As far as we know, our review is the first to evaluate the benefits of teleconsultation and videoconferencing for diabetes care, in particular with respect to clinical, behavioral, and care coordination aspects. Earlier reviews have focused on usability and costs of technology or considered mainly clinical (glucose and diet) outcomes [2
]. A systematic search and selection process produced only 39 studies. This may appear low, but it is comparable with previous reviews on ICT-based care [3
We can conclude that in the period under review (1994-2006), 39 studies had a scope broader than clinical outcomes and involved interventions allowing patient-caregiver interaction. Most of the reported findings concerned satisfaction with technology (26/39 studies), improved metabolic control (21/39), and cost reductions (16/39). Improvements in quality of life (6/39), transparency (5/39), and better access to care (4/39) were hardly observed. In 19 of 39 studies the control group was more or less comparable with the intervention group (see and ). It appeared that ICT-based care improved diabetes care compared to usual care; however, the improvements were mostly not statistically significant. In a sense it could be argued that technology did not compromise the care delivery process.
Only a minority of the studies (12/39) considered care settings involving teamwork of various caregivers (eg, nurses, case manager, psychologist, physician, general practitioner), which should be expected in integrated chronic care settings [1
]. Training was given when implementing the technology, but this was restricted to handling equipment and did not address the technology to solve health care problems, which is a prerequisite for eHealth literacy [54
The contribution of teleconsultation and videoconferencing to patients’ quality of life and ability to control their disease was not substantial (clinical and statistical), because of a limited intervention period and various shortcomings in research design and in implementing ICT-based care. Although previous reviews have indicated that the impact of technology on behavioral change (interaction and self-care) and on care coordination (cost savings) needs to be clarified to support decisions about the use of technology to supplement care [3
], only limited progress was observed. A possible reason that ICT-based care has not shown a high impact on diabetes care could be the absence of a long-term view on the potential of technology to reduce fragmentation and to improve diabetes care at acceptable costs. In most studies, patients’ perspectives with respect to emotional and social well-being (quality of life) and ability to cope with diabetes are underexposed, just as the feasibility, appropriateness, and meaningfulness of the interventions for care practice are [55
]. Moreover, the choice of a specific technology was mostly based on convenience arguments (access to a computer for instance, living in an underserved area) and not related to preferences and specific needs of patients or caregivers to manage diabetes. For example, a study on the attitude toward videoconferencing [40
] showed that patients prefer video visits while nurses wanted to deliver hands-on care in patients’ homes. Therefore, it is not certain that the most appropriate technology was used in the most effective way [9
], and, consequently, it might be rather premature to say that teleconsultation or videoconferencing as such is the best option to deliver cost-effective and worthwhile services.
Although these shortcomings can be seen as an inevitable part of innovating chronic care, one must consider the benefits of specific technologies to diabetes care to make progress. Based on our review, the benefits of teleconsultation concern the three levels of care. At the clinical level, this implies improvement of metabolic control. Improvements at the behavioral and care coordination level refer to reliable transmission of clinical data (eg, HbA1c), intensified patient-caregiver interaction, and enhanced self-care as a result of an improved understanding of the medical condition and higher quality of feedback (quicker response from caregivers and education about self-management).
Teleconsultation interventions [16
] with improvements in clinical, behavioral, and care coordination outcomes can be characterized as Web-based care management programs providing automatic transmission of clinical values, educational modules, and a messaging system for communication and personal feedback (warning messages and instruction). Conditions for implementing the technology were reported in some of these studies, such as using computer-based patient records for electronic data interchange between caregivers; guidelines for writing medical records; a close cooperation between patient, general practitioners, and specialists [16
]; access to a care manager to manage diabetes care with technology; and patients who favor ICT-based care [31
]. The technology was found not advanced enough to be sufficiently practical and cost-effective [25
], and more intensive techniques (like computerized decision support systems) are needed to help patients change their health behavior [19
Most of the studies reported none or limited information about preference for and persistence of technology for specific patient groups. The observed improvements were based on interventions directed at patients who were able to use the equipment (eg, having experience with cell phones and SMS) [14
], who were well motivated to take part in the intervention [13
], who already had a caregiver taking part in the intervention [17
], who were economically disadvantaged [17
], or who had type 1 diabetes that required strict monitoring of blood glucose levels [22
]. This might confound the practicability of the results [55
The benefits of videoconferencing can be particularly demonstrated at the usability level (convenient and easy to use) and care coordination level. Videoconferencing appeared to maintain quality of care while producing cost savings in patient at-home care settings. Real-time communication appeared particularly successful in group education, allowing patients to take more proactive roles in managing their diabetes, helping them to feel happier and to develop wider social networks. Monitoring combined with videoconferencing enabled “just-in-time preventive care” instead of more expensive “just-in-case care” and significantly reduced unscheduled clinic visits, hospital admissions, and days spent in hospital. Cost savings should be offset by increased staff costs and the costs of the development and implementation. For instance, increased patient-caregiver interactions or increased need-based primary care may imply an increase in workload. In two [38
] of the 11 studies on cost savings, the cost reductions were compared to increased system costs.
