The Outcomes and Influencing Factors of Telecare Managing Patients with Type 2 Diabetes

Yan-Ru Cheng

Nursing School，Henan University，Kaifeng，Henan 475004，China

Review article

The Outcomes and Influencing Factors of Telecare Managing Patients with Type 2 Diabetes

Yan-Ru Cheng*

Nursing School，Henan University，Kaifeng，Henan 475004，China

A R T I C L E I N F O

Article history:

17 March 2015

Accepted 22 April 2015

Published 20 September 2015

Telecare

Type 2 diabetes

Outcomes

Influencing factors

Objective:This review aimed to examine the outcomes and influencing factors of telecare management of type 2 diabetes，to provide some advice for medical staff and to inform decision makers to promote the development of telecare in specific areas.

Sources of information:The reference articles were mainly selected from the CNKI，Wanfang Database，PubMed，Science Direct and other resources.Following a systematic，comprehensive search of databases，a total of 1 062 qualitative，quantitative or mixed studies were initially selected；after careful review and screening，45 studies were coded and analysed.

Inclusion criteria:The articles were selected using the words“diabetic”，“type 2 diabetes”，“telecare，telenursing，remote care or telemedicine”，“outcomes or effect”and“influencing factors”.Type 2 diabetic who were intervened by electronic equipment are included.The patients who just have type1 diabetes are excluded，and those who were treated without using electronic equipment also are excluded.

Results:Telecare produces positive results with a variety of outcomes，such as an improvement in the overall status of patients with type 2 diabetes，making full use of the medical staff resources and promoting the popularity of the hospital remotely；however，the factors which may prevent the development of telecare are various.

Conclusions:Telecare has a positive effect in all aspects.With the development of technology and gradual changes in the people’s concept of e-health，telecare may have a brilliant future and may play a more important role in promoting human health.

?2015Shanxi Medical Periodical Press.Production and hosting by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http://creativecommons.org/licenses/by-nc-nd/4.0/）.

Diabetes has become one of the most serious problems in public health in the 21st century.1Previous studies have shown that the prevalence of diabetes in adults aged 20 and older has reached 9.7%；there are more than 92 million adults suffering from diabetes，and our country has the largest population with this disease in the world.2Among these adults with diabetes，95%-97% of patients are type 2 diabetics.3Telecare is a new type of care that provides health care services to clients by transmitting，managing and coordinating health information via electronic communication technology.4Previous studies have shown that telecare can improve health awareness in patients with type 2 diabetes and reduce negative emotions，thereby improve their quality of life.5，6To better promote the implementation of telecare in specific areas，this review will systematically examine recent studies that are relevant to telecare and that were used to manage patients with type 2 diabetes and will provide some useful advice for specialists and to inform decision makers.

1.Concepts related to telemedicine

Several definitions have been adopted for telemedicine，which may be summarized as a comprehensive applied science using computer，multimedia and other remote communication technologies to transmit medical information to diagnose，treat，nurse，teach and implement other medical activities.

1.1.Telemedicine

Telemedicine or Telehealth consists of the use of medical and other health information exchanged via electronic communications from one site to another with the intent of improving the health status of the consumers，7including services and activities such as remote diagnosis，consultation，education and information services. Both the United States and Europe have developed better telemedicine than other countries.In the 1960s，the United States used remote communication and computer technologies in telemedicine，which greatly promoted the development of telemedicine.However，the use of telemedicine began relatively late in our country.

1.2.Telecare

Telecare enhances patient care，which involves the use of electromagnetic channels to transmit voice，data and video communication signals.8Telecare services include remote monitoring，emergency，consultation and other remote nursing practices.Telecare is an important part of telemedicine and develops with the development of telemedicine.

2.Outcomes of telecare management of patients with type 2 diabetes

Type 2 diabetes is a complex condition that requires multiple lifestyle changes，including dietary changes，physical activity changes，taking medication and glucose monitoring.9We analyse the outcomes of managed patients with type 2 diabetes by telecare using the following aspects.

