  • Quasi-experimental studies: n = 275

  • Two conditions:

  1. Intervention: n = 215

  2. Control (usual care): n = 60

  • Intervention group consisted of patients from GPs with highest number of referred patients. Average age in intervention group higher; fewer type 1 patients than control group

-Nonstandardized questionnaire		 a) Decreased HbA1c (I: 7.0 to 6.8, P < .05; C: 6.6 to 6.5, P = .52). NSD between groups.
c) Increased frequency of patient-caregiver communication (P < .01); more complete information about patient care in I than in C.
[17]

  • United States

  • 2002

  • 12 months, follow-up unknown

 Secondary care.
Health Hero iCare Desktop and Health Buddy appliance for daily monitoring of clinical data and educational reinforcement by case manager (profession not specified) in medical center. System prompts to action if indicated by daily values. Personal feedback by telephone in case of alarming values.

  • Controlled observational studies (cohort studies): n = 338

  • Two conditions:

  1. Intervention: n = 169

  2. Control: n = 169 (cohort)

  • Cohort representative of the general population in terms of ethnicity

 b) Mean improvement in mental component (SF-12) after 6 months in I (P < .0264) and in physical component after 6 months (P < .0518).
c) Increased satisfaction regarding communication with caregivers in I (from 88% of patients after 3 months to 95% at 1 year).
d) Better understanding of their medical condition (93% of patients), better able to manage their disease (93% of patients) after 1 year.
e) Ease of use increased over time (75% of patients after 3 months to 88% after 1 year).
f) Reduction of overall utilization and charges after 1 year; in I overall charges of US $747 per patient per year; inpatient admissions reduced 32% (P < .07); emergency room encounters reduced 34% (P < .06); post-discharge care visits reduced 44% (P < .028); outpatient visits reduced 49% (P < .001).
[18]

  • Denmark

  • 2006

  • 6 months, follow-up unknown

 Integrated care.
Website for transmission of blood glucose data entered by patient and reviewed by diabetes team (2 diabetic nurses, 1 consultant doctor, 1 medical secretary, and 1 dietitian) and personal feedback by diabetes team by email about diabetes regimen. Frequency of feedback not specified. Based on theory of patient-centeredness and the Bayesian model of carbohydrate metabolism.

  • Observational studies without control group (case series): n = 13

  • Three conditions:

  1. Patients: n = 3

  2. Health care professionals: n = 5

  3. Health care professionals: n = 5 (focus group)

 c) Patients experienced greater confidence and a more personal report with staff after 6 months using the system. Email facilitated a dialogue between patient and diabetes team.
d) Improved self-control (patients checked blood glucose more often); increased awareness of blood sugar regulations.
e) DiasNet caused changes in tasks and duties of the diabetes team (required enhanced competence of nurse with regard to insulin dose adjustments); patients were dissatisfied with the feedback from staff.
[19]

  • United Kingdom

  • 2005

  • 9 months, follow-up unknown

 Secondary care.
Blood glucose monitor and telephone network for transmission of data and GPRS mobile phone to send data (daily) to diabetes nurse specialist in clinic. Real-time graphical phone-based feedback for the previous 2 weeks together with nurse-initiated support using a Web-based graphical analysis of glucose self-monitoring results and personal feedback by phone in case of concerns. Frequency of feedback not specified. Based on theory of patient-centeredness.

  • Experimental studies (RCT): n = 93

  • Two conditions:

  1. Intervention: n = 47 (Web-based graphical analysis, nurse initiated support)

  2. Control (real-time graphical phone-based): n = 46

  • Randomization (computer program); gender and psychiatric scores evenly distributed between the randomized groups

 a) Decreased HbA1c (I: 9.2 to 8.6 after 9 months, P < .001; C: 9.3 to 8.9 after 9 months, P < .05). NSD between groups.
e) Difference in proportion of transmitted blood glucose results (40% more in I than in C, P < .0001).
[20]

  • Spain

  • 2004

  • 9 months, follow-up unknown

 Care setting not specified.
PC, Web browser, or a cell phone with Wireless Application Protocol for transmission of clinical data. Automatic generated responses and personal feedback by physicians (not specified whether GPs or specialists in hospital) that could be read during patient’s next online session. Frequency of feedback not specified.

