Running head: INTEGRATIVE REVIEW 1

Integrative Review

Madison Caudill

Bon Secours Memorial College of Nursing

Dr. Holowaychuk

NUR 4122 Nursing Research

November 13, 2018

“I pledge”
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Abstract

The purpose of this integrated review is to examine research literature investigating the

researcher’s PICO question: In adult patients with Type II Diabetes Mellitus, what is the effect of

telehealth compared to traditional care on glycemic control? With the number of diabetic patients

rapidly growing, there comes a need for new healthcare models that allow patients the

opportunity for convenient monitoring of blood glucose and allow healthcare providers an

effective way of providing care to a growing population of Type II DM patients. Telehealth has

been proposed as a patient-centered self-management strategy that would allow for a more

timely and convenient way of managing glycemic control. The research design is an integrative

review. The databases EBSCO Discovery Services and PubMed were utilized to locate research

articles. The search yielded 573 articles. Five articles satisfied the specific research criteria set

for this topic. The findings of these studies presented the benefits of telehealth programs,

including improved glycemic control and positive patient perceptions surrounding telehealth

utilization, and support the role of telehealth in the care management of patients with Type II

DM. The integration of telehealth programs into clinical practice may have the potential to

improve patient outcomes and quality of care. Due to the researcher’s limited background

pertaining to research and sample sizes that were small and demographically similar, there are

limitations to this review. Further research is needed to investigate the role of eHealth models of

care and their sustainability over longer periods of time.

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Integrative Review

The purpose of this integrated review is to examine research literature that investigates

the potential role of telehealth monitoring in the care management of patients with Type II

Diabetes Mellitus. In 2015, 30.3 million Americans had diabetes and that number is rapidly

growing with 1.5 million Americans being diagnosed with diabetes every year (CDC, 2017).

With tight glycemic control and routine monitoring of blood sugars, diabetic complications and

morbidity can be greatly reduced. However, research has found that people with diabetes remain

at suboptimal glucose control for an average of 2.9 years (Greenwood, Blozis, Young, Nesbitt &

Quinn, 2015). With the number of patients with diabetes rapidly growing, there comes a need for

new healthcare models that allow healthcare professionals to effectively tackle the challenge of

Type II DM management. Telehealth has been proposed as a patient-centered self-management

strategy that would allow patients a more timely and convenient way of managing glycemic

control, improving clinical outcomes and patient satisfaction. Research has suggested that

telehealth programs may be a viable intervention as they allow remote monitoring of blood

glucose and patient-generated data and, subsequently, provide healthcare providers with the

ability to make timely behaviors and treatment changes. Using an integrative review, the

researcher aims to look further into the research surrounding the use of telehealth to manage

diabetes, both from the quantitative side of glycemic control and qualitative side of patient

perceptions surrounding the utilization of telehealth programs. Furthermore, the researcher aims

to determine the implications telehealth programs may have in the care management of a

growing population of individuals with Type II DM. Therefore, the proposed PICO question to
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be considered is: In adult patients with Type II DM, what is the effect of telehealth compared to

traditional care on glycemic control?

Design/Search Methods

The research method utilized is an integrative review. Two databases, PubMed and

EBSCO Discovery Service, were used to conduct a literature search and to find applicable

research articles using specific criteria set by the researcher. The search terms consisted of

‘telehealth’, ‘telemedicine’, ‘type 2 diabetes’, ‘remote monitoring of blood sugar’, ‘glycemic

control’, ‘diabetes mellitus’, ‘self-care’, ‘monitoring’, ‘hemoglobin A1c’, ‘self-monitoring of

blood glucose’, ‘qualitative’, and ‘patient perceptions’. The search generated 419 articles on

PubMed and 154 articles on EBSCO Discovery Service, demonstrating a significant amount of

literature and research interest on the topic. The literature was further limited to articles from the

past from the past five years, 2013-2018, peer-reviewed research studies, articles offered as full-

text through library databases, written in English and relevant to the PICO question: “In adult

patients with Type II DM, what is the effect of telehealth compared to traditional care on

glycemic control”. The articles selected were screened based on the following inclusion criteria:

adult patients diagnosed with Type II DM and the utilization of a telehealth intervention. The

remaining research articles were reviewed based on the inclusion criteria and their relevance to

the PICO question. Articles not meeting the inclusion criteria or those that were not relevant to

the PICO questions were excluded from the search. Based on the screening process, five research

articles, four quantitative and one qualitative, were identified and analyzed for the purpose of this

integrative review.

Findings/Results
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The findings and results of the reviewed studies suggest that telehealth is an effective

strategy for maintaining glycemic control (Greenwood et al., 2015; Kim et al., 2016; Wild et al.,

2016). Additionally, researchers found that telehealth programs were positively perceived by

research participants (Hanley et. al.,2015; Welch, Balder, & Zagarins, 2015). A summary of the

research articles discussed in this review can be found in Appendix 1. The findings within this

integrative review are presented according to the following themes: improved glycemic control

and patient perceptions of telehealth.

Improved glycemic control

Three of the research articles selected for this integrative review assessed patient clinical

outcomes by determining the impact of telehealth on glycemic control. In a study conducted by

Greenwood et al. (2015), researchers sought to test the effectiveness of a telehealth remote

monitoring intervention with paired glucose testing for adults with non-insulin treated Type II

DM. Researchers conducted a two-group randomized clinical trial with 1:1 randomization to

either usual care or the treatment group. The treatment group consisted of utilizing a telehealth

remote monitoring tablet that wirelessly transmitted glucose data to healthcare providers, who in

turn provided participants with feedback and changes to their care plan. Patients in the usual

care group received diabetes education booklets and referrals to formal diabetes education as

needed.

