Philip C. Morin

A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus

BACKGROUND Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness. METHODS The authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels. RESULTS In the intervention group (n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c > or =7% (n = 353). In the usual care group (n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18% (p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c > or =7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York. CONCLUSION Telemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up.

A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study

CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care. OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older, ethnically diverse, medically underserved patients with diabetes. DESIGN, Setting, and Patients A randomized controlled trial was conducted, comparing telemedicine case management to usual care, with blinded outcome evaluation, in 1,665 Medicare recipients with diabetes, aged >/= 55 years, residing in federally designated medically underserved areas of New York State. Interventions Home telemedicine unit with nurse case management versus usual care. Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c (HgbA1c), low density lipoprotein (LDL) cholesterol, and blood pressure levels. RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints (HgbA1c, p = 0.001; LDL, p < 0.001; systolic and diastolic blood pressure, p = 0.024; p < 0.001). Estimated differences (95% CI) in year 5 were 0.29 (0.12, 0.46)% for HgbA1c, 3.84 (-0.08, 7.77) mg/dL for LDL cholesterol, and 4.32 (1.93, 6.72) mm Hg for systolic and 2.64 (1.53, 3.74) mm Hg for diastolic blood pressure. There were 176 deaths in the intervention group and 169 in the usual care group (hazard ratio 1.01 [0.82, 1.24]). CONCLUSIONS Telemedicine case management resulted in net improvements in HgbA1c, LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries. Mortality was not different between the groups, although power was limited. Trial Registration http://clinicaltrials.gov Identifier: NCT00271739.

Usability in the real world: assessing medical information technologies in patient's homes

OBJECTIVE This paper presents an approach to usability evaluation of computer-based health care systems designed for patient use in their homes. Although such devices are becoming more prevalent, there is very little known about their usability. DESIGN The theoretical foundations for the methods are discussed. The approach incorporates a cognitive walkthrough usability evaluation and new methods for usability testing that can be conducted in patients homes. The method was applied to the IDEATel intervention, a multi-institution randomized controlled trial of the feasibility, acceptability, and clinical utility of a home-based telemedicine system for diabetic Medicare population. The usability study was designed to assess barriers to optimal use of the system. The focus was both on dimensions of the interface and on dimensions of patient skills and competency. The usability field research involved testing 25 patients in their homes using the system. The analysis included a range of video-analytic methods of varying levels of granularity. RESULTS The usability evaluation revealed aspects of the interface that were sub-optimal and impeded the performance of certain tasks. It also found a range of patient-related factors such as numeracy and psychomotor skills that constituted barriers to productive use. CONCLUSIONS A multifaceted usability approach provided important insight regarding use of technology by an elderly chronic-care patient population and more generally, for understanding how home health initiatives can more effectively use such technology.

Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes The randomized IDEATel trial

Diabetes case management (DCM) may improve medical outcomes (1,2). Case managers coordinate care and often provide a mix of interventions, e.g., telephone outreach, education, reminders. However, the efficacy of DCM is unclear. Three systematic reviews lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid, weight, or blood pressure benefits (3–5). DCM studies typically target biomedical outcomes and ignore potential psychosocial effects. Yet, psychosocial variables (e.g., depression, anxiety, social support) relate to hyperglycemia, complications, adherence, and quality of life (6–11). Thus, a positive impact of DCM on these factors is important. Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction (cluster visit) (12) and quality of life (dietitian-led DCM group) (13). Because barriers (e.g., distance, weather) limit DCM access, telemedicine can be used. A review of telemedicine versus face-to-face trials concluded that, while feasible and acceptable, there is little evidence that telemedicine has clinical benefits (14). Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients (15). The intervention resulted in significant improvements in glycemic control, blood pressure, and total and LDL cholesterol (16). The purpose of the Informatics for Diabetes Education and Telemedicine (IDEATel) project, funded by the Centers for Medicare and Medicaid Services, is to evaluate the feasibility and effectiveness of telemedicine with a diverse, medically underserved, elderly diabetic sample. The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes. A detailed description of the IDEATel study design has been previously reported (15,16). Medicare recipients were recruited if they were aged ≥55 years, diagnosed with diabetes, and without moderate/severe impairments or comorbidities. Research nurses blinded to the groups …

