title: Telemedicine influence on the follow-up of type 2 diabetes patients. Diabetes intervention in the information age. The impact of telehome care on health status and quality of life among patients with diabetes in a primary care setting in Poland. Web-based care management in patients with poorly controlled diabetes. Adoption and Use of an Online Patient Portal for Diabetes (Diabetes-STAR) Cluster-Randomized Trial of a Mobile Phone Personalized Behavioral Intervention for Blood Glucose Control Continued use of an integrated meter with electronic logbook maintains improvements in glycemic control beyond a randomized, controlled trial. Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Medicare payments, healthcare service use, and telemedicine implementation costs in a randomized trial comparing telemedicine case management with usual care in medically underserved participants with diabetes mellitus (IDEATel) Impact of MyCareTeam for poorly controlled diabetes mellitus. Improved Glycemic Control Without Hypoglycemia in Elderly Diabetic Patients Using the Ubiquitous Healthcare Service, a New Medical Information System Using the vista 350 telephone to communicate the results of home monitoring of diabetes mellitus to a central database and to provide feedback The Effects of a Web-Based Intervention on Psychosocial Well-Being Among Adults Aged 60 and Older With Diabetes Outcomes of a multifaceted physical activity regimen as part of a diabetes self-management intervention Telecommunication Support for Rural Women With Diabetes The effects of a computer-tailored message on secondary prevention in type 2 diabetes: a randomized trial. Online Diabetes Self-Management Program Implementation, generalization and long-term results of the "choosing well" diabetes self-management intervention. Interactive Health Communication Applications for people with chronic disease. Web-Based Collaborative Care for Type 2 Diabetes Quality of Outpatient Care Provided to Diabetic Patients: A health maintenance organization experience The development and evaluation of a computer-aided diabetes education program. Brief, Computer-Assisted Diabetes Dietary Self-Management Counseling: Effects on Behavior, Physiologic Outcomes, and Quality of Life Telemedicine intervention effects on waist circumference and body mass index in the IDEATel project. Utility of a Web-based Intervention for Individuals With Type 2 Diabetes: The Impact on Physical Activity Levels and Glycemic Control Web-Based Depression Treatment for Type 1 and Type 2 Diabetic Patients Effect of Computer-Generated Tailored Feedback on Glycemic Control in People With Diabetes in the Community Use of a real time continuous glucose monitoring system as a motivational device for poorly controlled type 2 diabetes. A nurse short message service by cellular phone in type-2 diabetic patients for six months. A randomized controlled trial of a nurse short-message service by cellular phone for people with diabetes. Diabetes NetPLAY: A physical activity website and linked email counselling randomized intervention for individuals with type 2 diabetes Effects of Self-Management Support on Structure, Process, and Outcomes Among Vulnerable Patients With Diabetes Establishment of blood glucose monitoring system using the internet. Active Care Management Supported by Home Telemonitoring in Veterans With Type 2 Diabetes 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. A patient-centric, provider-assisted diabetes telehealth self-management intervention for urban minorities. Research Paper: A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study Telematic expert system Diabeto: New Tool for Diet Self-Monitoring for Diabetic Patients A short message service by cellular phone in type 2 diabetic patients for 12 months. The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial Long-term effects and costs of brief behavioural dietary intervention for patients with diabetes delivered from the medical office. Long-Term Effect of the Internet-Based Glucose Monitoring System on HbA1c Reduction and Glucose Stability A Diabetes Report Card for the United States: Quality of Care in the 1990s Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes Mobile diabetes intervention study: testing a personalized treatment/behavioral communication intervention for blood glucose control. Outcomes of Minimal and Moderate Support Versions of an Internet-Based Diabetes Self-Management Support Program The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. A controlled study of the effect of computer-aided analysis of home blood glucose monitoring on blood glucose control. The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long‐Term Complications in Insulin‐Dependent Diabetes Mellitus Effects of a brief computer-assisted diabetes self-management intervention on dietary, biological and quality-of-life outcomes The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial Individualized electronic decision support and reminders to improve diabetes care in the community: COMPETE II randomized trial Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial Managing diabetes care using an integrated regional e-health approach Mobile telemonitoring for achieving tighter targets of blood pressure control in patients with complicated diabetes: a pilot study. Internet-Based Chronic Disease Self-Management: A Randomized Trial Improvement in diabetes control with a monitoring system based on a hand-held, touch-screen electronic diary The effects of a web-based intervention on the physical outcomes associated with diabetes among adults age 60 and older: a randomized trial. Mobile communication using a mobile phone with a glucometer for glucose control in Type 2 patients with diabetes: as effective as an Internet-based glucose monitoring system Development and reach of a web-based cognitive behavioural therapy programme to reduce symptoms of depression and diabetes-specific distress. A Ubiquitous Chronic Disease Care system using cellular phones and the internet. Telematic Transmission of Computerized Blood Glucose Profiles for IDDM Patients [Computer assisted nutrition therapy for patients with type 2 diabetes]. Randomized effectiveness trial of a computer-assisted intervention to improve diabetes care. Cost-Effectiveness of Automated Telephone Self-Management Support With Nurse Care Management Among Patients With Diabetes The Effects of Web-Based Diabetes Education on Diabetes Care Results: A Randomized Control Study Evaluating the impact of mobile telephone technology on type 2 diabetic patients' self-management: the NICHE pilot study. Development and evaluation of a patient-oriented education system for diabetes management Effectiveness of home telehealth in comorbid diabetes and hypertension: a randomized, controlled trial. Clinical Evaluation of Decision Support System for Insulin-Dose Adjustment in IDDM A telephone-delivered intervention to improve glycemic control in type 2 diabetic patients. Chronic Disease Self-Management Program: 2-Year Health Status and Health Care Utilization Outcomes Plasma-triglycerides and exercise: A delicate balance A brief office-based intervention to facilitate diabetes dietary self-management. Quality improvement in primary health care using computerised journal, exemplified by a smoking cessation programme for diabetic patients Rethink Organization to iMprove Education and Outcomes (ROMEO) Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. The Vermont Diabetes Information System (VDIS): study design and subject recruitment for a cluster randomized trial of a decision support system in a regional sample of primary care practices A randomized, controlled trial of an automated wireless messaging system for diabetes. Insulin dose titration system in diabetes patients using a short messaging service automatically produced by a knowledge matrix. Technological intervention for obese patients with type 2 diabetes. The Informatics for Diabetes and Education Telemedicine (IDEATel) project. Home telehealth reduces healthcare costs. Clinical application of two computerized diabetes management systems: comparison with the log-book method. WellDoc mobile diabetes management randomized controlled trial: change in clinical and behavioral outcomes and patient and physician satisfaction. Automated messaging to improve compliance with diabetes test monitoring. Improved diabetic prognosis following telecommunication and graphical processing of diabetic data. Physiological Outcomes of an Internet Disease Management Program vs. In-person Counselling:A Randomized, Controlled Trial A Randomized Controlled Trial of an Automated Telephone Intervention to Improve Glycemic Control in Type 2 Diabetes An automated telemedicine system improves patient-reported well-being. Web-based comprehensive information system for self-management of diabetes mellitus. Automated telephone reminder messages can assist electronic diabetes care
abstract: OBJECTIVE This study was design ed to evaluate the impact of a teleassistance system on the metabolic control of type 2 diabetes patients . RESEARCH DESIGN AND METHODS We conducted a 1-year controlled parallel-group trial comparing patients r and omized ( 1 ) to an intervention group , assigned to a teleassistance system using real-time transmission of blood glucose results , with immediate reply when necessary , and telephone consultations , or ( 2 ) to a control group , being regularly followed-up at their healthcare center . Study subjects were type 2 diabetes patients > 30 years of age followed in the primary care setting . RESULTS A total of 328 type 2 diabetes patients were recruited from 35 family practice s in the province of Málaga , Spain . There was a reduction in hemoglobin A1c after 12 months from 7.62 + /- 1.60 % to 7.40 + /- 1.43 % ( P = 0.027 ) in the intervention group and from 7.44 + /- 1.31 % to 7.35 + /- 1.38 % ( P = 0.303 ) in the control group . The difference in the change between groups was not statistically significant . There was also a significant decrease in systolic and diastolic blood pressure , total cholesterol , low-density lipoprotein cholesterol , and body mass index in the intervention group . In the control group , the only significant decline was in low-density lipoprotein cholesterol . CONCLUSIONS A teleassistance system using real-time transmission of blood glucose results with an option to make telephone consultations is feasible in the primary care setting as a support tool for family physicians in their follow-up of type 2 diabetes patients Sustained improvement in blood glucose control is the only treatment outcome which will reduce or eliminate the long term complications of diabetes mellitus . We have design ed and evaluated an electronic information system which facilitates this task . The system is voice-interactive , physician directed and affords , to remote patients , 24 h access via touch-tone telephone . Accordingly , patients access the system each day to report self-measured blood glucose levels or hypoglycaemic symptoms together with dietary changes , planned exercise , stress , illness or other lifestyle events . In turn they receive immediate advice with respect to medication dosing changes , and other pertinent feedback . Preliminary system beta-testing for safety and efficacy was performed for one year in an open study of 204 patients derived from two independent , health-care environments . Among the two testing centres , over 60,000 telephone cells were received by the computer systems during the start-up year . Safety and efficacy expectations were met . In addition , prevalence of diabetes related crises ( hyperglycaemia or hypoglycaemia ) fell approximately 3-fold . Glycated haemoglobin fell significantly ( 1.0 - 1.3 % ) in patients actively using the system . In control groups of patients not actively using the system , there were no improvements in metabolic control while body weights were stable in all groups . The new system was safe and effective in our h and s and empowered our health professionals to provide improved diabetes care BACKGROUND Telehome care has been proposed as a solution to the challenges of providing effective and affordable care for patients with diabetes . METHODS A total of 100 adult patients with type 2 diabetes-divided between insulin and noninsulin requiring-was enrolled in a r and omized , controlled trial aim ed at investigating the effects of telehome monitoring . The experimental group ( n = 50 ) received an in-home wireless glucose monitor and transmitter , whereas the control group ( n = 50 ) was instructed to follow the conventional arrangement . RESULTS There was an overall reduction in HbA1c values in both experimental and control groups after 6 months . A significant difference in HbA1c values between the groups was observed only among the noninsulin-requiring patients ( decline from 6.95 % ± 0.82 % to 6.66 % ± 0.86 % in IB vs. 7.21 % ± 2.02 % to 7.2 % ± 1.86 % in IIB ; p = 0.02 ) . The experimental group reported considerably less hyperglycemic and hypoglycemic events . The profile of the patient who benefited the most from telemonitoring consisted of older , more educated patient who had acquired the disease relatively recently , and who spends most of the time at home . The experimental group had higher overall scores on quality of life measures and sense of control over diabetes . There was a positive association between educational attainment and ability to use the telemonitoring system without help ( p = 0.045 ) . CONCLUSIONS Although not conclusive because of the small sample and short observation period , the study suggests that telehome monitoring is an effective tool in controlling type 2 diabetes in a primary care setting OBJECTIVE To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS For this study , 104 patients with diabetes and HbA(1c ) ( A1C ) > or = 9.0 % who received their care at a Department of Veterans Affairs medical center were recruited . All participants completed a  diabetes education class  and were r and omized to continue with their usual care ( n = 52 ) or receive web-based care management ( n = 52 ) . The web-based group received a notebook computer , glucose and blood pressure monitoring devices , and access to a care management website . The website provided educational modules , accepted uploads from monitoring devices , and had an internal messaging system for patients to communicate with the care manager . RESULTS Participants receiving web-based care management had lower A1C over 12 months ( P < 0.05 ) when compared with education and usual care . Persistent website users had greater improvement in A1C when compared with intermittent users ( -1.9 vs. -1.2 % ; P = 0.051 ) or education and usual care ( -1.4 % ; P < 0.05 ) . A larger number of website data uploads was associated with a larger decline in A1C ( highest tertile -2.1 % , lowest tertile -1.0 % ; P < 0.02 ) . Hypertensive participants in the web-based group had a greater reduction in systolic blood pressure ( P < 0.01 ) . HDL cholesterol rose and triglycerides fell in the web-based group ( P < 0.05 ) . CONCLUSIONS Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes Online patient portals , which provide patients with personal information and facilitate electronic doctor-patient communication , can help patients manage chronic diseases . These systems will be most beneficial if they have broad and durable appeal . In a r and omized trial , we compared a portal providing generic diabetes self-management information to one providing personalized information ( Diabetes-STAR ) . We assessed ( 1 ) the characteristics of patient-users  and ( 2 ) whether including personalized content promotes sustained use OBJECTIVE To test whether adding mobile application coaching and patient/provider web portals to community primary care compared with st and ard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS A cluster-r and omized clinical trial , the Mobile Diabetes Intervention Study , r and omly assigned 26 primary care practice s to one of three stepped treatment groups or a control group ( usual care ) . A total of 163 patients were enrolled and included in analysis . The primary outcome was change in glycated hemoglobin levels over a 1-year treatment period . Secondary outcomes were changes in patient-reported diabetes symptoms , diabetes distress , depression , and other clinical ( blood pressure ) and laboratory ( lipid ) values . Maximal treatment was a mobile- and web-based self-management patient coaching system and provider decision support . Patients received automated , real-time educational and behavioral messaging in response to individually analyzed blood glucose values , diabetes medications , and lifestyle behaviors communicated by mobile phone . Providers received quarterly reports summarizing patient ’s glycemic control , diabetes medication management , lifestyle behaviors , and evidence -based treatment options . RESULTS The mean declines in glycated hemoglobin were 1.9 % in the maximal treatment group and 0.7 % in the usual care group , a difference of 1.2 % ( P = 0.001 ) over 12 months . Appreciable differences were not observed between groups for patient-reported diabetes distress , depression , diabetes symptoms , or blood pressure and lipid levels ( all P > 0.05 ) . CONCLUSIONS The combination of behavioral mobile coaching with blood glucose data , lifestyle behaviors , and patient self-management data individually analyzed and presented with evidence -based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year BACKGROUND Blood glucose monitoring is an important component of diabetes self-management for individuals with insulin-treated diabetes . Although patient-maintained logbooks are routinely used , glucose values may be inaccurately recorded or not recorded at all . Electronic logbooks may help overcome such problems . We conducted a r and omized , controlled trial ( RCT ) to compare glycemic control in insulin-treated participants using  integrated glucose meters and electronic logbooks ( Electronic Group ) with participants using conventional meters and paper logbooks ( Paper Group ) , and to determine persistence of glycemic improvements during long-term observational follow-up . METHODS After a 4-week run-in , adult and pediatric participants ( n = 205 ) with stable hemoglobin A(1C ) ( A1C ) > or=8.0 % were r and omized , and their logbook data and A1C were monitored every 4 weeks for 16 weeks . After the RCT , patients selected their monitoring systems and resumed usual care . The four result ing subgroups , defined by whether patients continued or changed monitoring systems , were reassessed after 26 - 65 weeks . RESULTS During the RCT , mean A1C decreased -0.27 % in the Paper Group and -0.35 % in the Electronic Group . Repeated- measures analysis revealed that the mean decrease was significantly greater in the Electronic than the Paper Group ( P = 0.022 ) . From r and omization through observational follow-up , participants consistently using integrated meters/logbooks had an A1C decrease of -0.36 % ( P = 0.008 ) , whereas participants using conventional meters/logbooks throughout or switching meters returned to pre-enrollment A1C levels . CONCLUSIONS Compared to conventional monitoring systems , use of an integrated meter and electronic logbook result ed in modest , but significant and sustained , improvement in A1C in insulin-treated patients with suboptimal glycemic control during an RCT and observational follow-up BACKGROUND Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness . METHODS The authors conducted a r and omized , controlled trial comparing telemedicine case management to usual care , with blinding of those obtaining outcome data , in 1,665 Medicare recipients with diabetes , aged 55 years or greater , and living in federally design ated medically underserved areas of New York State . The primary endpoints were HgbA1c , blood pressure , and low-density lipoprotein ( LDL ) cholesterol levels . RESULTS In the intervention group ( n = 844 ) , mean HgbA1c improved over one year from 7.35 % to 6.97 % and from 8.35 % to 7.42 % in the subgroup with baseline HgbA1c > or = 7 % ( n = 353 ) . In the usual care group ( n = 821 ) mean HgbA1c improved over one year from 7.42 % to 7.17 % . Adjusted net reductions ( one-year minus baseline mean values in each group , compared between groups ) favoring the intervention were as follows : HgbA1c , 0.18 % ( p = 0.006 ) , systolic and diastolic blood pressure , 3.4 ( p = 0.001 ) and 1.9 mm Hg ( p < 0.001 ) , and LDL cholesterol , 9.5 mg/dL ( p < 0.001 ) . In the subgroup with baseline HgbA1c > or = 7 % , net adjusted reduction in HgbA1c favoring the intervention group was 0.32 % ( p = 0.002 ) . Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York . CONCLUSION Telemedicine case management improved glycemic control , blood pressure levels , and total and LDL cholesterol levels at one year of follow-up BACKGROUND Our objective was to test the effect of physicians providing brief health lifestyle counseling to patients with type 2 diabetes mellitus during usual care visits . METHODS We conducted a r and omized controlled trial of a 12-month intervention at 2 large community health centers , enrolling 310 patients with a body mass index ( calculated as weight in kilograms divided by height in meters squared ) of 25 or greater . In the intervention group , self-management goals for nutrition and physical activity were set using a tailored computer program . Goals were then review ed at each clinic visit by physicians . The control group received only printed health education material s. The main outcome measures included change in physical activity and body weight . RESULTS In the intervention group , recommended levels of physical activity increased from 26 % at baseline to 53 % at 12 months ( P < .001 ) compared with controls ( 30 % to 37 % ; P= .27 ) , and 32 % of patients in the intervention group lost 6 or more pounds at 12 months compared with 18.9 % of controls ( odds ratio , 2.2 ; P= .006 ) . CONCLUSION A brief intervention to increase the dialogue between patients and health care providers about behavioral goals can lead to increased physical activity and weight loss Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures , as measured by Medicare cl aims , and to assess the costs of developing and implementing the telemedicine intervention . Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine ( IDEATel ) , a r and omized controlled trial comparing telemedicine case management of diabetes to usual care . Participants were aged 55 years or older , and resided in federally design ated medically underserved areas of New York State . Measurements We analyzed Medicare cl aims payments for each participant for up to 60 study months from date of r and omization , until their death , or until December 31 , 2006 ( whichever happened first ) . We also analyzed study expenditures for the telemedicine intervention over six budget years ( February 28 , 2000- February 27 , 2006 ) . Results Mean annual Medicare payments ( SE ) were similar in the usual care and telemedicine groups , $ 9040 ( $ 386 ) and $ 9669 ( $ 443 ) per participant , respectively ( p>0.05 ) . Sensitivity analyses , including stratification by censored status , adjustment by enrollment site , and semi-parametric weighting by probability of dropping-out , rendered similar results . Over six budget years 28 821 participant/months of telemedicine intervention were delivered , at an estimated cost of $ 622 per participant/month . Conclusion Telemedicine case management was not associated with a reduction in Medicare cl aims in this medically underserved population . The cost of implementing the telemedicine intervention was high , largely representing special purpose hardware and software costs required at the time . Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used OBJECTIVE Web-based diabetes management can be used to provide frequent interactions between patients and providers and thus result in improved glycemic control . METHODS In a single-center , prospect i ve feasibility study , 16 poorly controlled patients with either type 1 or 2 diabetes mellitus were enrolled to assess the impact of using MyCareTeam , a web-based diabetes management application , for diabetes management . Patients were asked to transfer their blood glucose data electronically , maintain exercise logs , and communicate with their provider via MyCareTeam . The provider gave clinical interventions to optimize blood glucose control and provided feedback via MyCareTeam . Diabetes , nutrition , and exercise information was also available via MyCareTeam . RESULTS A significant reduction of over 2.22 % points in hemoglobin A1C was seen for the total patient population . Differences between moderate/heavy users ( n = 8) versus light/never users ( n = 8) of MyCareTeam were evaluated for intergroup differences based upon utilization . Moderate/heavy users had a significant 6-month A1C reduction of 3.15 percentage points compared with a reduction of 1.28 percentage points in light/never users . Other secondary end points were improved as well , including systolic blood pressure , diastolic blood pressure , total cholesterol , high-density lipoprotein , low-density lipoprotein , and triglycerides . However , as expected , body mass index levels increased because of aggressive diabetes management with insulin therapy . CONCLUSIONS These results demonstrate a significant treatment effect from the MyCareTeam application . A larger r and omized control trial is under way at the Boston Veterans Administration Healthcare System . If these results are confirmed as expected , then web-based diabetes management may prove to be the link to achieving target American Diabetes Association glycemic goals in patients with poorly controlled diabetes OBJECTIVE To improve quality and efficiency of care for elderly patients with type 2 diabetes , we introduced elderly-friendly strategies to the clinical decision support system (CDSS)-based ubiquitous healthcare ( u-healthcare ) service , which is an individualized health management system using advanced medical information technology . RESEARCH DESIGN AND METHODS We conducted a 6-month r and omized , controlled clinical trial involving 144 patients aged > 60 years . Participants were r and omly assigned to receive routine care ( control , n = 48 ) , to the self-monitored blood glucose ( SMBG  , n = 47 ) group , or to the u-healthcare group ( n = 49 ) . The primary end point was the proportion of patients achieving A1C < 7 % without hypoglycemia at 6 months . U-healthcare system refers to an individualized medical service in which medical instructions are given through the patient ’s mobile phone . Patients receive a glucometer with a public switched telephone network-connected cradle that automatically transfers test results to a hospital-based server . Once the data are transferred to the server , an automated system , the CDSS rule engine , generates and sends patient-specific messages by mobile phone . RESULTS After 6 months of follow-up , the mean A1C level was significantly decreased from 7.8 ± 1.3 % to 7.4 ± 1.0 % ( P < 0.001 ) in the u-healthcare group and from 7.9 ± 1.0 % to 7.7 ± 1.0 % ( P = 0.020 ) in the SMBG group , compared with 7.9 ± 0.8 % to 7.8 ± 1.0 % ( P = 0.274 ) in the control group . The proportion of patients with A1C < 7 % without hypoglycemia was 30.6 % in the u-healthcare group , 23.4 % in the SMBG group ( 23.4 % ) , and 14.0 % in the control group ( P < 0.05 ) . CONCLUSIONS The CDSS-based u-healthcare service achieved better glycemic control with less hypoglycemia than SMBG and routine care and may provide effective and safe diabetes management in the elderly diabetic patients PURPOSE Self-monitoring of blood glucose has become routine practice in the management of diabetes mellitus . When all the data is complete , however , the amount of information to be taken into account when making therapeutic decisions becomes overwhelming not only for the patient but for the healthcare provider . Computers excel at processing large amounts of information quickly and impassively , which makes them potentially helpful for collating and communicating the data in a manner that facilitates decision-making by patient and healthcare provider . This should in turn improve control and help prevent acute and chronic complications . METHOD Using the Vista 350 telephone , we have developed a system that enables patients with diabetes to record home monitoring data to a central data base and receive feedback summaries . A small trial was conducted to determine if the Vista 350 telephone is an acceptable and feasible method to communicate the results of home monitoring of diabetes mellitus to a central data base and receive feedback summaries . A total of 35 volunteers with insulin-requiring diabetes mellitus in the London area were r and omly allocated to either use the Vista 350 phone for 6 months , or to a control group that continued to use traditional methods for recording home monitoring data . RESULTS 33 of the 35 patients enrolled completed the trial . All 16 patients who began using the phone continued to do so for 6 months confirming the feasibility of the system . Question naires completed at 3 and 6 months confirmed the Vista 350 telephone system to be acceptable to the subjects . The results will enable some minor modifications to be made to the telephone system before a larger definitive trial , design ed to determine the effect on diabetes control , is conducted later this year Purpose The purpose of this study is to investigate the impact of a 6-month Web-based intervention on the psychosocial well-being of older adults with diabetes . Methods This study was a r and omized controlled trial ( N = 62 ) comparing the effects of a 6-month Web-based intervention plus usual care with usual care alone among adults aged 60 years or older with diabetes . The outcomes included quality of life , depression , social support , and self-efficacy . Results The intervention group showed significant improvement , F(4.48 ) = 4.03 P = .007 , when compared with the control group on measures of depression , quality of life , social support , and self-efficacy when controlling for all baseline outcome variables ( age , gender , and number of years with diabetes ) . Conclusions These findings provide support for the conclusion that a Web-based intervention is effective in improving the psychosocial well-being of participants at a 6-month follow-up . Future research needs to investigate the long-term effectiveness of Web-based interventions for sustaining psychosocial well-being , including factors that may affect quality of life , such as diabetes-specific beliefs , attitudes , social support , and disease-specific coping skills Background :  Physical activity ( PA )  is important for management of diabetes , yet practical interventions that achieve sustained behavior change are rare . Purpose : The goals of this research were to evaluate the effectiveness of a multifaceted PA intervention for people with type 2 diabetes that emphasized participant choice in activity selection . Baseline activity patterns were examined to determine whether they predicted changes in PA at 2 months . Methods : Three hundred thirty-five participants were recruited from 42 primary care physicians and then r and omized to either a computer-assisted , tailored self-management intervention ( N = 174 ) or health risk appraisal with feedback control ( N = 161 ) . Primary outcome measures included the Community Healthy Activities Model Program for Seniors Question naire , diet , and psychosocial assessment s at baseline and 2 months . Results : For 301 participants who completed the 2-month follow-up , the intervention significantly improved all PA ( p < .01 ) and moderate PA ( metabolic equivalents > 3.0 , p < .01 ) relative to controls . Baseline cluster analyses grouped participant activity patterns into three categories . At 2 months , cluster assignment differentially predicted change in calories expended in moderate , rote , sport , and lifestyle PA . Conclusions : A computer-assisted , multifaceted approach to PA demonstrated improvement after 2 months . The results suggest that individuals are capable of adjusting their activity patterns to maximize their PA PURPOSE The Women to Women Diabetes Project tested the use of telecommunication technology to deliver diabetes education and social support to rural women with diabetes . The aims were to ( 1 ) test the effects of the computer intervention in providing support , information , and education on selected outcomes , and ( 2 ) evaluate the women 's attitudes toward and satisfaction with the intervention and the support provided . METHODS Thirty women were r and omized into computer and noncomputer groups and participated for 10 months . For 5 months , one group participated in a self-help support and educational group via the computer ; the other group continued to use their usual modes of support and communication .  Psychosocial well-being scales were administered and attitudes were surveyed . RESULTS Improving health and higher educational levels positively influenced measures of social support and quality of life .  Women who were married or who reported greater support had higher scores on the Personal Re source Question naire . The women expressed positive effects of the computer-based support group on their lives . CONCLUSIONS The intervention was enthusiastically accepted , and could be conducted effectively in isolated rural areas The purpose of this study was to test the effect of computer-generated , tailored feedback on the quality of chronic disease management for type 2 diabetes when provided to a patient prior to a scheduled physician visit . A st and -alone computer application was developed to provide tailored feedback aim ed at empowering patients to engage more actively in their diabetes management . Adults with type 2 diabetes ( n = 203 ) were r and omly assigned to groups receiving either efficacy ( positive ) messages ( n = 68 ) , risk ( negative ) messages ( n = 67 ) , or to a delayed treatment control group ( n = 68 ) . The intervention was delivered prior to a patient 's visit with his or her physician so that patients would have the opportunity to discuss the messages at the clinical appointment . Although there were no significant differences in the percentage of participants who received intensified care or routine tests between the control and intervention groups , we learned that more directive messaging may be needed to help patients effectively manage their diabetes . Patients may benefit from directive feedback , providing them with specific questions to ask their physician that can lead to improved care , rather than receiving general and educational informational messages OBJECTIVE We hypothesized that people with type 2 diabetes in an online diabetes self-management program  , compared with usual-care control subjects , would 1 ) demonstrate reduced A1C at 6 and 18 months , 2 ) have fewer symptoms , 3 ) demonstrate increased exercise , and 4 ) have improved self-efficacy and patient activation . In addition , participants r and omized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement . RESEARCH DESIGN AND METHODS A total of 761 participants were r and omized to 1 ) the program  , 2 ) the program with e-mail reinforcement , or 3 ) were usual-care control subjects ( no treatment ) . This sample included 110 American Indians/Alaska Natives ( AI/ANs ) . Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups . RESULTS At 6 months , A1C , patient activation , and self-efficacy were improved for program participants compared with usual care control subjects ( P < 0.05 ) . There were no changes in other health or behavioral indicators . The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects . The subgroup with initial A1C > 7 % demonstrated stronger improvement in A1C ( P = 0.01 ) . At 18 months , self-efficacy and patient activation were improved for program participants . A1C was not measured . Reinforcement showed no improvement . CONCLUSIONS An online diabetes self-management program is acceptable for people with type 2 diabetes . Although the results were mixed they suggest 1 ) that the program may have beneficial effects in reducing A1C , 2 ) AI/AN population s can be engaged in and benefit from online interventions , and 3 ) our follow-up reinforcement appeared to have no value Prerequisites for translating intervention research findings into practice are maintenance of results , generalization of effects and consistency of implementation . This report presents 12 months follow-up information on a r and omized 2x2 factorial trial evaluating the incremental effects of adding ( 1 ) telephone follow-up or ( 2 ) a community re sources utilization component to a basic touchscreen computer-assisted dietary goal - setting intervention for 320 type 2 diabetes patients . All conditions evidence d significant improvement from baseline to the 12 months follow-up across behavioral , biological and psychosocial measures . There were few consistent differences between conditions , but results were robust across interventionists and clinics . The telephone follow-up component appeared to enhance long-term results on some measures . When considered along with earlier results from a r and omized trial that included a control condition without goal setting , it is concluded that this basic goal - setting intervention can be consistently implemented by a variety of interventionists and produce lasting improvements BACKGROUND : Interactive Health Communication Applications ( IHCAs ) are computer-based , usually web-based health information packages for patients that combine information with at least one of social support , decision support , or behaviour change support . These are innovations in health care and their effects on health are uncertain . OBJECTIVES : To assess the effects of IHCAs for people with chronic disease . SEARCH STRATEGY : We design ed a four-part search strategy . First , we search ed electronic bibliographic data bases for published work ; second , we search ed the grey literature and third , we search ed for ongoing and recently completed clinical trials in the appropriate data bases . Finally , research ers of included studies were contacted , and reference lists from relevant primary and review articles were followed up . As IHCAs require relatively new technology , the search commenced at 1990 where possible . SELECTION CRITERIA : R and omised controlled trials ( RCTs ) of Interactive Health Communication Applications for adults and children with chronic disease . DATA COLLECTION AND ANALYSIS : One review er screened abstract s. Two review ers screened all c and i date studies to determine eligibility , apply quality criteria , and extract data from included studies . Authors of included RCTs were contacted for missing data . Results of RCTs were pooled using a r and om effects model and st and ardised mean differences ( SMDs ) were calculated to provide net effect sizes . MAIN RESULTS : We screened 24,757 unique citations and retrieved 958 papers for further assessment , yielding 28 RCTs involving 4042 participants . One of these had an inadequate method of concealment of allocation , and sensitivity analyses were performed to determine the effects of including or excluding these data in the meta-analyses . Results in the abstract are from the meta-analyses excluding data from this study .IHCAs were found to have a positive effect on knowledge ( SMD 0.49 ; 95 % confidence interval ( CI ) 0.14 to 0.84 ) and on social support ( SMD 0.47 ; 95 % CI 0.28 to 0.66 ) . IHCAs were found to have no effect on self-efficacy ( SMD 0.15 ; 95 % CI -0.13 to 0.43 ) or behavioural outcomes ( SMD -0.09 ; 95 % CI -0.49 to 0.32 ) . IHCAs had a negative effect on clinical outcomes ( SMD -0.32 ; 95 % CI -0.63 to -0.02 ) . REVIEW ERS ' CONCLUSIONS : The number and range of IHCAs is increasing rapidly ; however there is a shortage of high quality evaluative data . Consumers who wish to increase their knowledge or social support amongst people with a similar problem may find an IHCA helpful . However , consumers whose primary aim is to achieve optimal clinical outcomes should not use an IHCA at present . Further research is needed to determine the reason for this negative effect on clinical outcomes , whether an optimal IHCA can achieve behaviour change and improved health outcomes , and if so , what are the essential features of such an IHCA , and the extent to which they differ according to patient group or condition OBJECTIVE —To test Web-based care management of glycemic control using a shared electronic medical record with patients who have type 2 diabetes . RESEARCH DESIGN AND METHODS —We conducted a trial of 83 adults with type 2 diabetes r and omized to receive usual care plus Web-based care management or usual care alone between August 2002 and May 2004 . All patients had GHb ≥7.0 % , had Web access from home , and could use a computer with English language –based programs . Intervention patients received 12 months of Web-based care management . The Web-based program included patient access to electronic medical records , secure e-mail with providers , feedback on blood glucose readings , an educational Web site , and an interactive online diary for entering information about exercise , diet , and medication . The primary outcome was change in GHb . RESULTS —GHb levels declined by 0.7 % ( 95 % CI 0.2−1.3 ) on average among intervention patients compared with usual-care patients . Systolic blood pressure , diastolic blood pressure , total cholesterol levels , and use of in-person health care services did not differ between the two groups . CONCLUSIONS —Care management delivered through secure patient Web communications improved glycemic control in type 2 diabetes OBJECTIVE To document the quality of diabetes care provided to patients in a large health maintenance organization ( HMO ) from 1 January 1993 to 1 January 1994 and compare it to the st and ards of the American Diabetes Association ( ADA ) . RESEARCH DESIGN AND METHODS To meet a Health Plan and Employer Data Information Set ( HEDIS ) requirement , a major HMO in California identified 14,539 members with diabetes and r and omly selected 384 individuals for review . Charts were available on 353 of these patients , and after obtaining the information for the HEDIS review , additional information was extracted from the charts by an outside chart review er . This data set was used for an analysis of the quality of diabetic care provided by the participating medical groups to these HMO members during 1 year . Documentation of follow-up and measures of glycemic and lipid control was examined both for absolute values and for the frequency of measurement over the year . These results were compared to the ADA st and ards of care . RESULTS Although patients averaged 4.5 visits to their primary care physicians ( PCPs ) over the year , 21 % had one or fewer visits per year . Glycated hemoglobin levels were not documented in 56 % of patients ( ADA recommends two to four measurements per year ) , and of those with a glycated hemoglobin level measured . 