The sample for the study consisted of 78 participants recruited from a large health care

system in California. Participants were recruited for the study based upon inclusion criteria

including a Type II DM diagnosis, age between 30 and 70 years, current HbA1c levels and

ability to speak English. Study measures included HbA1c levels, diabetes knowledge, self-
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management and self-efficacy assessments. Mixed-effects models were utilized to analyze the

significance of their findings.

Greenwood et al. (2015) found that while both the usual care group and the treatment

group had improved HbA1c levels at three months, only the treatment group continued to have a

statistically significant decrease in HbA1c levels at six months. HbA1c levels in the treatment

group statistically decreased by 1.11 percentage points over the six-month research period.

Additionally, the treatment group showed greater improvement in the self-management

behaviors of carbohydrate spacing, monitoring glucose and foot care. As a result of their

utilization of the telehealth intervention, treatment participants had more self-reported

medication changes compared to usual care participants and this was significantly associated

with improved HbA1c levels at both three- and six-month measurements.

Similarly, Wild et al. (2016) sought to investigate the effect of a telehealth program

among people with poorly controlled diabetes compared to usual care. Researchers conducted a

randomized control trial in family practices throughout areas of the United Kingdom.

Participants were randomly assigned to either the intervention or control group for a research

period of nine months. Participants in the intervention group were given blood glucose monitors

that used Bluetooth technology to transmit readings via a supplied modem to a remote secure

server that could be accessed by their research nurses. Participants in the intervention group were

then contacted weekly by nurses to discuss their results and offered changes to their care plan,

including lifestyle modifications and medication adjustments.

The sample was comprised of 285 participants, all of whom had a diagnosis of Type II

DM, were greater than 17 years of age and had poor glycemic control as defined by HbA1c >

8.5%. Study measures included HbA1c, quality of life, medication adherence, physical activity
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and knowledge of managing diabetes. Findings were analyzed using linear regression with a 95%

confidence interval. Similar to the results in the study conducted by Greenwood et al. (2015),

Wild et al. (2016) found significant differences in glycemic control between the treatment group

and usual care group, with the mean HbA1c at follow-up being 8.9% in the intervention group

and 9.4% in the usual care group. No significant differences were identified between groups in

weight, treatment pattern, adherence to medication, or quality of life in secondary analyses.

A final study conducted by Kim et al. (2016) investigated the outcome of integrating an

internet-based glucose monitoring system (IBGMS) into the care management of participants

with diabetes in China. Kim et. al utilized a randomized control trial design to place 182

participants in either the IBGMS group or the usual care group for a period of six months. In

order to participate in the study, individuals needed to have HbA1c levels of 7-10% at the time of

admission. The IBGMS group received blood sugar monitoring through the telehealth program

and the results were automatically saved and sent to the medical team via the internet. Using

their computer, participants in the IBGMS group were able to view changes in their blood sugar

levels as well as receive messages and feedback from the medical care team. Findings were

analyzed using paired t-tests with p-values <0.05 considered statistically significant.

Kim et al. (2016) had similar findings to those discussed regarding the previous two

studies in terms of glycemic control. At three months, the IBGMS group saw a greater decrease

in HbA1c, with HbA1c levels in the control group decreasing from 8.0% to 7.3% and the HbA1c

levels in the IBGMS group decreasing from 7.9% to 6.9%. Between the period of three to six

months, HbA1c levels in the control group tended to increase slightly while the HbA1c levels in

the IBGMS group tended to decrease slightly. Additionally, significant changes in fasting blood
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sugar were observed in the IBGMS group both at month three and six, and a significant decrease

in postprandial blood sugar level was observed at month six.

Patient perceptions of telehealth

Two research articles chosen for the purpose of this integrated review utilized qualitative

and quantitative approaches to gain insight into patient perspectives surrounding telehealth and

diabetes management. Hanley et al. (2015) utilized an interpretive descriptive study design to

explore the experiences of patients and medical professionals taking part in a randomized control

trial of blood glucose telemonitoring in patients with type II DM. The researchers sought to

identify factors that facilitate or hinder the effectiveness of the intervention and those likely to

impact its translation into routine practice. Their sample was composed of 23 patients, six nurses

and four doctors throughout 12 primary care practices in Scotland and England. Data was

collected via recorded semi-structured interviews. The researchers analyzed the data using an

inductive approach and employed multiple strategies to ensure credibility and trustworthiness.

Hanley et al. (2015) presented their findings as an overarching framework of factors that

may influence outcomes and potential adoption of telemonitoring of type II diabetes in primary

care, including contextual factors, communication (including performance of the technology),

telemonitoring as support for managing the condition, and ‘fit’ of telemonitoring with personal

lifestyles and professional practice in primary care. Participants who utilized the telehealth

monitoring program believed it was feasible and increased their motivation to self-manage their

diet and blood sugar monitoring. While participants expressed their acceptance of the

convenience of telemonitoring, medical professionals expressed some concerns about

telemonitoring increasing workload and costs. Ironically, participants felt that long-term
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utilization of a telehealth program would reduce the burden on professionals by reducing the

number of face-to-face appointments required.

