m-Health views and perception among Malaysian: findings from a survey among individuals living in Selangor.

BACKGROUND: Information and communication technology can be a useful tool to improve population health especially in low-middle income countries. However, the full potential of m-health may be limited by the users' health and technology literacy. This study aims to explore the m-health and technology literacy among Malaysians, and factors that may promote the use of m-health. METHODS: A cross-sectional study was performed among residents residing around Klang and Petaling district in Selangor, Malaysia from November 2015 to January 2017. Multivariable logistic regression models were used to assess the predictors of mobile device and health apps usage and examine the association between apps use and intention to change behavior with sociodemographic predictors. RESULTS: A total of 4,504 respondents participated in our survey. Most respondents reported that they owned a mobile or smartphone, which was commonly used to make calls and deliver text messages. However, only one-fifth (20.4%) of respondents were familiar with the term m-health or had used a health related application, with millennial (individuals aged ≤39 years) generally more aware of the term m-health and were more likely to use m-health as a tool for health management. The most commonly used application were for promoting adherence as well as self-efficacy (e.g., lifestyle advice). Other factors associated with higher levels of m-health use were individuals with higher level of education and individuals taking multiple medications. CONCLUSIONS: While most Malaysian were not familiar with m-health, they reported to have a positive attitude towards m-health. Malaysians were willing to use m-health to manage their health conditions but expressed that they required further education and training. As m-health is still at its infancy in Malaysia, there is potential to further develop m-health as an innovative solution to manage the population health.

Telemonitoring and Team-Based Management of Glycemic Control on People with Type 2 Diabetes: a Cluster-Randomized Controlled Trial.

BACKGROUND: Connected devices that allow people with diabetes to monitor their blood glucose levels remotely with data visualization have been shown to improve self-care behavior in diabetes management. However, their effectiveness and usability for a low-middle-income, racially diverse population are unknown. OBJECTIVE: This study aims to evaluate the effects of remote telemonitoring with team-based management on people with uncontrolled type 2 diabetes. DESIGN: This was a pragmatic 52-week cluster-randomized controlled study among 11 primary care government practices in Malaysia. PARTICIPANTS: People with type 2 diabetes aged 18 and above, who had hemoglobin A1c ≥ 7.5% but less than 11.0% within the past 3 months and resided in the state of Selangor. INTERVENTION: The intervention group received home gluco-telemonitors and transmitted glucose data to a care team who could adjust therapy accordingly. The team also facilitated self-management by supporting participants to improve medication adherence, and encourage healthier lifestyle and use of resources to reduce risk factors. Usual care group received routine healthcare service. MAIN MEASURE: The primary outcome was the change in HbA1c at 24 weeks and 52 weeks. Secondary outcomes included change in fasting plasma glucose, blood pressure, lipid levels, health-related quality of life, and diabetes self-efficacy. RESULTS: A total of 240 participants were recruited in this study. The telemonitoring group reported larger improvements in glycemic control compared with control at the end of study (week 24, - 0.05%; 95% CI - 0.10 to 0.00%) and at follow-up (week 52, - 0.03%; - 0.07 to 0.02%, p = 0.226). Similarly, no differences in other secondary outcomes were observed, including the number of adverse events and health-related quality of life. CONCLUSION: This study indicates that there is limited benefit of replacing telemedicine with the current practice of self-monitoring of blood glucose. Further innovative methods to improve patient engagement in diabetes care are needed. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02466880.

Using telemedicine to support care for people with type 2 diabetes mellitus: a qualitative analysis of patients' perspectives.