39 % had at least one value ≥ 10 % . Fasting plasma glucose concentrations were not documented in 65 % of patients ( four to six per year recommended ) . Foot exams ( which should be performed at each regular visit ) were not documented for 94 % of patients . Urine protein measurements were not performed in 52 % of patients . Additionally , many patients had elevated and untreated lipid abnormalities . CONCLUSIONS In spite of the frequency of PCP visits during the year for many of these patients , diabetes management was inadequate . This lack of adequate preventive care will lead to an increased risk of the development of the acute and chronic complications of diabetes , creating an even greater future burden on the health care system and negative consequences for patients This paper describes the development and evaluation of a computer-aided learning ( CAL ) program . The program was tested in a trial that involved 36 people with diabetes ; 20 received CAL lessons in diabetes management and 16 attended conventional diabetes classes conducted by diabetes educators . When measurements taken before and three months after the education were compared , both groups showed significant improvement in their knowledge ; the blood glucose levels of the CAL group were significantly lower but those of the conventional education group were higher . This means that the CAL program was as effective as conventional education in imparting knowledge but it was more likely to motivate people to control their glucose levels . The CAL program allows diabetes educators to spend less time on education in basic knowledge and to concentrate more on motivational and social factors that are important determinants of patient compliance . It can also benefit people with diabetes whose access to health professionals and /or conventional diabetes education is restricted Objectives .The objective of this work was to evaluate the reach , effectiveness , adoption , and implementation of a brief behavioral dietary intervention and 2 supplemental components of diabetes self-management support : telephone follow-up calls and community re sources enhancement . Design and Subjects . This was a 2 × 2 r and omized , controlled trial investigating the incremental effects of telephone follow-up and community re sources enhancement with 320 adult type 2 diabetes out patients . Methods .Key outcomes included behavioral ( dietary patterns , fat intake ) , physiologic ( HbA1C , lipids ) , and quality -of-life/patient satisfaction measures and were collected at baseline and 3- and 6-month follow-up . Results .Despite high reach ( 76 % patient participation ) , excellent adoption ( all 12 primary care practice s approached participated ) , and good implementation , there were few outcome differences among treatment conditions . There was significant improvement across conditions in most outcomes in each category at both follow-ups . Conclusions .A brief , computer-assisted , dietary goal – setting intervention basic treatment condition was moderately successful in producing dietary improvements but less so in producing biologic or quality -of-life outcomes . Additions of follow-up phone calls or a community re sources enhancement component did not produce incremental improvements over this basic intervention BACKGROUND We examine the changes in waist circumference ( WC ) and body mass index ( BMI ) in older adults enrolled in a diabetes telemedicine program . The subjects were elderly Medicare beneficiaries participating in the rural ( upstate New York ) cohort of Informatics and Diabetes Education and Telemedicine , a r and omized , controlled trial using telemedicine to improve diabetes care in which the primary outcome was glycemic control . METHODS Ninety-two percent of the subjects had BMI > 25 kg/m(2 ) , and 65.8 % had a BMI > or = 30 kg/m(2 ) . Intervention subjects received home televisits with a dietitian or nurse educator every 4 - 6 weeks .  Blood glucose and blood pressure values  were review ed , and lifestyle and medication changes were recommended . Non-intervention subjects received usual care through their primary care physicians . Change in WC , BMI , diet , and exercise behaviors and knowledge were examined at baseline and 12 and 24 months . A mixed-effects path analysis was performed to examine direct and indirect effects . RESULTS The telemedicine participants increased diet and exercise knowledge over time ( P < 0.001 ) . It was estimated that women in the  telemedicine  group reduced their WC over the 2 years by 1.2 cm , whereas women in the usual care group increased their WC by almost 1 cm ( P = 0.02 ) . Path analysis demonstrated that the intervention , through improved diet and exercise knowledge , was related to the decrease in WC ( P = 0.006 ) and BMI ( P = 0.004 ) . CONCLUSIONS Diabetes case management using telemedicine improved self-reported diet and exercise knowledge , practice s , and behaviors , which in turn was associated with reductions in WC and BMI at 2 years Despite the numerous benefits of physical activity for patients with diabetes , most healthcare providers in busy clinical setting s rarely find time to counsel their patients about it . A Web-based program for healthcare providers can be used as an effective counseling tool , when strategies are outlined for specific stages of readiness for physical activity . Seventy-three adults with type 2 diabetes were r and omly assigned to Web-based intervention , printed- material intervention , or usual care . After 12 weeks , the effects of the interventions on physical activity , fasting blood sugar , and glycosylated hemoglobin were evaluated . Both Web-based and printed material intervention , compared with usual care , were effective in increasing physical activity ( P < .001 ) and decreasing fasting blood sugar ( P<.01 ) and glycosylated hemoglobin ( P < .01 ) . Post hoc analysis for change scores indicated significant differences between Web-based intervention and usual care and between printed material intervention and usual care , but not between web-based and printed material intervention . The findings of this study support the value of Web-based and printed material interventions in healthcare counseling . With increasing Web access , the effectiveness of Web-based programs offered directly to patients needs to be tested OBJECTIVE Comorbid depression is common in patients with type 1 and type 2 diabetes , adversely affecting quality of life , diabetes outcomes , and mortality . Depression can be effectively treated with cognitive behavior therapy ( CBT ) . The Internet is a new and attractive method for delivering CBT intervention on a large scale at relatively low costs . This study evaluated the effectiveness of Web-based CBT for depression treatment in adults with type 1 or type 2 diabetes , with minimal guidance . RESEARCH DESIGN AND METHODS A r and omized controlled trial was conducted in the Netherl and s in 255 adult diabetic patients with elevated depressive symptoms . Primary outcomes were depressive symptoms . Secondary outcomes were diabetes-specific emotional distress and glycemic control . Assessment s were at baseline , after treatment , and at the 1-month follow-up . RESULTS The Web-based CBT was effective in reducing depressive symptoms by intention-to-treat analyses ( P = 0.04 , d = 0.29 ; clinical improvement 41 % vs. 24 % P < 0.001 ) and by per- protocol analyses ( P < 0.001 , d = 0.70 ; clinical improvement , 56 % vs. 24 % P < 0.001 ) . The intervention reduced diabetes-specific emotional distress ( P = 0.03 ) but had no beneficial effect on glycemic control ( P > 0.05 ) . CONCLUSIONS Web-based CBT depression treatment is effective in reducing depressive symptoms in adults with type 1 and type 2 diabetes . In addition , the intervention reduces diabetes-specific emotional distress in depressed patients OBJECTIVE It is unknown whether computer-generated , patient-tailored feedback leads to improvements in glycemic control in people with type 2 diabetes . RESEARCH DESIGN AND METHODS We recruited people with type 2 diabetes aged ≥40 years with a glycated hemoglobin ( A1C ) ≥7 % , living in Hamilton , Canada , who were enrolled in a community-based program ( Diabetes Hamilton ) that provided regular evidence -based information and listings of community re sources design ed to facilitate diabetes self-management . After completing a question naire , participants were r and omly allocated to either receive or not receive periodic computer-generated , evidence -based feedback on the basis of their question naire responses and design ed to facilitate improved glycemic control and diabetes self-management . The primary outcome was a change in A1C after 1 year . RESULTS A total of 465 participants ( 50 % women , mean age 62 years , and mean A1C 7.83 % ) were r and omly assigned , and 12-month A1C values were available in 96 % of all participants , at which time the A1C level had decreased by an absolute amount of 0.24 and 0.15 % in the intervention and control groups , respectively . The difference in A1C reduction for the intervention versus control group was 0.09 % ( 95 % CI −0.08 to 0.26 ; P = 0.3 ) . No between-group differences in measures of quality of life , diabetes self-management behaviors , or clinical outcomes were observed . CONCLUSIONS Providing computer-generated tailored feedback to registrants of a generic , community-based program that supports diabetes self-management does not lead to lower A1C levels or a better quality of life than participation in the community-based program ( augmented by periodic A1C testing ) alone OBJECTIVE The use of a real time continuous glucose monitoring system ( RT-CGM ) was studied as a behavior modification tool and the effectiveness of a RT-CGM in glucose control for patients with type 2 diabetes was determined . METHODS We conducted a prospect i ve , open-label , r and omized , controlled clinical trial in 65 patients with poorly controlled type 2 diabetes ( 8.0</=HbA1c</=10 % ) over a 3-month period . The intervention group was monitored monthly with a RT-CGM ( three days at a time for 3 months ) and the control group continued self-monitoring blood glucose ( SMBG ) at least four times a week for 3 months . RESULTS The HbA1c of the RT-CGM group was significantly reduced after 12 weeks compared with the SMBG group ( 9.1+/-1.0 % to 8.0+/-1.2 % vs. 8.7+/-0.7 % to 8.3+/-1.1 % , respectively ; P=0.004 ) . In the RT-CGM group , there was a significant reduction in total daily calorie intake , weight , body mass index ( BMI ) , and postpr and ial glucose level , and a significant increase in total exercise time per week after 3 months . CONCLUSIONS We demonstrated that the RT-CGM was useful in modifying a patient 's diet and exercise habits and could induce better glycemic control than SMBG for patients with type 2 diabetes AIM To investigate the effectiveness of a nurse short message service ( SMS ) by cellular phone and wire Internet on plasma glucose levels in people with diabetes for six months . BACKGROUND Blood glucose management system using telemedicine approaches may maintain the appropriate blood glucose levels in type-2 diabetic patients . DESIGN A control group pre-test-post-test design was used to assess the effectiveness of nurse 's education . METHODS Twenty-five patients were r and omly assigned to an intervention group and 26 to a control group . The intervention was applied for six months . The goal of the intervention was to keep blood glucose concentrations close to the normal range . Participants were requested to input their  blood glucose level , diet and exercise diary everyday in the website by cellular phone or wire Internet . The research er sends optimal recommendations to each patient using SMS by cellular phone and wire Internet weekly . RESULTS Glycosylated hemoglobin ( HbA(1)c ) decreased 1.15 % points at three months and 1.05 % points at six months compared with baseline in the intervention group . Patients in the intervention group had a decrease of two hours post meal glucose ( 2HPMG ) of 85.1 mg/dl at three months and 63.1 mg/dl at six months compared with baseline . CONCLUSION This web-based intervention using SMS of cellular phone improved HbA(1)c and 2HPMG for six months in type-2 diabetic patients . RELEVANCE TO CLINICAL PRACTICE An SMS of cellular phone intervention by a nurse can reduce HbA(1)c and 2HPMG for six months in type-2 diabetic patients BACKGROUND Nurse 's education using telemedicine results in a decrease in blood glucose levels in patients with type 2 diabetes . OBJECTIVE To investigate the effectiveness of an educational intervention that used both the cellular phone and the Internet to provide a short-messaging service ( SMS ) relating to plasma glucose levels . METHODS Twenty-five patients were r and omly assigned to an intervention group and 26 to a control group . The intervention was applied for 12 weeks . The goal of the intervention was to keep blood glucose concentrations close to the normal range . Patients in the intervention group were asked to access a website by using a cellular phone or to wiring the Internet and input their blood glucose levels every day . Participants were sent the optimal recommendations by both cellular phone and the Internet weekly . RESULTS Patients in the intervention group had a mean decrease in glycosylated haemoglobin ( HbA(1)c ) levels of 1.15 % and those in the control group had a mean increase of HbA(1)c levels of 0.07 % ( p=0.005 ) . There was a significant mean change in the 2hrs post-meal glucose ( 2HPMG ) level for the intervention group ( p<0.05 ) , with a mean change of -4.7mmol/l . The mean change in the control group was not significant . CONCLUSION This educational intervention using the Internet and an SMS by cellular phone improved levels of HbA(1)c and 2HPMG Background -This pilot study evaluated the feasibility ( recruitment , retention , adherence and satisfaction ) and preliminary efficacy of a 12-week website and email-linked counselling intervention on physical activity behaviour change in individuals with type 2 diabetes . Methods -A total of 49 individuals with type 2 diabetes ( 59 % female , average age 54.1 years ) were r and omized to the Diabetes NetPLAY intervention or control condition . The intervention condition received information grounded in the Social Cognitive Theory ( SCT ) , personalized weekly emails , an on-line logbook and message board . Key outcomes included physical activity behaviour and related cognition changes . The control condition was provided links to the Canadian Diabetes Association 's Clinical Practice Guidelines for Physical Activity and Canada 's Guide to Physical Activity . Results -Intervention participants indicated high levels of satisfaction for this mode of delivery and study results demonstrated the feasibility of web-based mediums for the delivery of physical activity information in this population . The intervention group demonstrated a significant improvement in total vigorous and moderate minutes of physical activity ( p = 0.05 ) compared to the control group over the 12-week study . Among the SCT variables , behavioural capacity , showed a significant increase ( p < 0.001 ) among intervention participants . Conclusion -Web-based interventions for individuals with type 2 diabetes are feasible and show promise for improving positive physical activity outcomes OBJECTIVE Despite the importance of self-management support ( SMS ) , few studies have compared SMS interventions , involved diverse population s , or entailed implementation in safety net setting s. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model . RESEARCH DESIGN AND METHODS A total of 339 out patients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial . Participants , more than half of whom spoke limited English , were uninsured , and /or had less than a high school education , were r and omly assigned to  usual care , interactive weekly automated telephone self-management support with nurse follow-up ( ATSM ) , or monthly group medical visits with physician and health educator facilitation ( GMV ) . We measured 1-year changes in structure ( Patient Assessment of Chronic Illness Care [ PACIC ] ) , communication processes ( Interpersonal Processes of Care [ IPC ] ) , and outcomes ( behavioral , functional , and metabolic ) . RESULTS Compared with the usual care group , the ATSM and GMV groups showed improvements in PACIC , with effect sizes of 0.48 and 0.50 , respectively ( P < 0.01 ) . Only the ATSM group showed improvements in IPC ( effect sizes 0.40 vs. usual care and 0.25 vs. GMV , P < 0.05 ) . Both SMS arms showed improvements in self-management behavior versus the usual care arm ( P < 0.05 ) , with gains being greater for the ATSM group than for the GMV group ( effect size 0.27 , P = 0.02 ) . The ATSM group had fewer bed days per month than the usual care group ( −1.7 days , P = 0.05 ) and the GMV group ( −2.3 days , P < 0.01 ) and less interference with daily activities than the usual care group ( odds ratio 0.37 , P = 0.02 ) . We observed no differences in A1C change . CONCLUSIONS Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior . ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life OBJECTIVE The Internet is used worldwide as a communication tool . To improve the quality of diabetes control , we investigated the effectiveness of an Internet-based blood glucose monitoring system ( IBGMS ) on controlling the changes in HbA(1c ) levels . RESEARCH DESIGN AND METHODS We conducted a r and omized clinical trial involving 110 patients who visited the outpatient clinic at the Kangnam St. Mary 's Hospital for 3 months . The study subjects were treated with IBGMS for 12 weeks , and the control group received the usual outpatient management over the same period .  