Similarly to Hanley et al. (2015), Welch et al. (2015) utilized a pre-post study design

method to examine the usability, satisfaction and clinical impact of a three-month diabetes

telehealth intervention for poorly-controlled type II diabetic patients. The study sample was

comprised of 29 poorly-controlled Type II DM patients who were seen at a local community

health center in Connecticut. All participants in the study had a diagnosis of Type II DM, a

HbA1c level between 7-11% at baseline, were greater than 50 years of age and were English-

speaking. At baseline and three-month follow-up, a nurse research coordinator taught the patient

to use the remote home monitoring devices, performed a point-of-care HbA1c test, guided the

patient through the study questionnaires, and measured vital signs. Participants received

feedback from telehealth nurses every two weeks who discussed the patient-generated data and

offered advice and changes to the care plan. At the three-month follow-up, patients, nurses and

providers completed questionnaires assessing usability and satisfaction with the telehealth

program using a 5-point Likert scale. The researchers do not mention the method of data analysis

within their study, therefore, it can be difficult to interpret the significance of their findings.

Welch et al. (2015) found that the majority of patients highly rated the Diabetes

Telehealth Program. The participants felt they were properly trained on how to use the devices,

felt supported by the care team, enjoyed getting help over the phone, would recommend the

program to other patients and they would continue using the program at home. In contrast to the

provider’s negative feelings towards telehealth found by Hanley et al. (2015), Welch et al.

(2015) found that clinic providers reported consistently high ratings for the clarity and ease of

use of the reports generated by the telehealth program, as well as high ratings for its clinical
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usefulness. The providers indicated that, in the future, the generated report should be located

within the hospital electronic medical record, where they could quickly access it while doing

their daily clinical work.

Discussion/Implications

The findings of the research articles discussed in this review demonstrate a correlation

between the implementation of telehealth programs and effective management of Type II DM.

Utilization of telehealth programs resulted in improved glycemic control (Greenwood et al.,

2015; Kim et al., 2016; Wild et al., 2016) and were associated with positive patient perspectives

regarding ease of use and feasibility for implementation into clinical practice (Hanley et al.,

2015; Welch et al., 2015). These findings support the PICO question set by the researcher: In

adult patients with Type II DM, what is the effect of telehealth compared to traditional care on

glycemic control? The findings support the integration of telehealth programs into clinical

practice to more effectively manage the care of patients with Type II DM.

Given the findings of the aforementioned research articles, the researcher suggests that

telehealth programs that utilize glucose monitoring technologies, including sensors that collect

and store glucose data for access by the care team, may improve the relationship between

primary care providers and their patients. Telehealth programs have the potential to increase

patient adherence to care plans and help fill the gaps between traditional hospital visits; thus,

allowing patients to receive consultations with their primary care providers in their day-to-day

lives (Kim et al., 2016). Therefore, the integration of telehealth programs into clinical practice

within primary care facilities may have the potential to improve patient outcomes and quality of

care. Further research is needed to investigate the role of eHealth models of care and their

sustainability over longer periods of time. Additionally, more research on the beneficial effects
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of these interventions on patients’ self-care motivation and behavior may help to encourage

clinicians to adopt these technologies in routine practice (Hanley et al., 2015).

Limitations

There are numerous limitations to note in regard to this integrated review. The content of

this review was based upon only five articles, all of which were published in the last five years.

Therefore, this is not an exhaustive review of the literature on the topic. Additionally, this review

is a class assignment and the researcher has limited experience analyzing research and writing

integrated reviews. All five of the articles utilized for the purpose of this review listed their own

individual limitations within their studies, a summary of which can be found in Appendix 1.

Major limitations to note are small sample size, lack of participant demographic variability and

limited duration of research period, which may impact the generalizability and sustainability of

the findings (Greenwood et al., 2015; Hanley et al., 2015; Welch et al., 2015; Wild et al., 2016).

Conclusion

The PICO question of interest for this integrative review is: In adult patients with Type II

DM, what is the effect of telehealth compared to traditional care on glycemic control? The

studies discussed in this integrative review support the role of telehealth programs in clinical

practice and find telehealth to be more effective than usual care in the care management of

patients with Type II DM. Findings from the articles support that telehealth programs are

effective in improving glycemic control in poorly controlled type II DM patients (Greenwood et

al., 2015; Kim et al., 2016; Wild et al., 2016). Additionally, patients and healthcare providers

who have participated in telehealth programs have reported positive perceptions surrounding the

usability and feasibility of telehealth utilization in clinical practice (Hanley et al., 2015; Welch et

al., 2015). Despite a plethora of evidence supporting the benefits of telehealth utilization, few
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healthcare facilities have integrated telehealth monitoring into their clinical practice.

Implementation of telehealth programs should be considered an effective solution for primary

care practices who are faced with the care management of a growing population of individuals

with Type II DM.

References

Centers for Disease Control and Prevention (2017). National Diabetes Statistics Report, 2017.

Retrieved from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-

statistics-report.pdf

Greenwood, D. A., Blozis, S. A., Young, H. M., Nesbitt, T. S., & Quinn, C. C. (2015).

Overcoming clinical inertia: a randomized clinical trial of a telehealth remote monitoring

intervention using paired glucose testing in adults with type 2 diabetes. Journal of

medical Internet research, 17(7). doi: 10.2196/jmir.4112

Hanley, J., Fairbrother, P., McCloughan, L., Pagliari, C., Paterson, M., Pinnock, H., Sheikh, A.,

Wild, S., & McKinstry, B. (2015). Qualitative study of telemonitoring of blood glucose

and blood pressure in type 2 diabetes. BMJ open, 5(12). doi: 10.1136/bmjopen-2015-

008896

Kim, H. S., Sun, C., Yang, S. J., Sun, L., Li, F., Choi, I. Y., Cho, J.H., Wang, G., & Yoon, K. H.