2.1.Physiological outcomes

Currently，diabetes is treated mainly to stabilize blood sugar，slow the progression of the disease and control complications.However，only approximately 11.5%of diabetics have HbA1c＜6.5%，and the blood glucose levels of the vast majority（88.5%）of patients do not meet the target.10Strict control of blood glucose can delay and reduce the progression and incidence of complications.Noh and his colleagues11used a webbased integrated information system to control the levels of haemoglobin A1c（HbA1c）and postprandial glucose of type 2 diabetics and found that HbA1cand postprandial glucose levels were significantly lower in the intervention group.In addition，there was a higher frequency of telephone counselling and a more obvious decline in the extent of the patients’HbA1clevels.Moreover，compared to traditional health education，a web-based remote education system can be more convenient and effective.

2.2.Behavioural outcomes

Lifestyle modification and behavioural changes are the key components of diabetic management，particularly for type 2 diabetes.12Numerous studies have reported that lifestyle modification and disease management have a great effect on improving the control of blood glucose and reducing the complications related to diabetes.12Al-though diabetes self-management has been shown to be effective，12，13many patients do not respond to it very well，14and the increasing rates of diabetes make it imperative to identify several efficient and practical methods to perform diabetic self-management.The Internet and related mobile technologies are widely accessible，24 h means to promote disease management and facilitate behavioural modification.15Glasgow et al.9used webbased intervention to treat individuals with diabetes and found significant dietary changes in diabetic patients（e.g.，eating habits and fat intake）compared to participants treated with non-web-based intervention.They observed that greater Internet use was associated with greater improvements in eating patterns.Glasgow also observed a correlation between greater Internet use and more physical activity.

2.3.Emotional outcomes

A meta-analysis found that approximately 11 percent of all patients with diabetes，who were assessed using standardized diagnostic interviews，suffered from depression.16Depression is associated with poor mental health and harmful medical outcomes.People affected by comorbid depression exhibit a lower quality of life，a greater risk of diabetes-related complications and worse blood glucose control.17，18Nobis used web-based intervention to treat the depression of the diabetic patients and found that the participants liked this method of intervention.Moreover，95%of patients recommended this training to diabetic patients who needed mental help. Furthermore，the severity of depression in the intervention group was significantly lower than that in the observation group.6

3.Factors affecting the implementation of telecare in diabetes

The implementation of web-based interventions to assist with diabetic management has exploded over the past decade.19，20Internet-based educational programs have demonstrated the ability to change behaviours and sometimes the patient’s health status.21The superiority of telecare has been well known，22but telecare has not yet been adopted widely in our country.Many factors may affect the adoption and acceptance of these systems，which may be summarized in four aspects:factors related to computer equipment，knowledge and skills，patients and the medical staff.

3.1.Factors related to computer equipment

Although there is a wide body of literature on the use of mobile devices in the self-management of diabetes，current knowledge about good practices in designing integrated health applications is rather limited，23and there is a lack of required technological infrastructure to establish a national health information system，which is a prevalent problem in our country.Limited financial resources also affect the promotion of telecare in public and private hospitals.23Other studies24，25addressing failure factors showed that obstacles such as technical limitations related to software or hardware，errors in data entry，security and privacy risks are barriers to the adoption of health information technology.Thus，if telecare is to be improved in specific areas，then we should take full advantage of the relatively limited resources，develop several efficient and high-quality software programs and provide better hardware.

3.2.Factors related to the users’knowledge and skills

To develop better telecare，we should not only provide expensive software and hardware equipment，we should also provide adequate knowledge and skills.Doctors and nurses are the main staff in hospitals，and their comprehensive knowledge is the solid foundation of successfully performing telecare.A lack of knowledge and recognition about the system has been recognized as a barrier to the implementation of telecare in many studies.26However，as the service’s receiver，although Internet health information has rapidly grown，the average person lacks the skills to identify and use the health information strategically for his or her own benefit.27The importance of computer literacy suggests the need to assess and improve users’computer skills，which may affect not only the early implementation of telecare but also the later adoption and use of these processes.Thus，health care decision makers and managers need to address the user’s training once the telecare is scheduled to be implemented in specific areas.