OBJECTIVE: Telemedicine has been promoted as an economical and effective way to enhance patient care, but its acceptance among patients in low-income and middle-income countries is poorly understood. This study is aimed to explore the experiences and perspectives of people with type 2 diabetes mellitus that used telemedicine to manage their condition. DESIGN: In-depth and focus group interviews were conducted with participants who have engaged in telemedicine. Questions included were participants' perception on the programme being used, satisfaction as well as engagement with the telemedicine programme. All interviews and focus groups were audio-recorded and transcribed verbatim. Data were analysed using a thematic approach. PARTICIPANTS AND SETTING: People with type 2 diabetes (n=48) who participated in a randomised controlled study which examined the use of telemedicine for diabetes management were recruited from 11 primary care clinics located within the Klang Valley. RESULTS: Twelve focus groups and two in-depth interviews were conducted. Four themes emerged from the analysis: (1) generational difference; (2) independence and convenience, (3) sharing of health data and privacy and (4) concerns and challenges. The main obstacles found in patients using the telemedicine systems were related to internet connectivity and difficulties experienced with system interface. Cost was also another significant concern raised by participants. Participants in this study were primarily positive about the benefits of telemedicine, including its ability to provide real-time data and disease monitoring and the reduction in clinic visits. CONCLUSION: Despite the potential benefits of telemedicine in the long-term care of diabetes, there are several perceived barriers that may limit the effectiveness of this technology. As such, collaboration between educators, healthcare providers, telecommunication service providers and patients are required to stimulate the adoption and the use of telemedicine.NCT0246680.

Telemedicine Cost-Effectiveness for Diabetes Management: A Systematic Review.

BACKGROUND: Telemedicine has been utilized increasingly worldwide for diabetes management, due to its potential to improve healthcare access and clinical outcomes. Few studies have assessed the economic benefits of telemedicine, which may contribute to underfunding in potentially important programs. We aim to systematically review the literature on economic evaluations of telemedicine in diabetes care, assess the quality, and summarize the evidence on driver of cost-effectiveness. MATERIALS AND METHODS: A literature search was performed in 10 databases from inception until February 2018. All economic evaluations assessing the economic evaluation of telemedicine in diabetes were eligible for inclusion. We subsequently evaluated the study quality in terms of effectiveness measures, cost measure, economic model, as well as time horizon. RESULTS: Of the 1877 studies identified, 14 articles were included in our final review. The healthcare providers' fees are a major predictor for total cost. In particular, the use of telemedicine for retinal screening was beneficial and cost-effective for diabetes management, with an incremental cost-effectiveness ratio between $113.48/quality-adjusted life year (QALY) and $3,328.46/QALY (adjusted to 2017 inflation rate). Similarly, the use of telemonitoring and telephone reminders was cost-effective in diabetes management. CONCLUSIONS: Among all telemedicine strategies examined, teleophthalmology was the most cost-effective intervention. Future research is needed to provide evidence on the long-term experience of telemedicine and facilitate resource allocation.

Telemonitoring in fasting individuals with Type 2 Diabetes Mellitus during Ramadan: A prospective, randomised controlled study.

We determined the impact of a remote blood glucose telemonitoring program with feedback in type 2 diabetes mellitus patients fasting during Ramadan compared to conventional self-monitoring method. A twelve-week cluster randomised study, with 85 participants who wish to fast for at least 15 days during Ramadan was conducted. Self-measurement and transmission of blood glucose results were performed six times daily during Ramadan. Results were transmitted to a secure website for review with feedback from case manager if necessary. The control group received usual care. The main outcome was the number of participants experiencing hypoglycaemia during Ramadan and at the end of the study. During Ramadan, the number of participants reporting hypoglycaemia was significantly lower in the telemonitoring group [Odds ratio (OR): 0.186, 95% confidence interval: 0.04-0.936; p = 0.04]. Similarly, the proportion of participants reporting symptomatic hypoglycaemia at the end of the study was significantly lower in the telemonitoring group (OR: 0.257, 95% CI: 0.07-0.89; p = 0.03). A reduction of 1.07% in glycated haemoglobin levels was observed in the telemonitoring group compared to 0.24% in the control group (p < 0.01). Overall, telemonitoring was a useful adjunct to reduce the risk of hypoglycaemia during Ramadan with no deterioration in glycaemic control.

Type 2 diabetes patient's perspective on Ramadan fasting: a qualitative study.