(2016). Randomized, open-label, parallel group study to evaluate the effect of internet-

based glucose management system on subjects with diabetes in China. Telemedicine and

e-Health, 22(8), 666-674. doi: 10.1089/tmj.2015.0170

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Welch, G., Balder, A., & Zagarins, S. (2015). Telehealth program for type 2 diabetes: usability,

satisfaction, and clinical usefulness in an urban community health center. Telemedicine

and e-Health, 21(5), 395-403. doi: 10.1089/tmj.2014.0069

Wild, S. H., Hanley, J., Lewis, S. C., McKnight, J. A., McCloughan, L. B., Padfield, P. L.,

Parker, R.A., Paterson, M., Pinnock, H., Sheikh, A., & McKinstry, B. (2016). Supported

telemonitoring and glycemic control in people with type 2 diabetes: the telescot diabetes

pragmatic multicenter randomized controlled trial. PLoS medicine, 13(7). doi:

10.1371/journal.pmed.1002098
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Appendix 1

Reference (APA) Greenwood, D. A., Blozis, S. A., Young, H. M., Nesbitt, T. S., & Quinn, C. C. (2015). Overcoming
clinical inertia: a randomized clinical trial of a telehealth remote monitoring intervention using paired
glucose testing in adults with type 2 diabetes. Journal of medical Internet research, 17(7).

Author/Qualifications Greenwood – Clinical performance improvement consultant, program coordinator for Integrated
Diabetes Education Network
Blozis – Associate Professor, Department of Psychology, University of California Davis
Young – Associate Vice Chancellor for Nursing, Dean and Professor, Betty Irene Moore School of
Nursing
Nesbitt – Associate Vice Chancellor, Strategic Technologies and Alliances, Director, Center for Health
and Technology
Quinn – Associate Professor, Department of Epidemiology and Public Health

Introduction/ Research indicates people with diabetes remain at suboptimal glucose control for 2.9 years from patient
Background/Problem and provider clinical inertia limiting treatment intensification. Self-management of diabetes is a critical
Statement component of diabetes care and self-monitoring of blood glucose (SMBG) is an essential self-
management behavior. A complete feedback loop—data collection and interpretation combined with
feedback to the patient to modify treatment plan—has been associated with improved outcomes. Novel
clinical interventions are needed that expand existing paradigms of diabetes care by utilizing telehealth
remote monitoring and actionable patient-generated data for timely behavior and treatment changes. The
purpose of this study was to test the effectiveness of a telehealth remote monitoring intervention with
paired glucose testing for adults with noninsulin-treated type 2 diabetes.

Conceptual/ None stated by researchers in the article

Theoretical Framework

Design/Research Design: 2-group randomized clinical trial with 1:1 randomization to usual care or telehealth remote
Methods/Sample/ monitoring with paired glucose testing (treatment group). The telehealth remote monitoring tablet
Setting/Ethical computer transmitted glucose data and facilitated a complete feedback loop to educate participants,
Considerations/ analyze actionable glucose data, and provide feedback. Data from paired glucose testing were analyzed
Major Variable Studied/ asynchronously using computer-assisted pattern analysis and were shared with patients via the EHR
INTEGRATIVE REVIEW 15

Measurement Tool/Data weekly. CDEs called participants monthly to discuss paired glucose testing trends and treatment
Collection Tool/Data changes. Participants in usual care received diabetes education booklets and referral for formal diabetes
Analysis education as needed.
Sample: Sample size was determined based on the main outcome: mean change in A1c between
treatment and usual care over 6 months. The comparison of usual care (n=39) to treatment participants
(n=39) had 80% power to detect a 0.9% difference in A1c between treatment and usual care after 6
months (α=.05, 2-tailed).
Inclusion Criteria: Type 2 diabetes diagnosis treated with oral antihyperglycemic medications,
noninsulin injectable medications, or lifestyle alone; participant in the diabetes management program for
previous 12 months; Aged between 30 and 70 years; A1c between 7.5% and 10.9% (58-96 mmol/mol)
in previous 6 months; Internet or 3G connection with email access; Landline or cellular phone; English
speaking; and Primary care provider in health system.
Exclusion Criteria: Insulin prescription; Unable to independently self-manage (diagnosis of
dementia, severe depression, schizophrenia, or cognitive impairment for previous 12 months); and/or
Diagnoses of debilitating stroke, heart failure, end-stage renal disease, or legally blind.
Setting: The study was conducted between January and October 2013 in a large health care system in
California with an established diabetes management program with telephonic nurse care coordination
for diabetes population health management.
Measurement Tools: difference in mean change in A1c from baseline to 6 months between groups,
Diabetes knowledge was measured using the Diabetes Knowledge Test (DKT), Self-management was
measured by the Summary of Diabetes Self-Care Activities, Self-efficacy was measured by the Diabetes
Empowerment Scale short form (DES-SF)
Statistical Analysis: Mixed-effects models were used to compare mean change over time in primary
and secondary outcomes between groups. Tests used a significance level of P<.05 or a 95% confidence
interval that excluded zero.

Findings/Results Both groups had improved A1c levels at 3 months without a significant difference between groups in
the rate of change (P=.06). However, at 6 months, the treatment group continued to have a statistically
significant decrease in A1c levels (demonstrating sustained benefit from the intervention), whereas the
usual care group participants were no longer improving (P=.005). Both groups had lower A1c levels
with an estimated average decrease of 0.70 percentage points in the usual care group and 1.11
percentage points in the treatment group, with a significant group difference of 0.41 percentage points at
6 months.
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Both groups showed improvement on average for general diet, specific diet, carbohydrate spacing, and
foot care self-management behaviors measured by the SDSCA. The treatment group showed greater
improvement in the self-management behaviors of carbohydrate spacing, monitoring glucose, and foot
care. In this study, treatment participants had more self-reported medication changes compared to usual
care participants and this was significantly associated with A1c level at both 3 (P<.001) and 6 months
(P<.001).