HbA(1c ) and other laboratory tests were performed twice , once at the beginning of the study and again at the end of the study . RESULTS The test results from the beginning of the study established that there were no significant differences between the two groups with respect to age , sex , diabetes duration , BMI , blood pressure , HbA(1c ) , and other laboratory data . On follow-up examination 12 weeks later , HbA(1c ) levels were significantly decreased from 7.59 to 6.94 % within the intervention group ( P < 0.001 ) . At the end of the study , HbA(1c ) levels in the intervention group were significantly lower than in the control group after adjusting the baseline HbA(1c ) ( 6.94 vs. 7.62 % ; P < 0.001 , respectively ) . Among patients with baseline HbA(1c ) < 7.0 % , the patients in the intervention group had lower HbA(1c ) than those in the control group ( 6.38 vs. 6.99 % ; P < 0.05 ) . Among the patients with a baseline HbA(1c ) > or = 7.0 % , the difference between the two groups appeared more obvious : HbA(1c ) levels at the end of the study were 8.12 % . CONCLUSIONS This new IBGMS result ed in a significant reduction of HbA(1c ) during the study period . We propose that this IBGMS be used as a method for improving diabetes control OBJECTIVE We compared the short-term efficacy of home telemonitoring coupled with active medication management by a nurse practitioner with a monthly care coordination telephone call on glycemic control in veterans with type 2 diabetes and entry A1C ≥7.5 % . RESEARCH DESIGN AND METHODS Veterans who received primary care at the VA Pittsburgh Healthcare System from June 2004 to December 2005 , who were taking oral hypoglycemic agents and /or insulin for ≥1 year , and who had A1C ≥7.5 % at enrollment were r and omly assigned to either active care management with home telemonitoring ( ACM+HT group , n = 73 ) or a monthly care coordination telephone call ( CC group , n = 77 ) . Both groups received monthly calls for diabetes education and self-management review . ACM+HT group participants transmitted blood glucose , blood pressure , and weight to a nurse practitioner using the Viterion 100 TeleHealth Monitor ; the nurse practitioner adjusted medications for glucose , blood pressure , and lipid control based on established American Diabetes Association targets . Measures were obtained at baseline , 3-month , and 6-month visits . RESULTS Baseline characteristics were similar in both groups , with mean A1C of 9.4 % ( CC group ) and 9.6 % ( ACM+HT group ) . Compared with the CC group , the ACM+HT group demonstrated significantly larger decreases in A1C at 3 months ( 1.7 vs. 0.7 % ) and 6 months ( 1.7 vs. 0.8 % ; P < 0.001 for each ) , with most improvement occurring by 3 months . CONCLUSIONS Compared with the CC group , the ACM+HT group demonstrated significantly greater reductions in A1C by 3 and 6 months . However , both interventions improved glycemic control in primary care patients with previously inadequate control OBJECTIVE We evaluated automated telephone disease management ( ATDM ) with telephone nurse follow-up as a strategy for improving diabetes treatment processes and outcomes in Department of Veterans Affairs ( VA ) clinics . We also compared the results with those of a prior ATDM trial conducted in a county health care system . RESEARCH DESIGN AND METHODS A total of 272 VA patients with diabetes using hypoglycemic medications were r and omized . During the 1-year study period , intervention patients received biweekly ATDM health assessment and self-care education calls , and a nurse educator followed up with patients based on their ATDM assessment reports . Telephone surveys were used to measure patients ' self-care , symptoms , and satisfaction with care . Outpatient service use was evaluated using electronic data bases and self-reports , and glycemic control was measured by HbA1c and serum glucose testing . RESULTS At 12 months , intervention patients reported more frequent glucose self-monitoring and foot inspections than patients receiving usual care and were more likely to be seen in podiatry and diabetes specialty clinics . Intervention patients also were more likely than control patients to have had a cholesterol test . Among patients with baseline HbA1c levels > or = 8 % , mean end-point values were lower among intervention patients than control patients ( 8.7 vs. 9.2 % , respectively ; P = 0.04 ) . Among intervention and control patients with baseline values > or = 9 % , mean end-point values were 9.1 and 10.2 % , respectively ( P = 0.04 ) . At follow-up , intervention patients reported fewer symptoms of poor glycemic control than control patients and greater satisfaction with their health care . CONCLUSIONS This intervention improved the quality of VA diabetes care . Intervention effects for most end points replicated findings from the prior county clinic trial , although intervention-control differences in the current study were smaller because of the relatively good self-care and health status among the current study 's enrollees This article describes the design and implementation of an online diabetes self-management intervention for a sample of inner-city African Americans with diabetes . Study participants were r and omly assigned to the treatment ( 26 ) and control ( 21 ) conditions . The results indicate that treatment group participants were more likely to achieve positive outcomes in terms of lowered hemoglobin A1c and body mass index measurements than were control group members . These findings support the development of telehealth interventions to promote effective chronic disease management in medically underserved communities CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care . OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older , ethnically diverse , medically underserved patients with diabetes . DESIGN , Setting , and Patients A r and omized controlled trial was conducted , comparing telemedicine case management to usual care , with blinded outcome evaluation , in 1,665 Medicare recipients with diabetes , aged > /= 55 years , residing in federally design ated medically underserved areas of New York State . Interventions Home telemedicine unit with nurse case management versus usual care . Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c ( HgbA1c ) , low density lipoprotein ( LDL ) cholesterol , and blood pressure levels . RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints ( HgbA1c , p = 0.001 ; LDL , p < 0.001 ; systolic and diastolic blood pressure , p = 0.024 ; p < 0.001 ) . Estimated differences ( 95 % CI ) in year 5 were 0.29 ( 0.12 , 0.46)% for HgbA1c , 3.84 ( -0.08 , 7.77 ) mg/dL for LDL cholesterol , and 4.32 ( 1.93 , 6.72 ) mm Hg for systolic and 2.64 ( 1.53 , 3.74 ) mm Hg for diastolic blood pressure . There were 176 deaths in the intervention group and 169 in the usual care group ( hazard ratio 1.01 [ 0.82 , 1.24 ] ) . CONCLUSIONS Telemedicine case management result ed in net improvements in HgbA1c , LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries . Mortality was not different between the groups , although power was limited . Trial Registration http:// clinical trials.gov Identifier : NCT00271739 Objective — To evaluate Diabeto , a computer-assisted diet education system . Research Design And Methods — One hundred five patients with insulin-dependent diabetes mellitus ( IDDM ) or non-insulin-dependent diabetes mellitus ( NIDDM ) were divided into two r and omized groups to participate in the evaluation of Diabeto . With free access through Minitel , the French public videotex network , Diabeto helps diabetic patients self-monitor their diets and balance their meals with personalized counseling . Results — During the first 6-mo study , group A ( 54 patients ) used Diabeto , whereas group B ( 51 patients ) were control subjects . For the second 6-mo study , group B used the system . Evaluation was based on patients ' dietetic knowledge , dietary habits , and metabolic balance . Conclusions –Diabeto led to a significant improvement of dietetic , knowledge in group A ( P < 0.0005 ) and also to improved dietary habits ; decreased caloric intake in patients initially overeating ( P < 0.05 ) , increase of dietary carbohydrate from 39.7 ± 0.7 to 42.9 ± 0.9 % in patients with an initial intake < 45 % carbohydrate , and decrease of fat intake from 41.9 ± 0.9 to 37.4 ± 1.1 % in patients with an initial intake of > 35 % fat ( P < 0.0005 ) . In the second study , in addition to similar improvements to those observed in the first study , HbA1 decreased from 11.0 ± 0.4 to 9.9 ± 0.4 % ( P < 0.005 ) and fructosamine from 5.00 ± 0.17 to 4.57 ± 0.17 % ( P < 0.001 ) . Diabeto appears to be an effective therapeutic tool in the control of metabolic diseases OBJECTIVE Investigate the effectiveness of an educational intervention that used both the cellular phone with a short messaging service ( SMS ) and the Internet on the glycemic control of the patients with type 2 diabetes mellitus . METHODS Twenty-five patients were r and omly assigned to an  intervention  group and twenty-six to a  control group . The intervention was applied for 12 months . The goal of the intervention was to keep blood glucose concentrations close to the normal range ( HbA(1)c<7 % ) . Patients in the intervention group were asked to access a website by using a cellular phone or to wiring the Internet and input their blood glucose levels weekly . Participants were sent the optimal recommendations by both cellular phone and the Internet weekly . RESULTS Participants in the intervention group had lower HbA(1)c over 12 months when compared with the control group . At 12 months the change from baseline in HbA(1)c was -1.32 in the intervention group versus + 0.81 in the control group . Two hours post-meal glucose ( 2HPMG ) had a significantly greater decline in the intervention group after 12 months when compared with the control group ( -100.0 versus + 18.1mg/dl ) . CONCLUSION This educational intervention using the Internet and a SMS by cellular phone rapidly improved and stably maintained the glycemic control of the patients with type 2 diabetes mellitus BACKGROUND A prerequisite to translating research findings into practice is information on consistency of implementation , maintenance of results , and generalization of effects . This follow-up report is one of the few experimental studies to provide such information on Internet-based health education . METHODS We present follow-up data 10 months following r and omization on the " Diabetes Network ( D-Net ) " Internet-based self-management project , a r and omized trial evaluating the incremental effects of adding ( 1 ) tailored self-management training or ( 2 ) peer support components to a basic Internet-based , information-focused comparison intervention .  Participants were 320 adult type 2 diabetes patients from participating primary care offices , mean age 59 ( SD = 9.2 ) , who were relatively novice Internet users . RESULTS All intervention components were consistently implemented by staff , but participant website usage decreased over time . All conditions were significantly improved from baseline on behavioral , psychosocial , and some biological outcomes ; and there were few differences between conditions . Results were robust across on-line coaches , patient characteristics , and participating clinics . CONCLUSIONS The basic D-Net intervention was implemented well and improvements were observed across a variety of patients , interventionists , and clinics . There were , however , difficulties in maintaining usage over time and additions of tailored self-management and peer support components generally did not significantly improve results Abstract Objectives : To evaluate whether a course teaching flexible intensive insulin treatment combining dietary freedom and insulin adjustment can improve both glycaemic control and quality of life in type 1 diabetes . Design : R and omised design with participants either attending training immediately ( immediate DAFNE ) or acting as waiting list controls and attending “ delayed DAFNE ” training 6 months later . Setting : Secondary care diabetes clinics in three English health districts . Participants : 169 adults with type 1 diabetes and moderate or poor glycaemic control . Main outcome measures : Glycated haemoglobin ( HbA1c ) , severe hypoglycaemia , impact of diabetes on quality of life ( ADDQoL ) . Results : At 6 months , HbA1c was significantly better in immediate DAFNE patients ( mean 8.4 % ) than in delayed DAFNE patients ( 9.4 % ) ( t=6.1 , P<0.0001 ) . The impact of diabetes on dietary freedom was significantly improved in immediate DAFNE patients compared with delayed DAFNE patients ( t=−5.4 , P<0.0001 ) , as was the impact of diabetes on overall quality of life ( t=2.9 , P<0.01 ) . General wellbeing and treatment satisfaction were also significantly improved , but severe hypoglycaemia , weight , and lipids remained unchanged . Improvements in “ present quality of life ” did not reach significance at 6 months but were significant by 1 year . Conclusion : Skills training promoting dietary freedom improved quality of life and glycaemic control in people with type 1 diabetes without worsening severe hypoglycaemia or cardiovascular risk . This approach has the potential to enable more people to adopt intensive insulin treatment and is worthy of further investigation This study evaluated the 12-month follow-up results and costs of a personalized , medical office-based intervention focused on behavioral issues related to dietary self-management . Two hundred and six adults having diabetes attending an internal medicine outpatient clinic visit were r and omized to either Usual Care or to Brief Intervention . The single session intervention involved touchscreen computer-assisted assessment that provided immediate feedback on key barriers to dietary self-management , goal setting and problem-solving counselling . Follow-up components included phone calls and videotape intervention relevant to each participant . Brief Intervention produced significantly greater improvement than Usual Care on multiple measures of change in dietary behaviour ( e.g. , covariate adjusted difference of 2.2 % of calories from fat ; p = 0.023 ) and on serum cholesterol levels ( covariate adjusted difference of 15 mg/dl ; p = 0.002 ) at 12-month follow-up . There were also significant differences favouring intervention on patient satisfaction ( p < 0.02 ) but not on HbA1c levels . The costs of intervention ( $ 137 per patient ) were modest relative to many commonly used practice OBJECTIVE —To investigate the long-term effectiveness of the Internet-based glucose monitoring system ( IBGMS ) on glucose control in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS —We conducted a prospect i ve , r and omized , controlled trial in 80 patients with type 2 diabetes for 30 months . The intervention group was treated with the IBGMS , while the control group made conventional office visits only . HbA1c ( A1C ) was performed at 3-month intervals . For measuring of the stability of glucose control , the SD value of A1C levels for each subject was used as the A1C fluctuation index ( HFI ) . RESULTS —The mean A1C and HFI were significantly lower in the intervention group ( n = 40 ) than in the control group ( n = 40 ) . ( A1C [ mean ± SD ] 6.9 ± 0.9 vs. 7.5 ± 1.0 % , P = 0.009 ; HFI 0.47 ± 0.23 vs. 0.78 ± 0.51 , P = 0.001 ; intervention versus control groups , respectively ) . Patients in the intervention group with a basal A1C ≥7 % ( n = 27 ) had markedly lower A1C levels than corresponding patients in the control group during the first 3 months and maintained more stable levels throughout the study ( P = 0.022 ) . Control patients with a basal A1C < 7 % ( n = 15 ) showed the characteristic bimodal distribution of A1C levels , whereas the A1C levels in the intervention group remained stable throughout the study with low HFI . CONCLUSIONS —Long-term use of the IBGMS has proven to be superior to conventional diabetes care systems based on office visits for controlling blood glucose and achieving glucose stability Context There are no recent national evaluations of diabetes care in the United States . Contribution Using data from two national surveys , this study documents a substantial gap between the recommended and actual care of diabetes in the United States between 1988 and 1995 . Many participants had hemoglobin A1c levels greater than 9.5 % ( 18.0 % ) , poorly controlled blood pressure ( 34.3 % ) , and elevated cholesterol levels ( 58.0 % ) . Implication s As a nation , the United States is falling short in caring for patients with diabetes . A periodic national report card may help us to gauge the success of future efforts to improve . The Editors Diabetes , a typical example of chronic disease , currently affects 16 million people in the United States , causes considerable morbidity and mortality , and costs the nation almost $ 100 billion per year ( 1 , 2 ) . Fortunately , several efficacious treatment strategies to prevent or delay diabetes complications have emerged during the past decade , including  control of glycemia , lipids , and hypertension ; early detection and treatment of diabetic retinopathy , nephropathy , and foot disease ;  therapy with aspirin and angiotensin-converting enzyme inhibitors ; and influenza and pneumococcal vaccines ( 3 - 12 ) . Many of these treatments are cost-effective ( 13 - 17 ) . However , their implementation in the United States remains suboptimal and varied ( 18 - 22 ) . There is considerable pressure on U.S. health care systems to improve this situation and to deliver high- quality care while controlling costs . Influential bodies , such as the Institute of Medicine , have recently emphasized the need for strategies to improve the current quality of all medical care in the United States ( 23 ) . Federal agencies are also increasingly responding with initiatives to address quality of care ( 24 , 25 ) . One powerful quality initiative in the United States is the Diabetes Quality Improvement Project ( DQIP ) , which is design ed to influence the care of millions of U.S. patients with diabetes ( 26 ) . The st and ard measures of quality of diabetes care proposed by DQIP were incorporated into the National Committee for Quality Assurance ( NCQA ) Health Plan Employer and Data Information Set . In contrast to guidelines or clinical goals for individual care , DQIP measures are design ed to assess the performance of health care systems for a population , and they offer a wayto make comparisons across health care systems . Several public and private health care systems , including the Indian Health Service ( 27 ) , the Veterans Administration , the U.S. Department of Defense , and numerous managed care organizations , have adopted these indicators . Currently , there is no national reference for assessing the quality of diabetes care using a st and ard set of measures . Such a reference could help health care systems using DQIP measures to compare their own performance against population norms rather than the norms of other health systems . This reference could be a benchmark for assessing population changes in quality of diabetes care after implementation of national quality improvement initiatives recommended by the Institute of Medicine and NCQA . Furthermore , the use of a st and ard set of measures to assess the quality of diabetes care at a national level can facilitate international comparison . For this report , we used U.S. national data to provide a reference and benchmark of the quality of diabetes care as measured by the DQIP indicators . Methods Surveys We used two federally funded , nationally representative population -based surveys , the Third U.S. National Health and Nutrition Examination Survey ( NHANES III ) ( 19881994 ) and the Behavioral Risk Factors Surveillance System ( BRFSS ) ( 1995 ) . Data from these two surveys were analyzed separately . Some measures came exclusively from NHANES III , and others came from BRFSS . We included adults 18 to 75 years of age who reported receiving a previous diagnosis of diabetes from a physician . Women with gestational diabetes were excluded . The two survey groups were similar in demographic characteristics , household income , health insurance coverage , and prevalence of diabetes . In NHANES III compared with BRFSS , more persons did not have a high school education ( 41.5 % vs. 27.1 % ) and fewer persons used insulin ( 30.9 % vs. 39.8 % ) ( Table 1 ) . Table 1 . Characteristics of Persons with Self-Reported Diabetes in the Third U.S. National Health and Nutrition Examination Survey ( 19881994 ) and the Behavioral Risk Factors Surveillance System1995 The methods