Nus Systematic Review Assignment

Determine the Usefulness of Adjunct Automated Telephone Care as an Alternative to Usual Face to Face Patient Care in Chronic Diseases Management in Outpatient Settings Introduction Since the introduction of the telephone line, the usage of telecommunications in the healthcare setting varies from appointment setting, reminders, health education, consultation and patient follow-up. With the emergence of computers, the combination of computers and telephone has led to development of Interactive Voice Response system (IVRS). In other words, this technology involves touch-tone telephones with interactive voice programs. It is more commonly known as automated telephone services. This technology is not unfamiliar in Singapore, other settings such as telecommunications companies e.g. M1 and Singtel, government taxation office, health promotion board etc. have used IVRS to provide information, services, health education and filing of taxation information. In National University of Singapore, IVRS is used to release examination results to the students. The main distinguished characteristic from the normal telephone service and the IVRS is that the latter is fully automated without needing manpower to answer the calls. In Singapore, with the emphasis of disease management of the lifestyle related chronic illnesses like diabetes, hypertension and hyperlipidemia, which are significant contributing risk factors to ischaemic heart diseases, cerebrovascular disease, and kidney diseases, have led to the emergence of Care Managing in the National Healthcare Group polyclinics (NHGP). Care Managing is a care program emphasizing on early detection/ screening, clinical management and rehabilitation and the nurses in this program are specially trained in disease management. The number of patients to do health education, monitoring and proper follow up is immensely large. This large number is contributed by the diversity of care given to the community, ranging from primary prevention, secondary prevention to tertiary prevention. Interventions at primary prevention level in disease management, besides early detection and screening, also involve health education and promotion. In secondary and tertiary prevention level, more intensive health

education and promotion is needed. Monitoring of the patients’ illnesses progression and reinforcing importance of follow up are also important elements of care in these 2 levels. Lee, Friedman, Cukor and Ahern (2003) commented that telecommunications technology can enhance quality of health care services. Besides, being easily accessible round the clock and it is able to provide, patient-specific information, self-help treatment, reinforcement and support on request. In the present situation in National Healthcare Group polyclinics, the nurses are already pro-actively calling the patients to provide health information; self-help treatment, disease monitoring, and even clinic follow up reminder calls. The main disadvantage is the large number of patients they are caring for which thus requires a certain number of manpower to pro-actively calling the patients. Second, there is the disadvantage of not being accessible 24 hours a day. IVRS or automated telephone services might be the solution for better management of patients with appropriate use, due to the availability of the services, and the ability to tailor to large population numbers without the certain manpower requirement. In this paper, the evidence of for the effectiveness of the IVRS or automated telephone services on improving patients’ medical conditions in the outpatient setting will be examined. The patients with medical conditions in this review are mainly patients with Type 2 diabetes, hypertension and hyperlipidemia. The objective of this assignment is to establish the usefulness of adjunct automated telephone care as an alternative to usual face to face patient care only. Effectiveness in this review will be indicated by physiological outcomes of care, change of health behaviors, psychological outcomes, satisfaction with care, and economic measures. The questions will be: (1) Is there a difference in improving physiological outcome indicators between adjunct automated telephone care and usual care in patients with chronic diseases, mainly Type 2 diabetes, hypertension and hyperlipidemia in outpatient setting? (2) Is there a difference in self-care behaviors between adjunct automated telephone care and usual care patients with the 3 chronic diseases?

(3) Is there an improvement in the psychological outcomes in the group under adjunct automated telephone care? (4) Is there a higher level of satisfaction with care in the group under adjunct automated telephone care? (5) Is there any evidence of cost-effectiveness in adjunct automated telephone care? (6) What are the features in an adjunct automated telephone care in the above studies that had shown evidences of improved outcomes? This review although is not a full systematic review, will provide a basis for drafting the proposal for implementing a full proper systematic review to further examine this area of interest. Search Strategy #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12

Telecommunications [MESH] OR Telecommunications [text word] “automated telephone” [all fields] Telemedicine [MESH] OR Telemedicine [text word] #1 OR #2 OR #3 "chronic disease" [MESH] OR “chronic disease” [text word] "diabetes mellitus" [MESH] OR diabetes [text word] OR "high blood glucose" [all fields] NOT "diabetes insipidus" [MESH] [text word] "hypertension" [MESH] OR hypertension [text word] OR "high blood pressure" [all fields] Hyperlipidemia [text word] OR hyperlipidaemia [text word] OR "hyperlipidemia"[MESH]) OR "high cholesterol"[All Fields] #4 AND #5 #4 AND #6 #4 AND #7 #4 AND #8

Table 1: Initial Search Framework Computerized search from PubMed, Science Direct (1995 – 2005), Cochrane Database of Systematic Reviews (1800 – 2005) and Cochrane Central Register of Controlled Trials (1800 – 2005) was done. EMBASE and PsychLit databases are available in National University of Singapore’s (NUS) library e-resources databases collection. Nursing evidence-based practice and best practices websites like Joanna Briggs Institute, the University of York Centre for EvidenceBased Nursing and the Sarah Cole Hirsh Institutes, which are good and relevant websites for searching clinical guidelines and best practices guidelines, are not available in NUS e-resources subscription list (Morris, 2001). Other clinical guidelines websites like Singapore Ministry of

Health clinical guidelines websites and Guidelines Clearing House websites have been searched but to no avail. An initial search strategy framework (Table 1) has been designed to find any publications about automated telephone services and used it to search the above databases. The search framework is appropriate for both PubMed and Cochrane database. A different search strategy has to be employed when searching Science Direct database. A final search strategy table with the number of search results is shown in Table 2. The full search summary table with number of results from each search and the final number of articles obtained is found in Appendix A1. The following inclusion and exclusion criteria are used to limit the initial search findings to potential articles for review. Inclusion criteria include: (1) telemedicine involving telephone as an intervention in (a) disease management in chronic diseases like diabetes Type 2, hyperlipidemia and hypertension (b) telephone health education given in terms of smoking cessation and dietary habits. The reason for including the inclusion criteria of smoking cessation and dietary habits is that these 2 are important elements in disease management of the 3 chronic diseases. (2) The subject populations of interest in the studies are from medical centers or outpatient clinics. Exclusion criteria for the studies include: (1) populations of interest in studies which are hospitalized patients or patients recently discharged from hospitals (2) surgery, radiation, infection control, addiction, gynecology, obstetric, pediatric, and neonatal studies (3) drug and blood enzyme trials (4) body wellness program studies (5) Type 1 diabetes or studies examining insulin related interventions

(6) chronic heart failure populations are excluded as the number of patient with chronic heart failure in polyclinics under nursing care managing are not in large numbers compared to the other 3 chronic diseases . A total of 84 potential articles were found after initial setting of inclusion and exclusion criteria. However, only 55 articles were obtained, as the remaining articles are from journals that are not in NUS library subscribing list or library. 2 more articles were handpicked resulting in a total of 57 articles for second elimination (See Appendix A2 for the full articles log). In a full systematic review, it will be advisable that each title/abstract of the results was reviewed by 2 reviewers. If 1 reviewer disagreed, a third reviewer opinion will be sought. This is to ensure that the elimination of the results from the search is done in an unbiased manner. Due to the unknown number of studies done specifically looking into automated telephone services in terms of disease management in these 3 group of illnesses, the initial inclusion criteria was set on just “telemedicine” to prevent over-restriction of area for exploration. With 57 articles, it is possible to restrict the number of articles further for this assignment. In the 2nd elimination round, only studies or systematic reviews on automated telephone services as interventions are accepted. Telephone services that needed a nurse or interventionist to be at the other end of the phone at the time of conversation as the main intervention of the studies are excluded from this assignment review. Due to the limited number of the studies and the heterogeneity of studies critiqued for the requirement of this assignment, it is not appropriate to conduct any pooled statistical analyses. A proper systematic review that reviews a substantial number of randomized controlled trials will be able to demonstrate the differences in effect size with a forest plot.