Discussion/ Implementation of all complete feedback loop elements (telehealth remote monitoring, structured
Implications SMBG, nurse care coordination, and treatment change) is necessary to improve outcomes and future
clinical translational research needs to be conducted in the context of the complete feedback loop.
Newer glucose monitoring technologies, including continuous glucose sensors that collect and store
glucose data with minimal fingerstick requirements, may improve primary care provider and patient
access to glucose data and reduce clinical inertia.

Limitations/ Limitations included a small sample size, study lasting only 6 months (difficulty assessing long-term
Conclusions outcomes and sustainability), possible Hawthorne effect, no data collected on exercise or diet changes,
decreased variability among sample demographics, and no cost analysis.
At present, this level of nurse care coordination has limited reimbursement. Further research is needed
to support eHealth models of care that incorporate remote nurse care coordination by CDEs.

Appraisal/Worth to Implementing a complete feedback loop in the primary care setting, supported by telehealth remote
practice monitoring and paired glucose testing, improves A1c and self-management behaviors in adults with type
2 diabetes.
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Reference (APA) Wild, S. H., Hanley, J., Lewis, S. C., McKnight, J. A., McCloughan, L. B., Padfield, P. L., ... &
McKinstry, B. (2016). Supported telemonitoring and glycemic control in people with type 2 diabetes:
the Telescot diabetes pragmatic multicenter randomized controlled trial. PLoS medicine, 13(7),
e1002098.

Author/Qualifications Wild - Usher Institute of Population Health Sciences and Informatics

Hanley - Edinburgh Napier University School of Nursing, Midwifery and Social Care,
Lewis - Usher Institute of Population Health Sciences and Informatics
McKnight - Metabolic Unit, Western General Hospital, College of Medicine and Veterinary Medicine
McCloughan, Padfield, Parker, Paterson, Pinnock, Sheikh and McKinstry - Usher Institute of Population
Health Sciences and Informatics

Introduction/ The traditional clinician-led model with regular face-to-face consultations for managing diabetes and
Background/Problem hypertension is costly in terms of health care professionals’ time, rarely supports self-management by
Statement patients, and is often not very effective, partly because therapeutic inertia may result in reluctance to
change treatments. Self-monitoring of blood glucose among people with type 2 diabetes not treated with
insulin does not appear to be effective in improving glycemic control. The aim of the Telescot Diabetes
Trial was to investigate the effect of supervised, self-monitoring of glycemic control, blood pressure,
and weight with telemetric transmission of measurements (hereafter described as supported
telemonitoring) among people with poorly controlled diabetes compared with a control group receiving
usual care.

Conceptual/ None stated by researchers in the article

Theoretical Framework

Design/Research Design & Setting: randomized, parallel, investigator-blind, controlled trial in family practices in four
Methods/Sample/ regions of the United Kingdom. Participants in the intervention group were given instructions for use of
Setting/Ethical blood pressure, blood glucose, and weight monitors, that used Bluetooth technology to transmit readings
Considerations/ via a supplied modem to a remote secure server by research nurses. The participant and their family
Major Variable Studied/ practice professionals were able to access password-protected records on the server. Participants were
Measurement Tool/Data asked to measure one fasting and one nonfasting blood glucose at least twice weekly and measure BP
Collection Tool/Data and weight at least weekly (with increased testing as recommended by the clinician for people treated
Analysis with insulin). Participants were given advice on lifestyle modification, on lag time for effects of lifestyle
INTEGRATIVE REVIEW 18

and medication change on glucose and blood pressure, and when and how to contact their family
practice team via research nurses. Primary care nurses were asked to check participants’ results weekly
and to organize treatment changes based on national guidelines for diabetes and hypertension
management. The intervention lasted 9 mo, when patients were asked to attend for follow-up. The
comparison group received usual care.
Sample: Data for the primary outcome were available for 146 people (91%) in the intervention group
and 139 people (86%) in the control group.
Inclusion criteria: diagnosis of type 2 diabetes managed in family practice, age over 17 years,
availability of a mobile telephone signal at home, and poor glycemic control, defined as HbA1c >58
mmol/mol.
Exclusion criteria: blood pressure >210/135 mmHg, hypertension or renal disease managed in
secondary care, treatment for a cardiac event or other life-threatening illness within the previous 6 mo,
major surgery within the last 3 mo, atrial fibrillation unless successfully treated or cardioverted, inability
to use self-monitoring equipment, and pregnancy.
Measures: Baseline measurements included HbA1c, smoking history, height and weight, exhaled
carbon monoxide, questionnaire data on anxiety/depression (Hospital Anxiety and Depression Scale),
quality of life (EQ-5D), self-efficacy, medication adherence, physical activity, and knowledge of
managing diabetes (based on responses from the first 14 items of the diabetes knowledge test).
Statistical Analysis: Difference in mean HbA1c estimated using linear regression with a 95%
confidence interval for the difference.

Findings/Results The mean (SD) HbA1c at follow-up was 63.0 (15.5)mmol/mol in the intervention group and 67.8 (14.7)
mmol/mol in the usual care group. For primary analysis, adjusted mean HbA1c was 5.60mmol/mol /
0.51%lower (95%CI 2.38 to 8.81mmol/mol/ 95%CI 0.22%to 0.81%, p = 0_0007). No significant
differences were identified between groups in weight, treatment pattern, adherence to medication,
or quality of life in secondary analyses.