for NHANES III are described elsewhere ( 28 ) . Briefly , the NHANES III survey used a nationally representative sample of the civilian noninstitutionalized population obtained through a complex multistage cluster sampling design , with oversampling of non-Hispanic black persons , Mexican-American persons , and elderly persons . During a household interview , data were collected on sociodemographic characteristics and medical and family history . Within 4 weeks , this was followed by a clinical examination at a mobile examination center . The procedures for blood collection and processing have also been described elsewhere ( 29 , 30 ) . Low-density lipoprotein ( LDL ) cholesterol level was calculated by using the Friedwald equation for persons who fasted more than 8 hours ( n = 302 ) . Data from NHANES III were self-reported ( demographic and clinical variables ) or were obtained during clinical examination ( hemoglobin A1c level , cholesterol level , triglyceride level , and blood pressure ) . The survey included 16 705 participants 18 to 75 years of age , 1026 of whom reported receiving a diagnosis of diabetes from a physician before the survey . The BRFSS is an annual r and om-digit telephone survey of state population based sample s of the civilian noninstitutionalized population of adults ( 18 years of age ) in each of the 50 states and the District of Columbia . Its purpose , methods , and data analyses have been described in detail elsewhere ( 31 ) . A diabetes-specific BRFSS module was used to collect data on clinical characteristics and preventive care practice s from respondents with diabetes . Data from BRFSS were self-reported ( dilated eye examination , lipid test , foot examination , and demographic and clinical variables ) . The survey included 103 929 participants 18 to 75 years of age , 3059 of whom completed the diabetes module and reported receiving a diagnosis of diabetes from a physician . We used the 1995 BRFSS so that the time frame would correspond with NHANES III . Quality -of-Care Measures We assessed the quality of diabetes care using indicators from the DQIP measurement set for which data were available . The DQIP began under the sponsorship of a coalition that included the American Diabetes Association , the Foundation for Accountability , the Health Care Financing Administration , and NCQA . The American Academy of Physicians , the American College of Physicians , the Veterans Administration , and the Centers for Disease Control and Prevention later joined the coalition . A committee of experts in diabetes care was responsible for developing the DQIP measure set . The DQIP classified the proposed indicators into three categories : accountability indicators , quality improvement indicators , and indicators under field-testing . The accountability measures , which are well grounded in evidence , have received consensus support from the scientific and medical community and have been extensively field-tested in a variety of health care setting s. These measures are used to compare health systems and plans or providers . The quality improvement measures are not considered appropriate for comparing systems and plans or providers but were recommended by the NCQA for assessing internal performance . Table 2 shows all of the analyzed quality indicators and their data sources . The DQIP measures are a combination of process and outcome measures . In this paper , we use DQIP terminology and DQIP accountability and quality improvement measures . Table 2 . Diabetes Quality Improvement Project Indicators and Related Data Sources Statistical Analysis All analyses were conducted by using SAS software ( SAS Institute , Inc. , Cary , North Carolina ) for data management and SUDAAN ( Research Triangle Institute , Research Triangle Park , North Carolina ) to account for the complex sampling scheme , the unequal probability of selection , the oversampling of certain demographic groups , and nonresponse factors ( 32 , 33 ) . Level of care was estimated by the percentage , with corresponding 95 % CIs , of respondents who reported each preventive care practice . We estimated prevalence by groups of sex , age , ethnicity , education , health insurance , type of treatment , and duration of diabetes .  Multiple logistic regression and computation of predictive margins were used to estimate the probability of receiving DQIP indicators when we controlled for all other independent variables . Predictive margins are a type of direct st and ardization in which the predicted values from the logistic regression models are averaged over the covariate distribution in the population ( 34 ) . Predictive margins and their st and ard errors from logistic regression models are provided by the current version of SUDAAN ( 33 ) . Taylor linearization is used in SUDAAN for calculating these st and ard errors . Odds ratios are usually used to display the result from logistic regression models . However , predictive margins are easier to interpret than odds ratios , and they do not require design ating one of the groups as the referent group . Results Diabetes Quality Improvement Project Accountability and Quality Improvement Measures Among adults 18 to 75 years of age with diabetes , 28.8 % had had  hemoglobin A1c levels  tested in the past year , and 18.0 % had a  hemoglobin A1c  level greater than 9.5 % .  Biannual lipid testing  was done in 85.3 % of participants , but only 42.0 % had an LDL cholesterol level less than 3.4 mmol/L ( < 130 mg/dL ) . Only 65.7 % had blood pressure less than 140/90 mm Hg , 63.3 % had an annual dilated eye examination , Diabetes case management ( DCM ) may improve medical outcomes ( 1,2 ) . Case managers coordinate care and often provide a mix of interventions , e.g. , telephone outreach , education , reminders . However , the efficacy of DCM is unclear . Three systematic review s lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid , weight , or blood pressure benefits ( 3–5 ) . DCM studies typically target biomedical outcomes and ignore potential psychosocial effects . Yet , psychosocial variables ( e.g. , depression , anxiety , social support ) relate to hyperglycemia , complications , adherence , and quality of life ( 6–11 ) . Thus , a positive impact of DCM on these factors is important . Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction ( cluster visit ) ( 12 ) and quality of life ( dietitian-led DCM group ) ( 13 ) . Because barriers ( e.g. , distance , weather ) limit DCM access , telemedicine can be used . A review of telemedicine versus face-to-face trials concluded that , while feasible and acceptable , there is little evidence that telemedicine has clinical benefits ( 14 ) . Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients ( 15 ) . The intervention result ed in significant improvements in glycemic control , blood pressure , and total and LDL cholesterol ( 16 ) . The purpose of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project , funded by the Centers for Medicare and Medicaid Services , is to evaluate the feasibility and effectiveness of telemedicine with a diverse , medically underserved , elderly diabetic sample . The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes . A detailed description of the IDEATel study design has been previously reported ( 15,16 ) . Medicare recipients were recruited if they were aged ≥55 years , diagnosed with diabetes , and without moderate/severe impairments or comorbidities . Research nurses blinded to the groups BACKGROUND National data find glycemic control is within target ( A1c<7.0 % ) for 37 % of patients with diabetes , and only 7 % meet recommended glycemic , lipid , and blood pressure goals . OBJECTIVES To compare active interventions and usual care for  glucose control  in a r and omized clinical trial ( RCT ) among persons with diabetes cared for by primary care physicians ( PCPs ) over the course of 1 year . METHODS Physician practice s ( n=36 ) in 4 geographic areas are r and omly assigned to 1 of 4 study groups . The intervention is a diabetes communication system , using mobile phones and patient/physician portals to allow patient-specific treatment and communication . All physicians receive American Diabetes Association ( ADA ) Guidelines for diabetes care . Patients with poor diabetes control ( A1c > or = 7.5 % ) at baseline ( n=260 ) are enrolled in study groups based on PCP r and omization . All study patients receive blood glucose ( BG ) meters and a year 's supply of testing material s. Patients in three treatment groups select one of two mobile phone models , receive one-year unlimited mobile phone data and service plan , register on the web-based individual patient portal and receive study treatment phone software based on study assignment . Control group patients  receive usual care from their PCP . The primary outcome is mean change in A1c over a 12-month intervention period . CONCLUSION Traditional methods of disease management have not achieved adequate control for BG and other conditions important to persons with diabetes . Tools to improve communication between patients and PCPs may improve patient outcomes and be satisfactory to patients and physicians . This RCT is ongoing OBJECTIVE Internet and other interactive technology-based programs offer great potential for practical , effective , and cost-efficient diabetes self-management ( DSM ) programs capable of reaching large numbers of patients . This study evaluated minimal and moderate support versions of an Internet-based diabetes self-management program , compared to an enhanced usual care condition . RESEARCH DESIGN AND METHODS A three-arm practical r and omized trial was conducted to evaluate minimal contact and moderate contact versions of an Internet-based diabetes self-management program , offered in English and Spanish , compared to enhanced usual care .  A heterogeneous sample of 463 type 2 patients was r and omized and 82.5 % completed a 4-month follow-up . Primary outcomes were behavior changes in healthy eating , physical activity , and medication taking . Secondary outcomes included hemoglobin A1c , body mass index , lipids , and blood pressure . RESULTS The Internet-based intervention produced significantly greater improvements than the enhanced usual care condition on three of four behavioral outcomes ( effect sizes [ d ] for healthy eating = 0.32 ; fat intake = 0.28 ; physical activity= 0.19 ) in both intent-to-treat and complete-cases analyses . These changes did not translate into differential improvements in biological outcomes during the 4-month study period . Added contact did not further enhance outcomes beyond the minimal contact intervention . CONCLUSIONS The Internet intervention meets several of the RE- AIM criteria for potential public health impact , including reaching a large number of persons , and being practical , feasible , and engaging for participants , but with mixed effectiveness in improving outcomes , and consistent results across different subgroups . Additional research is needed to evaluate longer-term outcomes , enhance effectiveness and cost-effectiveness , and underst and the linkages between intervention processes and outcomes OBJECTIVE We evaluated the impact of automated telephone disease management ( ATDM ) calls with telephone nurse follow-up as a strategy for improving outcomes such as mental health , self-efficacy , satisfaction with care , and health-related quality of life ( HRQL ) among low-income patients with diabetes mellitus . RESEARCH DESIGN This was a r and omized , controlled trial . SUBJECTS Two hundred forty-eight primarily English- and Spanish-speaking adults with diabetes enrolled at the time of visits to a county health care system . INTERVENTION In addition to usual care , intervention patients received biweekly ATDM calls with telephone follow-up by a diabetes nurse educator . Patients used the ATDM calls to report information about their health and self-care and to access self-care education . The nurse used patients ' ATDM reports to allocate her time according to their needs . MEASURES Patient-centered outcomes were measured at 12 months via telephone interview . RESULTS Compared with patients receiving usual care , intervention patients at follow-up reported fewer symptoms of depression ( P = 0.023 ) , greater self-efficacy to conduct self-care activities ( P = 0.006 ) , and fewer days in bed because of illness ( P = 0.026 ) . Among English-speaking patients , those receiving the intervention reported greater satisfaction with their health care overall and with the technical quality of the services they received , their choice of providers and continuity of care , their communication with providers , and the quality of their health outcomes ( all P < 0.042 ) . Intervention and control patients had roughly equivalent scores for established measures of anxiety , diabetes-specific HRQL , and general HRQL . CONCLUSIONS This intervention had several positive effects on patient-centered outcomes of care but no measurable effects on anxiety or HRQL A 6-month study of the effects on blood glucose control of computer-aided analysis of glucose self-monitoring results was performed . Eighteen clinical ly insulin-dependent patients were ranked in order of haemoglobin A1 and r and omly allocated in consecutive pairs to either a conventional group , using diaries to record self-monitoring meter-read results , or a memory group using meters with inbuilt memories which were linked to a computer at each visit for the analysis of self-monitoring results . There was a significant decline in haemoglobin A1 ( p less than 0.001 ) and fructosamine ( p = 0.002 ) over the 6-month period in the whole population but there was no difference between the study groups . The absolute or percentage changes in haemoglobin A1 and fructosamine did not correlate significantly with any of the patient characteristics examined . The memory system was popular with the patients . At present no benefit in terms of blood glucose control from such systems has been demonstrated BACKGROUND Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus ( IDDM ) . We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications . METHODS A total of 1441 patients with IDDM--726 with no retinopathy at base line ( the primary -prevention cohort ) and 715 with mild retinopathy ( the secondary -intervention cohort ) were r and omly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections . The patients were followed for a mean of 6.5 years , and the appearance and progression of retinopathy and other complications were assessed regularly . RESULTS In the primary -prevention cohort , intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent ( 95 percent confidence interval , 62 to 85 percent ) , as compared with conventional therapy . In the secondary -intervention cohort , intensive therapy slowed the progression of retinopathy by 54 percent ( 95 percent confidence interval , 39 to 66 percent ) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent ( 95 percent confidence interval , 14 to 67 percent ) . In the two cohorts combined , intensive therapy reduced the occurrence of microalbuminuria ( urinary albumin excretion of > or = 40 mg per 24 hours ) by 39 percent ( 95 percent confidence interval , 21 to 52 percent ) , that of albuminuria ( urinary albumin excretion of > or = 300 mg per 24 hours ) by 54 percent ( 95 percent confidence interval 19 to 74 percent ) , and that of clinical neuropathy by 60 percent ( 95 percent confidence interval , 38 to 74 percent ) . The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia . CONCLUSIONS Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy , nephropathy , and neuropathy in patients with IDDM Objective : There is a need for practical , efficient and broad-reaching diabetes self-management interventions that can produce changes in lifestyle behaviours such as healthy eating and weight loss . The objective of this study was to evaluate such a computer-assisted intervention . Methods : Type 2 diabetes primary care patients ( n=335 ) from fee-for-service and health maintenance organization setting s were r and omized to social cognitive theory-based tailored self-management ( TSM ) or computer-aided enhanced usual care ( UC ) .  Intervention consisted of computer-assisted self-management assessment and feedback , tailored goal - setting , barrier identification , and problem-solving , followed by health counsellor interaction and follow-up calls . Outcomes were changes in dietary behaviours ( fat and fruit/vegetable intake ) , haemoglobin A1c ( HbA1c ) , lipids , weight , quality of life , and depression . Results : TSM patients reduced dietary fat intake and weight significantly more than UC patients at the 2-month follow-up . Among patients having elevated levels of HbA1c , lipids or depression at baseline , there were consistent directional trends favouring intervention , but these differences did not reach significance . The intervention proved feasible and was implemented successfully by a variety of staff . Conclusions : This relatively low-intensity intervention appealed to a large , generally representative sample of patients , was well implemented , and produced improvement in targeted behaviours . Implication s of this practical clinical trial for dissemination are discussed Objective : Supporting patients ’ self care could have a major effect on the management of long-term conditions , which has led to worldwide interest in effective self care interventions . In Engl and , self care support is being developed through the “ Expert Patients Programme ” , which provides lay-led generic courses to improve patients ’ self care skills . However , the clinical and cost effectiveness of such courses remains unclear . Methods : Two-arm pragmatic r and omised controlled trial design with waiting list control in community setting s in Engl and . 629 patients with a wide range of self-defined long-term conditions were studied . The lay-led self care support group involved 6-weekly sessions to teach self care skills . Primary outcomes were self-efficacy , reported energy and routine health services utilisation at 6 months . A cost-effectiveness analysis was also conducted . Results : Patients receiving immediate course access reported considerably greater self-efficacy and energy at 6-month follow-up , but reported no statistically significant reductions in routine health services utilisation over the same time period . The cost-effectiveness analysis showed that patients receiving immediate course access reported considerably greater health related quality of life , and a small reduction in costs . If a quality adjusted life year was valued at £ 20 000 ( $ 39 191 ; € 30 282 ) , there was a 70 % probability that the intervention was cost effective . Conclusions : Lay-led self care support groups are effective in improving self-efficacy and energy levels among patients with long-term conditions , and are likely to be cost effective over 6 months at conventional values of a decision-maker ’s willingness to pay . They may be a useful addition to current services in the management of long-term conditions Background : Diabetes mellitus is a complex disease with serious complications . Electronic decision support , providing information that is shared and discussed by both patient and physician , encourages timely interventions and may improve the management of this chronic disease . However , it has rarely been tested in community-based primary care . Methods : In this pragmatic r and omized trial , we r and omly assigned adult primary care patients with type 2 diabetes to receive the intervention or usual care .  