  • Observational studies without control group (case series): n = 172

  • Two conditions:

  1. Case study: n = 12

  2. Questionnaire: n = 160 (135 non-diabetic students, 25 diabetic patients)

 d) Patients were satisfied with the continuity and self-efficacy of care; lack of time was a drawback for 38%; 75% expressed a preference for sending data via a cellular phone (SMS).
e) Patients used the system every 2.0 days (SD 2.1), and doctors reviewed patient data every 4.0 days (SD 3.9); the average number of visits to the website was 477 per month.
[21]

  • Spain

  • 2004

  • 8 months, follow-up unknown

 Care setting not specified.
Patients send blood glucose levels and body weight to a server by SMS. Automatic server answers SMS each time data were sent. Monthly hemoglobin results automatically sent to physicians (not specified whether GPs or specialists in hospital). Physicians can send messages to patients if necessary.

  • Observational studies without control group (case series): n = 23

  • One condition

 e) SMS provided a simple, fast, efficient, and low-cost adjunct to the medical management of diabetes at a distance. Particularly useful for age groups (elderly, teenagers) that are known to have difficulty in controlling diabetes well.
f) Total of 25 messages per month; €3.75 per month per patient.
[22]

  • France

  • 2006

  • 6 months, follow-up unknown

 Secondary care.
Clinical data from patients’ glucose meters are downloaded every 2 weeks to pharmacists’ PC. Reinforced follow-up via fax mediated by the local pharmacist in contact with the specialist in the hospital (diabetologist). Diabetologist sends instruction to family by email or phone within 5 days.

  • Experimental studies (RCT): n = 100

  • Two conditions:

  1. Intervention: n = 50

  2. Control (usual care): n = 50

  • Randomization via computer-generated sequence using block randomization with stratification by age

  • Comparable intervention and control groups (age, gender, HbA1c, frequency of SBGM, type of insulin therapy program)

 a) Decreased HbA1c (I: 9.3 to 9.27, P = .59; C: 9.2 to 9.12, P = .58). NSD between groups.
c) Caregivers’ response to faxes was 81% (at 3 months); decreased to 50% (6 months).
d) Frequency of self blood glucose monitoring per day did not differ between groups at the end of the study (P = .53).
e) Only 32% of faxes (out of 100% expected) from family homes were received due to technical problems.
[23]

  • Spain

  • 2002

  • 12 months, follow-up expected

 Secondary care.
Clinical data from a blood glucose meter are sent (automatically or manually) from a patient unit to the medical workstation for physicians (diabetologist in hospital). System offers tools to collect, manage, view, and interpret data and to exchange data and messages. Physicians personally answer patients’ questions within 24 hours via system. Frequency of feedback not specified.

  • Quasi-experimental studies: n = 10

  • Two conditions:

  1. Intervention: n = 5

  2. Control: n = 5 (cross-over design, switch half way through the trial)

  • Both groups comparable concerning intervention time and inclusion criteria (inadequate metabolic control, DM duration greater than 5 years)

 a) Decreased HbA1c (I: 8.4 to 7.9, P = .053); increased in C (8.10 to 8.15, P = .58). NSD between groups.
c) Patients transmitted 3524 blood glucose readings, 1649 daily insulin adjustments, 24 exercise reports, and 10 diet modifications. Electronic communication with caregivers was limited; a total of 63 text messages were sent by all patients. Caregivers sent 118 text messages to patients (feedback and therapy modifications). Caregivers performed more therapy changes in I than in C due to the ability to assess patient’s condition on a frequent basis.
d) Increased confidence in daily self-management.
e) Patients found the system has high utility despite several technical problems.
[24]

  • United States

  • 2002

  • 3 months, follow-up unknown

 Primary care.
Email for communicating disease management issues between Veterans Affairs primary caregiver and pharmacists. Personal feedback to patients via telephone by pharmacist. Frequency of feedback not specified.