Discussion/ Clinically and statistically significantly greater improvements in glycemic control were found among
Implications people with poor glycemic control of type 2 diabetes who were offered supported telemonitoring over 9
mo than among the comparison group offered usual care. There were also significant reductions in
blood pressure. The key feature of our trial is robust evidence suggesting that blood glucose monitoring
with relatively little additional support from health professionals can be of value in terms of improving
glycemic control in people who have previously had poor glycemic control. Further work is required to
INTEGRATIVE REVIEW 19

identify whether telemonitoring is helpful in normal healthcare, which people find it most useful, and
how long it should be used for.

Limitations/ Key limitations include potential lack of representativeness of trial participants, inability to blind
Conclusions participants and health professionals, and uncertainty about the mechanism, the duration of the effect,
and the optimal length of the intervention. Supported telemonitoring resulted in clinically important
improvements in control of glycaemia in patients with type 2 diabetes in family practice

Appraisal/Worth to The key feature of our trial is robust evidence suggesting that blood glucose monitoring with relatively
practice little additional support from health professionals can be of value in terms of improving glycemic
control in people who have previously had poor glycemic control.
INTEGRATIVE REVIEW 20

Reference (APA) Hanley, J., Fairbrother, P., McCloughan, L., Pagliari, C., Paterson, M., Pinnock, H., ... & McKinstry, B.
(2015). Qualitative study of telemonitoring of blood glucose and blood pressure in type 2 diabetes. BMJ
open, 5(12), e008896.

Author/Qualifications Hanley - Edinburgh Napier University School of Nursing, Midwifery and Social Care,
Fairbrother - Department of Public Health, NHS Lothian
Wild, McCloughan, Pagliari, Paterson, Pinnock, Sheikh and McKinstry - Usher Institute of Population
Health Sciences and Informatics

Introduction/ As the prevalence of chronic conditions such as type 2 diabetes increases, it will become difficult to
Background/Problem continue to provide the same level of healthcare staffing to manage these conditions as we do now.
Statement Many healthcare strategy documents advocate the use of telehealth (particularly telemonitoring and
teleconsultation) to streamline and improve the management of long-term conditions and produce
engaged and activated patients who manage their own condition well, requiring fewer consultations and
fewer admissions to hospital. The purpose of the study was to explore the experiences of patients and
professionals taking part in a randomized controlled trial (RCT) of blood glucose, blood pressure (BP)
and weight telemonitoring in type 2 diabetes supported by primary care, and identify factors facilitating
or hindering the effectiveness of the intervention and those likely to influence its potential translation to
routine practice.

Conceptual/ None stated by researchers in the article

Theoretical Framework

Design/Research Design: Qualitative study adopting an interpretive descriptive approach.

Methods/Sample/ Participants: 23 patients, 6 nurses and 4 doctors who were participating in a RCT of blood glucose and
Setting/Ethical BP telemonitoring. A maximum variation sample of patients from within the trial based on age, sex and
Considerations/ deprivation status of the practice was sought.
Major Variable Studied/ Setting: 12 primary care practices in Scotland and England.
Measurement Tool/Data Method: Data were collected via recorded semistructured interviews.
Collection Tool/Data Data Analysis: Analysis was inductive with themes presented within an overarching thematic
Analysis framework. Multiple strategies were employed to ensure that the analysis was credible and trustworthy.
Constant comparison was used to ensure consistency in coding and negative cases were sought for each
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coding category. Coding was checked and iteratively refined using paired analysis of transcripts by two
researchers.

Findings/Results The results are presented in the context of a broad overarching framework of factors which influence
outcomes and potential adoption of telemonitoring of type 2 diabetes in primary care including
contextual factors, communication (including performance of the technology), telemonitoring as support
for managing the condition, and ‘fit’ of telemonitoring with personal lifestyles and professional practice
in primary care.
Telemonitoring of blood glucose, BP and weight by people with type 2 diabetes was feasible.
The data generated by telemonitoring supported self-care decisions and medical treatment decisions.
Motivation to self-manage diet was increased by telemonitoring of blood glucose, and the ‘benign
policing’ aspect of telemonitoring was considered by patients to be important.
The convenience of home monitoring was very acceptable to patients although professionals had some
concerns about telemonitoring increasing workload and costs.
For patients telemonitoring was not a burden, it was convenient and made sense.
Patients also thought that in the longer term it would reduce the burden on the practice by reducing the
number of appointments required.

Discussion/ The findings from this study suggest that telemonitoring of blood glucose and BP by people with type 2
Implications diabetes was feasible.
The convenience of telemonitoring was very acceptable to patients although professionals had some
concerns about telemonitoring increasing workload and costs.
The findings indicated that there was a lack of consensus on who (patient or practitioner) should initiate
communication if readings were out with the target range and the mode of communication, with
telephone and letter being used but some practitioners preferring to see patients face to face.
However, some professional responses were more wary and suggest a lack of ‘fit’ between
telemonitoring and current expectations of professional practice which may limit translation into routine
practice.
There is need for further refinement of telehealth care delivery models and technical improvements in
telemonitoring systems, as well as wider cultural change on the part of patients and clinicians.
More evidence of the beneficial effects of these interventions on patients’ self-care motivation and
behavior may help to encourage clinicians to adopt these technologies in routine practice.
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Limitations/ Key limitations included a lack of variability in participant demographic, lack of adoption of telehealth
Conclusions programs by clinical practices at full scale and small sample size. Telemonitoring in type 2 diabetes was
well accepted by trial participants and increased motivation to improve self-management.
It also provided clinicians with a quantitative basis on which to improve the medical management of BP.
Some professionals harbored concerns about the potential for the service to increase workload and cost
and some expressed a reluctance to move away from traditional exclusive face to face care, but this was
not universal.