Sources

PubMed

#1 = telecommunications [MESH] OR telecommunications [textword] OR "automated telephone" [all fields] OR telemedicine [MESH] OR telemedicine [textword] (28665)

Science Direct

#1 = telecommunication [keyword, limit to title and abstract] OR "automated telephone" [keyword, limit to title and abstract] (2542)

After setting limits

Potential Articles (Screening through abstracts)

Articles Obtained

#2 = "chronic disease" [Mesh term] OR chronic disease [text word] (161201)

#1 AND #2 (237)

23

8

3

#3 = "diabetes mellitus" [Mesh term] OR diabetes [text word] OR "high blood glucose" [all fields] NOT "diabetes insipidus" [Mesh term] [text word] (207822)

#1 AND #3 (346)

35

18

12

#4 = "hypertension" [Mesh term] OR hypertension [textword] OR "high blood pressure" [all fields] (245517)

#1 AND #4 (188)

15

10

6

#5 = hyperlipidemia[Text Word] OR hyperlipidaemia[Text Word] OR "hyperlipidemia"[MeSH Terms]) OR "high cholesterol"[All Fields] (44728)

#1 AND #5 (28)

8

3

3

Search within results #1 (a)"diabetes" OR "high blood glucose" (20)

12

12

(b)"cholesterol" OR "hyperlipidemia" OR "hyperlipidaemia"(6)

3

3

(c)hypertension OR "high blood presure" (14)

8

8

(d)"chronic disease" (14)

4

4

Cochrane Database of Systematic Reviews

#1 = telecommunication [keyword] (0) "automated telephone" OR automated telephone [keyword] (0) #2 = telecommunication [search all text] OR "automated telephone" [search all text] (13)

6

6

Cochrane Central Register of Controlled Trials

#1 = "automated telephone" [all fields] OR telecommunication [keyword] (35)

12

8

Table 2: Search Strategy with search results (See Appendix A for full search results)

Description of Studies Out of the 10 articles reviewed, 5 articles are systematic reviews, 4 are randomized controlled trials and the last 1 is a non-experimental quantitative with a qualitative component study. The full summary of all the articles can be found in Appendix A3. All of the systematic reviews that are critiqued have automated telephone as one of the main telemedicine categories under examination. 4 out of 5 articles looked specifically into comparing the effectiveness of telemedicine either as an alternative mode of care or as an extension of care versus face to face patient care alone. All of these 4 articles examined comparison studies between 2 modalities of care except Liss, Glueckauf and Ecklund-Jonhnson (2002) had a component of comparative studies comparing 3 or more modalities of care. The similar outcome indicator used in these 4 studies to demonstrate effectiveness was reported improved outcomes of care from individual studies. However, all 4 studies categorized their findings differently, Currell, Urguhart, Wainwright and Lewis (2000) used outcome measures as categories, Hersh et al (2001) used clinical specialty, Roine, Ohinmaa and Hailey (2001) and Liss, Glueckauf and Ecklund-Johnson (2002) both used categories of applications. Still, the conclusion for all these 4 systematic reviews had similar conclusions. (1) Evidence of the effectiveness of telemedicine is limited. (2) Larger sample sizes and further research are necessary. (3) Cost-effectiveness in these studies was not well-analyzed. Revere and Dunbar’s (2001) systematic review looked at the effectiveness of computergenerated outpatient health behavior interventions which included “print communications” like appointment letters, reminder slips, feedback reports etc. which is not considered under the category of telemedicine. However, this systematic review is critiqued and retained for use in this assignment due to the exploration of the effectiveness in regards to the health behavior model or feature behind the interventions. The review reported that tailored interventions can more positively affect health behavior change than targeted personalized or generic interventions, though more studies were also needed to compare the different protocols with each

other. This information is useful when writing a guideline to initiate or implementing the automated telephone service. The qualities of the 5 systematic reviews are assessed using the SIGN Methodology Checklist for Systematic Reviews and Meta-analyses (Appendix B1). A brief summary of the 5 systematic reviews’ objectives, conclusions and internal validity can be found in Table 3. The 4 randomized controlled trials (RCTs) are similar in comparing the effectiveness of automated telephone care as an extension to usual care with the usual care alone. 3 of the studies’ populations of interest are people with diabetes only, and the other one is elderly people with hypertension. The studies by Piette et al (2000) and Piette, Weinberger and Mcphee (2000) were the same study using the same interventions and control and analyzing the same sample size results but both papers had reported different outcome indicators. Piette et al (2000) explored the effects of automated telephone calls in improving self-care and glycemic control, whereas Piette, Weinberger and Mcphee (2000) examined the impact of the automated telephone calls in patientcentered outcomes like psychological outcomes, self-efficacy, satisfaction with care and quality of life. Piette, Weinberger, Kraemer and McPhee (2001) did another study using the same research methodology, with the same intervention and control, on another group of patients from a different site. These studies were based on United States. Friedman et al (1996) did the study on a group of elderly patients with hypertension looking in to medication adherence and their blood pressure control in England. The location of studies done is an important consideration when analyzing the difference in economic benefits due to the differences in health care finance structure. Table 4 shows the brief summary of the 4 RCTs and the similarities of outcome indicators measured to demonstrated effectiveness of the automated telephone services as an extension of care. The qualities of the RCTs are assessed using SIGN Methodology checklist for Randomized Controlled Trials (Appendix B2).

Author/ Title/ Types of Studies Included

Currell, Urquhart, Wainwright and Lewis (2000) Telemedicine versus face to face patient care: effect on professional practice and health care outcomes

Revere and Dunbar (2001) Review of computergenerated outpatient health behavior interventions: clinical encounters “in Absentia”

Roine, Ohinmaa and Hailey (2001) Assessing telemedicine: a systematic review of the literature.

