Using technology to support care in gestational diabetes mellitus: Quantitative outcomes of an exploratory randomised control trial of adjunct telemedicine for gestational diabetes mellitus (TeleGDM).

AIMS: The increasing incidence and prevalence of gestational diabetes mellitus (GDM) on a background of limited resources calls for innovative approaches healthcare provision. Our aim was to explore the effects of telemedicine supported GDM care on a range of health service utilisation and maternal and foetal outcomes. METHODS: An exploratory randomised controlled trial of adjunct telemedicine support in the management of insulin-treated GDM compared to usual care control. Outcomes included health service use, maternal and foetal clinical outcomes as well as costs. Groups were compared on outcomes and Poisson and Cox regression analysis were performed for predictors of health service utilisation, glycaemic control and costs. RESULTS: 95 participants were recruited (intervention n = 61, control n = 34). There were no differences between the groups in number of face-to-face appointments (median (IQR) intervention = 8(7), control = 8(6), p = 0.843), rates of caesareans, macrosomia, large for gestational age, special care nursery admission or newborn birth-weight. The intervention had no impact on total (IRR = 1.04, p = 0.596) or face-to-face (IRR = 1.09, p = 0.257) clinic appointments or service provider costs. Participants receiving the intervention reached optimum glycaemic control quicker: mean (SD) 4.3(4.2) weeks vs. 7.6(4.5) weeks, p = 0.0001). Telemedicine was a significant predictor of better glycaemic control (HR = 1.71(95%CI: 1.11, 2.65, p = 0.015). CONCLUSIONS: Telemedicine support for GDM care showed no impact on service utilisation and costs. The intervention produced similar GDM clinical outcomes as usual care and posed no added risk to clinical quality of care. The intervention may be associated with fewer insulin dose titrations and participants achieved optimum glycaemic control sooner.

Telemedicine interventions for gestational diabetes mellitus: A systematic review and meta-analysis.

OBJECTIVE: To evaluate the effect of telemedicine on GDM service and maternal, and foetal outcomes. METHODS: A systematic review and meta-analysis of randomised controlled trials (RCT) of telemedicine interventions for GDM was conducted. We searched English publications from 01/01/1990 to 31/08/2013, with further new publication tracking to June 2015 on MEDLINE, EMBASE, PUBMED, CINAHL, the Cochrane Central Register of Controlled Trials and the World Health Organization International Clinical Trials Registry electronic databases. Findings are presented as standardised mean difference (SMD) and odds ratios (OR) or narrative and quantitative description of findings where meta-analysis was not possible. RESULTS: Our search yielded 721 abstracts. Four met the inclusion criteria; two publications arose from the same study, resulting in three studies for review. All studies compared telemedicine to usual care. Telemedicine was associated with significantly fewer unscheduled GDM clinic visits, SMD. Quality of life, glycaemic control (HbA1c, pre and postprandial blood glucose level (BGL)), and caesarean section rate were similar between the telemedicine and usual care groups. None of the studies evaluated costs. CONCLUSIONS: Telemedicine has the potential to streamline GDM service utilisation without compromising maternal and foetal outcomes. Its advantage may lie in the convenience of reducing face-to-face and unscheduled consultations. Studies are limited and more trials that include cost evaluation are required.

Prevalence and impact of urinary incontinence in men with cystic fibrosis.

OBJECTIVES: To determine the prevalence and impact of urinary incontinence (UI) in men with cystic fibrosis (CF). DESIGN: Prospective observational study. SETTING: Adult CF clinics at tertiary referral centres. PARTICIPANTS: Men with CF (n=80) and age-matched men without lung disease (n=80). INTERVENTIONS: Validated questionnaires to identify the prevalence and impact of UI. MAIN OUTCOME MEASURES: Prevalence of UI and relationship to disease specific factors, relationship of UI with anxiety and depression. RESULTS: The prevalence of UI was higher in men with CF (15%) compared to controls (10%) (p=0.339). Men with CF and UI had higher scores for anxiety than those without UI (mean 9.1 (SD 4.8) vs 4.7 (4.1), p=0.003), with similar findings for depression (6.8 (4.6) vs 2.8 (3.4), p=0.002) using the Hospital Anxiety and Depression Scale. CONCLUSIONS: Incontinence is more prevalent in adult men with CF than age matched controls, and may have an adverse effect on mental health. The mechanisms involved are still unclear and may differ from those reported in women.

Reduced physical activity associated with work and transport in adults with cystic fibrosis.

BACKGROUND: Habitual physical activity (HPA) is believed to contribute to overall fitness in CF, however little is known about HPA patterns in adults. METHODS: Adults with CF were recruited from a tertiary hospital outpatient clinic and were compared with controls without CF. HPA was measured as MET·minutes·week(-1) using the long-form International Physical Activity Questionnaire. The relationship between HPA and lung function was explored. RESULTS: CF-group, n=101 [45% females, mean(sd) age=29(9), FEV1 % pred=60(23)] and controls, n=35 [69% females, age 32(10), FEV1 % pred=101(130)]. Both groups reported similar levels of moderate and vigorous activities but the CF-group accumulated significantly less total HPA than controls, mean(sd)=5309(6277) vs. 7808(5493), due to less HPA associated with work, 1887(4285) vs. 3707(5292) and transport 613(1018) vs. 1315(1123). Females with CF showed low to moderate correlations of HPA with lung function (R from 0.30 to 0.42, p<0.05). CONCLUSIONS: Adults with CF accumulate less HPA than non-CF peers. Work and transportation form important targets through which physical activity may be accumulated to supplement prescribed exercise. In females with CF, declining physical activity seen in older adolescents carries into adulthood, which may have implications for wellbeing and outcome.

Effect of a chronic disease management service for patients with diabetes on hospitalisation and acute care costs.

OBJECTIVE: To evaluate the effect of a diabetes-management program for patients with type 2 diabetes and related comorbidities on acute healthcare utilisation and costs. METHODS: This was a retrospective administrative dataset analysis using data for patients enrolled from 2007 to 2008. Inpatient admissions for diabetes-related conditions were compared before, during and following enrolment. Costs per episode were estimated from Weighted Inlier Equivalent Separations (WIES) funding. A cost model was then developed based on admission rates per 100 patients. RESULTS: Data were retrieved for 357 patients; 49% males, mean age 62 years. The mean per-patient cost of the program was AU$524 (s.d. $213). The mean cost of an inpatient admission was $4357(95% CI 2743-5971) pre-enrolment and $4396 (95% CI 2888-5904) post-enrolment. Following program completion the annual costs (per 100 patients) for managing 'diabetes with multiple complications' and hypoglycaemia decreased from $10181 to $1710 and $9947 to $7800. In contrast, the annual cost of cardiovascular disorders increased from $14485 to $40071 per 100 patients. CONCLUSIONS: In the short-term diabetes-management programs for patients with comorbid vascular disease may reduce hospital utilisation for diabetes but not for cardiovascular disease. Longer-term follow-up is needed to determine whether intensive management of vascular complications can reduce costs.