3.3.Factors related to patients

Social aspects and experience sharing are important for patients with diabetes，and the use of communitybased telehealth kiosks and clinician-supported patient self-management reduces overall care costs by improving care coordination and reducing service delivery time.28，29However，it is not easy to share graphs and data on mobile applications with friends or relatives in social networks.30In addition，individuals of a lower socioeconomic status are at a higher risk of diabetes and worse outcomes compared to those with more resources.31The same groups who suffer from the greatest burden of diabetes are also often least likely to access the Internet.32Thus，to develop better telecare in specific areas，we should not only improve the patients’socioeconomic status，but we should also fully use the society group related to the chronic illnesses.

3.4.Factors related to medical staff

Leila et al’s study indicated that the negative attitude of patients and colleagues toward the system is the main factor of the human environment，which hinders the implementation of electronic information systems.33In addition，F(xiàn)aridi et al.34found that there was no statistically significant improvement in glycosylated haemoglobin with the use of mobile applications compared with standard therapy.These poor results may greatly reduce the specialists’confidence in implementing telecare.Several studies have reported that poor management and bureaucracy，complex clinical settings，time constraints，lack of financial resources，high costs，lack of a national regulator，non-applicability with regard to patient characteristics and lack of organizational training are barriers to the successful performance of telecare.22，35Thus，managers，assistants，clerks and all of the employees of an organization who are supposed to interact with the system must have sufficient skills，a positive attitude and an interest in the system36to reduce the limiting factors of the medical environment.

4.Prospects of telecare

Although there are many difficulties in developing telecare，previous studies have consistently shown that diabetic management is one application area in which mobile devices could enhance the quality of life of people living with chronic illnesses.With an improvement in computer equipment，computer literacy of the medical staff and patients and the human environment，the difficulties limiting the development of telecare implementation in specific areas may gradually disappear.Telecare can build a health bridge beyond the limitation of space and time for patients and their specialist and can play a more important role in promoting human health.

Conflicts of interest

None declared.

References

1.Wang H，Liu HP.The research status of low glycemic index diet on long-term glucose and lipid control in type 2 diabetes mellitus.Chin J Nurs.2010；45:858-860［in Chinese］.

2.Yang W，Lu J，Weng J，et al.Prevalence of diabetes among men and women in China.N Engl J Med.2010；362:1090-1101.

3.Gao Y.Diabetes standard，global consensus.China Med News.2006；21:20［in Chinese］.

4.Zhang YC，F(xiàn)eng XQ.The application and research status of remote-nursing.Chin Nurs Manag.2013；13:107-110［in Chinese］.

5.Lyles CR，Harris LT，Le T，et al.Qualitative evaluation of a mobile phone and web-based collaborative care intervention for patients with type 2 diabetes.Diab Technol Ther.2011；13: 563-569.

6.Nobis S，Lehr D，Ebert DD，et al.Efficacy and cost-effectiveness of a web-based intervention with mobile phone support to treat depressive symptoms in adults with diabetes mellitus type 1 and type 2:design of a randomized controlled trial. BMC Psychia.2013；13:1-24.

7.American Telemedicine Association.Defining Teemedicine. 2014-11-20.http://www.Americantelemed.org/news/ definition.Html.

8.American Association of Ambulatory Care Nursing.The Domain of Tele-nursing.2014-11-24.http://www.aaacn. org/.

9.Glasgow RE，Kurz D，King D，et al.Outcomes of minimal and moderate support versions of an internet based diabetes self-management support program.J Gen Intern Med.2010；25:1315-1322.

10.Changyu Pan.Chinese diabetes control situation-guide and practice gap.Endocrinol For Med Sci.2005；25:174-178.

11.Noh JH，Cho YJ，Nam HW，et al.Web-based comprehensive information system for self management of diab mellitus.Diab Technol Ther.2010；12:333-337.

12.Norris SL，Lau J，Smith SJ，et al.Self-management education for adults self-management of diabetes mellitus.DiabTechnol Ther.2010，12（5）:376-378.

13.Deakin T，McShane CE，Cade JE，et al.Group based training for self-management strategies in people with type 2 diabetes mellitus.Cochrane Database Syst Rev.2005；18: CD003417.

14.Lavizzo-Mourey R，Jung M.Fighting unequal treatment:the Robert Wood Johnson foundation and a quality-improvement approach to disparities.Circulation.2005；111:1208-1209.

15.Kaufman N.Internet and information technology use in treatment of diabetes.Int J Clin Pract Suppl.2010；166:41-46.