Objectives / Outcome Indicators

Findings Synthesis

Assess the effectiveness of telemedicine as an alternative to face to face patient care. Differences in: (1) Outcomes of care (2) Economic consequences of care (3) Acceptability of care from patient and provider point of view (4) Professional practice during delivery of care (5) Transfer of skills between clinicians Evaluate effectiveness of computer generated health behavior intervention – clinical encounters “in absentia” – as an extension of face to face patient care in an ambulatory setting. 2 main specific areas: (1) health behavior model used (2) devices used for health education, counseling, and reminder systems Outcome Indicators: Reported improved outcomes from individual studies Examine the effectiveness and economic efficiency of telemedicine. Outcome indicators: Reported improved outcomes from individual studies.

Table 3: Brief Summary of Systematic Reviews Critiqued

Conclusions*

**Section 1: Internal Validity

***Section 2: Overall Assessment 2.1 +

Similarities and differences in the studies were combined by the outcome measures categories

1) None of the included studies demonstrated any detrimental effects from the interventions 2) There is also little evidence of clinical, psychological benefits and cost effectiveness

1.1 WC 1.2 WC 1.3 WC 1.4 WC 1.5 PA

3) Larger samples needed for further research

The findings were presented in a table according to the delivery devices categories. The results are analyzed by grouping the results according to intervention types: tailored and targeted.

Similarities and differences in the studies were combined by categories of applications studied

1) Evidence that tailored interventions can more positively affect health behavior change than targeted, personalized or generic interventions. 2) More research studies need to compare different tailoring protocols with another.

Evidence of effectiveness of telemedicine remains limited. Most of the studies are pilot projects or short-term outcomes. Only transmission of ECG and tele-dermatology have shown promising results.

2.2 The inclusion criteria and the categories of the findings can result in the biasness of results. Acute patients discharge from the hospitals, e.g. MI and antenatal women clinical outcomes and psychological benefits and even cost calculations are very different from patients with chronic diseases like hypertension and diabetes.

2.1 + 1.1 1.2 1.3 1.4 1.5

PA WC WC PA AA

1.1 1.2 1.3 1.4 1.5

AA WC WC WC AA

2.2 The lack of information on who and how many number of reviewers selecting and critiquing the articles allow room for biasness towards a particular direction of the meta-analysis

2.1 ++

Author/ Title/ Types of Studies Included

Hersh, Helfand, Wallace, Kraemer, Patricia, Shapiro and Greenlick (2001) Clinical outcomes resulting from telemedicine interventions: a systematic review. Liss, Glueckauf and Ecklund-Johnson (2002) Research on Telehealth and Chronic Medical Conditions: Critical Review, Key Issues, and Future Directions

Objectives / Outcome Indicators

Findings Synthesis

Conclusions*

Evaluate the effectiveness of telemedicine interventions for health outcomes in 2 classes of application: home-based and office/hospitalbased.

Similarities and differences in the studies were combined by the categories of clinical specialty

The strongest evidence for efficacy of telemedicine in clinical outcomes from homebased telemedicine in areas of hypertension, chronic disease management and AIDs.

4 Categories (a) internet studies (b) standard telephone and automated telephone system studies (c) videoconferencing investigations (d) comparative studies using 3 or more modalities serve as a framework for organizing data for data synthesis

Overall results suggested that the Internet, telephone and videoconferencing are efficacious and efficient modes of treatment for people with chronic medical conditions. Particularly telehealth interventions that targeted adherence or health promotion

**Section 1: Internal Validity 1.1 AA 1.2 WC 1.3 WC 1.4 PA 1.5 WC

***Section 2: Overall Assessment 2.1 + 2.2 The lack of information on who and how many number of reviewers are critiquing the articles allow room for biasness towards a particular direction of the meta-analysis.

Outcome indicators: Reported clinical care outcomes from individual studies Evaluate the impact of telecommunication-based interventions for persons with chronic disabilities 2 main interests: perceived utility and cost-effectiveness of tele-health interventions

* Full conclusions see Appendix A3 **, *** SIGN Methodology Checklist 1 for systematic reviews and meta-analysis (See Appendix B1 ). WC – well covered; AA - adequately addressed; PA – poorly addressed; ND – not addressed; NR – not reported; NA – not applicable

Table 3: Brief Summary of Systematic Reviews Critiqued (cont’)

1.1 1.2 1.3 1.4 1.5

AA AA PA PA PA

2.1 – 2.2 (a) The lack of information on who and how many number of reviewers selecting and critiquing the articles allow room for biasness towards a particular direction of the meta-analysis (b) Only PsychLit, PubMed and PsycINFO have been searched (c) categorizing the findings with different forms of telecommunications as a framework can result in the biasness of results.

Authors/ Title

Randomized % drop out No. of subjects

Intervention and Control

Yes.

Automated telephone, calls outbound with nurse followup adjunct to usual care vs Usual care

* S C

* M P

* P D

* R S

* U S

* S W C

* P S Y

* S E

* H S

* Q O L

* C D

** SIGN Internal Validity

Conclusion***

1.1 WC 1.2 WC 1.3 AA 1.4 NA 1.5 WC 1.6 WC 1.7 PA 1.8 5.5% dropped out in each arm (total <20%) 1.9 WC 1.10 NA

2.1 + More detailed of the instruments measuring self care, medication problems and related symptoms will be appreciated. 2.2 Might not affect the study that much as frequency of these indicators can be used to report. 2.3 The sig difference in the physiological data can be contributed to the change in health behavior or less medication problems. 4 out of 5 certain. 2.4 Yes

Significant Diff (p<0.05) 1) Self care Glucose monitoring: Diff: 0.4 Foot inspection: Diff: 0.3 Weight monitoring: Diff: 0.6 Medication problems: Diff: -21% 2) Glycemic control Normal HbA1C% level: Diff: 9% Serum glu levels: Diff: -41mg/dL Self-perceived glycemic control mean rating: Diff: 0.4 3) Diabetes-related symptoms (higher number indicates higher frequency) All types: Diff: -1.4 Hyperglycemic symptoms: Diff: -0.7 Hypoglycemic symptoms: Diff: -0.5

1.1 WC 1.2 WC 1.3 AA 1.4 NA 1.5 WC 1.6 WC 1.7 AA 1.8 6.8% total dropped out 1.9 WC 1.10 NA

2.1 + More detailed of the instruments measuring self care, medication problems and related symptoms will be appreciated. 2.2 Might not affect the study that much as frequency of these indicators can be used to report. 2.3 The sig difference in the decreased of percentage of subjects with high HbA1C% can be due to study effect with changes to other variables causing the decreased. 4 out of 5 certain. 2.4 Yes

Significant Diff (p<0.05) 1) Self Care Glucose monitoring: diff=0.2 Foot inspection: diff=0.2 2) Use of specialty services Podiatry: diff=20% Diabetes clinic: diff=36% Cholesterol test: diff=9% Medical foot exam: diff=20%, 3) Diabetes related severity of illness HbA1c > or equal to 8% subjects’ mean HbA1C%: diff=-0.5% HbA1c > or equal to 9% subjects’ mean HbA1c%: diff=-1.1% 4) Diabetes related symptoms - all symptoms: diff=-0.7 - other symptoms: diff=-0.2 5) Satisfaction of care summary scale: diff=0.1 interpersonal aspects of care: diff=0.2 quality of outcomes: diff=0.3