The intervention involved shared access by the primary care provider and the patient to a Web-based , colour-coded diabetes tracker , which provided sequential monitoring values for 13 diabetes risk factors , their respective targets and brief , prioritized messages of advice . The primary outcome measure was a process composite score . Secondary outcomes included clinical composite scores , quality of life , continuity of care and usability . The outcome assessors were blinded to each patient ’s intervention status . Results : We recruited sequentially 46 primary care providers and then 511 of their patients ( mean age 60.7 [ st and ard deviation 12.5 ] years ) . Mean follow-up was 5.9 months . The process composite score was significantly better for patients in the intervention group than for control patients ( difference 1.27 , 95 % confidence interval [ CI ] 0.79–1.75 , p < 0.001 ) ; 61.7 % ( 156/253 ) of patients in the intervention group , compared with 42.6 % ( 110/258 ) of control patients , showed improvement ( difference 19.1 % , p < 0.001 ) . The clinical composite score also had significantly more variables with improvement for the intervention group ( 0.59 , 95 % CI 0.09–1.10 , p = 0.02 ) , including significantly greater declines in blood pressure ( −3.95 mm Hg systolic and −2.38 mm Hg diastolic ) and glycated hemoglobin ( −0.2 % ) . Patients in the intervention group reported greater satisfaction with their diabetes care . Interpretation : A shared electronic decision-support system to support the primary care of diabetes improved the process of care and some clinical markers of the quality of diabetes care . ( Clinical Trials.gov trial register no. NCT00813085 . Objective To evaluate the effectiveness of a structured group education programme on biomedical , psychosocial , and lifestyle measures in people with newly diagnosed type 2 diabetes . Design Multicentre cluster r and omised controlled trial in primary care with r and omisation at practice level . Setting 207 general practice s in 13 primary care sites in the United Kingdom . Participants 824 adults ( 55 % men , mean age 59.5 years ) . Intervention A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care . Main outcome measures Haemoglobin A1c levels , blood pressure , weight , blood lipid levels , smoking status , physical activity , quality of life , beliefs about illness , depression , and emotional impact of diabetes at baseline and up to 12 months . Main results Haemoglobin A1c levels at 12 months had decreased by 1.49 % in the intervention group compared with 1.21 % in the control group . After adjusting for baseline and cluster , the difference was not significant : 0.05 % ( 95 % confidence interval −0.10 % to 0.20 % ) . The intervention group showed a greater weight loss : −2.98 kg ( 95 % confidence interval −3.54 to −2.41 ) compared with 1.86 kg ( −2.44 to −1.28 ) , P=0.027 at 12 months . The odds of not smoking were 3.56 ( 95 % confidence interval 1.11 to 11.45 ) , P=0.033 higher in the intervention group at 12 months . The intervention group showed significantly greater changes in illness belief scores ( P=0.001 ) ; directions of change were positive indicating greater underst and ing of diabetes . The intervention group had a lower depression score at 12 months : mean difference was −0.50 ( 95 % confidence interval −0.96 to −0.04 ) ; P=0.032 . A positive association was found between change in perceived personal responsibility and weight loss at 12 months ( β=0.12 ; P=0.008 ) . Conclusion A structured group education programme for patients with newly diagnosed type 2 diabetes result ed in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A1c levels up to 12 months after diagnosis . Trial registration Current Controlled Trials IS RCT N17844016 A total of 175 patients with Types 1 and 2 diabetes in primary care and university hospital outpatient departments were r and omized into a study group ( n = 101 ) or usual care ( n = 74 ) . The study group used an e-health application with a diabetes management system and a home care link . Usual care did not involve e-health , i.e. the patients made regular general practitioner visits about every three months . After 12 months HbA1c decreased significantly in both groups of patients . The differences were small , but HbA1c was significantly lower in the study group than the controls . Diastolic blood pressure , fasting plasma glucose , serum total cholesterol , serum LDL-cholesterol and serum triglycerides were significantly lower in the study than in the control group . This was achieved with fewer visits by study patients to doctors and nurses . Use of e-health in diabetes care for 12 months was able to provide equivalent diabetic control to usual care , and improved cardiovascular risk factors BACKGROUND Hypertension is a major risk factor for the long-term complications of diabetes . Mobile , self-measurement of blood pressure is emerging as a method to manage blood pressure in general , but its impact in patients with diabetes is unclear . METHODS We r and omized 137 patients with diabetes and hypertension to either  mobile telemonitoring  ( n = 72 ) or usual care ( n = 65 ) . Clinic blood pressure was recorded at baseline and after 6 months . Patients in the intervention arm transmitted weekly blood pressure readings wirelessly , using adapted sensors via mobile phones to a central server . Clinicians received the data in real-time and using a web-based application provided management advice to the patient and their physicians . RESULTS Systolic blood pressure fell significantly in the patients in the intervention group ( mean [ 95 % confidence interval ] , -6.5 [ -0.8 to -12.2 ] mm Hg ; P = 0.027 ) and remained unchanged in the control group ( 2.1 [ 9.3 to -5.0 ] mm Hg ; P = 0.57 ) . Patients within the intervention arm of African origin seemed to benefit more from the intervention . In addition , those who achieved a systolic blood pressure of < 120 mm Hg had lower average blood sugars than those with higher readings ( 7.8 [ SD 1.6 ] vs. 8.9 [ SD 2.2 ] mmol/L ; P = 0.02 ) . CONCLUSIONS In patients with diabetes , mobile telemonitoring has potential for delivering intensified care to improve blood pressure control , and its use may be associated with reduced exposure to hyperglycemia Background : The small-group Chronic Disease Self-Management Program ( CDSMP ) has proven effective in changing health-related behaviors and improving health statuses . An Internet-based CDSMP was developed to reach additional chronic-disease patients . Objectives : We sought to determine the efficacy of the Internet-based CDSMP . Design : We compared r and omized intervention participants with usual-care controls at 1 year . We compared intervention participants with the small-group CDSMP at 1 year . Subjects : Nine-hundred fifty-eight patients with chronic diseases ( heart , lung , or type 2 diabetes ) and Internet and e-mail access were r and omized to intervention ( 457 ) or usual care control ( 501 ) . Measures : Measures included 7 health status variables ( pain , shortness of breath , fatigue , illness intrusiveness , health distress , disability , and self-reported global health ) , 4 health behaviors ( aerobic exercise , stretching and strengthening exercise , practice of stress management , and communication with physicians ) , 3 utilization variables ( physician visits , emergency room visits , and nights in hospital ) , and self-efficacy . Results : At 1 year , the intervention group had significant improvements in health statuses compared with usual care control patients . The intervention group had similar results to the small-group  CDSMP participants . Change in self-efficacy at 6 months was found to be associated with better health status outcomes at 1 year . Conclusions : The Internet-based CDSMP proved effective in improving health statutes by 1 year and is a viable alternative to the small-group Chronic Disease Self Management Program We conducted a six-month prospect i ve interventional crossover study examining a computerized diabetes monitoring system ( DMS ) that conveyed dietary information . The objectives were to compare glycaemic control between intervention and control periods , and to assess patients ' acceptance of the DMS . Nineteen patients were r and omized into two groups , each using the DMS for three months and serving as the control group for another three months . The patients recorded information about their meal portions and blood glucose readings in a h and -held electronic diary . After transmitting the data to the DMS through a telephone modem , the patients received immediate feedback about the carbohydrate , protein and fat content of the meal , as well as the calorie content . A significant improvement in glycaemic control was achieved during intervention compared with control periods ( mean HbA1C reduction of 0.825 % ) . The DMS was also highly acceptable : 95 % patients found it easy to operate while 63 % found it useful . The DMS was thus a feasible model of telemedicine in diabetes care and a larger study is warranted to examine its cost-effectiveness BACKGROUND The emergence of the World Wide Web in the last decade has made it feasible for the Internet to be a vehicle for chronic disease management . METHODS A r and omized controlled trial ( n = 62 ) testing the effects of a 6-month web-based intervention plus usual care , compared with usual care alone , among adults 60 years of age and older with diabetes . The outcomes were hemoglobin A1c ( HbA1c ) , blood pressure , weight , cholesterol , and high-density lipoprotein ( HDL ) levels . RESULTS A multivariate analysis of covariance controlling for all baseline outcome variables , age , gender , and number of years with diabetes showed significant ( P = 0.001 ) reductions in HbA1c , weight , and cholesterol level and significant improvement in HDL levels in the intervention versus the control group . CONCLUSIONS Findings show a web-based intervention was effective in improving HbA1c , weight , cholesterol , and HDL levels at a 6-month follow-up . Future research is needed to investigate the long-term effectiveness of web-based interventions A mobile phone with a glucometer integrated into the battery pack ( the ‘ Diabetes Phone ’ ) was launched in Korea in 2003 . We compared its effect on management of type 2 diabetes to the Internet-based glucose monitoring system ( IBGMS ) , which had been studied previously . We conducted a r and omized trial involving 69 patients for three months . Participants were assigned to an Internet group or a phone group . The phone group communicated with medical staff through the mobile phone only . Their glucose-monitoring data were automatically transferred to individual , web-based charts and they received medical recommendations by short message service . The Internet group used the IBGMS . There were no significant differences between the groups at baseline . After three months ' intervention , HbA1c levels of both groups had decreased significantly , from 7.6 % to 6.9 % for the Internet group and from 8.3 % to 7.1 % for the phone group ( P < 0.01 ) . Levels of patient satisfaction and adherence to medical advice were similar . Mobile , bidirectional communication between doctors and patients using the diabetes phone was as effective for glucose control as the previously-studied Internet-based monitoring system and it was good for patient satisfaction and adherence OBJECTIVES There is an urgent need for more effective and efficient depression treatments in diabetes . We developed a diabetes-specific version of the Dutch web-based ' Coping with Depression ' ( CWD ) course . Here , we report on the development , reach , patients ' reasons for choosing our intervention and their characteristics . METHODS The CWD programme was amended for use in diabetes patients with co-morbid depression . Data were collected using a telephone interview , self-report question naires , and medical records . RESULTS Adding diabetes-specific topics to an effective web-based depression programme result ed in an 8-lesson intervention ( " www.diabetergestemd.nl " ) , with minimal guidance by coaches . In the framework of a r and omised trial , the intervention attracted serious interest of 540 patients . After screening , 255 depressed diabetes patients were enrolled . Less than half had a history of depression treatment ; 80 % reported the diabetes-specific approach to be an important reason for signing up . CONCLUSION We successfully developed a diabetes-specific version of the web-based CWD course , which attracted a large group of patients . Our results affirm the importance of addressing diabetes-specific issues in the context of depression treatment . PRACTICE IMPLICATION S Our intervention could be implemented on a large scale at low costs , and may serve as a model on how to develop other illness-specific online self-help interventions AIMS The rapidly increasing prevalence of chronic diseases is an important challenge to healthcare systems worldwide . To improve the quality and efficiency of chronic disease care , we investigated the effectiveness and applicability of the Ubiquitous Chronic Disease Care ( UCDC ) system using cellular phones and the internet for overweight patients with both Type 2 diabetes and hypertension . METHODS We conducted a r and omized , controlled clinical trial over 3 months that included 123 patients at a university hospital and a community public health centre . RESULTS After 12 weeks , there were significant improvements in HbA(1c ) in the intervention group ( 7.6 + /- 0.9 % to 7.1 + /- 0.8 % , P < 0.001 ) compared with the control group ( 7.4 + /- 0.9 % to 7.6 + /- 1.0 % , P = 0.03 ) . Furthermore , we observed a significant reduction in systolic and diastolic blood pressure , as well as improvements in total cholesterol , low-density lipoprotein-cholesterol and triglyceride levels in the intervention group . Furthermore , there was a significant increase in adiponectin levels in the intervention group compared with the control group , although high-sensitivity C-reactive protein and interleukin-6 levels did not change in either group . CONCLUSIONS The novel UCDC system presented in this paper improved multiple metabolic parameters simultaneously in overweight patients with both Type 2 diabetes and hypertension Objective To improve the analysis of  self-monitoring of blood glucose ( SMBG ) and its communication between patients and physicians by a telematic transmission of computerized SMBG and to study the consequences of its use on glucose control of insulin-dependent diabetic ( IDDM ) patients . Research Design and Methods A prospect i ve r and omized crossover trial with two 3-mo periods , one with SMBG recorded on traditional booklets ( booklet period ) and another with computerized SMBG transmitted to a central data base through a telematic network ( telematic period ) , comprised the study . During the latter phase , patients could receive computerized SMBG analysis on individual terminals connected to the telephone network ( Minitel system ) . Blood glucose recordings and HbA1c were measured at inclusion and end of each period . Eleven pairs of IDDM patients on intensified insulin therapy  were r and omized within each pair to start with the telematic period ( group A ) or the booklet period ( group B ) . Results Telematic transmissions were successful ( < 1 % failure rate ) . Although initial HbA1c was low ( 6.7 % ) , it declined during the telematic period ( Δ = -0.41 % ) compared with the booklet period ( Δ = + 0.37 % , P = 0.05 ) . The percentage of low ( < 3.3 mM ) blood glucose values correlated with HbA1c changes during the telematic period ( r = 0.714 , P= 0.0014 ) but not the booklet period . The patients favored the telematic tool to analyze SMBG . Conclusions Telematic transmission of SMBG is feasible . It can improve SMBG analysis and perhaps glucose control , therefore offering a new way of communication between diabetic patients and their physicians OBJECTIVE To evaluate the efficacy of the " Diabetes Diet Advisor"(PC-DR vision 1.0 ) " for type 2 diabetes . METHODS One hundred and fifty type 2 diabetic patients were divided in the 2 groups . The study group included 88 type 2 diabetic patients managed by " Diabetes Diet Advisor(PC-DR vision 1.0 ) " ;  the control group included 62 cases with a fixed carbohydrate content . All patients were followed up for 8 weeks . RESULTS After 8 weeks dietary therapy , the fasting blood glucose ( FBG ) , cholesterol ( TC ) , triglycerides ( TG ) , HDL-cholesterol ( HDL- C ) and body mass index ( BMI ) in study group were all significantly less than those in the control group ( P<0.05 ) . In the study group , the significant decrease were achieved in all indicates and FBG and 2hPBG decreased persistently . Twenty-five patients ( 28.41 % ) in study group and 6 patients ( 9.68 % ) in control group reduced their dosage of hypoglycemic agents or stopped drug therapy ( P=0.007 ) . CONCLUSION The software " Diabetes Diet Advisor ( PC-DR vision 1.0 ) " is a useful tool of dietary management for patients with type 2 diabetes OBJECTIVE There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care setting s. This report presents 12-month follow-up results from a computer-assisted , patient-centered intervention to improve the level of recommended services patients received from a variety of primary care setting s. RESEARCH DESIGN AND METHODS A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program . Physicians were stratified and r and omized to intervention or control conditions and evaluated on two primary outcomes : number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program ( PRP ) . Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale , lipid and HbA1c levels , and the Patient Health Question naire-9 depression scale . RESULTS The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition . There was overall improvement on secondary outcomes of lipids , HbA1c , quality of life , and depression scores ; between-condition differences were not significant . CONCLUSIONS Staff in small , mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care . Alternative explanations for why these process improvements did not lead to improved outcomes , and suggested directions for future research are discussed PURPOSE This study evaluated the cost-effectiveness of an automated telephone self-management support with nurse care management ( ATSM ) intervention for patients with type 2 diabetes , which was tested among patients receiving primary care in publicly funded ( safety net ) clinics , focusing on non-English speakers . METHODS We performed cost analyses in the context of a r and omized trial among primary care patients comparing the effects of ATSM ( n = 112 ) and usual care ( n = 114 ) on diabetes-related outcomes in 4 San Francisco safety net clinics .  ATSM uses interactive phone technology to provide surveillance , patient education , and one-on-one counseling , and was implemented in 3 language s for a 9-month period . Cost utility was examined using quality -adjusted life-years ( QALYs ) derived from changes in scores on the 12-Item Short Form Health Survey . We also examined cost-effectiveness for costs associated with a 10 % increase in the proportion of patients meeting diabetes-specific public health goals for increasing exercise , as recommended by Healthy People 2010 and the American Diabetes Association . RESULTS The annual cost of the ATSM intervention per QALY gained , relative to usual care , was $ 65,167 for start-up and ongoing implementation costs combined , and $ 32,333 for ongoing implementation costs alone . In sensitivity analyses , costs per QALY ranged from $ 29,402 to $ 72,407 . The per-patient cost to achieve a 10 % increase in the proportion of intervention patients meeting American Diabetes Association exercise guidelines was estimated to be $ 558 when all costs were considered and $ 277 when only ongoing costs were considered . CONCLUSIONS The ATSM intervention for diverse patients with diabetes had a cost utility for functional outcomes similar to that of many other accepted interventions targeted at diabetes prevention and treatment , and achieved public health physical activity objectives at modest costs . Because a considerable proportion of costs were fixed , cost-utility and cost-effectiveness estimates would likely be substantially improved in a scaled-up ATSM program This study aim ed to test the effects of providing Web-based diabetes education to individuals with type 2 diabetes on the A1c level and health check attendance .  