  • Quasi-experimental studies: n = 65

  • Two conditions:

  1. Intervention: n = 30

  2. Control (usual care): n = 35

  • Intervention: patients had a recent change made to their therapy to lower blood glucose levels

  • Control: remaining patients of the 65

  • Comparable HbA1c at baseline in two groups

 a) Decreased HbA1c (I: 10.0 to 8.2; P < .001; C: 10.2 to 8.6, P < .001). NSD between groups.
f) Email communication reduced the number of face-to-face and telephone consultations between caregivers.
g) Clinical recommendations for altering diabetes care sent via email to primary caregiver resulted in a significant reduction in HbA1c in I.
[25]

  • Spain

  • 2006

  • 12 months, follow-up unknown

 Secondary care.
Data from glucose meter and vocal messages concerning insulin doses and events are sent via modem (twice a week) to diabetes team (in hospital, members of diabetes team not specified). Diabetes team provides personal feedback. No details provided about form and frequency of feedback.

  • Experimental studies (RCT): n = 30

  • Two conditions:

  1. Intervention: n = 18

  2. Control (usual care): n = 15

  • Randomization via random variable generator; baseline data (HbA1c, BMI, weight, insulin, DM) and characteristics (age, gender, daily activities) comparable in two groups

 a) Decreased HbA1c (I: 8.4 to 7.6; C: 8.9 to 7.6, after 12 months); NSD between groups.
b) General health status did not change in groups (SF-12); quality of life improved in I (NS) and C (P < .05); significant increase in knowledge in I (P < .05) and C (P < .05).
d) 80% of patients reported that appointments in I did not interfere with daily life; 100% of patients in C reported daily interference with outpatient appointments.
f) Time and costs saved by patients. Costs were lower (length of appointment 0.25 h in I versus 0.5 h in C). But 30% of the diabetes team and patient appointments were longer than expected due to technical problems (0.25 h versus 1 h).
[26]

  • South Korea

  • 2006

  • 12 weeks, follow-up unknown

 Tertiary care.
Clinical data are entered daily in system via website or cellular phone (SMS). Automatic feedback (reminder) is generated in case patient has not forwarded data for more than a week. Personal feedback provided weekly by nurse in tertiary care hospital via SMS, telephone, or Internet.

  • Observational studies without control group (before-and-after design): n = 42

  • One condition

 a) Patients had a mean decrease of 28.6 mg/dL in fasting plasma glucose (P= .006) and 78.4 mg/dL in 2-hour postprandial blood sugar levels (P= .003).
d) Mean increase in care satisfaction score in I (68.6 to 79.5,P= .03).
[27]

  • Italy

  • 2006

  • 56 weeks, follow-up unknown

 Care setting not specified.
Blood glucose data from a glucose meter are sent via Internet or telephone to the system. Data are automatically analyzed in order to detect metabolic alterations and, if necessary, generate alarms. If necessary, physician (not specified whether GP or specialist in hospital) responds and a message is automatically sent to patient by email or SMS. Frequency of feedback not specified. Based on a general model for the coordination of care (Chronic Care Model).

  • Experimental studies (RCT): n = 56

  • Two conditions:

  1. Intervention: n = 30

  2. Control (usual care): n = 26

  • No randomization details; both groups comparable (age, treatment)

 a) Location 1 decreased HbA1c (I: 8.52 to 8.30, P < .05; C: 8.97 to 8.82). NSD between groups. Location 2 decreased HbA1c (I: 8.40 to 7.75; C: 10.15 to 9.28, after 12 months). NSD between groups.
c) Patients transferred 20000 BGL readings and 2000 insulin doses (56 weeks, over 2 locations); the frequency of service usage and quantity of data collected were considered satisfactory.
e) Overall usability perception was high (TSQ), especially in adult patients.
[28]

  • United States

  • 2005

  • At least 24 months, follow-up unknown

 Primary care setting.
Blood glucose data from glucose meters sent to the diabetes team weekly (team composition not specified) and nurses of the children’s medical care service clinic. Feedback is provided during a clinical, face-to-face session. Online education for school personnel, families, and caregivers is provided on a website. No details provided about form and frequency of feedback.