Appraisal/Worth to Telemonitoring of blood glucose, BP and weight in primary care is a promising way of improving
practice diabetes management which would be highly acceptable to the type of patients who volunteered for this
study.
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Reference (APA) Kim, H. S., Sun, C., Yang, S. J., Sun, L., Li, F., Choi, I. Y., ... & Yoon, K. H. (2016). Randomized,
open-label, parallel group study to evaluate the effect of internet-based glucose management system on
subjects with diabetes in China. Telemedicine and e-Health, 22(8), 666-674.

Author Departments of Medical Informatics and Endocrinology and Metabolism, College of Medicine, The
(Year)/Qualifications Catholic University of Korea, Seoul, Republic of Korea.
Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun,
China.

Introduction/ Among these new systems, the Internet-based glucose monitoring system (IBGMS) has been shown to
Background/Problem effectively increase blood sugar control in several studies. It has also reported to have commercial
Statement potential. However, other studies have reported that these systems have negative effects on blood sugar
control programs, due to transmission errors, system failures, and poor management. Therefore,
development and introduction of an IBGMS into a clinical setting require large amounts of time, effort,
and expertise in planning, developing, applying, and operating the service program. Therefore, our
expertise and experience, while operating an IBGMS in Korea, were applied to implementing and
evaluating the efficacy of an IBGMS in a Chinese hospital.

Conceptual/ None stated by researchers in the article

Theoretical Framework

Design/Research Design: a randomized, open-label, parallel group design

Methods/Sample/ Sample: The study subjects were male and female outpatients at the First Bethune Hospital at Jilin
Setting/Ethical University, China, who had been diagnosed with diabetes for over 1 year
Considerations/ Inclusion criteria: subjects who had glycated hemoglobin (HbA1c) levels of 7.0–10.0% at the
Major Variable Studied/ time of admission, had an Internet connection at home, and provided their voluntary informed consent.
Measurement Tool/Data Exclusion criteria: patients who were pregnant or who had a serious medical disease, serious diabetic
Collection Tool/Data complication, or aspartate transaminase (AST) or alanine transaminase (ALT) levels of ‡2.5· above the
Analysis normal upper limit. In addition, we excluded patients who had not taken their medication regularly in
the
3 months before enrollment, those who were engaged in other clinical studies, and those without access
to computers.
Methods: The IBGMS group received blood sugar monitoring through the Internet, while the
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control group received the conventional treatment. However, both the IBGMS and the control groups
visited the hospital every 3 months for laboratory testing and a clinical examination to evaluate the
safety and efficacy of their treatment. Laboratory testing included baseline HbA1c levels, white blood
cell counts with the differential counts, red blood cell counts, hemoglobin and hematocrit levels, platelet
counts, fasting blood sugar, blood urea nitrogen, creatinine, AST, ALT, sodium, and potassium levels.
The subjects’ in both groups were also provided glucometers (My- GlucoHealth OneTouch UltraEasy;
LifeScan) and 150 testing strips. Using this system, the subjects measured their blood sugar using a
system that was connected to their computer, and the results were automatically sent and saved to an
online server. Using their computer, subjects were able to view changes in their blood sugar levels as
well as receive messages from the medical team.
Statistical Analysis: We conducted an analysis of the mean intragroup change at each time point using
a paired t-test. p-Values <0.05 were considered statistically significant, and data were analyzed using a
standard statistical software package.

Findings/Results At 3 months, the HbA1c levels in the control group were reduced from 8.0% to 7.3% ( p < 0.001), and
the HbA1c levels in the IBGMS group were reduced from 7.9% to 6.9% ( p < 0.001). Both groups also
exhibited significant reductions in blood sugar levels. However, the IBGMS group exhibited a more
significant 6-month decrease compared to the control group (6.7% vs. 7.4%,p < 0.001), although there
were no significant differences in the HbA1c changes between months 3 and 6. However, the
HbA1c levels in the control group tended to increase slightly over this period (7.3% to 7.4%, p = 0.605)
and the HbA1c levels in the IBGMS group tended to decrease slightly (6.9% to 6.7%, p = 0.081). In the
control group, there were no significant changes in the subjects’ fasting and postprandial blood sugar
levels. However, significant changes in fasting blood sugar were observed in the IBGMS group at
month 3 ( p = 0.003) and month 6 ( p = 0.005), and a significant decrease in postprandial blood sugar
level was observed at month 6 ( p < 0.001).

Discussion/ IBGMS allows users to upload their self-assessed blood sugar data during their day-to-day lives and
Implications record additional personal information, which includes their medical history, family medical history,
complications, and current medications. Based on these data, the patient’s medical team can then
generate appropriate recommendations and feedback for the patient, which helps the patient to more
effectively control their blood sugar levels. Therefore, if the patient can easily utilize the IBGMS, the
fact that it requires Internet use does not appear be significantly affected by the patient’s age. Thus,
medical services for patients should be redeveloped with a specific consideration of patient needs, and
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new processes should be established to increase patient compliance. These processes and services
should help fill the gaps between traditional hospital visits and allow patients to receive consultations in
their day-to-day lives.

