Trust and Uncertainty in the Implementation of a Pilot Remote Blood Pressure Monitoring Program in Primary Care: Qualitative Study of Patient and Health Care Professional Views.

BACKGROUND: Trust is of fundamental importance to the adoption of technologies in health care. The increasing use of telemedicine worldwide makes it important to consider user views and experiences. In particular, we ask how the mediation of a technological platform alters the trust relationship between patient and health care provider. OBJECTIVE: To date, few qualitative studies have focused on trust in the use of remote health care technologies. This study examined the perspectives of patients and clinical staff who participated in a remote blood pressure monitoring program, focusing on their experiences of trust and uncertainty in the use of technology and how this telehealth intervention may have affected the patient-provider relationship. METHODS: A secondary qualitative analysis using inductive thematic analysis was conducted on interview data from 13 patients and 8 staff members who participated in a remote blood pressure monitoring program to elicit themes related to trust. RESULTS: In total, 4 themes were elicited that showed increased trust (patients felt reassured, patients trusted the telehealth program, staff felt that the data were trustworthy, and a better patient-provider partnership based on the mutually trusted data), and 4 themes were elicited that reflected decreased trust (patients' distrust of technology, clinicians' concerns about the limitations of technologically mediated interactions, experiences of uncertainty, and institutional risk). CONCLUSIONS: Managing trust relationships plays an important role in the successful implementation of telemedicine. Ensuring that trust building is incorporated in the design of telehealth interventions can contribute to improved effectiveness and quality of care.

Association of diabetes treatment with long-term glycemic patterns in patients with type 2 diabetes mellitus: A prospective cohort study.

AIM: This study aimed to analyze diabetes treatment and treatment changes in association with long-term glycemic patterns in an Asian population with diabetes. MATERIALS AND METHODS: This was a prospective cohort study of 6218 patients with type 2 diabetes managed in public primary care clinics in Singapore. Clinical data from 2011 to 2016 were extracted from electronic medical records, including serial HbA1c measurements and dispensed antidiabetic medication records. Patterns of longitudinal HbA1c trajectories were identified using latent class growth analysis, and patients' annual treatment plans were compared between subgroups with different HbA1c patterns. RESULTS: We identified four distinct HbA1c patterns. Eighty-one percent of patients were classified in the low-stable group, where monotherapy and dual therapy with oral agents were the most common treatments. We also identified three groups with poorer control, with moderate-stable (14%), moderate-increase (3%), and high-decrease (2%) HbA1c patterns. Insulin treatment was most prevalent in these groups, with 61% to 72% of subjects receiving insulin treatment in 2016. More than 60% of subjects in poorer control groups had experienced treatment intensification during follow-up. Addition of multiple insulin injections was the most common intensification in moderate-increase and high-decrease groups. CONCLUSIONS: Treatment reflected and was appropriate to the extent of dysglycemia in this population. A small group of patients had deteriorating glycemic control, in spite of being treated with multiple insulin injections, suggesting non-response or non-adherence to treatment. Further investigation is needed to identify reasons for the deteriorating control observed and design effective interventions for these patients.

The prevalence of albuminuria among diabetic patients in a primary care setting in Singapore.

INTRODUCTION: Microalbuminuria is an early sign of kidney damage. The prevalence of microalbuminuria in Singapore has been reported to be 36.0%-48.5%. However, the prevalence of microalbuminuria reported in these studies was determined with one urine sample using a qualitative urine test. The aim of this study was to determine the prevalence of micro- and macroalbuminuria using a more stringent criterion of two positive quantitative urine albumin-creatinine ratio (ACR) tests. METHODS: We conducted a cross-sectional study of patients with type 2 diabetes mellitus (T2DM) who were followed up at a primary care clinic in Singapore. Patients were diagnosed to have albuminuria if they had two positive ACR tests within a seven-month period. RESULTS: A total of 786 patients with T2DM met the study's inclusion criteria. 55.7% were already on an angiotensin-converting enzyme inhibitor (ACEI) and/or angiotensin receptor blocker (ARB). The prevalence rates of micro- and macroalbuminuria were 14.2% and 5.7%, respectively. Patients with albuminuria were more likely to have hypertension (odds ratio [OR] 3.47, 95% confidence interval [CI] 1.55-7.80). Diabetics with poorer diabetic control (OR 1.88, 95% CI 1.26-2.79), and higher systolic (OR 1.69, 95% CI 1.14-2.49) and diastolic (OR 1.96, 95% CI, 1.20 to 3.22) blood pressures were more likely to have albuminuria. CONCLUSION: In the present study, the prevalence of microalbuminuria is significantly lower than that previously reported in Singapore. The presence of hypertension, poor diabetic control and suboptimal blood pressure control are possible risk factors for albuminuria in patients with T2DM.