  • Observational studies without control group (case series): n = 74

  • Four conditions:

  1. Patients: n = 44

  2. Caregivers: n = 6

  3. Case managers: n = 6

  4. School nurses: n = 18

 c) Improved patient-caregiver communication for patients in a remote area. Use of website by nurses increased substantially when it was approved for 3 contact hours of continuing education.
d) 40% of patients completed educational modules on the website.
e) Users (patients, family, and school nurses) expressed satisfaction with the technology.
g) Compliance with school health plans improved compared with baseline.
[29]

  • Australia

  • 2002

  • 6 weeks, no follow-up

 Care setting not specified.
Internet-based diabetes management systems (myDiabetes, LifeMasters) for evaluation of diabetes management. No details about form and frequency of feedback. Based on the push-pull model for retrieving and seeking information.

  • Expert opinion based on consensus: n = 5 (1 caregiver, 3 diabetic patients, 1 expert)

  • One condition

 e) LifeMasters appeared successful in integrating the health care provider in diabetes management; myDiabetes is effective in providing a communication channel for community creation. LifeMasters appeared a more complete system than myDiabetes (monitoring, personalization, communication, information, technology).
[30]

  • United States

  • 3 months, follow-up unknown

 Primary care.
Internet-based, diabetes self-management and peer support intervention (chat room). The Diabetes Network was designed to complement medical treatment by providing personalized lifestyle interventions and social support via an Internet-based program accessible from patients’ home. Simplified computers and training were used. Intervention included online blood glucose tracking, twice weekly patient-physician (primary care provider) contact (questions), and message postings on forum (real time chat discussion). Personal dietary advice by primary care provider via website, forum.

  • Experimental studies (RCT): n = 133

  • Four conditions:

  1. Information only group: n = 33

  2. Peer support group: n = 30

  3. Personal self-management coach condition: n = 37

  4. Combined condition of the three above: n = 33

  • Randomization by presence or absence of each of the components (peer support, personalized self-management); groups comparable (gender, education, age, years diagnosed)

 a) Decreased HbA1c in PSMCC (I: 7.75 to 7.73), in PSC (I: 7.64 to 7.59), in CC (I: 7.46 to 7.28). HbA1c increased in C (7.20 to 7.37 after 3 months)
Overall improvement in dietary behavior (reduction of fat intake, improved dietary practices) in 4 conditions, but no significant between-condition differences.
b) Slight improvements in quality of life (psychological well-being SF-12) in 4 conditions, especially for PSMCC and CC.
c) Two support conditions (PSC, CC) generated significantly more log-ons (M = 61 and 70, respectively, for PSC and CC; M = 40 (PSMCC); M = 25 in IOC; P < .02).
[31]

  • United States

  • 2005

  • 12 months, follow-up unknown

 Primary care.
Clinical data from glucose meters are sent three times a week via Internet to a website. Web-based care management group received a notebook, glucose and blood pressure monitoring devices, and access to a care management website. The site provides educational modules, accepting uploads from monitoring devices and an internal messaging system for patients to communicate with the care manager. Automatic feedback is provided if patients have not forwarded data in 2 weeks. Care manager contacts patients by phone; diabetes nurse communicates with patients about education using the internal messaging system. The care manager responded to queries within 1 working day during office hours.