Limitations/ Key limitations include that the study wasn’t blinded, the dropout rate was high, lack of qualitative data
Conclusions to identify difficulties with the new IBGMS or relationship between blood sugar control and treatment
satisfaction.
This study and other studies have proven that IBGMS is effective in improving blood sugar
control. Therefore, this study can serve as an example of successfully transferring an existing IBGMS
between institutions and countries. Moreover, this transfer was relatively simple, did not require an
extended period of time, and was effective in controlling the patients’ blood sugar levels.
In the future, we suggest that studies should evaluate blood sugar control using mobile phones rather
than the Internet, to improve cost effectiveness.

Appraisal/Worth to Our results indicate that the present IBGMS effectively improved blood sugar control and confirm that
practice teams in different countries can successfully implement an IBGMS using a cooperative approach.
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Reference (APA) Welch, G., Balder, A., & Zagarins, S. (2015). Telehealth program for type 2 diabetes: usability,
satisfaction, and clinical usefulness in an urban community health center. Telemedicine and e-
Health, 21(5), 395-403.

Author/Qualifications Garry Welch, PhD, Andrew Balder, MD, and Sofija Zagarins, PhD
Silver Fern Healthcare, West Hartford, Connecticut.
Mason Square Neighborhood Health Center, Baystate Medical Center, Springfield, Massachusetts.

Introduction/ Scalable, population-based healthcare models are urgently needed to meet the growing public health
Background/Problem challenge of T2D. These models should incorporate a team approach and care delivery strategies such as
Statement telehealth with a focus on daily patient self-management support and early detection of avoidable
medical complications and crises. Nurse-led telehealth has emerged as a patient-centered strategy for the
delivery of diabetes self-management education that leverages communication and information
technologies to provide more timely and convenient support in the patient’s home. We examined the
usability, satisfaction, and clinical impact of a 3-month diabetes telehealth intervention for poorly
controlled type 2 diabetes (T2D) patients. The urban community health center sample (n= 30) was
56.7% female, mean age of 60.6 years, 56.7% high school education or higher, and 73% African
American and 26% Latino.

Conceptual/ None stated by researchers in the article

Theoretical Framework

Design/Research Design: single sample, pre–post study design

Methods/Sample/ Sample: 29 poorly controlled T2D patients seen at a local community health center. Study eligibility
Setting/Ethical included the following: being a T2D patient seen within the previous 12 months at the clinic, not on
Considerations/ multiple daily insulin therapy, HbA1c level between 7% and 11% at baseline, age > 50 years, no serious
Major Variable Studied/ psychiatric or medical health complications present, English speaking, and the patient’s provider
Measurement Tool/Data approves his or her participation in the program.
Collection Tool/Data Methods: Each patient enrolled in this study received three monitoring devices (BG monitor, automatic
Analysis BP cuff, and MedMinder pillbox). A review of each patient’s medication list was generated from the
electronic medical record and baseline patient interview to set up the MedMinder pillbox with
medications to manage hyperglycemia, hypertension, and dyslipidemia for up to four daily dosing times.
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At the 3-month follow-up, patients completed questionnaires assessing usability and satisfaction with
the telehealth program using a 5-point Likert scale.

Findings/Results Positive ratings were consistently found for the BG meter and BP cuff (88.8% and 84%, respectively,
were ‘‘strongly agree’’). Patient satisfaction ratings with the telehealth program were strongly loaded
toward ‘‘strongly agree’’ and ‘‘somewhat agree’’ for items assessing happiness with device training and
feelings of support from diabetes team, and all patients reported they would either ‘‘strongly agree’’ (n
= 25) or ‘‘somewhat agree’’ (n = 4) that they would recommend the program to other T2D patients
based on their experience. The majority of the 11 participating clinic providers endorsed that they
‘‘strongly agreed’’ that the CDS report summarizing BG values, BP values, and medication adherence
was clear and easy to understand (Table 4). All providers wanted these reports to be made available in
future within the hospital system’s electronic medical record, and 8 of the 11 providers (72%) reported
they ‘‘strongly agreed’’ that hard copy (paper) reports were also wanted.

Discussion/ The current study showed that T2D patients taking part in a brief diabetes telehealth program focusing
Implications on daily medication adherence rated the usability of our BG meter, BP cuff, and pillbox RHM device
suite highly for its ease of use, usefulness, and convenience when used in the home. Patients also rated
program satisfaction highly in terms of support from the diabetes care team, helpfulness of nurse
outreach calls, and their wish to keep using the program if it were available and indicated that they
would recommend the program to other patients. Improvement in BG control was clinically and
statistically significant with an HbA1c drop of 0.6% observed over the 3-month program. This benefit
was achieved with minimal nurse outreach (three brief scheduled calls), minimal nurse and provider
staff training, and no structured diabetes education protocol in place for the nurses to deliver.
The results also showed that clinic providers reported consistently high ratings for the clarity and ease of
use of the CDS reports we provided in the form of summary RHM graphs at the end of the 3-month
program, as well as high ratings for its clinical usefulness. The providers indicated that the report should
be located in the future within the hospital electronic medical record, where they did their daily clinical
work.
Future studies could adopt a strategy we have used in prior local studies to include bicultural, bilingual
Latino research staff and diabetes team staff to provide the appropriate culturally competent staffing
capacity to manage a more representative study population.
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Limitations/ Key limitations include small sample size, short study period, no analysis of sustainability or long-term
Conclusions barriers.
These findings provide encouraging empirical support for the usability and clinical usefulness of our 3-
month diabetes telehealth program that was delivered to an urban poor clinic population and that was
enriched by the integration of a user-friendly cellular pillbox and CDS tools.

Appraisal/Worth to These findings provide encouraging empirical support for the usability and clinical value of a diabetes
practice telehealth program integrating a user-friendly cellular pillbox and clinical decision support tools that
was delivered to an urban poor T2D clinic population.