School-Centered Telemedicine for Children with Type 1 Diabetes Mellitus

OBJECTIVES To test the feasibility and effectiveness of telemedicine to improve care of children with type 1 diabetes in schools. STUDY DESIGN Subjects, ages 5 to 14 years (grades kindergarten through eighth) were randomized to usual care (18 students; 13 schools) or intervention (23 students; 12 schools). Usual care included medical visits every 3 months and communication between school nurse and diabetes team as needed by phone. The intervention group received usual care plus a telemedicine unit in the school nurse office to videoconference between the school nurse, child, and diabetes team every month. Hemoglobin A1c and pediatric quality of life were measured every 3 months for 1 year. Analyses used multilevel modeling. RESULTS A1c values increased from baseline to 6 months for students in the usual care group and decreased in the telemedicine cohort (P < .02). Lower A1c levels in the telemedicine group were maintained over the next several months, and significant improvements in several subscales of the Pediatric Diabetes Quality of Life questionnaire were observed. In the telemedicine group, urgent diabetes-related calls initiated by the school nurse were significantly reduced, and there were fewer hospitalizations and emergency department visits. CONCLUSIONS A school telemedicine program can improve diabetes care in grades kindergarten through eighth.

Lessened decline in physical activity and impairment of older adults with diabetes with telemedicine and pedometer use: results from the IDEATel study

OBJECTIVE to examine the effects of the Informatics for Diabetes Education and Telemedicine (IDEATel) telemedicine intervention and pedometer use on physical activity (PA) and impairment in older adults with diabetes. DESIGN randomised clinical trial. Subjects ethnically diverse medically underserved Medicare beneficiaries with diabetes (n= 1,650). METHODS participants received home videovisits with a diabetes educator every 4-6 weeks or usual care. All received a pedometer. Annual measurements included hemoglobin A1c, Comprehensive Assessment and Referral Evaluation Activities of Daily Living, Diabetes Self-Care Activities, Charlson Comorbidity Index, Luben Social Support and pedometer use. Mixed model analyses were performed using random effects to adjust for clustering within primary care physicians. RESULTS in the telemedicine group compared with the usual care group, the rate of decline in PA (P= 0.0128) and physical impairment (PI) (P= 0.0370) was significantly less over time. Significant mean endpoint differences were observed for PA (P= 0.003). Pedometer use was significantly associated with PA (P= 0.0006) and PI (P< 0.0001). Baseline characteristics associated with greater PA included having fewer comorbid conditions (P= 0.0054), less depression (P< 0.0001), more social networking (P< 0.0001), lower BMI (P< 0.0001), male gender (P< 0.0001) and lower hemoglobin A1c level (P= 0.0045). Similar predictors were observed for PI, except duration of diabetes also predicted increased impairment (P< 0.0001). Significant indirect effects were observed through use of the pedometer on reduced decline in PA (P= 0.0024, 0.0013) and PI (P= 0.0024, P< 0.0001). CONCLUSIONS this telemedicine intervention reduced rates of decline in PA and impairment in older adults with diabetes. Pedometers may be a helpful inexpensive adjunct to diabetes initiatives delivered remotely with emerging technologies. ClinicalTrials.gov identifier NCT 00271739.

Medicare payments, healthcare service use, and telemedicine implementation costs in a randomized trial comparing telemedicine case management with usual care in medically underserved participants with diabetes mellitus (IDEATel).

Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention. Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State. Measurements We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000- February 27, 2006). Results Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups,

Psychosocial outcomes of telemedicine case management for elderly patients with diabetes: IDEATel, a randomized trial

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Diabetes management assisted by telemedicine: patient perspectives.

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Use of Telemedicine to Improve Glycemic Management in a Skilled Nursing Facility: A Pilot Study

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