  • Experimental studies (RCT): n = 104

  • Two conditions:

  1. Intervention: n = 52

  2. Control (usual care): n = 52

  • No randomization details; both groups comparable (age, gender, education, metabolic values)

 a) Significant decrease in HbA1c in I and C (P < .001). A greater decline over time (12 months) in I (10.0, −1.6%) and C (9.9, −1.2%, P < .05): Individuals who persisted with website usage (at least one website log-in every 3 months, P < .05) had a greater improvement in HbA1c than usual care.
HDL cholesterol rose and triglycerides fell in the Web-based group (P < .05).
d) Regular data uploads (P < .02) were more likely to achieve and maintain reductions in HbA1c.
[32]

  • United States

  • 2004

  • 3 months, follow-up unknown

 Primary care.
Web-based disease management program based on an interactive electronic medical record and secure email system. System contains My Upload Meter to automatically upload clinical data daily sent and Diabetes Daily Diary educational website. Automatically generated clinical reminder, email response every weekday (by nurse practitioner in primary care internal medicine clinic). Based on a general model for the coordination of care such as the Chronic Care Model.

  • Observational studies without control group (before-and-after design): n = 9

  • One condition

 c) If expectations were not met, participants felt their concerns were less valued, and they felt more isolated from their caregiver.
d) Participants felt safer having real-time access to their personal health information. They felt more able to manage diabetes by means of seeing laboratory results in the live record at home.
e) Frustration with unmet expectations when program did not work as expected (technical failures).
[33]

  • Netherlands

  • 2001

  • duration not specified, follow-up unknown

 Primary/secondary care.
Shared-care project whereby all examinations, which take place every 3 months and are performed by the GP, follow standardized procedures. Results are emailed to the diabetologist and laboratory results are automatically sent to both GP and diabetologist. Feedback by post mail from diabetologist to GP.

  • Observational studies without control group (case series): n = 594

  • Three conditions:

  1. Patients treated in project: n = 336

  2. Patients treated by GP: n = 225

  3. Patients treated in outpatient clinic: n = 33

 a) Decreased HbA1c in UDP (7.8 to 6.8, P < .0001); mean inclusion duration 3.2 years. Lipid profiles improved in I: plasma cholesterol decreased (6.1 to 5.9, P < .0001), plasma triglyceride decreased (1.9 to 1.7, P < .0001), and diastolic blood pressure decreased (86 to 83, P < .001).
d) Data records of UDP cohort were most complete compared to other groups.
e) GPs intended to continue participating in UDP despite shared care taking more time.
g) Standardized data transfer (protocol driven) between GP, diabetologist, and laboratory established an effective infrastructure for shared diabetes care.
[34]

  • China

  • 2001

  • 12 weeks, follow-up unknown

 Secondary care.
Dietary and clinical data are recorded in hand-held computer and sent twice a week via a modem to the diabetes team of a hospital diabetes clinic (composition of diabetes team not specified). System generates automatic feedback about content of food.

  • Quasi-experimental studies: n = 19

  • Two conditions:

  1. Intervention: n = 10

  2. Control: n = 9

  • Each group used the DMS for 3 months; served as the control group for another 3 months (cross-over design); comparable groups

 a) Decreased HbA1c (I: 8.56 to 7.55 after treatment, to 7.84 at end of 12-week project; C: 8.81 to 8.76 after treatment, to 8.40 after end of 12-week project). Mean difference was 0.825 (P < .019, n = 19).
e) The DMS was acceptable; 95% found it easy to use, and 63% found it useful.

* a) clinical values, b) quality of life, c) interaction, d) self-care, e) usability of technology, f) cost reduction, g) transparency of guidelines, h) equity (availability of health care to everyone)

BG, blood glucose; BGL, blood glucose levels; BMI, body mass index; C, control group; CC, combined condition; DM, diabetes mellitus; DMS, diabetes monitoring system; GP, general practitioner; I, intervention; IOC, information only condition; M, mean; NS, not statistically significant; NSD; not statistically significant difference, PSC, peer support condition; PSMCC, personalized self-management coach condition; SBGM, self blood glucose monitoring; SMS, Short Message Service; TSQ, Telemedicine Satisfaction Questionnaire; UDP, Utrecht Diabetes Project; WHO, World Health Organization