Successful management of diabetes requires frequent appointments with healthcare professionals, many of which take place in hospital outpatient departments. Trips to hospital can be both burdensome and expensive for patients. Several studies have investigated the feasibility and effectiveness of videoconferencing for remote provision of diabetes care, but most have focused on behavioural therapy interventions such as diabetes education, self-management training, and nutrition consultations which are commonly provided by non-physician health professionals. A few clinical trials have reported the clinical outcome of videoconferencing for diabetes care, but no study has been reported on the reliability of video consultation for diabetes specialised care.
The aim of this research was to evaluate the reliability of videoconferencing for clinical management of diabetes. Three preliminary studies were conducted to inform the design of a randomised controlled trial. In the first study, the process of care, delivered by endocrinologists during conventional consultations in a diabetes outpatient clinic was analysed. This study showed that physical examination was not performed in 34% of in-person consultations. The endocrinologists reported that in 86% of the cases, it would be possible to safely provide the same consultation remotely via videoconferencing if the patient was accompanied by a general practitioner at the remote site. This could save the patients cost and inconvenience of long trips.
In the second study, the process of consultations provided remotely by endocrinologists via videoconference was analysed. This study was conducted in the tele-endocrinology clinic of a tertiary teaching hospital in Brisbane, which provides specialty consultations remotely to the patients living up to 1800 km away. Fifty six video consultations during a 5-month period were analysed. A nurse accompanied the patients at the remote site in 66% of the consultations, and in 18% of these cases, the endocrinologists requested the nurse to perform a physical examination. The most frequent recommendations were requesting lab tests (75%), adjustment of insulin dose (39%) and referring to an allied health professional (13%). Of these 56 consultations, the endocrinologists requested an in-person visit for three patients.
In the third study in the same tele-endocrinology clinic, a questionnaire for assessing the level of patient satisfaction with video consultation was developed. It comprised 15 multiple choice items exploring four dimensions: equipment/technical issues, communication and rapport, clinical assessment, and program evaluation. This questionnaire was then used to assess the satisfaction of the patients living in rural areas of Queensland who had been remotely consulted by two endocrinologists via videoconferencing. In Autumn 2013 the questionnaire was sent by mail to 62 patients and 39% were completed and returned. The 'communications and rapport' dimension received the highest satisfaction rate and the 'clinical assessment' the lowest. The item with highest satisfaction rate was 'video quality' and the least satisfaction rate was reported for 'physical contact'.
Based on the findings of the three preliminary studies, a non-inferiority randomised controlled trial was designed to evaluate the reliability of videoconferencing for remote consultation of people with diabetes who needed to see an endocrinologist in an outpatient clinic. This trial was conducted in the outpatient diabetes clinic of a tertiary teaching hospital in Brisbane. 75 participants were recruited from October 2012 to July 2013. The participants were randomly allocated into a telemedicine group or reference group. Each participant in the telemedicine group received two consultations: one in-person consultation and one video consultation. In the reference group the participants had two in-person (face-to-face) consultations. The paired consultations for each participant were provided by two different endocrinologists. To evaluate the reliability of the video consultation, the level of agreement between endocrinologists in the telemedicine group was calculated by comparing their recommendations on medication changes. In order to be able to assess the impact of videoconferencing on the level of agreement between endocrinologists, similar measures were also calculated in the reference group where two endocrinologists consulted the participants in-person. The findings of this study showed that the level of agreement between two endocrinologists on changing anti-diabetes drugs was 64% in telemedicine group and 78% in the reference group. Although the level of agreement was lower when one of the consultations was via videoconference, the difference was neither statistically, nor clinically significant. The level of agreement on changing cardiovascular drugs was 78% in the telemedicine group and 76% in the reference group, again not significantly different. This first rigorous trial of the reliability of videoconferencing for diabetes remote consultation produced evidence that the technique is acceptable for the patients who need specialist consultation with an endocrinologist.