1.1 AA 1.2 AA 1.3 AA 1.4 NA 1.5 WC 1.6 WC 1.7 PA 1.8 Not clear 1.9 AA 1.10 PA

2.1 + 2.2 Might not affect the study by measuring 2 outcomes in English-speaking patients only There are generally decreased in depression, increased in self-efficacy. 2.3 3 out of 5 certain 2.4 Neutral

1) Mean depression score diff=-4.1 2) Mean self-efficacy score: diff=0.3 3) Mean no. of days in bed: diff=-0.5 4) Satisfaction with care Summary scale: diff=0.2 Technical aspects of care: diff=0.2 Choice of providers and continuity: diff=0.2 communication with providers: diff=0.2 Quality of outcomes: diff=0.2

DIABETES Piette, Weinberger, Mcphee, Mah, Kraemer and Crapo Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? Duration: 12month

Piette, Weinberger, Kraemer and McPhee Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial Duration: 12 months

Piette, Weinberger and McPhee The Effect of automated calls with telephone nurse follow-up on patientcentered outcomes of diabetes care: a randomized, controlled trial Duration: 12 months

248 patients’ data analyzed (89%), 11% dropped out. 124 subjects in each arm.

Yes. Final no. of subjects at end of study Intervention: 132 Control: 140 (6.8% drop out)

Yes. 248 patients’ data analyzed (89%), 11% dropped out. 124 subjects in each arm.

Automated telephone, calls outbound with nurse followup adjunct to usual care vs Usual care

   

     

Automated telephone, calls outbound with nurse followup adjunct to usual care vs Usual care

Table 4: Brief Summary of RCTs and their Internal Validity

     

Authors/ Title

Randomized % drop out No. of subjects

Intervention and Control

Yes.

Patientinitiated automated telephone, calls adjunct to usual care vs Usual care

* S C

* M P

* P D

* R S

* U S

* S W C

* P S Y

* S E

* H S

* Q O L

* C D

** SIGN Internal Validity

Conclusion***

1.1 WC 1.2 WC 1.3 AA 1.4 NA 1.5 WC 1.6 WC 1.7 AA 1.8 11% 1.9 AA 1.10 NA

2.1 ++

HYPERTENSION Friedman et al. A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control.

267 (89%) subjects’ data were analyzed at the end of the study (11% drop out)

 







Duration: 6 months

Results: 1) Effects on antihypertensive medication adherence: Mean adherence improvement: diff=6% 2) Effects of blood pressure: Adjusted mean diastolic blood pressure changes: Total study population: diff=4.4 NonAdherent subjects: diff=8.8 3) Relationship of TLC use and adherence change to blood pressure  Adj. mean sys BP change in TLC group: 12.7mmHg (increased adherence) vs 2.5mmHg (decreased adherence) Adj. mean dia BP change in TLC group: 5.5mmHg (increased adherence) vs 0.6mmHg (decreased adherence) 4) Attitudes of TLC users and their physicians  69% satisfied. 54% satisfied with health benefit. 5% and 6% scored the items in the lower quartile for satisfaction and health benefit respectively. 85% of the physicians read the TLC reports regularly. 84% filed reports in patients’ records. 40% discuss the information with the patients. 5) Cost effectiveness

* SC – self-care behaviors, MP – medication problem, PD – disease related physiological data, RS – related symptoms, SWC – satisfaction with care, US - used of specialty services, PSY – psychosocial indicators (depression, anxiety), SE – self-efficacy, HS – General health status using SF 36, QOL – quality of life, CD – cost discussion. ** SIGN internal validity (see Appendix B2 for the questions) WC- well covered; AA – adequately addressed; PA- poorly addressed; ND- not addressed; NR- not reported; NA- not applicable. *** Full conclusion of results in Appendix A3

Table 4: Brief Summary of RCTs and their Internal Validity (Con’t)

The economic benefits are not analyzed in a statistical way which comparisons can be made between the studies. The differences between the studies in the intervention of “automated telephone”, is an important consideration in this research review. In the diabetes population studies were out-bound and in addition there is telephone nurse follow-up involvement. Whereas, the hypertension study “automated telephone” intervention, the calls were patient-initiated with no regular telephone nurse follow-up. Though the main outcome effects in the diabetes studies were due to the “intervention” in study after considering the biasness, the intervention is however “diluted” by the nurse telephone follow-up component. In other words, the effects of the outcome differences can be due to the automated telephone alone or the telephone nurse follow-up alone or both. The last study is an evaluation study by Kaplan, Farzanfar and Friedman (2003). This study evaluated the personal relationships that can evolve from interaction with the automated telephone care which was known as “an intelligent interactive telephone health behavior advisor system” in the study. The criteria for evaluating this evaluation study is adapted from SullivanBolyai and Grey (2002), found in Appendix B3. The conclusion of this study found that most people using the automated telephone care were satisfied with care and personal relationships were even formed in 3 particular forms: feelings of love, guilt and ambivalence. Synthesis of Evidence According to SIGN (2004), considered judgment is a concept to summarize the total body of evidence by addressing the following aspects: •

Quantity, quality and consistency of evidence

•

Generalizability of the study findings

•

Directness of application to the target population for the guideline

•

Clinical impact

•

Implementability

The “Considered Judgment” table is shown in Table 5. Clinical impact in this guideline implementation is large, due to the amount of people it is going to impact during the implementation. The extent of impact is a consideration due to the resources that will be allocated in the process. The practicability of this automated telephone care which is addressed under the heading of “Implementability”, is an important consideration but of lesser priority to the clinical impact due to the advanced telecommunications structure in Singapore. The selection of the 5 articles that have the best evidence to develop the practice guidelines for this assignment needs to be balanced between 2 important factors. (1) Internal validity of the study and (2) Level of applicability to the targeted population addressed in this assignment. Articles which have a level of biasness during internal validity grading will be excluded. Level of applicability of less than 50% will not be short listed. The final 5 articles and their summaries of evidence are shown in Table 6.

Key Question 1: Is there a difference in improving physiological outcome indicators between automated telephone care and usual care in patients with chronic diseases mainly Type 2 diabetes, hypertension and hyperlipidemia in outpatient setting? Author/ Title/

Type

Conclusions

Systematic Review

1) None of the included studies demonstrated any detrimental effects from the interventions 2) There is also little evidence of clinical benefits 3) Larger samples needed for further research

Currell, Urquhart, Wainwright and Lewis Telemedicine versus face to face patient care: effect on professional practice and health care outcomes Roine, Ohinmaa and Hailey Assessing telemedicine: a systematic review of the literature Hersh, Helfand, Wallace, Kraemer, Patricia, Shapiro and Greenlick Clinical outcomes resulting from telemedicine interventions: a systematic review.

Systematic Review

+

Directness of application to Target Population of Guideline

Systematic Review

The strongest evidence for efficacy of telemedicine in clinical outcomes from home-based telemedicine in areas of hypertension, chronic disease management and AIDs.