OBJECTIVE: We evaluated the beliefs, experience and diabetes management strategies of type 2 diabetes mellitus (T2DM) Muslim patients that chose to fast during Ramadan. RESEARCH DESIGN AND METHODS: A semistructured focus group interview was conducted with 53 participants with T2DM. Participants were purposefully sampled and asked to share their perspective on Ramadan fasting. All interviews were audio recorded, transcribed verbatim and analyzed thematically. RESULTS: Participants reported optimism towards fasting during Ramadan, as they believed that fasting was beneficial to their overall well-being, and a time for family bonding. Most participants made limited attempts to discuss with their doctors on the decision to fast and self-adjusted their medication based on experience and symptoms during this period. They also reported difficulty in managing their diet, due to fear of hypoglycemia and the collective social aspect of fasting. CONCLUSION: Muslims are optimistic about their well-being when fasting during Ramadan. Many choose to fulfill their religious obligation despite being discouraged by their doctors. Collaboration with religious authorities should be explored to ensure patients receive adequate education before fasting during Ramadan. TRIAL REGISTRATION NUMBER: NCT02189135; Results.

Intervention for Diabetes with Education, Advancement and Support (IDEAS) study: protocol for a cluster randomised controlled trial.

BACKGROUND: The high market penetration of mobile phones has triggered an opportunity to combine mobile technology with health care to overcome challenges in today's health care setting. Although Malaysia has a high Internet and mobile penetration rate, evaluations of the efficacy of incorporating this technology in diabetes care is not common. We report the development of a telemonitoring coaching system, using the United Kingdom (UK) Medical Research Council (MRC) framework, for patients with type 2 diabetes mellitus. METHODS: The Intervention for Diabetes with Education, Technological Advancement and Support (IDEAS) study is a telemonitoring programme based on an empowerment philosophy to enable participants to be responsible for their own health decision and behaviour. An iterative cycle of development, piloting, and collating qualitative and quantitative data will be used to inform and refine the intervention. To increase compliance, the intervention will be designed to encourage self-management using simple, non-technical knowledge. The primary outcomes will be HbA1c, blood pressure, total cholesterol, and quality of life and diabetes self-efficacy. In addition, an economic analysis on health service utilisation will be collected. DISCUSSION: The mixed-method approach in this study will allow for a holistic overview of using telemonitoring in diabetes care. This design enables researchers to understand the effectiveness of telemonitoring as well as provide insights towards the receptiveness of incorporating information technology amongst type 2 diabetes patients in a community setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02466880 Registered 2 June 2015.

Strategies to Make Ramadan Fasting Safer in Type 2 Diabetics: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Observational Studies.

Ramadan is the holy month for Muslims whereby they fast from predawn to after sunset and is observed by all healthy Muslim adults as well as a large population of type 2 diabetic Muslims.To determine the comparative effectiveness of various strategies that have been used for type 2 diabetic Muslim who fast during Ramadan.A systematic review and network meta-analysis of randomized controlled studies (RCT) as well as observational studies for patients with type 2 diabetes who fasted during Ramadan was conducted. Eight databases were searched from January 1980 through October 2015 for relevant studies. Two reviewers independently screened and assessed study for eligibility, assessed the risk of bias, and extracted relevant data. A network meta-analysis for each outcome was fitted separately, combining direct and indirect evidence for each comparison.Twenty-nine studies, 16 RCTs and 13 observational studies each met the inclusion criteria. The most common strategy used was drug changes during the Ramadan period, which found that the use of DPP-4 (Dipeptidyl peptidase inhibitor -4) inhibitors were associated with a reduction in incidence of experiencing hypoglycemia during Ramadan in both RCTs (pooled relative risk: 0.56; 95% confidence interval: 0.44-0.72) as well as in observational studies (pooled relative risk: 0.27; 0.09-0.75). Ramadan-focused education was shown to be beneficial in reducing hypoglycemia in observational studies but not RCTs (0.25 versus 1.00). Network meta-analyses suggest that incretin mimetics can reduce the risk of hypoglycemia by nearly 1.5 times.The newer antidiabetic agents appear to lower the risk of hypoglycemia and improved glycemic control when compared with sulfonylureas. Ramadan-focused education shows to be a promising strategy but more rigorous examination from RCTs are required.