This paper discusses eight published articles that explore results from research conducted using telehealth and its effect on diabetes management in adults. The articles vary in their modes of intervention. Most articles used traditional intervention such as an office visit for comparison. This paper examines all articles included to suggest that telehealth in general has an effect of diabetes management in adults, and that different modes of intervention should be studied in order to fully understand how telehealth intervention influences diabetic patients.
Telehealth can be defined as a means of delivering healthcare communications through telecommunications technology (Hovey, 2018). This allows a provider to treat a patient without physically being in the same location. Telehealth is a broad topic that encompasses the term telemedicine. Telemedicine can be defined as the exchange of medical information from one site to another via electronic communications for improving patients health, according to the American Telemedicine Association (2012). This can include the use of remote technology to replace office visits with remote visits, and remote patient training and monitoring. Many of the references used include the terms telehealth and telemedicine, and often use similar interventions.
Providers and patients, in different locations, are connected through audio or video communication tools. Remote patient monitoring tools such as home blood pressure monitors can be incorporated in. There are many benefits and few drawbacks to telehealth. Some drawbacks of telehealth can be difficulty differentiating symptoms, such as a runny nose versus tearing eyes (Bowman, 2014). Certain behaviors and symptoms concerning domestic violence and suicide risk may also be easily overlooked. In America, healthcare is expensive for all parties involved. The implantation of telehealth offers technology that can offer increased access to healthcare at a value. This can include less travel and reduced emergency room visits.
Telehealth is a significant part of healthcare in that it offers an alternative means of treating patients that can benefit both the provider and patient. According to the Center for Disease Control (National Diabetes Statistics Report, 2017), more than one hundred million U.S adults are now living with pre-diabetes or diabetes and it remains one of the most leading causes of death in the Unites States.
Diabetes is a condition in which the body does not properly process food to use as energy (National Diabetes Statistics Report, 2017). Diabetes has two types. Though there is childhood diabetes and gestational diabetes, they will not be discussed in this paper. Type 1 is known as insulin dependent diabetes mellitus which can include autoimmune, genetic and environmental risk factors. Type 2 diabetes is when the body does not use insulin properly, and causes blood glucose levels to rise higher than normal. Type 2 risk factors include age, family history, obesity, impaired glucose tolerance, physical inactivity and race/ethnicity. Diabetes can lead to other comorbidities such as heart disease, blindness, kidney failure and lower extremity amputation (National Diabetes Statistics Report, 2017). Hemoglobin A1c (HbA1c) is an indicator of treatment effectiveness in patients with diabetes as it reflects average glycemia over many months and is heavily correlated with diabetes complications (Marcolino et al., 2013).
Replacing an in-office visit with a telephone visit offers the ability to save time and money. Telehealth has the advantage of convenience allowing for patients to be treated in the comfort of their own homes and eliminates transportation and travel difficulties and expenses. At home tools such as glucometers and blood pressure monitors can be used and incorporated into telehealth consultations. A pilot study involving one nurse practitioner (NP) and adults with type 2 diabetes utilized telephone intervention to see the effectiveness in improving A1C. The NP used the phone calls for interactive educational sessions following the American Association of Diabetes Educators (AADE7) principles for diabetes management skills (Barker, Mallow, Theeke & Schwertfeger, 2016).
An evaluation of studies using telemedicine to manage diabetes included the use of automated phone calls and installation of blood glucose monitors in patients homes (Garelick, 2015). A systematic review and meta-analysis of randomized control trials studied the effect of telemedicine interventions on change in blood pressure, LDL cholesterol, HbA1c, and body mass index included computerized systems for information exchange, video conferencing, and exchange of information via telephone or other mobile devices, short message service, or through the internet (Marcolino et al., 2013). Sixteen randomized control trials on diabetic patients were used to assess the effect computer based self-management interventions, which included clinic based brief interventions, internet interventions that could be accessible from home and mobile phone-based interventions (Pal et al. 2013).
Rural and underserved areas can have a lot to gain from the accessibility of telehealth. For nurse practitioners, it is a great tool for interacting with their patients as colleagues as well. Practitioners must still abide by the Health Insurance Portability and Accountability Act (HIPAA), which provides guidelines and security for electronic health data. This also offer a challenge, as there is more opportunity for exposure of patient information through technology.
Though it can replace an office visit, this does not mean the care is subpar. Nurse practitioner telephone intervention showed effectiveness in improving A1c (Barker, Mallow, Theeke & Schwertfeger, 2016). When used for educating themselves, telemedicine enables practitioners to better assess, identify and treat diabetic foot ulcers (Beate, Gjengedal, Graue, Thorne & Kirkvolde, 2016). Education received via telehealth intervention helped increase patient knowledge of their conditions, treatments and healthy living (Lee, Greenfield & Pappas, 2018).
Telehealth and telemedicine have proved to be a beneficial source for managing diabetes in adults. Telehealth intervention by practitioners showed improvements in lowering blood pressure, LDL, and HgbA1c and empowered clients to better manage their diabetes (Zavana & Millian, 2014). Six studies with varying telehealth interventions form automated phone calls to home devices showed a decrease in patients Hba1c regardless of study size and demographics (Garelick, 2015). Computer-based and mobile phones diabetes self-management interventions to manage type 2 diabetes have a small beneficial effect on blood glucose control (Pal et al., 2013). A telephone intervention focused on education with adult diabetic patients resulted in a decrease in mean blood glucose values (Barker, Mallow, Theeke & Schwertfeger, 2016).
An evaluation of four randomized controlled studied using telemedicine intervention showed a decrease in HbA1c levels in the intervention groups compared to control groups (Garelick, 2015). A systematic review and meta-analysis showed that telemedicine strategies in combination with the typical care are correlated with improved glycemic control and BMI reduction in diabetic patients. However, the review also stated there was no clinically relevant impact on LDL and blood pressure (Marcolino et al., 2013). A review of sixteen randomized control trials using computer based self-management showed a small beneficial effect on blood glucose control, with the largest effect being on the mobile phone subgroup as opposed to clinic and home-based groups (Pal et al, 2013).
Though telehealth intervention proved to be beneficial in adult diabetes management, these studies offer many limitations as well. Many studies included small sample sizes, causing even large changes in values to be possibly statistically insignificant. Short durations preventing an end A1c evaluation to assess was another limitation, as well as lack of reimbursement for providers (Barker, Mallow, Theeke & Schwertfeger, 2016). Regarding a voluntary study, motivation became a possible limitation, due to its contribution to decreasing HbA1c levels in relation to the control group (Garelick, 2015).
Having participants that were computer literate and well educated posed as a limitation as well, being that it may have over represented the results due to participants motivation and engagement in self-management. (Pal et al., 2013). The themes of sample size and motivation stayed fairly consistent as a limitation throughout the studies included.
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