Level of applicability: 40%

++

+

Internet, telephone and videoconferencing are efficacious and efficient modes of treatment for people with chronic medical conditions.

Table 5: Considered Judgment Table

Furthermore, telehealth interventions that targeted adherence or health promotion (particularly automated phone technology) showed incremental gains in comparison to routine care.

_

Implementability

(1) Resources: NHG Polyclinics have a main call center. The main line telephone introduction is automated, interacted with touch-tone phone pads.

Review not 100% directly applicable to the assignment. Studies involving acute medical conditions other than chronic diseases are included in review.

Review is applicable to the target population in both chronic disease and outpatient management. Level of applicability: 70%

Systematic Review

Clinical Impact

Review not 100% directly applicable to the assignment. Studies involving acute medical conditions are included in review.

Level of applicability: 40%

Liss, Glueckauf and Ecklund-Johnson Research on Telehealth and Chronic Medical Conditions: Critical Review, Key Issues, and Future Directions

Evidence of effectiveness of telemedicine remains limited. Most of the studies are pilot projects or short-term outcomes. Only transmission of ECG and teledermatology have shown promising results.

SIGN Internal Quality

Review is applicable to the target population of chronic disease, however the review includes studies of hospitalized patients. Level of applicability: 60%

Large due to the large number of patients this “automated telephone care” will serve if implemented

(2) In Singapore, most of the households have touch-tone telephones. (3) Setting up the system will require additional course for the planning and the usage of the telephone lines (4) The implementation of this intervention is not justifiable at the moment, due to the unknown cost of setting up the system comparison to the benefits.

Key Question 1: Is there a difference in improving physiological outcome indicators between automated telephone care and usual care in patients with chronic diseases mainly Type 2 diabetes, hypertension and hyperlipidemia in outpatient setting? Author/ Title/ Piette, Weinberger, Mcphee, Mah, Kraemer and Crapo

Type

RCT

Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? Piette, Weinberger, Kraemer and McPhee

A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control.

Findings of this study reported: 1) Intervention group increase number of subjects with Normal HbA1C% level 2) Intervention group has a lower mean serum glucose levels of 41mg/dL

SIGN Internal Quality

+

Findings not generalized to all diabetes population, main characteristics of patients in study are low-income, from United States

RCT

Impact of Automated Calls with Nurse Followup on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial

Friedman et al.

Conclusions

Findings of this study reported: (1) Subjects with HbA1c > or equal to 8% mean HbA1c% decreased by 0.5 (2) Subjects with HbA1c > or equal to 9% mean HbA1c% decreased by 1.1

Findings of this study reported: (1) Subjects in the intervention group in general have a greater decrease in mean diastolic blood pressure vs the control group. Diff of 4.4 (2) Especially evident in the non-adherent group with a greater change in mean diastolic blood pressure. Diff of 8.8 In summary, there are improved clinical physiological outcomes especially in the nonadherent group. Findings only generalized to Elderly hypertensive patients in England.

Table 5: Considered Judgment Table (con’t)

Clinical Impact

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level.

+

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level. Level of applicability for diabetes population only: 60%

Same as above for applicability. ++

Level of applicability for hypertension population only: 55% (due to elderly subjects as focus)

Implementability

(1) Resources: NHG Polyclinics have a main call center. The main line telephone introduction is automated, interacted with touch-tone phone pads.

Level of applicability for diabetes population only: 60%

Findings not generalized to all diabetes population, main characteristics of patients in study are low-income, from United States.

RCT

Directness of application to Target Population of Guideline

Large due to the large number of patients this “automated telephone care” will serve if implemented

(2) In Singapore, most of the households have touch-tone telephones. (3) Setting up the system will require additional course for the planning and the usage of the telephone lines (4) The implementation of this intervention is not justifiable at the moment, due to the unknown cost of setting up the system comparison to the benefits.

Key Question 2: Is there a difference in self-care behaviors between automated telephone care and usual care patients with the 3 chronic diseases? Author/ Title/

Type

Piette, Weinberger, Mcphee, Mah, Kraemer and Crapo

RCT

Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? Piette, Weinberger, Kraemer and McPhee

Conclusions

Findings of this study reported: 1) Intervention group increases frequency of glucose monitoring, foot inspection and weight monitoring

SIGN Internal Quality

+

Clinical Impact

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level. Level of applicability for diabetes population only: 60%

RCT

Findings of this study reported: (1) Intervention group increases frequency in glucose monitoring and foot inspection (2) Intervention group uses more specialty services, podiatry, cholesterol test, diabetes clinic and medical foot exam.

+

Findings not generalized to all diabetes population, main characteristics of patients in study are low-income, from United States.

Level of applicability for diabetes population only: 60%

Friedman et al. RCT

Findings of this study reported: Improved medical adherence especially in the non-adherent groups. Findings only generalized to Elderly hypertensive patients in England.

Table 5: Considered Judgment Table (con’t)

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level.

Same as above for applicability. ++

Level of applicability for hypertension population only: 55% (due to elderly subjects as focus)

Implementability

(1) Resources: NHG Polyclinics have a main call center. The main line telephone introduction is automated, interacted with touch-tone phone pads.

2) Decrease medication problems adherence

Impact of Automated Calls with Nurse Followup on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial

A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control.

Directness of application to Target Population of Guideline

Large due to the large number of patients this “automated telephone care” will serve if implemented

(2) In Singapore, most of the households have touch-tone telephones. (3) Setting up the system will require additional course for the planning and the usage of the telephone lines (4) The implementation of this intervention is not justifiable at the moment, due to the unknown cost of setting up the system comparison to the benefits.

Key Question 3: Is there an improvement in the psychological outcomes in patients with the 3 chronic diseases under the automated telephone care? Author/ Title/

Type

Currell, Urquhart, Wainwright and Lewis (2000)

Systematic Review

Telemedicine versus face to face patient care: effect on professional practice and health care outcomes Piette, Weinberger and McPhee

Conclusions

Findings of this review reported: 1) There is little evidence of psychological benefits 2) Large samples needed for further research

SIGN Internal Quality

+

Clinical Impact

Cannot direct 100% to the target population of this question. Patient populations in the studies review contain both acute and chronic disease patients.

RCT

Findings of this study reported: (1) Intervention group has lower mean depression score, mean number of days in bed. (2) Intervention group has higher mean selfefficacy score

+

Findings not generalized to all diabetes population, main characteristics of patients in study are low-income, from United States

Level of applicability for diabetes population only: 60%

Friedman et al. RCT

Findings of this study reported: 54% scored the upper quartile for general HRQL SF-36 health benefit. Findings only generalized to Elderly hypertensive patients in England.

Table 5: Considered Judgment Table (con’t)

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level.

Same as above for applicability. ++

Level of applicability for hypertension population only: 55% (due to elderly subjects as focus)

Implementability

(1) Resources: NHG Polyclinics have a main call center. The main line telephone introduction is automated, interacted with touch-tone phone pads.