The results were based on interventions directed at patients in underserved or remote areas, with complex medical conditions (elderly, immobile, or with poor metabolic control), or meeting some practical conditions, such as having access to a physician in the intervention setting, which should be taken into account when implementing videoconferencing in practice, for reasons of selection bias [55
Successful interventions [38
] with improvements in clinical, behavioral, or care coordination levels included programs aimed at teaching patients to cope with and control their diabetes, mostly settings in which patients at home consulted with their caregivers at hospitals or diabetes centers via video. Reported conditions for implementing these interventions were training of patients and staff throughout the implementation to learn to deal with the equipment [38
], alternative markets to reduce investment costs, like purchasing “used” equipment at reduced costs [38
], and a health care system that has an ongoing and well supported clinical infrastructure to support professionals competent to deal with ICT-based care [48
The observed benefits are consistent with prior reviews regarding cost savings, efficacy of applications, and improved communication between primary and secondary health care providers [4
]. The scope of the reviews differs from our study, which is particularly aimed at diabetes care.
Some Limitations of Our Study
Due to the diversity and variance in study designs, inclusion criteria, and a lack of required data, a meta-analysis could not be conducted on the RCTs reporting HbA1c levels (videoconferencing) and other outcomes (quality of life, behavior, and care coordination). In particular, studies on quality of life, behavior, and care coordination used different outcome measures or calculated the same outcome (eg, well-being) in different ways. Lack of required data hampered a statistical combination and therefore may have biased the review’s results. To avoid spurious preciseness, we did not combine observational studies for a meta-analysis.
To evaluate the contribution of technology to diabetes care, we developed a checklist based on principles for chronic care [1
] because existing evaluation systems are directed at usability and acceptability of equipment rather than care service delivery [9
]. Future research should validate this checklist. We reported the outcomes of the interventions per level of care, although they are interdependent in a chronic care setting; the usability of the equipment influences the reliability of monitoring and patient-caregiver interaction, which can influence behavior and care coordination [1
We chose to review various systems of teleconsultation and videoconferencing to shed light on different functions of the systems (monitoring, information exchange, communication) to support diabetes care. This might increase the heterogeneity in our study results.
When patient self-care and care coordination are the focus of the intervention, we need to evaluate the process of implementation more thoroughly (eg, which patients persist and which drop out) and the quality of communication. We observed that patients need more help with self-care than they received in the intervention settings, and online training and personal assistance might be necessary in cases of ICT-based care. A supportive health policy environment (and appropriate financing) is necessary to guarantee continuity after a pilot period. Successful diabetes management systems should integrate several functions to provide collaborative care and to meet the needs of patients and caregivers. Moreover, the shift from hospital to community centers or home care requires technology that integrates lifestyle and education functions for simultaneous group education and for encouraging self-care. Future research should be directed at the development of patient-centered technology personalized to specific needs and capacities. More rigorous methods are needed to measure the effects of an intervention on quality of life, well-being, and organizational issues such as cost effectiveness to make decisions on implementation and to encourage better care coordination. By means of usability tests and log files, patients’ needs for care and technology support can be measured, and test results can be linked to education and behavior changes [59
]. By means of critical incidents techniques [60
], the conditions that permit technology to be implemented successfully can be assessed. More transparency is needed in reporting economic evaluations. The costs included in the studies varied so that comparison of the reported savings is hardly possible, which is also demonstrated in a former review [57
]. Cost effects should be studied with a clear perspective that reflects the purpose of the evaluation and the viewpoint of analysis (eg, cost-benefit, cost-effectiveness analysis).
We conclude that further assessment studies are needed to evaluate the contribution of ICT-based care to diabetes management. Future research should examine the potential of technology to enhance self-efficacy with the aim of making life worth living for someone with certain limitations, in cases where the disease is incurable. Technology can easily overstress the negative aspects of disease and illness because of the focus on collecting health data (eg, food intake). In the end, self-efficacy and social support are possibly the main conditions for changing health behavior [61