A Randomized Trial on Home Telemonitoring for the Management of Metabolic and Cardiovascular Risk in Patients with Type 2 Diabetes.

BACKGROUND: This study evaluated whether a home telehealth (HT) system enabling the patient to monitor body weight, blood glucose values, and blood pressure values, associated with remote educational support and feedback to the general practitioner, can improve metabolic control and overall cardiovascular risk in individuals with type 2 diabetes mellitus, compared with usual practice. MATERIALS AND METHODS: This was a randomized, parallel-group (1:1), open-label, multicenter study conducted in general practice. Follow-up was for 12 months. RESULTS: Overall, 29 general practitioners enrolled 302 patients (153 assigned to the HT group and 149 to the control group). Use of the HT system was associated with a statistically significant reduction in glycated hemoglobin (HbA1c) levels compared with the control group (estimated mean difference, 0.33±0.1; P=0.001). No difference emerged as for body weight, blood pressure, and lipid profile. The proportion of patients reaching the target of HbA1c <7.0% was higher in the HT group than in the control group after 6 months (33.0% vs. 18.7%; P=0.009) and 12 months (28.1% vs. 18.5%; P=0.07). As for quality of life (evaluated with the 36-item Short Form health survey), significant differences in favor of the HT group were detected as for physical functioning (P=0.01), role limitations due to emotional problems (P=0.02), mental health (P=0.005), and mental component summary (P=0.03) scores. A lower number of specialist visits was reported in the telemedicine group (incidence rate ratio, 0.72; 95% confidence interval, 0.51-1.01; P=0.06). CONCLUSIONS: Use of the HT system was associated with better metabolic control and quality of life; a marginally nonsignificant lower resource utilization was also documented. No impact was documented on blood pressure, lipid profile, and body weight.

[Role of intensive medical training on Law 38 to improve pain management in primary care]. / La gestione del dolore nella medicina primaria: esiti di un progetto di fomazione sulla Legge 38/2010.

The Italian Law no. 38/2010 requires that the physician reports in the medical record the type and the intensity of pain, analgesic therapies and clinical results. We developed a training model for 256 primary care physicians (GPs). After a period of intensive training on the content of the law no. 38, diagnostic and pharmacological approach of pain, we carried out a clinical audit by a web based clinical record to assess doctor's compliance to Law no. 38 and the use of opioids. 2631 patients were assessed (age 71,5±13,7 years; median 74). The mean of chronic non oncologic pain intesity was 5.41±2.0 (static) and 6.10±2.32 (dynamic). After a systematic measurement of pain, a better control of patients was achieved (2.22±2.12 points lower for static, 2.37±2.34 lower for dynamic pain (p<0.001 vs basal time). An increased use of opioids have been detected. GPs have also used strong opioids in opioid-naïve patients, avoiding the first or the second step if intensity of pain detected was severe. In fact, a greater pain control was achieved with oxycodone compared to tramadol or codeine (all of them with normal release and combined with acetaminophen). Chronic non cancer pain remains one of the major clinical problems in the primary care setting, especially in the elderly. The standard measurement of parameters related to pain and the proper use of opioids depends on the scientific update and how this is delivered. GPs are crucial to implement the Law 38 and to increase the degree of complexity of the patient to be properly admitted to a SPOKE/HUB center.

[Continuity of care in heart failure: pilot study of the Tuscany region]. / Continuità assistenziale nello scompenso cardiaco: studio pilota della regione Toscana.

BACKGROUND: Heart failure (HF) is one of the leading causes of hospitalization and medical expenditure, especially in elderly patients. Cooperation between specialists and general practitioners may improve outcomes. A 1-year hospital-territory disease management program was designed in collaboration with the Tuscany Region and the Ministry of Health involving specialists, general practitioners and nurses to investigate the impact of our model on healthcare organization and hospitalization rates in patients with HF. METHODS: The program used a web-based clinical report form, and monitoring of patients from specialists and nurses was coordinated by the general practitioners. We enrolled 106 patients (78.3% male, mean age 74.6 years), with a mean left ventricular ejection fraction 49% and mean Charlson index 2.2. RESULTS: A statistically significant reduction was observed in the number of hospitalizations and emergency calls compared with the previous year. HF severity did not substantially changed in 69.8% of patients, whereas it improved in 17.0% and worsened in 13.2% (NYHA class). CONCLUSIONS: Our preliminary data suggest that cooperation between hospitals and medical systems in the territory by means of a web-based clinical report may result in better management of healthcare interventions in the territory with subsequent reduction of hospitalizations. An extension of this model is now ongoing for collecting data from different areas, both within and outside Tuscany.