Level of applicability: 40%

The Effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial

A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control.

Directness of application to Target Population of Guideline

Large due to the large number of patients this “automated telephone care” will serve if implemented

(2) In Singapore, most of the households have touch-tone telephones. (3) Setting up the system will require additional course for the planning and the usage of the telephone lines (4) The implementation of this intervention is not justifiable at the moment, due to the unknown cost of setting up the system comparison to the benefits.

Key Question 4: Is there a higher level of satisfaction with care in patients with the 3 chronic diseases under the automated telephone care? Author/ Title/

Piette, Weinberger and McPhee

Type

RCT

The Effect of automated calls with telephone nurse follow-up on patientcentered outcomes of diabetes care: a randomized, controlled trial Piette, Weinberger, Kraemer and McPhee

RCT

Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial Friedman et al. RCT A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control. Kaplan, Farzanfar and Friedman Personal relationships with an intelligent interactive telephone health advisor system: a multi-method study using surveys and ethnographic interviews

Evaluation Study

Conclusions Findings of this study reported: Using Employee Health Care Value Survey – intervention group has a higher mean score in the (1)summary scale (2)technical aspects of care (3)choice of providers and continuity (4)communication with providers and the (5)quality of outcomes Findings not generalized to all diabetes population, main characteristics of patients in study are low-income, from United States Findings of this study reported: Using Employee Health Care Value Survey – intervention group has a higher mean score in the (1)summary scale (2)interpersonal aspects of care and the (3) quality of outcomes Findings not generalized to all diabetes population, main characteristics of patients in study are low-income, from United States. Findings of this study reported: 64% scored satisfaction in the upper quartile of the scale. Findings only generalized to Elderly hypertensive patients in England. ** The findings on satisfaction of care in this study are not presented in comparison with the control group. Findings of this study reported: (1) Individuals using TLC were satisfied and find it helpful. (2) Personal relationships with TLC were formed in 3 different ways, feelings of love, guilt and ambiguity or ambivalence. Study did not mention if the sample characteristics, if subjects have chronic diseases.

SIGN Internal Quality

+

Directness of application to Target Population of Guideline

Clinical Impact

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level. (1) Resources: NHG Polyclinics have a main call center. The main line telephone introduction is automated, interacted with touch-tone phone pads.

Level of applicability for diabetes population only: 60%

+

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level. Level of applicability for diabetes population only: 60% Same as above for applicability.

++

+

Implementability

Level of applicability for hypertension population only: 55% (due to elderly subjects as focus)

Findings cannot be applied 100% due to patient factors. The study however explores people’s responses using automated telephone care. Level of applicability: 80%

Large due to the large number of patients this “automated telephone care” will serve if implemented

(2) In Singapore, most of the households have touch-tone telephones. (3) Setting up the system will require additional course for the planning and the usage of the telephone lines (4) The implementation of this intervention is not justifiable at the moment, due to the unknown cost of setting up the system comparison to the benefits.

Table 5: Considered Judgment Table (con’t) Key Question 5: Is there any evidence of cost-effectiveness using automated telephone care? Author/ Title/ Currell, Urquhart, Wainwright and Lewis (2000)

Type

Systematic Review

Telemedicine versus face to face patient care: effect on professional practice and health care outcomes

Conclusions

1) There is little evidence of cost effectiveness 2) Larger samples needed for further research

SIGN Internal Quality

+

Same as above for applicability.

RCT A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control.

Impact of Automated Calls with Nurse Followup on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial

Clinical Impact

Findings of this study reported: No concrete evidence of cost-effectiveness due to the short implementation and evaluation time period.

++

RCT Findings of this study reported: No proper analysis of economic statistics. Non-conclusive for cost-effectiveness.

Table 5: Considered Judgment Table (con’t)

+

Level of applicability for hypertension population only: 55% (due to elderly subjects as focus)

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level. Level of applicability for diabetes population only: 60%

Implementability

(1) Resources: NHG Polyclinics have a main call center. The main line telephone introduction is automated, interacted with touch-tone phone pads.

Level of applicability: 40%

Friedman et al.

Piette, Weinberger, Kraemer and McPhee

Directness of application to Target Population of Guideline Cannot direct 100% to the target population of this question. Patient populations in the studies review contain both acute and chronic disease patients.

Large due to the large number of patients this “automated telephone care” will serve if implemented

(2) In Singapore, most of the households have touch-tone telephones. (3) Setting up the system will require additional course for the planning and the usage of the telephone lines (4) The implementation of this intervention is not justifiable at the moment, due to the unknown cost of setting up the system comparison to the benefits.

Key Question 5: What are the features in an automated telephone care in the above studies that had shown evidences of improved outcomes? Author/ Title/ Piette, Weinberger, Kraemer and McPhee Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial

Type

RCTs

Piette, Weinberger, Mcphee, Mah, Kraemer and Crapo Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? RCT Friedman et al. A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control.

Revere and Dunbar (2001) Review of computer-generated outpatient health behavior interventions: clinical encounters “in Absentia”

Systematic Review

Table 5: Considered Judgment Table (con’t)

Conclusions Automated Telephone Care Services included: 1) targeted and tailored self-care education messages. 2) Check patient health status, assessment on self care issues 3) Nature of calls: Calls outbound, up to 6 tempted calls. Touch-tone keypads used to communicate. 4) Frequency and duration: Biweekly basis. 5 to 8 minute assessment. 5) Telephone nurse follow up involved.

Automated Telephone Care Services included: 1) targeted and tailored self-care education and motivational messages to improve medication adherence. 2) Check patient health status, assessment on medication issues 3) Nature of calls: Patient-initiated calls. Touch-tone keypads used to communicate. 4) Frequency and duration: Weekly basis. 4 minute. 5) Reports transmitted to physicians. 1) Evidence that tailored interventions can more positively affect health behavior change than targeted, personalized or generic interventions. 2) More research studies need to compare different tailoring protocols with another. .

SIGN Internal Quality

+

Directness of application to Target Population of Guideline

Clinical Impact

Findings cannot be directly applied due to patient factors: difference in ethnicity factor and cultural factors. Asian low-income group might have a different health literacy level.

(1) Resources: NHG Polyclinics have a main call center. The main line telephone introduction is automated, interacted with touch-tone phone pads.

Level of applicability for diabetes population only: 60%

Same as above for applicability. ++

+

Level of applicability for hypertension population only: 55% (due to elderly subjects as focus)

Due to the inclusion of printed communications and other forms of interventions besides automated telephone care. Level of applicability: 60%

Implementability

Large due to the large number of patients this “automated telephone care” will serve if implemented

(2) In Singapore, most of the households have touch-tone telephones. (3) Setting up the system will require additional course for the planning and the usage of the telephone lines (4) The implementation of this intervention is not justifiable at the moment, due to the unknown cost of setting up the system comparison to the benefits.