16.Nobis S，Di Lehr，Ebert DD，et al.Efficacy and cost-effectiveness of a web-based intervention with mobile phone support to treat depressive symptoms in adults with diabetes mellitus type 1 and type 2:design of a randomized controlled trial.BMC Psychiat.2013；13:306.

17.Baumeister H，Hutter N，Bengel J，Harter M.Quality of life in medically ill persons with comorbid mental disorders:a systematic review and meta-analysis.Psychother Psychosom. 2011；80:275-286.

18.Papelbaum M，Moreira RO，Coutinho W，et al.Depression，glycemic control and type 2 diabetes.Diabetol Metab Syndr. 2011；3:26.

19.Chomutare T，F(xiàn)ernandez-Luque L，Arsand E，et al.Features of mobile diabetes applications:review of the literature and analysis of current applications compared against evidencebased guidelines.J Med Intern Res.2011；13:65.

20.Osborn CY，Mayberry LS，Mulvaney SA.Patient web portals to improve diabetes outcomes:a systematic review.Curr Diab Rep.2010；10:422-435.

21.Cotter AP，Durant N，Agne AA，Cherrington AL.Internet interventions to support lifestyle modification for diabetes management:a systematic review of the evidence.J Diab Complic.2014；28:243-251.

22.Lai HM，Lin IC，Tseng LT.High-level managers’considerations for RFID adoption in hospitals:an empirical study in Taiwan.J Med Syst.2014；38:3.

23.Anvar F，Shamim A.Barriers in adoption of health information technology in developing Societies.Int J Advan Comput Sci.2011；2:40-45.

24.McGinn CA，Grenier S，Duplantie J，et al.Comparison of user groups’perspectives of barriers and facilitators to implementing electronic health records:a systematic review.BMC Med.2011；9:46.

25.Alkraiji A，Jackson T，Murray I.Barriers to the widespread adoption of health data standards:an exploratory qualitative study in tertiary healthcare organizations in Saudi Arabia.J Med Sys.2013；37:9895.

26.Boonstra A，Broekhuis M.Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions.BMC Health Serv Res.2010；10:231.

27.Van Deursen AJ，van Dijk JA.Internet skills performance tests:are people ready for e-Health？J Med Internet Res. 2011；13:35.

28.Lowe C，Cummin D.The use of Kiosk technology in general practice.J Telemed Telecare.2010；16:201-203.

29.Brennan T，Spettell C，Villagra V，et al.Disease Management to promote blood pressure control among African Americans.Popul Health Manag.2010；13:65-72.

30.Chen Y.Take it personally:accounting for individual difference in designing diabetes management systems.In:Proceedings；the 8th ACM Conference on Designing Interactive Systems；August 16-20；Aarhus，Denmark.2010.

31.Rabi DM，Edwards AL，Southern DA，et al.Association of socio-economic status with diabetes prevalence and utilization of diabetes care services.BMC Health Serv Res.2006；6: 124.

32.Sarkar U，Karter AJ，Liu JY，et al.Social disparities in internet patient portal use in diabetes:evidence that the digital divide extends beyond access.J Am Med Inform Assoc. 2011；18:318-321.

33.Ahmadian L，Khajouei R，Nejad SS，et al.Prioritizing barriers to successful implementation of hospital information systems.J Med Syst.2014；38:150-156.

34.Faridi Z，Liberti L，Shuval K，et al.Evaluating the impact of mobile telephone technology on type 2 diabetic patients’self-management:the NICHE pilot study.J Eval Clin Pract. 2008；14:465-469.

35.Lin HY.On the security of a dynamic ID-based authentication scheme for telecare medical information systems.J Med Syst. 2013；37:9929.

36.Hsu HM，Hou YH，Chang IC，Yen DC.Factors influencing computer literacy of Taiwan and South Korea nurses.J Med Syst.2009；33:133-139.

11 December 2014

in revised form

.

E-mail address:15226027969@163.com（Y.-R.Cheng）.

Peer review under responsibility of Shanxi Medical Periodical Press.

http://dx.doi.org/10.1016/j.cnre.2015.09.002

2095-7718/?2015 Shanxi Medical Periodical Press.Production and hosting by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http://creativecommons.org/licenses/by-nc-nd/4.0/）.