The study participants comprised 122 individuals with type 2 diabetes , who had access to the Internet , had completed their basic diabetes education , and had similar basic situational factors . Using a r and omization method , these participants were chosen from the patients being monitored by the diabetes nurses . The experimental group ( n = 61 ) was monitored via the Web . From measurements recorded in the sixth month of monitoring , we found that A1c levels of the individuals with diabetes who were monitored through the Web decreased ( t = 6.63 ; P < .05 ) , and the rate of attending health check visits increased ( z = 5.97 ; P < .05 ) , while no difference was detected in the control group ( t = −0.63 ; P = .534 ; z = −0.80 ; P = .426 ) . To maintain glycemic control , Web use could be adopted as a complementary tool for monitoring individuals with diabetes RATIONALE , AIMS AND OBJECTIVES Utilizing information technology , such as Internet and cellphones , holds great promise in enhancing diabetic care . Yet few studies have examined the impact of cellphone technology on type 2 diabetics ' self-care . The primary aim of the study is to examine the feasibility of utilizing this technology to assist with diabetes self-care in a clinic population as well as its impact on clinical outcomes . METHODS Thirty patients with a diagnosis of type 2 diabetes at two Community Health Centers were r and omized to intervention or control . Intervention patients participated in a brief intervention and received tailored daily messages via cellphone prompting them to enhance their diabetic self-care behaviour .  Patients at the control site continued with their st and ard diabetes self-management .  RESULTS A mean improvement in HbA1c levels was apparent ( -0.1 , SD = 0.3 % ; P = 0.1534 ) in the intervention group , compared with a mean deterioration in the control ( 0.3 , SD = 1.0 % ; P = 0.3813 ) , yet without statistical significance . Self-efficacy scores improved significantly in the intervention group ( -0.5 , SD = 0.6 ; P = 0.0080 ) compared with no improvement in the control ( 0.0 , SD = 1.0 ; P = 0.9060 ) . Participants encountered numerous technological barriers when attempting to adhere to the intervention protocol . CONCLUSION The results indicate the intervention had a positive impact on some clinical outcome and self-efficacy . Although the technology appears feasible in a clinical setting technology must be made more user-friendly before a larger phase II trial is conducted PURPOSE To develop and evaluate a Web-based , patient-orientated diabetic education management ( POEM ) system . METHODS The POEM system has been developed to extend hospital patient education by integrating patients ' medical care data into their education program components and presenting them on the Web . Since most patients are concerned about their medical care data , the POEM system can provide the incentives for patients to continuously and persistently log in and learn the required knowledge and skills , improving their clinical outcomes . A quasi-experimental method that uses control groups and pretests was used to evaluate the outcomes of the system intervention . We recruited patients with type-2 diabetes and alternatively assigned them to intervention and control groups . We compared laboratory test results including fasting blood glucose , HbA1c , total cholesterol , triglyceride ( TG ) , and HDL between the two groups from the first visit through each follow-up visit . The study period progressed from September 2003 to May 2004 at the Metabolism Center of a medical teaching hospital in Taipei . RESULTS In this study , we recruited 274 participants : 134 ( 57 % males and 43 % females ) in the intervention group and 140 ( 46 % males and 54 % females ) in the control group . The patients ' laboratory test results from the first visit for fasting blood glucose , HbA1c , total cholesterol level , TG , and HDL in the intervention and control groups were respectively 187.54+/-77.10 and 189.99+/-73.49 mg/dl , 9.03 + /- 2.79 % and 8.95 + /- 2.23 % , 193.29 + /- 47.93 and 202.52 + /- 58.45 mg/dl , 152.48 + /- 70.85 and 157.37 + /- 74.88 mg/dl , and 44.97 + /- 12.09 and 45.32 + /- 12.08 mg/dl . There were three follow-up visits during the study period . We collected laboratory test results of the two groups through each of the following visits and analyzed them using ANCOVA . We discovered a significant difference in fasting blood glucose levels between intervention and control group as early as the first follow-up . At the second follow-up , both fasting blood glucose and HBA1c levels were significantly different between intervention and control group . At the third follow-up , there was a significant difference in fasting blood glucose , HBA1c , and total cholesterol between intervention and control group . We also monitored the number of logins for the patients in the intervention group during the follow-up period . The result showed the patients had consistently logged into the POEM system  ( about 8.5 + /- 3.7 logins per person per month after 3 months enrollment ) . Thus , the patients in the intervention group had better control of their fasting blood glucose , HbA1c and total cholesterol levels than those in the control group due to the assistance of the system . CONCLUSIONS The POEM system can help patients control their glucose , HbA1c and total cholesterol levels to manage their diabetes , providing an easy and inexpensive way to extend hospital-based patient education services for community-based continuous patient education BACKGROUND Increased emphasis is being placed on the critical need to control hypertension ( HTN ) in patients with diabetes . OBJECTIVE The objective of this study was to evaluate the efficacy of a nurse-managed home telehealth intervention to improve outcomes in veterans with comorbid diabetes and HTN . DESIGN A single-center , r and omized , controlled clinical trial design comparing two remote monitoring intensity levels and usual care in patients with type 2 diabetes and HTN being treated in primary care was used . MEASUREMENTS Primary outcomes were hemoglobin A1c and systolic blood pressure ( SBP ) ; secondary outcome was adherence . RESULTS Intervention subjects experienced decreased A1c during the 6-month intervention period compared with the control group , but 6 months after the intervention was withdrawn , the intervention groups were comparable with the control group . For SBP , the high-intensity subjects had a significant decrease in SBP compared with the other groups at 6 months and this pattern was maintained at 12 months . Adherence improved over time for all groups , but there were no differences among the three groups . LIMITATIONS Subjects had relatively good baseline control for A1c and SBP ; minorities and women were underrepresented . CONCLUSIONS Home telehealth provides an innovative and pragmatic approach to enhance earlier detection of key clinical symptoms requiring intervention . Transmission of education and advice to the patient on an ongoing basis with close surveillance by nurses can improve clinical outcomes in patients with comorbid chronic illness Objective We developed a wallet-sized learning memory decision support system that helps patients with insulin-dependent diabetes mellitus adjust their insulin dosages . Research Design and Methods To determine the efficacy of the support system , we design ed a r and omized clinical trial with patients participating in a program in a diabetes education center . Patients were assigned to two groups of 21 patients each . All patients performed self-monitoring of blood glucose ( SMBG ) and were treated with multiple daily injections of insulin . Each of the patients was examined over a 32-day period . The basic educational program , i.e. , practical advice in SMBG , diet , and exercise under homelike conditions , was identical in both groups . The only difference was that the first group used the computer for adjusting the insulin dose , whereas the second group received recommendations from the education team . Results The baseline HbA1 levels ( 9.8 ± 1.6 vs. 9.9 ± 1.6 % ) of both groups did not differ significantly . Mean blood glucose over the last 2 wk of the study was higher ( P < 0.01 ) in the second group ( 8.4 ± 1.4 vs. 9.2 ± 2.0 mM ) ; the frequencies of hypoglycemic episodes were not different ( 1.7 vs. 2.3 % ) . Conclusions Metabolic control and safety were comparable in both groups . Thus , patients may benefit from such a system at home where no support by diabetes educators is available This study was performed to investigate the effect of a telephone-delivered intervention on glycemic control and body mass index in Korean type 2 diabetic patients . 38 patients were r and omly selected , with 20 assigned to a telephone group and 18 to a control group . The goal of the intervention was to keep blood glucose concentrations close to the normal range . The intervention was applied to the telephone group for 12 weeks . It consisted of continuous education and reinforcement of diet , exercise and medication adjustment , as well as frequent self-monitoring of blood glucose levels . Telephone intervention was performed twice per week for the first month , and then weekly for the second and third months . Subjects were requested to write self- management logs , including blood glucose , diet and an exercise diary . The  diet diaries  were analyzed by a dietitian , and subjects instructed about the results by telephone counseling or mail . All medication adjustments were communicated to the subjects ' diabetes specialist . Glycosylated hemoglobin ( HbA1c ) , fasting blood glucose ( FBG ) and 2-hour postpr and ial glucose were measured before , and after , the intervention . Patients in the telephone group had a mean decrease of 1.2 % , with those in the control group having a mean increase of 0.6 % , in HbA1c . There were no significant differences in the body mass index ( BMI ) between the two groups . These findings indicated that a telephone-delivered intervention would improve HbA1c , but would not affect BMI Objectives .To assess the 1- and 2-year health status , health care utilization and self-efficacy outcomes for the Chronic Disease Self-Management Program ( CDSMP ) . The major hypothesis is that during the 2-year period CDSMP participants will experience improvements or less deterioration than expected in health status and reductions in health care utilization . Design .Longitudinal design as follow-up to a r and omized trial . Setting .Community . Participants .Eight hundred thirty-one participants 40 years and older with heart disease , lung disease , stroke , or arthritis participated in the  CDSMP . At 1- and 2-year intervals respectively 82 % and 76 % of eligible participants completed data . Main Outcome Measures . Health status ( self-rated health , disability , social/role activities limitations , energy/fatigue , and health distress ) , health care utilization ( ER/outpatient visits , times hospitalized , and days in hospital ) , and perceived self-efficacy were measured . Main Results . Compared with baseline for each of the 2 years , ER/outpatient visits and health distress were reduced ( P < 0.05 ) . Self-efficacy improved ( P < 0.05 ) . The rate of increase is that which is expected in 1 year . There were no other significant changes . Conclusions .A low-cost program for promoting health self-management can improve elements of health status while reducing health care costs in population s with diverse chronic diseases Summary Alimentary lipemia was studied in 12 healthy young men with and without exercise .  Three sets of experiments were performed . While continuous exercise of 90 min duration significantly reduced postpr and ial triglycerides by 26 % ( study I ) , this effect could not be observed when exercise was interrupted for 5 min after each 25 min ( study II ) . Plasma free fatty acid concentrations , in the latter experiment , were significantly higher ( by 311 % ) than during rest . When , in a third experiment continuous exercise was compared with intermittent physical activity , the latter condition significantly increased postpr and ial triglyceridemia , most probably due to precipitous rises of free fatty acids on each interruption of ergometry . It is concluded that in the third experiment the balance between triglyceride removal and triglyceride synthesis was shifted toward the latter . Whether exercise lowers , leaves unaltered , or raises plasma triglyceride levels may depend on subtle changes of experimental design There is a pressing need for brief , practical interventions that address diabetes management . We have developed an office-based intervention to prompt both patients and providers to focus on behavioral issues relevant to dietary self-management that is being evaluated in a r and omized trial . The intervention is design ed to be broadly applicable to the majority of adult diabetes out patients during medical visits ; uses touchscreen computer assessment to provide immediate feedback on key issues to patients and providers just prior to their interaction ; and provides goal setting and problem-solving assistance to patients following their meeting with the physician . Follow-up components include phone calls and videotape or interactive video instruction as needed . The program is described , and demographic and behavioral characteristics of participants are presented for the first 95 patients r and omized . Initial process results suggest success in producing modest , targeted behavior changes among a broad cross-section of patients . If the long-term results are equally positive , this intervention could provide a prototype for a feasible , cost-effective way to integrate patient views and behavioral management into office-based care for diabetes Objective - To study the possibility of using the computerised journal for quality improvement in diabetes care . Design - The computerised journal was used to reach all diabetic smokers aged 30 -75 years and to invite them to a structured smoking cessation programme . The follow-up time was 18 months . Setting - Habo , a Swedish community with 9600 inhabitants , with one primary health care centre . Subjects - 147 subjects , aged 30 - 75 years , were registered with the diagnosis of diabetes mellitus in the computerised journal at the primary health care centre . Altogether 25 of these patients were registered as smokers in the journal . All of them were invited to a smoking cessation group . Results - Information about smoking habits in the journal was available for all but 11 % . After 18 months ' follow-up , 9 of the 14 patients ( 64 % ) who started in the smoking cessation group had become non-smokers . Of those 11 subjects who did not attend the group , 6 had stopped smoking during the follow-up time in spite of not participating in the structured programme . Conclusion ? The computerised journal is a useful tool for quality improvement , giving the opportunity for directed preventive efforts on selected patient groups OBJECTIVE A trial was performed to establish whether our group care model for lifestyle intervention in type 2 diabetes can be exported to other clinics . RESEARCH DESIGN AND METHODS This study was a 4-year , two-armed , multicenter controlled trial in 13 hospital-based diabetes clinics in Italy ( current controlled trials no. IS RCT N19509463 ) . A total of 815 non – insulin-treated patients aged < 80 years with ≥1 year known diabetes duration were r and omized to either group or individual care . RESULTS After 4 years , patients in group care had lower A1C , total cholesterol , LDL cholesterol , triglycerides , systolic and diastolic blood pressure , BMI , and serum creatinine and higher HDL cholesterol ( P < 0.001 , for all ) than control subjects receiving individual care , despite similar pharmacological prescriptions . Health behaviors , quality of life , and knowledge of diabetes had become better in group care patients than in control subjects ( P < 0.001 , for all ) . CONCLUSIONS The favorable clinical , cognitive , and psychological outcomes of group care can be reproduced in different clinical setting BACKGROUND Cardiovascular morbidity is a major burden in patients with type 2 diabetes . In the Steno-2 Study , we compared the effect of a targeted , intensified , multifactorial intervention with that of conventional treatment on modifiable risk factors for cardiovascular disease in patients with type 2 diabetes and microalbuminuria . METHODS The primary end point of this open , parallel trial was a composite of death from cardiovascular causes , nonfatal myocardial infa rct ion , nonfatal stroke , revascularization , and amputation .  Eighty patients were r and omly assigned to receive conventional treatment in accordance with national guidelines and 80 to receive intensive treatment , with a stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia , hypertension , dyslipidemia , and microalbuminuria , along with secondary prevention of cardiovascular disease with aspirin . RESULTS The mean age of the patients was 55.1 years , and the mean follow-up was 7.8 years . The decline in glycosylated hemoglobin values , systolic and diastolic blood pressure , serum cholesterol and triglyceride levels measured after an overnight fast , and urinary albumin excretion rate were all significantly greater in the intensive-therapy group than in the conventional-therapy group . Patients receiving intensive therapy also had a significantly lower risk of cardiovascular disease ( hazard ratio , 0.47 ; 95 percent confidence interval , 0.24 to 0.73 ) , nephropathy ( hazard ratio , 0.39 ; 95 percent confidence interval , 0.17 to 0.87 ) , retinopathy ( hazard ratio , 0.42 ; 95 percent confidence interval , 0.21 to 0.86 ) , and autonomic neuropathy ( hazard ratio , 0.37 ; 95 percent confidence interval , 0.18 to 0.79 ) . CONCLUSIONS A target-driven , long-term , intensified intervention aim ed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50 percent Background Despite evidence that optimal care for diabetes can result in reduced complications and improved economic outcomes , such care is often not achieved . The Vermont Diabetes Information System ( VDIS ) is a registry-based decision support and reminder system based on the Chronic Care Model and targeted to primary care physicians and their patients with diabetes . Purpose To develop and evaluate a regional decision support system for patients with diabetes . Methods R and omized trial of an information system with clustering at the practice level . Ten percent r and om sub sample of patients selected for a home interview . Subject and setting includes 10 hospitals , 121 primary care providers , and 7348 patients in 55 Vermont and New York primary care practice s. Results We report on the study design and baseline characteristics of the population . Patients have a mean age of 63 years and a mean glycosolated hemoglobin A1C of 7.1 % . Sixty percent of the population has excellent glycemic control ( A1C , 7 % ) ; 45 % have excellent lipid control ( serum LDL-cholesterol,100 mg /dL and serum triglycerides,400 mg/dL ) . Twenty-five percent have excellent blood pressure control ( , 130/80 mm Hg ) . These results compare favorably to recent national reports . However , only 8 % are in optimal control for all three of hyperglycemia , lipids and blood pressure . Conclusions Our experience to date indicates that a low cost decision support and information system based on the Chronic Care Model is feasible in primary care practice s that lack sophisticated electronic information systems . VDIS is well accepted by patients , providers and laboratory staff . If proven beneficial in a rigorous , r and omized , controlled evaluation , the intervention could be widely disseminated to practice s across America and the world with a substantial impact on the outcomes and costs of diabetes . It could also be adapted to other chronic conditions . We anticipate the results of the study will be available in 2006 BACKGROUND Aggressive management of blood glucose reduces future diabetes-related complications , but this is difficult to achieve . METHODS This r and omized , controlled study tested the effect of using a wireless two-way pager-based automated messaging system to improve diabetes control through facilitated self-management . The system sent health-related messages to patients , with automatic forwarding of urgent patient responses to the health care team . RESULTS Participants in both the experimental ( pager ) and the control groups experienced an average hemoglobin A1c decrease of 0.1 - 0.3 % . More patients in the pager group were  normotensive  , and more felt that their health care was better by the end of the study . A total of 79 % of participants enjoyed using the pager , and 68 % wanted to continue using the system . CONCLUSIONS Utilizing a wireless , automated messaging system in clinical practice is a feasible , low-cost , interactive way to facilitate diabetes self-management , which is acceptable to patients . While providing a convenient way for patients and providers to communicate , this system can support automated recording and ready retrieval of these real-time interactions BACKGROUND We design ed a system for diabetes patients treated with glargine , a long-acting insulin  , to make an automatic adjustment of insulin dose based on glucose level data and to provide the patients with the needed insulin dose by using a short message service ( SMS ) . We also compared diabetes patients who used our system with patients who received the conventional titration scheme .  