Author/ Title/ Hersh, Helfand, Wallace, Kraemer, Patricia, Shapiro and Greenlick Clinical outcomes resulting from telemedicine interventions: a systematic review. *Piette, Weinberger, Mcphee, Mah, Kraemer and Crapo Do Automated Calls with Nurse followup improve self care and glycemic control among vulnerable patients with Diabetes? **Piette, Weinberger and McPhee The Effect of automated calls with telephone nurse follow-up on patientcentered outcomes of diabetes care: a randomized, controlled trial Piette, Weinberger, Kraemer and McPhee Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial Friedman et al. A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control. Kaplan, Farzanfar and Friedman Personal relationships with an intelligent interactive telephone health advisor system: a multi-method study using surveys and ethnographic interviews

Type

Systematic Review

RCT

RCT

SIGN Internal Quality +

+

+

RCT +

Level of Application

70% all 3 populations

60% for diabetes population only

Self-Care Behavior



Evaluation Study

+

80%

CostEffectiveness

Features







++

Satisfaction with Care



60% for diabetes population only

RCT

Psychological outcomes



60% for diabetes population only

55% for hypertension elderly population only

Table 6: Summary of Evidence for 5 Articles

Physiological Outcomes



* and ** are the same study on same population

























Recommendations for Practice The specific evidence grade is given according to the SIGN grading system (2004). Grades for levels of evidence and grades of recommendations are given according to (1) the type of study, (2) quality of study and (3) risk of bias. The assignment of a level of evidence and associated grade of recommendation should be agreed unanimously by the guideline development group. In face of a difference in opinion of the grades of recommendation, the difference should be formally recorded and the reasons for disagreement noted (SIGN, 2004). SIGN’s criteria for grading the levels of evidence and assigning the grade of recommendation can be found in Appendix C. Practice Recommendation 1: Adjunct automated telephone care in addition to usual care improves physiological outcomes than usual care alone especially in hypertension and diabetes disease management. Supporting evidence: (a) Clinical outcomes resulting from telemedicine interventions: a systematic review (Hersh et al, 2001). Level of evidence: 1+ (b) Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? (Piette et al, 2000). Level of evidence: 1+ (c) Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial (Piette, Weinberger, Kraemer and McPhee, 2001). Level of evidence: 1+ (d) A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control (Friedman et al, 1996). Level of evidence: 1+ Grade of Recommendation: B

Practice Recommendation 2: There is some evidence that adjunct automated telephone care increases frequencies of self-care behaviors especially glucose monitoring and foot inspection in diabetes population. Supporting evidence: (a) Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? (Piette et al, 2000), Level of evidence: 1+ (b) Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial. (Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+ Grade of Recommendation: B Practice Recommendation 3: There is some evidence that adjunct automated telephone care improves medication adherence in diabetes and hypertension population. Supporting evidence: (a) Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? (Piette et al, 2000), Level of evidence: 1+ (b) A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control (Friedman et al, 1996). Level of evidence: 1+ Grade of Recommendation: B Practice Recommendation 4: There is limited consistent evidence that adjunct telephone care improves psychological outcomes in patients with chronic diseases. Supporting evidence: (a) The Effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial (Piette, Weinberger and McPhee, 2000). Level of evidence: 1+

(b) A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control (Friedman et al, 1996). Level of evidence: 1+ Grade of Recommendation: B Practice Recommendation 5: There is increased satisfaction with care especially in the summary scale and the quality of outcomes for patients receiving adjunct telephone care compared to the patients receiving usual care alone in diabetes population. Supporting evidence: (a) Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial. (Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+ (b) The Effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial (Piette, Weinberger and McPhee, 2000). Level of evidence: 1+ Grade of Recommendation: B Practice Recommendation 5: There is some evidence that satisfaction with care in patients receiving adjunct telephone care with personal relationships formed. Supporting evidence: (a) Personal relationships with an intelligent interactive telephone health advisor system: a multimethod study using surveys and ethnographic interviews (Kaplan, Farzanfar and Friedman, 2003). Level of evidence: 3 Grade of Recommendation: D

Practice Recommendation 6: There is limited consistent evidence that adjunct telephone care is cost-effective in chronic diseases management. Supporting evidence: a) Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial. (Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+ b) A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control (Friedman et al, 1996). Level of evidence: 1+ Grade of Recommendation: B Practice Recommendation 7: There is some evidence that tailored health behavior change model underlying adjunct automated telephone care can produce better outcomes. Supporting evidence: a) Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial. (Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+ b) A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control (Friedman et al, 1996). Level of evidence: 1+ c) Review of computer-generated outpatient health behavior interventions: clinical encounters “in Absentia” (Revere and Dunbar, 2001). Level of evidence: 1+ Grade of Recommendation: B

Practice Recommendation 8: There is limited and consistency evidence of the nature of adjunct automated telephone care in chronic diseases outpatient management, in regards of (1)duration (2)frequency (3)patientinitiated or calls outbound etc. Supporting evidence: a) Impact of Automated Calls with Nurse Follow-up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System – a randomized controlled trial. (Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+ b) A telecommunications system for monitoring and counseling patients with hypertension – impact on medication adherence and blood pressure control (Friedman et al, 1996). Level of evidence: 1+ c) Do Automated Calls with Nurse follow-up improve self care and glycemic control among vulnerable patients with Diabetes? (Piette et al, 2000). Level of evidence: 1+ Grade of Recommendation: B Implementation Before implementation of guidelines, using Iowa Model of evidence-based practice to promote quality care, consideration if the research base if sufficient is important (Titler et al, 2001). In this research review, the research base is definitely insufficient. There is limited evidence from systematic reviews to demonstrate effectiveness of adjunct automated telephone care.1 RCT done on hypertension population and 2 RCTs on diabetes population. Besides, RCT on hyperlipidemia population has not been evaluated due to the article unavailability. A research on adjunct automated telephone care to usual care should be done locally on these 3 populations, gathering expert opinions and determining scientific principles before implementation of guidelines. Before the full implementation of guidelines, an action plan for piloting the evidence-based practice has to be drawn. The action plan involves mainly identifying (1)practice setting,(2)staff involved, (3)targeted patient population, (4)one or more units with a small number of patients

and (5)indicators that evaluate the process and outcomes of the pilot trial (Titler et al, 2001). A team of dedicated people from different organization levels within an institute is necessary to draw up the action plan, as different perspectives on the barriers for the whole implementation process are necessary. For this assignment, XXX polyclinics will be chosen as the unit for pilot change due to the smallest amount of chronic diseases patients among the 9 polyclinics. The targeted patient population will be patients with hypertension. For diabetes population, though the advantage of using HbA1C% as an outcome indicator, which is less fluctuant and operator-dependent compared to blood pressure, assessment of health status and education are longer due to a larger number of items to cover (see Table 7). The reason for not considering hyperlipidemia population is the lack of studies done around the population group. Diabetes

Hypertension

Disease knowledge

Disease knowledge

Medication knowledge and side effects

Medication knowledge and side effects

Diet – low carbohydrate, high fibre, low fat and low

Diet – low fat and low salt

free sugar

Self-care Behaviors

Self-care Behaviors

- Blood pressure monitoring

- Glucose monitoring

- Medication adherence

- Medication adherence

- Diet adherence

- Diet adherence

- Annual blood screening for cholesterol and kidney

- Foot inspection

function

- Usage of screening services – eye screening, foot screening, annually blood screening for cholesterol and kidney function

Table 7: Education and Assessment components for Diabetes and Hypertension groups The consideration of considering the number education and assessment components is important when structuring the adjunct automated telephone care. Care managers, or expert nursing opinions in hypertension disease management have to be considered or involved in structuring the automated telephone care conversations and infrastructure. Telecommunications experts, dietician, family physicians, care managers and policy administrators are people involved in the

team to structure the automated telephone care infrastructure. Another team will be formed to see to the implementation process. Strategies for promoting Change Adopting a new practice into the practice area can be facilitated through mainly in the following 5 areas (Titler et al 2001). (1) organization support (2) education to staff on the usage of adjunct automated telephone care and promoting this usage to patients involved (3) ownership of the new practice by nurses and all affected disciplines from family physicians, to the administrative staff of the polyclinics (4) perception by staff that the introduction of this adjunct automated telephone care improves quality of care and (5) perception by staff that it is the right time to carry out this change. In the above 5 areas, the art of dealing with people and communication hold the key to success. Viewing evidence-based practice, which is implementation of adjunct automated telephone care in chronic disease management, as an innovation in this assignment, Rogers’ model of diffusion of innovation can serve as a conceptual guide to design interventions to promote the rate and extend of the evidence-based practice adoption (Titler and Everett, 2001 and Berwick, 2003). According to this model, 2 important components affect the diffusion of “new practice”, the nature of the “new practice” and the manner in which the “new practice” is communicated to the members of the social system in other words the people involved. Nature of the Innovation Before adopting the adjunct automated telephone care, careful considerations of the nature of this “new practice” on its credibility, localization of guidelines and use of practice prompts from both the staff and the patients’ perspectives are important (Titler and Everett, 2001). The less complex or more user-friendly this adjunct automated telephone care is and the more credible that this practice can result in improvement of health status will ensure faster adoption and adherence. Localization of guidelines is definitely necessary and might even be appropriate to adapt the guidelines for each disease group, e.g. the difference in the frequencies of calls for patients with

different chronic diseases or in terms of their severity of illnesses. Finally practice prompts for the new practice have to be simple to read and understandable for both patients and staff. Publicity in terms of posters containing essential practice prompts with a “catchy slogan”, “Dial for Health”, can be placed around the premise of the polyclinics for the patients. For the nurses, decision making algorithms might be useful in selecting the patients to be under the adjunct automated telephone care and the frequencies to instruct patients to call. Having computerized prompting to the family physicians to send the patients to the nurse might also be useful. Finally, user-friendly and easy to read pamphlets in all 4 languages have to be designed for patients to bring home to facilitate usage. Communication of Innovation The 2nd component is the communication of innovation. Methods of communication include educating, use of opinion leaders, change champions, core groups and outreach visits (Titler and Everett, 2001). The aim of the education intervention is to educate the staff involve in using the automated telephone care and obtaining patients’ reports from the adjunct automated telephone care service. Besides that, educating staff in “selling” the practice to the patients and encourage their usage will be part of the learning objectives of the teaching session. The decision on the instructor, learning materials, education strategies, number of students, venue and duration of teaching session has to be carefully considered. Printed materials in form of “visuals”, e.g. small tabletop cards or bookmarks with the instructions for usage are strongly encouraged. Careful selection of opinion leaders, change champions and core groups is important for the success of practice adoption. The process of change is difficult and resistance against change will definitely be present. Opinion leaders, change champions and core groups have to consist of people that are dedicated to make things work and believe in the implementation of the new practice. All of them should not only have the passion in raising the quality of care but also working with people. In summary, opinion leaders, change champions and core group have to

people who belong to the early adopters group in order to move the diffusion of practice (Berwick, 2003). Evaluation Process Evaluation Titler (2002) commented that process evaluation include (1) measuring implementation and adherence to the practice by the written evidenced-based practice standard (2) noting the barriers the staff encountered in the practice (3) differences in opinions among the health care providers and (4) difficulty and carrying out the steps of the practice originally designed. Using Rogers’ diffusion of innovation model when considering the indicators to evaluate process, the process evaluation can be divided into mainly 2 parts evaluating the rate of adoption (adherence) and the extent of adoption (Titler and Everett, 2001). The following are some of the indicators for process evaluation: Proportion of patients documented in the medical records to have being educated on the use of the adjunct automated telephone care. •

Proportion of patients that use the adjunct automated telephone care.

•

Proportion of doctors that referred patients to the nurses for adjunct telephone care introduction and education.

•

Survey among the nursing staff and family physicians on the usage of the adjunct automated telephone care covering the following:  satisfaction on this automated telephone care in improving their patients’ outcomes  self-reported stage of adoption and degree of adherence  barriers to adoption and adherence of practice

Outcome Evaluation Outcome indicators measured should be those initially set to change when introducing the adjunct automated telephone care, which in this case, the most importantly is patients’ with chronic diseases physiological, psychological outcomes and self-care behaviors (Titler, 2002).

Next, the cost-effectiveness or “savings” from which this new practice can bring. It is therefore important to collect pre-implementation and post-implementation data for comparison. Using consistency and reliable measuring tools throughout the 9 polyclinics is a criterion for just comparison. The following are the outcome indicators for evaluation: Hypertension Population Physiological Data •

Systolic and Diastolic blood pressure

•

Weight and BMI

Self-Care Behaviors •

Medication adherence

•

Annual blood check

•

Low salt and low fat diet adherence

Diabetes Population Physiological Data •

HbA1C%

•

Serum blood glucose

•

Weight and BMI

Self-Care Behaviors •

Medication adherence

•

Foot inspection

•

Diet adherence – low CHO, low sugar, low fat and high fiber

•

Usage of specialty services – foot screening, eye screening and annual blood test

Hyperlipidemia Population Physiological Data •

Low-density lipoprotein levels

•

High-density lipoprotein levels

•

Triglycerides

•

Weight and BMI

Self-Care Behaviors •

Medication adherence

•

Low-fat diet adherence

Psychological Data for all 3 Populations •

Depression Score

•

Self-efficacy scoring

•

Satisfaction with Care survey

•

Quality of Life Survey

Cost Analysis Conclusion Adjunct automated telephone care has limited evidence in clinical benefits. The decision to implement or even do a pilot project has to be carefully balanced against the cost of building the telecommunication infrastructure. From the writing of this assignment, it has only made the point clearer that passion for commitment and a team effort is needed to have an evidence-based culture in the workplace. Only a team effort with a dedicated purpose can not only provide holistic view of the whole process of evidence-based practice from deciding the topic, to literature review, doing systematic review, drawing out the guidelines, piloting the change, implementing the change and evaluating the process and outcome.

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