METHODS Included were 100 type 2 diabetes patients whose blood glucose was suboptimally controlled on their previous antidiabetes treatment . Each participant was assigned to either the intervention or control group , each with 50 patients , using adaptive r and omization . We applied our system to the intervention group for 12 weeks , whereas the control group received a conventional titration scheme , seeking a target fasting blood glucose of < 120 mg/dL. RESULTS The fasting and postpr and ial glucose levels of the intervention group declined earlier than those of the control group . Lastly , a greater ( P = 0.023 ) reduction in hemoglobin A(1C ) from baseline to the end point was observed in the intervention group ( from 9.8 + /- 1.3 % to 7.4 + /- 0.7 % ) than in the control group ( from 9.8 + /- 1.2 % to 7.8 + /- 0.8 % ) . The incidence of symptomatic , asymptomatic , and nocturnal hypoglycemia was similar in both groups . There was a small increase in body weight from baseline to the end point with both the intervention ( 2.4 + /- 3.0 kg ) and control ( 2.2 + /- 2.8 kg ) groups . CONCLUSIONS This study demonstrated that SMS based on our specialized Internet-supported system is an effective and safe approach to long-acting insulin dose adjustments in patients with type 2 diabetes This study applied a 6-month educational intervention that used the technology of the short message service ( via cellular phones ) and the Internet for obese patients with type 2 diabetes . Eighteen patients were r and omly assigned to an intervention group and 16 were assigned to a control group ( N = 34 ) . Patients in the intervention group were asked to access a web site by using personal cellular phones or computer Internet services to input their blood glucose levels daily . Participants were then sent optimal recommendations via cellular phone and the Internet weekly . After 6 months , the intervention group had a statistically significant decrease in glycosylated hemoglobin , fasting plasma glucose , 2-hour postmeal glucose , and total cholesterol , as compared with the control group Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness . We conducted a r and omized controlled trial comparing telemedicine case management to usual care , with blinding of those obtaining outcome data , in 1,665 Medicare recipients with diabetes , aged 55 years or greater , and living in federally design ated medically underserved areas of New York State . In New York City , 98 % of participants were black or Hispanic , 69 % were Medicaid-eligible , and 93 % reported annual household income < or = $ 20,000 . In upstate New York , 91 % were white , 14 % Medicaid eligible , and 50 % reported annual household income < or = $ 20,000 . A baseline survey found that 95 % of participants in New York City and 67 % in upstate New York reported that they did not know how to use a computer . The primary endpoints were HgbA1c , blood pressure , and low density lipoprotein ( LDL ) cholesterol levels . In the intervention group ( N = 844 ) , mean HgbA1c improved over 1 year from 7.35 % to 6.97 % , and from 8.35 % to 7.42 % in the subgroup with baseline HgbA1c > or = 7 % ( N = 353 ) . In the usual care group ( N = 821 ) , mean HgbA1c improved over 1 year from 7.42 % to 7.17 % . Adjusted net reductions ( 1-year minus baseline mean values in each group , compared between groups ) favoring the intervention were as follows : HgbA1c , 0.18 % ( p = 0.006 ) , systolic and diastolic blood pressure , 3.4 ( p = 0.001 ) and 1.9 mmHg ( p < 0.001 ) , and LDL cholesterol , 9.5 mg/dl ( p < 0.001 ) . In the subgroup with baseline HgbA1c > or = 7 % , net adjusted reduction in HgbA1c favoring the intervention group was 0.32 % ( p = 0.002 ) . Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dl . The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York . A satisfaction survey of intervention group participants ( N = 346 respondents ) showed high levels of satisfaction with major intervention components . A satisfaction survey of participating primary care physicians ( N = 116 respondents ) showed positive perceptions for acceptability , impact on patients and communication .  Telemedicine case management  improved glycemic control , blood pressure levels , and total and LDL-cholesterol levels at 1 year of follow-up . Telemedicine is an effective method for translating modern approaches to disease management into effective care for underserved population The aim of this study was to determine whether home telehealth , when integrated with the health facility 's electronic medical record system , reduces healthcare costs and improves quality -of-life outcomes relative to usual home healthcare services for elderly high re source users with complex co-morbidities . Study patients were identified through the medical center 's data base . Intervention patients received home telehealth units that used st and ard phone lines to communicate with the hospital . FDA -approved peripheral devices monitored vital signs and valid question naires were used to evaluate quality -of-life outcomes . Out-of-range data triggered electronic alerts to nurse case managers . ( No live video or audio was incorporated in either direction . ) Templated progress notes facilitated seamless data entry into the patient 's electronic medical record . Participants ( n = 104 ) with complex heart failure , chronic lung disease , and /or diabetes mellitus were r and omly assigned to an intervention or control group for 6 - 12 months . Parametric and nonparametric analyses were performed to compare outcomes for ( 1 ) subjective and objective quality -of-life measures , ( 2 ) health re source use , and ( 3 ) costs . In contrast to the control group , scores for home telehealth subjects showed a statistically significant decrease at 6 months for bed-days-of-care ( p < 0.0001 ) , urgent clinic/emergency room visits ( p = 0.023 ) , and A1C levels ( p < 0.0001 ) ; at 12 months for cognitive status ( p < 0.028 ) ; and at 3 months for patient satisfaction ( p < 0.001 ) . Functional levels and patient-rated health status did not show a significant difference for either group . Integrating home telehealth with the healthcare institution 's electronic data base significantly reduces re source use and improves cognitive status , treatment compliance , and stability of chronic disease for homebound elderly with common complex co-morbidities In two consecutive studies the clinical application and suitability of two computer-assisted data management systems ( Camit and Cadmo ) were evaluated in a prospect i ve manner . In each study nineteen long-st and ing , stable insulin-dependent patients were r and omly assigned to one of two groups . In study I assessment of metabolic control and insulin dose adjustments were based either on the Camit S1 data analysis or on the conventional log-book method , whereas in study II the Camit S2 and the Cadmo simulation programs were evaluated . HbA1c values decreased significantly in both studies ( p < 0.05 ) . A clear decline in hypoglycemic events as well as a significant reduction of the percentage of glucose values below 4.0 mmol/l ( p < 0.005 ) and a marked increase ( p < 0.05 ) in the percentage of glucose levels in the target range ( 4.0 - 10.0 mmol/l ) were observed . We found both computerized assessment systems to be reliable and suitable for the assessment of blood glucose control and for insulin dose finding . The graphical and statistical presentation of the numerous glucose and insulin data allowed a better summary of blood glucose control and metabolic trends . More time could be spent for problem solving , which proved to be much less exhausting with the computer for the attending physician . Further studies should address the educational potential of computerized systems for the patient as well as for the physician BACKGROUND Less than 63 % of individuals with diabetes meet professional guidelines target of hemoglobin A1c < 7.0 % , and only 7 % meet combined glycemic , lipid , and blood pressure goals . The primary study aim was to assess the impact on A1c of a cell phone-based diabetes management software system used with web-based data analytics and therapy optimization tools . Secondary aims examined health care provider ( HCP ) adherence to prescribing guidelines and assessed HCPs ' adoption of the technology . METHODS Thirty patients with type 2 diabetes were recruited from three community physician practice s for a 3-month study and evenly r and omized . The intervention group received cell phone-based software design ed by endocrinologists and CDEs ( WellDoc Communications , Inc. , Baltimore , MD ) . The software provided real-time feedback on patients ' blood glucose levels , displayed patients ' medication regimens , incorporated hypo- and hyperglycemia treatment algorithms , and requested additional data needed to evaluate diabetes management . Patient data captured and transferred to secure servers were analyzed by proprietary statistical algorithms . The system sent computer-generated logbooks ( with suggested treatment plans ) to intervention patients ' HCPs . RESULTS The average decrease in A1c for intervention patients was 2.03 % , compared to 0.68 % ( P < 0.02 , one-tailed ) for control patients . Of the intervention patients , 84 % had medications titrated or changed by their HCP compared to controls ( 23 % , P = 0.002 ) . Intervention patients ' HCPs reported the system facilitated treatment decisions , provided organized data , and reduced logbook review time . CONCLUSIONS Adults with type 2 diabetes using WellDoc 's software achieved statistically significant improvements in A1c . HCP and patient satisfaction with the system was clinical ly and statistically significant OBJECTIVES To evaluate the use of automated systems to prompt patients with diabetes mellitus to obtain overdue laboratory tests for its effectiveness in promoting test compliance and to compare letters , telephone messages , and combinations . STUDY DESIGN R and omized controlled trial . METHODS All subjects ( N = 13,057 ) were adult members of Southern California Kaiser Permanente with diabetes and with no record of glycosylated hemoglobin , low-density lipoprotein cholesterol , and urinary microalbumin tests in more than 1 year . The effectiveness of automated telephone calls and letters was compared versus a no-contact control group using the following 5 intervention groups : letter , call , letter that is followed by a call 4 weeks later , call that is followed by a letter 4 weeks later , and letter-call-letter combination . Messages were in English and in Spanish . Adherence to all testing was compared at 8 weeks and 12 weeks after initial contact using chi(2 ) test and logistic regression analysis . RESULTS The proportions of each study group compliant with all tests were 18 % to 19 % among controls , 21 % for a letter or a call , 25 % for a letter-call or call-letter , and 26 % for a letter-call-letter ; letter-call and call-letter were significantly different versus controls ( P < .001 ) , and letter-call-letter was not significantly different versus letter-call .  Older age was associated with compliance ( P < .001 ) . CONCLUSIONS The pairing of automated letters and telephone calls in any order was more effective than any single intervention in promoting compliance with diabetes monitoring tests . The relative cost of the letter-call and call-letter approaches to outreach should be considered to determine which is preferred in any given situation The thesis that an integrated telecommunications/reporting system would affect diabetic prognosis was tested . Over fifteen months a double crossover study compared traditional diaries versus graphical display of telecommunicated blood glucose data . Significant drops in glycohemoglobin were observed in both groups during the telecommunications period , while no significant drops were observed in the groups while diaries were employed ABSTRACT OBJECTIVE To compare physiological outcomes and satisfaction for followup care between an interactive diabetes internet program and Diabetes Education Centres . METHOD A r and omized , controlled trial with outcomes of glycosylated hemoglobin ( A1C ) , fasting blood glucose , total cholesterol , triglycerides ( TG ) , high-density lipoprotein cholesterol , lowdensity lipoprotein cholesterol and patient satisfaction . Enrollment was staggered , with individuals assessed at baseline , 3 , 6 and 12 months . RESULTS Fifty-seven participants completed the study ( 20 control , 37 internet ) . Physiological outcomes were not statistically different between the 2 groups . However , within-group comparisons demonstrated a significant improvement in the internet group 's A1C , TG and satisfaction levels from baseline to 3 and 6 months ( p<0.0452 , p<0.0428 and p<0.0138 , respectively ) . CONCLUSION Although the trial was limited in sample size , it yielded significant findings for diabetes management , within group . Further research in using the internet program in other applications for diabetes management is needed A r and omized controlled trial was conducted to evaluate the impact of an automated telephone intervention on glycemic control in patients with type 2 diabetes . One hundred twenty participants were r and omly assigned to a treatment group that received a daily , automated telephone message regarding diabetes or to a control group that received usual care . The treatment group demonstrated a significant improvement in the frequency of self-monitoring of blood glucose levels compared with the control group ( P < .001 ) . A favorable trend in positive attitudes toward diabetes and a reduction in perceived monitoring and exercise barriers were seen in the intervention group compared with the control group BACKGROUND Control of serum glucose levels is essential for the reduction of complications of diabetes . Telemedicine is one strategy through which serum glucose control can be improved . METHODS A total of 35 adult , insulin-treated patients with diabetes ( type 1 and type 2 ) were enrolled in the present study ( 63.0 + /- 10 years of age , 63 % female ) and r and omized to telemedicine monitoring ( including cordless , remote glucose monitor , and transmitter , n =  17  ) , or conventional follow-up ( n = 18 ) . Metabolic parameters were evaluated , and a quality of life question naire was administered both pre- and post-treatment . RESULTS Groups were similar at baseline in terms of demographic , quality of life , and metabolic parameters . Significant differences in post-treatment metabolic parameters were not observed , although serum glucose was marginally elevated in the control group compared to the telemedicine group ( 214 + /- 65 mg/dL vs. 171 + /- 77 mg/dL , P = 0.09 ) . On the other h and , being clinical ly symptom-free ( 71 % vs. 11 % , P = 0.003 ) , having no hypoglycemic events ( 82 % vs. 17 % , P = 0.0001 ) , and having no hyperglycemic events ( 65 % vs. 17 % , P = 0.004 ) were all significantly more frequently reported in the telemedicine group compared to the control group . Compared to the control group , the telemedicine group reported experiencing significantly less anxiety , treatment difficulty , depression , disease-associated life complications , and feelings of impotence or ineptitude and significantly greater improvement in personal control over glucose , weight , and overall diabetes . CONCLUSIONS Though post-treatment metabolic differences were not observed between treatment groups , the telemedicine group reported significantly greater post-treatment experiences of improved quality of life and sense of control over the disease . Thus patient satisfaction can be enhanced through the use of telemedicine BACKGROUND The aim of this study is to evaluate the effect of a web-based comprehensive information system , consisting of Internet and cellular phone use , on blood glucose control . METHODS We established eMOD ( electronic Management of Diabetes ) , a web-based ubiquitous information system , for cell phone users along with a website for Internet users to provide diabetes education . We examined whether this information system has the same impact on glycemic control as conventional education for the diabetes patient . Forty volunteers were enrolled and r and omly assigned to either the eMOD experimental group ( n = 20 ) or the control group ( n = 20 ) .  Blood glucose and glycated hemoglobin ( A1C ) levels were evaluated at baseline and after 6 months . RESULTS The two groups were homogeneous in terms of age , sex , and diabetes ' duration at baseline . A1C ( from 9.0 + /- 2.3 % to 7.5 + /- 1.4 % , P = 0.031 ) and postpr and ial glucose level ( 228.1 + /- 79.7 to 173.5 + /- 50.2 mg/dL , P = 0.030 ) were significantly decreased over time in the intervention group but not in the control group . There was a significant relationship between the change in A1C and the frequency of access to the eMOD system via cellular phone ( r = 0.766 , P = 0.03 ; coefficient -0.147 ) . CONCLUSIONS A1C was improved by a web-based intervention not only via computer but also via cellular phone at 6 months post-initiation in patients with type 2 diabetes . These results indicate that the use of a convenient web-based education system could be more effective for glycemic control than traditional education for diabetes patients Summary Telephone reminder systems have been used to assist in the treatment of many chronic diseases . However , it is unclear if these systems can increase medication and appointment adherence in patients with diabetes without direct patient – provider telephone contact . We tested the feasibility of using an automated telephone reminder system ( ATRS ) to deliver reminder messages to 253 adults with diabetes enrolled in a r and omized controlled trial . Eighty-four percent of the patients were able to register using voice recognition and at least one reminder was delivered to 95 % of registered patients over a period of 7.5 months . None of the demographic features studied predicted a patient 's ability to enrol or to receive reminder calls . At the end of the study , 63 % of patients indicated that they wished to continue to receive ATRS calls . The level of system use as determined by the number of received reminder calls was not associated with a change in the number of physician visits or diabetes-related laboratory tests during follow-up . The clinical benefits and sustainability of ATRS remain unproven , but our results indicate that an automated reminder system can be effective for providing messages to a large group of older patients with diabetes
target: There were three reported  deaths out of 3578 participants .Computer-based  diabetes self-management interventions currently have limited effectiveness .
  Current interventions do not show adequate evidence for improving depression , health-related quality of life or weight .
  AUTHORS ' CONCLUSIONS Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup .
  There is no evidence to show benefits in other biological outcomes or any cognitive , behavioural or emotional outcomes
background: BACKGROUND Diabetes is one of the commonest chronic medical conditions , affecting around 347 million adults worldwide .
  Structured patient education programmes reduce the risk of diabetes-related complications four-fold .
  Internet-based self-management programmes have been shown to be effective for a number of long-term conditions , but it is unclear what are the essential or effective components of such programmes .
  If computer-based self-management interventions improve outcomes in type 2 diabetes , they could potentially provide a cost-effective option for reducing the burdens placed on patients and healthcare systems by this long-term condition .
  OBJECTIVES To assess the effects on health status and health-related quality of life of computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus .