Determine the Usefulness of Adjunct Automated Telephone Care as an Alternative

to Usual Face to Face Patient Care in Chronic Diseases Management in

Outpatient Settings

Introduction
Since the introduction of the telephone line, the usage of telecommunications in the healthcare
setting varies from appointment setting, reminders, health education, consultation and patient
follow-up. With the emergence of computers, the combination of computers and telephone has
led to development of Interactive Voice Response system (IVRS). In other words, this
technology involves touch-tone telephones with interactive voice programs. It is more commonly
known as automated telephone services. This technology is not unfamiliar in Singapore, other
settings such as telecommunications companies e.g. M1 and Singtel, government taxation office,
health promotion board etc. have used IVRS to provide information, services, health education
and filing of taxation information. In National University of Singapore, IVRS is used to release
examination results to the students. The main distinguished characteristic from the normal
telephone service and the IVRS is that the latter is fully automated without needing manpower to
answer the calls.

In Singapore, with the emphasis of disease management of the lifestyle related chronic illnesses
like diabetes, hypertension and hyperlipidemia, which are significant contributing risk factors to
ischaemic heart diseases, cerebrovascular disease, and kidney diseases, have led to the
emergence of Care Managing in the National Healthcare Group polyclinics (NHGP). Care
Managing is a care program emphasizing on early detection/ screening, clinical management and
rehabilitation and the nurses in this program are specially trained in disease management. The
number of patients to do health education, monitoring and proper follow up is immensely large.
This large number is contributed by the diversity of care given to the community, ranging from
primary prevention, secondary prevention to tertiary prevention. Interventions at primary
prevention level in disease management, besides early detection and screening, also involve
health education and promotion. In secondary and tertiary prevention level, more intensive health
education and promotion is needed. Monitoring of the patients’ illnesses progression and
reinforcing importance of follow up are also important elements of care in these 2 levels.

Lee, Friedman, Cukor and Ahern (2003) commented that telecommunications technology can
enhance quality of health care services. Besides, being easily accessible round the clock and it is
able to provide, patient-specific information, self-help treatment, reinforcement and support on
request. In the present situation in National Healthcare Group polyclinics, the nurses are already
pro-actively calling the patients to provide health information; self-help treatment, disease
monitoring, and even clinic follow up reminder calls. The main disadvantage is the large number
of patients they are caring for which thus requires a certain number of manpower to pro-actively
calling the patients. Second, there is the disadvantage of not being accessible 24 hours a day.
IVRS or automated telephone services might be the solution for better management of patients
with appropriate use, due to the availability of the services, and the ability to tailor to large
population numbers without the certain manpower requirement.

In this paper, the evidence of for the effectiveness of the IVRS or automated telephone services
on improving patients’ medical conditions in the outpatient setting will be examined. The
patients with medical conditions in this review are mainly patients with Type 2 diabetes,
hypertension and hyperlipidemia. The objective of this assignment is to establish the usefulness
of adjunct automated telephone care as an alternative to usual face to face patient care only.

Effectiveness in this review will be indicated by physiological outcomes of care, change of

health behaviors, psychological outcomes, satisfaction with care, and economic measures. The
questions will be:
(1) Is there a difference in improving physiological outcome indicators between adjunct
automated telephone care and usual care in patients with chronic diseases, mainly Type 2
diabetes, hypertension and hyperlipidemia in outpatient setting?
(2) Is there a difference in self-care behaviors between adjunct automated telephone care and
usual care patients with the 3 chronic diseases?
(3) Is there an improvement in the psychological outcomes in the group under adjunct automated
telephone care?
(4) Is there a higher level of satisfaction with care in the group under adjunct automated
telephone care?
(5) Is there any evidence of cost-effectiveness in adjunct automated telephone care?
(6) What are the features in an adjunct automated telephone care in the above studies that had
shown evidences of improved outcomes?

This review although is not a full systematic review, will provide a basis for drafting the proposal
for implementing a full proper systematic review to further examine this area of interest.

Search Strategy
#1 Telecommunications [MESH] OR Telecommunications [text word]
#2 “automated telephone” [all fields]
#3 Telemedicine [MESH] OR Telemedicine [text word]
#4 #1 OR #2 OR #3
#5 "chronic disease" [MESH] OR “chronic disease” [text word]
#6 "diabetes mellitus" [MESH] OR diabetes [text word] OR "high blood glucose" [all fields] NOT
"diabetes insipidus" [MESH] [text word]
#7 "hypertension" [MESH] OR hypertension [text word] OR "high blood pressure" [all fields]
#8 Hyperlipidemia [text word] OR hyperlipidaemia [text word] OR "hyperlipidemia"[MESH]) OR
"high cholesterol"[All Fields]
#9 #4 AND #5
#10 #4 AND #6
#11 #4 AND #7
#12 #4 AND #8
Table 1: Initial Search Framework
Computerized search from PubMed, Science Direct (1995 – 2005), Cochrane Database of
Systematic Reviews (1800 – 2005) and Cochrane Central Register of Controlled Trials (1800 –
2005) was done. EMBASE and PsychLit databases are available in National University of
Singapore’s (NUS) library e-resources databases collection. Nursing evidence-based practice and
best practices websites like Joanna Briggs Institute, the University of York Centre for Evidence-
Based Nursing and the Sarah Cole Hirsh Institutes, which are good and relevant websites for
searching clinical guidelines and best practices guidelines, are not available in NUS e-resources
subscription list (Morris, 2001). Other clinical guidelines websites like Singapore Ministry of
Health clinical guidelines websites and Guidelines Clearing House websites have been searched
but to no avail.

An initial search strategy framework (Table 1) has been designed to find any publications about
automated telephone services and used it to search the above databases. The search framework is
appropriate for both PubMed and Cochrane database. A different search strategy has to be
employed when searching Science Direct database. A final search strategy table with the number
of search results is shown in Table 2. The full search summary table with number of results from
each search and the final number of articles obtained is found in Appendix A1.

The following inclusion and exclusion criteria are used to limit the initial search findings to
potential articles for review.
Inclusion criteria include:
(1) telemedicine involving telephone as an intervention in (a) disease management in chronic
diseases like diabetes Type 2, hyperlipidemia and hypertension (b) telephone health education
given in terms of smoking cessation and dietary habits. The reason for including the inclusion
criteria of smoking cessation and dietary habits is that these 2 are important elements in disease
management of the 3 chronic diseases.
(2) The subject populations of interest in the studies are from medical centers or outpatient
clinics.

Exclusion criteria for the studies include:

(1) populations of interest in studies which are hospitalized patients or patients recently
discharged from hospitals
(2) surgery, radiation, infection control, addiction, gynecology, obstetric, pediatric, and neonatal
studies
(3) drug and blood enzyme trials
(4) body wellness program studies
(5) Type 1 diabetes or studies examining insulin related interventions
(6) chronic heart failure populations are excluded as the number of patient with chronic heart
failure in polyclinics under nursing care managing are not in large numbers compared to the
other 3 chronic diseases
.
A total of 84 potential articles were found after initial setting of inclusion and exclusion criteria.
However, only 55 articles were obtained, as the remaining articles are from journals that are not
in NUS library subscribing list or library. 2 more articles were handpicked resulting in a total of
57 articles for second elimination (See Appendix A2 for the full articles log). In a full systematic
review, it will be advisable that each title/abstract of the results was reviewed by 2 reviewers. If 1
reviewer disagreed, a third reviewer opinion will be sought. This is to ensure that the elimination
of the results from the search is done in an unbiased manner.

Due to the unknown number of studies done specifically looking into automated telephone
services in terms of disease management in these 3 group of illnesses, the initial inclusion criteria
was set on just “telemedicine” to prevent over-restriction of area for exploration. With 57
articles, it is possible to restrict the number of articles further for this assignment. In the 2nd
elimination round, only studies or systematic reviews on automated telephone services as
interventions are accepted. Telephone services that needed a nurse or interventionist to be at the
other end of the phone at the time of conversation as the main intervention of the studies are
excluded from this assignment review.

Due to the limited number of the studies and the heterogeneity of studies critiqued for the
requirement of this assignment, it is not appropriate to conduct any pooled statistical analyses. A
proper systematic review that reviews a substantial number of randomized controlled trials will
be able to demonstrate the differences in effect size with a forest plot.
 Potential
After Articles
Articles
Sources setting (Screening
Obtained
limits through
abstracts)
PubMed
#2 = "chronic disease" [Mesh term] OR #1 AND
23 8 3
chronic disease [text word] (161201) #2 (237)

#3 = "diabetes mellitus" [Mesh term]

OR diabetes [text word] OR "high
#1 AND
blood glucose" [all fields] NOT 35 18 12
#3 (346)
"diabetes insipidus" [Mesh term] [text
#1 = telecommunications [MESH] OR
word] (207822)
telecommunications [textword] OR "automated
telephone" [all fields] OR telemedicine [MESH] OR
#4 = "hypertension" [Mesh term] OR
telemedicine [textword] (28665) #1 AND
hypertension [textword] OR "high 15 10 6
#4 (188)
blood pressure" [all fields] (245517)

#5 = hyperlipidemia[Text Word] OR
hyperlipidaemia[Text Word] OR #1 AND
8 3 3
"hyperlipidemia"[MeSH Terms]) OR #5 (28)
"high cholesterol"[All Fields] (44728)
#1 = telecommunication [keyword, limit to title and
Search within results #1 (a)"diabetes"
Science Direct abstract] OR "automated telephone" [keyword, limit to 12 12
OR "high blood glucose" (20)
title and abstract] (2542)
(b)"cholesterol" OR "hyperlipidemia"
3 3
OR "hyperlipidaemia"(6)

(c)hypertension OR "high blood

8 8
presure" (14)

(d)"chronic disease" (14) 4 4

#1 = telecommunication [keyword] (0) "automated
Cochrane Database of telephone" OR automated telephone [keyword] (0)
6 6
Systematic Reviews #2 = telecommunication [search all text] OR
"automated telephone" [search all text] (13)
Cochrane Central
#1 = "automated telephone" [all fields] OR
Register of Controlled 12 8
telecommunication [keyword] (35)
Trials
Table 2: Search Strategy with search results (See Appendix A for full search results)
Description of Studies
Out of the 10 articles reviewed, 5 articles are systematic reviews, 4 are randomized controlled
trials and the last 1 is a non-experimental quantitative with a qualitative component study. The
full summary of all the articles can be found in Appendix A3.

All of the systematic reviews that are critiqued have automated telephone as one of the main
telemedicine categories under examination. 4 out of 5 articles looked specifically into comparing
the effectiveness of telemedicine either as an alternative mode of care or as an extension of care
versus face to face patient care alone. All of these 4 articles examined comparison studies
between 2 modalities of care except Liss, Glueckauf and Ecklund-Jonhnson (2002) had a
component of comparative studies comparing 3 or more modalities of care. The similar outcome
indicator used in these 4 studies to demonstrate effectiveness was reported improved outcomes of
care from individual studies. However, all 4 studies categorized their findings differently,
Currell, Urguhart, Wainwright and Lewis (2000) used outcome measures as categories, Hersh et
al (2001) used clinical specialty, Roine, Ohinmaa and Hailey (2001) and Liss, Glueckauf and
Ecklund-Johnson (2002) both used categories of applications. Still, the conclusion for all these 4
systematic reviews had similar conclusions. (1) Evidence of the effectiveness of telemedicine is
limited. (2) Larger sample sizes and further research are necessary. (3) Cost-effectiveness in
these studies was not well-analyzed.

Revere and Dunbar’s (2001) systematic review looked at the effectiveness of computer-
generated outpatient health behavior interventions which included “print communications” like
appointment letters, reminder slips, feedback reports etc. which is not considered under the
category of telemedicine. However, this systematic review is critiqued and retained for use in
this assignment due to the exploration of the effectiveness in regards to the health behavior
model or feature behind the interventions. The review reported that tailored interventions can
more positively affect health behavior change than targeted personalized or generic
interventions, though more studies were also needed to compare the different protocols with each
other. This information is useful when writing a guideline to initiate or implementing the
automated telephone service.

The qualities of the 5 systematic reviews are assessed using the SIGN Methodology Checklist for
Systematic Reviews and Meta-analyses (Appendix B1). A brief summary of the 5 systematic
reviews’ objectives, conclusions and internal validity can be found in Table 3.

The 4 randomized controlled trials (RCTs) are similar in comparing the effectiveness of
automated telephone care as an extension to usual care with the usual care alone. 3 of the studies’
populations of interest are people with diabetes only, and the other one is elderly people with
hypertension. The studies by Piette et al (2000) and Piette, Weinberger and Mcphee (2000) were
the same study using the same interventions and control and analyzing the same sample size
results but both papers had reported different outcome indicators. Piette et al (2000) explored the
effects of automated telephone calls in improving self-care and glycemic control, whereas Piette,
Weinberger and Mcphee (2000) examined the impact of the automated telephone calls in patient-
centered outcomes like psychological outcomes, self-efficacy, satisfaction with care and quality
of life. Piette, Weinberger, Kraemer and McPhee (2001) did another study using the same
research methodology, with the same intervention and control, on another group of patients from
a different site. These studies were based on United States. Friedman et al (1996) did the study
on a group of elderly patients with hypertension looking in to medication adherence and their
blood pressure control in England. The location of studies done is an important consideration
when analyzing the difference in economic benefits due to the differences in health care finance
structure.

Table 4 shows the brief summary of the 4 RCTs and the similarities of outcome indicators
measured to demonstrated effectiveness of the automated telephone services as an extension of
care. The qualities of the RCTs are assessed using SIGN Methodology checklist for Randomized
Controlled Trials (Appendix B2).
 **Section
Author/ Title/ Objectives / 1: ***Section 2:
Findings Synthesis Conclusions*
Types of Studies Included Outcome Indicators Internal Overall Assessment
Validity

Assess the effectiveness of 2.1 +

telemedicine as an alternative to face
Currell, Urquhart,
to face patient care. 1) None of the included studies
Wainwright and Lewis
demonstrated any detrimental 2.2 The inclusion criteria and the
(2000)
Differences in: Similarities and effects from the interventions 1.1 WC categories of the findings can result in
(1) Outcomes of care differences in the 1.2 WC the biasness of results.
Telemedicine versus face
(2) Economic consequences of care studies were combined 2) There is also little evidence of 1.3 WC Acute patients discharge from the
to face patient care: effect
(3) Acceptability of care from patient by the outcome clinical, psychological benefits 1.4 WC hospitals, e.g. MI and antenatal women
on professional practice
and provider point of view measures categories and cost effectiveness 1.5 PA clinical outcomes and psychological
and health care outcomes
(4) Professional practice during benefits and even cost calculations are
delivery of care 3) Larger samples needed for very different from patients with
(5) Transfer of skills between further research chronic diseases like hypertension and
clinicians diabetes.

Evaluate effectiveness of computer

generated health behavior
The findings were 1) Evidence that tailored
Revere and Dunbar intervention – clinical encounters “in
presented in a table interventions can more
(2001) absentia” – as an extension of face to
according to the positively affect health behavior 2.1 +
face patient care in an ambulatory
delivery devices change than targeted, 1.1 PA
Review of computer- setting.
categories. personalized or generic 1.2 WC 2.2 The lack of information on who and
generated outpatient
interventions. 1.3 WC how many number of reviewers
health behavior 2 main specific areas:
The results are analyzed 1.4 PA selecting and critiquing the articles
interventions: clinical (1) health behavior model used
by grouping the results 2) More research studies need to 1.5 AA allow room for biasness towards a
encounters “in Absentia” (2) devices used for health education,
according to compare different tailoring particular direction of the meta-analysis
counseling, and reminder systems
intervention types: protocols with another.
Outcome Indicators:
tailored and targeted.
Reported improved outcomes from
individual studies

Examine the effectiveness and Evidence of effectiveness of

Roine, Ohinmaa and Similarities and 1.1 AA
economic efficiency of telemedicine. telemedicine remains limited.
Hailey (2001) differences in the 1.2 WC
Most of the studies are pilot
studies were combined 1.3 WC 2.1 ++
Outcome indicators: projects or short-term outcomes.
Assessing telemedicine: a by categories of 1.4 WC
Reported improved outcomes from Only transmission of ECG and
systematic review of the applications studied 1.5 AA
individual studies. tele-dermatology have shown
literature.
promising results.
Table 3: Brief Summary of Systematic Reviews Critiqued
 Author/ Title/
Types of Studies Included
Hersh, Helfand,
Wallace, Kraemer,
Patricia, Shapiro and
Greenlick (2001)
Clinical outcomes
resulting from
telemedicine
interventions: a
systematic review.
Liss, Glueckauf and
Ecklund-Johnson (2002)
Research on Telehealth
and Chronic Medical
Conditions: Critical
Review, Key Issues, and
Future Directions
* Full conclusions see Appendix A3 **, *** SIGN Methodology Checklist 1 for systematic reviews and meta-analysis (See Appendix B1 ).
WC – well covered; AA - adequately addressed; PA – poorly addressed; ND – not addressed; NR – not reported; NA – not applicable
Table 3: Brief Summary of Systematic Reviews Critiqued (cont’)
Objectives / Findings Synthesis
Outcome Indicators
Evaluate the effectiveness of Similarities and
telemedicine interventions for health differences in the
outcomes in 2 classes of application: studies were combined
home-based and office/hospital- by the categories of
based. clinical specialty
Outcome indicators:
Reported clinical care outcomes from
individual studies
Evaluate the impact of 4 Categories
telecommunication-based (a) internet studies (b)
interventions for persons with standard telephone and
chronic disabilities automated telephone
system studies
2 main interests: perceived utility and (c) videoconferencing
cost-effectiveness of tele-health investigations
interventions (d) comparative studies
using 3 or more
modalities serve as a
framework for
organizing data for data
synthesis
Conclusions* **Section ***Section 2:
1: Overall Assessment
Internal
Validity
1.1 AA 2.1 +
The strongest evidence for 1.2 WC
efficacy of telemedicine in 1.3 WC 2.2 The lack of information on who and
clinical outcomes from home- 1.4 PA how many number of reviewers are
based telemedicine in areas of 1.5 WC critiquing the articles allow room for
hypertension, chronic disease biasness towards a particular direction
management and AIDs. of the meta-analysis.
1.1 AA
Overall results suggested that the 1.2 AA 2.1 –
Internet, telephone and 1.3 PA
videoconferencing are 1.4 PA 2.2 (a) The lack of information on who
efficacious and efficient modes 1.5 PA and how many number of reviewers
of treatment for people with selecting and critiquing the articles
chronic medical conditions. allow room for biasness towards a
Particularly telehealth particular direction of the meta-analysis
interventions that targeted (b) Only PsychLit, PubMed and
adherence or health promotion PsycINFO have been searched
(c) categorizing the findings with
different forms of telecommunications
as a framework can result in the
biasness of results.
Authors/ Title Randomized Intervention * * * * * * * * * * * ** SIGN Internal Validity Conclusion***
% drop out and Control S M P R U S P S H Q C
No. of subjects C P D S S W S E S O D
C Y L
DIABETES
Piette, Weinberger, Yes. Automated 1.1 WC 2.1 + Significant Diff (p<0.05)
Mcphee, Mah, Kraemer telephone, 1.2 WC More detailed of the 1) Self care
and Crapo 248 patients’ data calls out- 1.3 AA instruments measuring self Glucose monitoring: Diff: 0.4
analyzed (89%), bound with
    1.4 NA care, medication problems Foot inspection: Diff: 0.3
Do Automated Calls with 11% dropped nurse follow- 1.5 WC and related symptoms will be Weight monitoring: Diff: 0.6
Nurse follow-up improve out. up adjunct to 1.6 WC appreciated. Medication problems: Diff: -21%
self care and glycemic 124 subjects in usual care vs 1.7 PA 2.2 Might not affect the study 2) Glycemic control
control among vulnerable each arm. Usual care 1.8 5.5% that much as frequency of Normal HbA1C% level: Diff: 9%
patients with Diabetes? dropped out these indicators can be used Serum glu levels: Diff: -41mg/dL
Duration: 12month in each arm to report. Self-perceived glycemic control mean
(total <20%) 2.3 The sig difference in the rating: Diff: 0.4
1.9 WC physiological data can be 3) Diabetes-related symptoms (higher
1.10 NA contributed to the change in number indicates higher frequency)
health behavior or less All types: Diff: -1.4
medication problems. 4 out of Hyperglycemic symptoms: Diff: -0.7
5 certain. Hypoglycemic symptoms: Diff: -0.5
2.4 Yes

Piette, Weinberger, Automated 1.1 WC 2.1 + Significant Diff (p<0.05)

Yes.
Kraemer and McPhee telephone, 1.2 WC More detailed of the 1) Self Care
Final no. of
calls out- 1.3 AA instruments measuring self Glucose monitoring: diff=0.2
Impact of Automated Calls
subjects at end of
bound with
      1.4 NA care, medication problems Foot inspection: diff=0.2
study
with Nurse Follow-up on nurse follow- 1.5 WC and related symptoms will be 2) Use of specialty services
Intervention: 132
Diabetes Treatment up adjunct to 1.6 WC appreciated. Podiatry: diff=20%
Control: 140
Outcomes in a Department usual care vs 1.7 AA 2.2 Might not affect the study Diabetes clinic: diff=36%
(6.8% drop out)
of Veterans Affairs Health Usual care 1.8 6.8% that much as frequency of Cholesterol test: diff=9%
Care System – a total dropped these indicators can be used Medical foot exam: diff=20%,
randomized controlled out to report. 3) Diabetes related severity of illness
trial 1.9 WC 2.3 The sig difference in the HbA1c > or equal to 8% subjects’
Duration: 12 months 1.10 NA decreased of percentage of mean HbA1C%: diff=-0.5%
subjects with high HbA1C% HbA1c > or equal to 9% subjects’
can be due to study effect mean HbA1c%: diff=-1.1%
with changes to other 4) Diabetes related symptoms
variables causing the - all symptoms: diff=-0.7
decreased. 4 out of 5 certain. - other symptoms: diff=-0.2
2.4 Yes 5) Satisfaction of care
summary scale: diff=0.1
interpersonal aspects of care: diff=0.2
quality of outcomes: diff=0.3

Piette, Weinberger and Yes. Automated 1.1 AA 2.1 + 1) Mean depression score diff=-4.1
McPhee telephone, 1.2 AA 2.2 Might not affect the study 2) Mean self-efficacy score: diff=0.3
248 patients’ data calls out- 1.3 AA by measuring 2 outcomes in 3) Mean no. of days in bed: diff=-0.5
The Effect of automated analyzed (89%), bound with
      1.4 NA English-speaking patients 4) Satisfaction with care
calls with telephone nurse 11% dropped nurse follow- 1.5 WC only There are generally Summary scale: diff=0.2
follow-up on patient- out. up adjunct to 1.6 WC decreased in depression, Technical aspects of care: diff=0.2
centered outcomes of 124 subjects in usual care vs 1.7 PA increased in self-efficacy. Choice of providers and continuity:
diabetes care: a each arm. Usual care 1.8 Not clear 2.3 3 out of 5 certain diff=0.2
randomized, controlled 1.9 AA 2.4 Neutral communication with providers:
trial 1.10 PA diff=0.2
Duration: 12 months Quality of outcomes: diff=0.2
Table 4: Brief Summary of RCTs and their Internal Validity
Authors/ Title Randomized Intervention * * * * * * * * * * * ** SIGN Conclusion***
% drop out and Control S M P R U S P S H Q C Internal
No. of subjects C P D S S W S E S O D Validity
C Y L
HYPERTENSION
Friedman et al. Yes. Patient- 1.1 WC 2.1 ++ Results:
initiated 1.2 WC 1) Effects on antihypertensive medication
A telecommunications 267 (89%) automated 1.3 AA adherence:
system for monitoring subjects’ data telephone,
     1.4 NA Mean adherence improvement:
and counseling patients were analyzed at calls adjunct to 1.5 WC diff=6%
with hypertension – the end of the usual care vs 1.6 WC 2) Effects of blood pressure:
impact on medication study Usual care 1.7 AA Adjusted mean diastolic blood pressure
adherence and blood (11% drop out) 1.8 11% changes:
pressure control. 1.9 AA Total study population: diff=4.4
1.10 NA NonAdherent subjects: diff=8.8
Duration: 6 months 3) Relationship of TLC use and
adherence change to blood pressure 
Adj. mean sys BP change in TLC group:
12.7mmHg (increased adherence) vs
2.5mmHg (decreased adherence)
Adj. mean dia BP change in TLC group:
5.5mmHg (increased adherence) vs
0.6mmHg (decreased adherence)
4) Attitudes of TLC users and their
physicians 
69% satisfied.
54% satisfied with health benefit.
5% and 6% scored the items in the
lower quartile for satisfaction and health
benefit respectively.
85% of the physicians read the TLC
reports regularly.
84% filed reports in patients’ records.
40% discuss the information with the
patients.
5) Cost effectiveness

* SC – self-care behaviors, MP – medication problem, PD – disease related physiological data, RS – related symptoms, SWC – satisfaction with care, US - used of specialty services, PSY – psychosocial indicators (depression,
anxiety), SE – self-efficacy, HS – General health status using SF 36, QOL – quality of life, CD – cost discussion.

** SIGN internal validity (see Appendix B2 for the questions)

WC- well covered; AA – adequately addressed; PA- poorly addressed; ND- not addressed; NR- not reported; NA- not applicable.

*** Full conclusion of results in Appendix A3

Table 4: Brief Summary of RCTs and their Internal Validity (Con’t)

The economic benefits are not analyzed in a statistical way which comparisons can be made
between the studies. The differences between the studies in the intervention of “automated
telephone”, is an important consideration in this research review. In the diabetes population
studies were out-bound and in addition there is telephone nurse follow-up involvement. Whereas,
the hypertension study “automated telephone” intervention, the calls were patient-initiated with
no regular telephone nurse follow-up. Though the main outcome effects in the diabetes studies
were due to the “intervention” in study after considering the biasness, the intervention is
however “diluted” by the nurse telephone follow-up component. In other words, the effects of
the outcome differences can be due to the automated telephone alone or the telephone nurse
follow-up alone or both.

The last study is an evaluation study by Kaplan, Farzanfar and Friedman (2003). This study
evaluated the personal relationships that can evolve from interaction with the automated
telephone care which was known as “an intelligent interactive telephone health behavior advisor
system” in the study. The criteria for evaluating this evaluation study is adapted from Sullivan-
Bolyai and Grey (2002), found in Appendix B3. The conclusion of this study found that most
people using the automated telephone care were satisfied with care and personal relationships
were even formed in 3 particular forms: feelings of love, guilt and ambivalence.

Synthesis of Evidence
According to SIGN (2004), considered judgment is a concept to summarize the total body of
evidence by addressing the following aspects:
• Quantity, quality and consistency of evidence
• Generalizability of the study findings
• Directness of application to the target population for the guideline
• Clinical impact
• Implementability
The “Considered Judgment” table is shown in Table 5. Clinical impact in this guideline
implementation is large, due to the amount of people it is going to impact during the
implementation. The extent of impact is a consideration due to the resources that will be
allocated in the process. The practicability of this automated telephone care which is addressed
under the heading of “Implementability”, is an important consideration but of lesser priority to
the clinical impact due to the advanced telecommunications structure in Singapore.

The selection of the 5 articles that have the best evidence to develop the practice guidelines for
this assignment needs to be balanced between 2 important factors. (1) Internal validity of the
study and (2) Level of applicability to the targeted population addressed in this assignment.
Articles which have a level of biasness during internal validity grading will be excluded. Level
of applicability of less than 50% will not be short listed. The final 5 articles and their summaries
of evidence are shown in Table 6.
Key Question 1: Is there a difference in improving physiological outcome indicators between automated telephone care and usual care in patients with chronic
diseases mainly Type 2 diabetes, hypertension and hyperlipidemia in outpatient setting?
Author/ Title/
Currell, Urquhart,
Wainwright and Lewis
Systematic
Telemedicine versus face
to face patient care: effect
on professional practice
and health care outcomes
Roine, Ohinmaa and
Hailey
Systematic
Assessing telemedicine: a
systematic review of the
literature
Hersh, Helfand,
Wallace, Kraemer,
Patricia, Shapiro and
Greenlick
Systematic
Clinical outcomes
resulting from
telemedicine
interventions: a
systematic review.
Liss, Glueckauf and
Ecklund-Johnson
Research on Telehealth
Systematic
and Chronic Medical
Conditions: Critical
Review, Key Issues, and
Future Directions
Table 5: Considered Judgment Table
Type Conclusions
1) None of the included studies
demonstrated any detrimental effects from
the interventions
2) There is also little evidence of clinical
Review
benefits
3) Larger samples needed for further
research
Evidence of effectiveness of telemedicine
remains limited. Most of the studies are
pilot projects or short-term outcomes.
Review Only transmission of ECG and tele-
dermatology have shown promising
results.
The strongest evidence for efficacy of
telemedicine in clinical outcomes from
home-based telemedicine in areas of
Review hypertension, chronic disease
management and AIDs.
Internet, telephone and videoconferencing
are efficacious and efficient modes of
treatment for people with chronic medical
conditions.
Review Furthermore, telehealth interventions that
targeted adherence or health promotion
(particularly automated phone
technology) showed incremental gains in
comparison to routine care.
SIGN
Directness of application to
Internal
Target Population of Guideline
Quality
Review not 100% directly
applicable to the assignment.
Studies involving acute
+ medical conditions are
included in review.
Level of applicability: 40%
Review not 100% directly
applicable to the assignment.
Studies involving acute
medical conditions other than
++
chronic diseases are included
in review.
Level of applicability: 40%
Review is applicable to the
target population in both
chronic disease and outpatient
+ and the usage of the
management.
Level of applicability: 70%
Review is applicable to the
target population of chronic
disease, however the review
_ includes studies of
hospitalized patients.
Level of applicability: 60%
Clinical Impact Implementability
(1) Resources: NHG
Polyclinics have a main
call center. The main line
telephone introduction is
automated, interacted with
touch-tone phone pads.
(2) In Singapore, most of
the households have
Large due to the
touch-tone telephones.
large number of
patients this
(3) Setting up the system
“automated
will require additional
telephone care”
course for the planning
will serve if
implemented
telephone lines
(4) The implementation of
this intervention is not
justifiable at the moment,
due to the unknown cost
of setting up the system
comparison to the
benefits.
Key Question 1: Is there a difference in improving physiological outcome indicators between automated telephone care and usual care in patients with chronic
diseases mainly Type 2 diabetes, hypertension and hyperlipidemia in outpatient setting?
Author/ Title/ Type
Piette, Weinberger,
Mcphee, Mah, Kraemer RCT
and Crapo
Do Automated Calls with
Nurse follow-up improve
self care and glycemic
control among vulnerable
patients with Diabetes?
Piette, Weinberger,
Kraemer and McPhee RCT
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
RCT
Friedman et al.
A telecommunications
system for monitoring
and counseling patients
with hypertension –
impact on medication
adherence and blood
pressure control.
Table 5: Considered Judgment Table (con’t)
SIGN
Directness of application to
Conclusions Internal Clinical Impact Implementability
Target Population of Guideline
Quality
Findings of this study reported: Findings cannot be directly
1) Intervention group increase number of applied due to patient factors:
subjects with Normal HbA1C% level difference in ethnicity factor
2) Intervention group has a lower mean and cultural factors. Asian
serum glucose levels of 41mg/dL + low-income group might have
a different health literacy level.
(1) Resources: NHG
Findings not generalized to all diabetes
Polyclinics have a main
population, main characteristics of patients in Level of applicability for
call center. The main line
study are low-income, from United States diabetes population only: 60%
telephone introduction is
automated, interacted with
touch-tone phone pads.
Findings of this study reported:
Findings cannot be directly
(1) Subjects with HbA1c > or equal to 8%
applied due to patient factors: (2) In Singapore, most of
mean HbA1c% decreased by 0.5
difference in ethnicity factor the households have
(2) Subjects with HbA1c > or equal to 9% Large due to the
and cultural factors. Asian touch-tone telephones.
mean HbA1c% decreased by 1.1 + large number of
low-income group might have
patients this
a different health literacy level. (3) Setting up the system
Findings not generalized to all diabetes “automated
will require additional
population, main characteristics of patients in telephone care”
Level of applicability for course for the planning
study are low-income, from United States. will serve if
diabetes population only: 60% and the usage of the
implemented
telephone lines
Findings of this study reported: (4) The implementation of
(1) Subjects in the intervention group in this intervention is not
general have a greater decrease in mean justifiable at the moment,
Same as above for
diastolic blood pressure vs the control group. due to the unknown cost
applicability.
Diff of 4.4 of setting up the system
(2) Especially evident in the non-adherent comparison to the
++ Level of applicability for
group with a greater change in mean diastolic benefits.
hypertension population only:
blood pressure. Diff of 8.8
55% (due to elderly subjects as
In summary, there are improved clinical
focus)
physiological outcomes especially in the non-
adherent group.
Findings only generalized to Elderly
hypertensive patients in England.
Key Question 2: Is there a difference in self-care behaviors between automated telephone care and usual care patients with the 3 chronic diseases?
Author/ Title/ Type
Piette, Weinberger,
Mcphee, Mah, Kraemer RCT
and Crapo
Do Automated Calls with
Nurse follow-up improve
self care and glycemic
control among vulnerable
patients with Diabetes?
Piette, Weinberger,
Kraemer and McPhee RCT
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
Friedman et al.
RCT
A telecommunications
system for monitoring
and counseling patients
with hypertension –
impact on medication
adherence and blood
pressure control.
Table 5: Considered Judgment Table (con’t)
SIGN
Directness of application to
Conclusions Internal Clinical Impact Implementability
Target Population of Guideline
Quality
Findings cannot be directly
Findings of this study reported: applied due to patient factors:
1) Intervention group increases frequency of difference in ethnicity factor
glucose monitoring, foot inspection and and cultural factors. Asian (1) Resources: NHG
+
weight monitoring low-income group might have Polyclinics have a main
a different health literacy level. call center. The main line
2) Decrease medication problems adherence telephone introduction is
Level of applicability for automated, interacted with
diabetes population only: 60% touch-tone phone pads.
Findings of this study reported: (2) In Singapore, most of
(1) Intervention group increases frequency in Findings cannot be directly the households have
Large due to the
glucose monitoring and foot inspection applied due to patient factors: touch-tone telephones.
large number of
(2) Intervention group uses more specialty difference in ethnicity factor
patients this
services, podiatry, cholesterol test, diabetes and cultural factors. Asian (3) Setting up the system
+ “automated
clinic and medical foot exam. low-income group might have will require additional
telephone care”
a different health literacy level. course for the planning
will serve if
Findings not generalized to all diabetes and the usage of the
implemented
population, main characteristics of patients in Level of applicability for telephone lines
study are low-income, from United States. diabetes population only: 60%
(4) The implementation of
this intervention is not
justifiable at the moment,
Same as above for
due to the unknown cost
Findings of this study reported: applicability.
of setting up the system
Improved medical adherence especially in the
comparison to the
non-adherent groups. ++ Level of applicability for
benefits.
hypertension population only:
Findings only generalized to Elderly 55% (due to elderly subjects as
hypertensive patients in England. focus)
Key Question 3: Is there an improvement in the psychological outcomes in patients with the 3 chronic diseases under the automated telephone care?
SIGN Directness of application to
Author/ Title/ Type Conclusions Internal Target Population of Clinical Impact Implementability
Quality Guideline

Currell, Urquhart, Cannot direct 100% to the

Wainwright and Lewis Systematic target population of this
(2000) Review Findings of this review reported: question. Patient populations
(1) Resources: NHG
1) There is little evidence of psychological in the studies review contain
+ Polyclinics have a main
Telemedicine versus face benefits both acute and chronic
call center. The main line
to face patient care: 2) Large samples needed for further research disease patients.
telephone introduction is
effect on professional
automated, interacted
practice and health care Level of applicability: 40%
with touch-tone phone
outcomes
pads.
Findings of this study reported:
Findings cannot be directly
Piette, Weinberger and (1) Intervention group has lower mean (2) In Singapore, most of
RCT applied due to patient factors:
McPhee depression score, mean number of days in Large due to the the households have
difference in ethnicity factor
bed. large number of touch-tone telephones.
and cultural factors. Asian
The Effect of automated (2) Intervention group has higher mean self- patients this
low-income group might have
calls with telephone efficacy score + “automated (3) Setting up the system
a different health literacy
nurse follow-up on telephone care” will require additional
level.
patient-centered Findings not generalized to all diabetes will serve if course for the planning
outcomes of diabetes population, main characteristics of patients implemented and the usage of the
Level of applicability for
care: a randomized, in study are low-income, from United States telephone lines
diabetes population only:
controlled trial
60%
(4) The implementation
of this intervention is not
Friedman et al.
Same as above for justifiable at the moment,
RCT
Findings of this study reported: applicability. due to the unknown cost
A telecommunications
54% scored the upper quartile for general of setting up the system
system for monitoring
HRQL SF-36 health benefit. ++ Level of applicability for comparison to the
and counseling patients
hypertension population only: benefits.
with hypertension –
Findings only generalized to Elderly 55% (due to elderly subjects
impact on medication
hypertensive patients in England. as focus)
adherence and blood
pressure control.
Table 5: Considered Judgment Table (con’t)
Key Question 4: Is there a higher level of satisfaction with care in patients with the 3 chronic diseases under the automated telephone care?
Author/ Title/
Piette, Weinberger and
McPhee
The Effect of automated
calls with telephone nurse
follow-up on patient-
centered outcomes of
diabetes care: a
randomized, controlled trial
Piette, Weinberger,
Kraemer and McPhee
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
Friedman et al.
A telecommunications
system for monitoring and
counseling patients with
hypertension – impact on
medication adherence and
blood pressure control.
Kaplan, Farzanfar and
Friedman
Personal relationships with
an intelligent interactive
telephone health advisor
system: a multi-method
study using surveys and
ethnographic interviews
SIGN
Directness of application to Clinical
Type Conclusions Internal Implementability
Target Population of Guideline Impact
Quality
Findings of this study reported:
Findings cannot be directly
RCT Using Employee Health Care Value Survey –
applied due to patient factors:
intervention group has a higher mean score in
difference in ethnicity factor
the
and cultural factors. Asian
(1)summary scale (2)technical aspects of care
+ low-income group might have
(3)choice of providers and continuity
a different health literacy
(4)communication with providers and the
level.
(5)quality of outcomes
(1) Resources: NHG
Findings not generalized to all diabetes
Level of applicability for Polyclinics have a main
population, main characteristics of patients in
diabetes population only: 60% call center. The main line
study are low-income, from United States
telephone introduction is
automated, interacted
Findings cannot be directly
Findings of this study reported: with touch-tone phone
RCT applied due to patient factors:
Using Employee Health Care Value Survey – pads.
difference in ethnicity factor
intervention group has a higher mean score in
and cultural factors. Asian
the Large due to (2) In Singapore, most of
+ low-income group might have
(1)summary scale (2)interpersonal aspects of the large the households have
a different health literacy
care and the (3) quality of outcomes number of touch-tone telephones.
level.
Findings not generalized to all diabetes patients this
population, main characteristics of patients in “automated (3) Setting up the system
Level of applicability for
study are low-income, from United States. telephone will require additional
diabetes population only: 60%
care” will course for the planning
serve if and the usage of the
Findings of this study reported: Same as above for
implemented telephone lines
RCT 64% scored satisfaction in the upper quartile of applicability.
the scale.
(4) The implementation
Findings only generalized to Elderly ++ Level of applicability for
of this intervention is not
hypertensive patients in England. hypertension population only:
justifiable at the moment,
** The findings on satisfaction of care in this 55% (due to elderly subjects
due to the unknown cost
study are not presented in comparison with the as focus)
of setting up the system
control group.
comparison to the
benefits.
Findings of this study reported: Findings cannot be applied
Evaluation
(1) Individuals using TLC were satisfied and 100% due to patient factors.
Study
find it helpful. The study however explores
(2) Personal relationships with TLC were formed + people’s responses using
in 3 different ways, feelings of love, guilt and automated telephone care.
ambiguity or ambivalence.
Study did not mention if the sample Level of applicability: 80%
characteristics, if subjects have chronic diseases.
Table 5: Considered Judgment Table (con’t)
Key Question 5: Is there any evidence of cost-effectiveness using automated telephone care?
Author/ Title/
Currell, Urquhart,
Wainwright and Lewis
(2000)
Telemedicine versus face
to face patient care: effect
on professional practice
and health care outcomes
Friedman et al.
A telecommunications
system for monitoring
and counseling patients
with hypertension –
impact on medication
adherence and blood
pressure control.
Piette, Weinberger,
Kraemer and McPhee
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
Table 5: Considered Judgment Table (con’t)
SIGN Directness of application to
Type Conclusions Internal Target Population of Clinical Impact Implementability
Quality Guideline
Cannot direct 100% to the
target population of this
question. Patient
1) There is little evidence of cost
Systematic populations in the studies
effectiveness + (1) Resources: NHG
Review review contain both acute
2) Larger samples needed for further Polyclinics have a main
and chronic disease
research call center. The main line
patients.
telephone introduction is
automated, interacted with
Level of applicability: 40%
touch-tone phone pads.
Same as above for (2) In Singapore, most of
RCT
applicability. the households have
Large due to the
Findings of this study reported: touch-tone telephones.
large number of
No concrete evidence of cost-effectiveness ++ Level of applicability for
patients this
due to the short implementation and hypertension population (3) Setting up the system
“automated
evaluation time period. only: 55% (due to elderly will require additional
telephone care” will
subjects as focus) course for the planning
serve if
and the usage of the
implemented
telephone lines
Findings cannot be directly
(4) The implementation of
RCT applied due to patient
this intervention is not
factors: difference in
justifiable at the moment,
ethnicity factor and cultural
due to the unknown cost
Findings of this study reported: factors. Asian low-income
+ of setting up the system
No proper analysis of economic statistics. group might have a different
comparison to the
Non-conclusive for cost-effectiveness. health literacy level.
benefits.
Level of applicability for
diabetes population only:
60%
Key Question 5: What are the features in an automated telephone care in the above studies that had shown evidences of improved outcomes?
Author/ Title/ Type
Piette, Weinberger, Kraemer
and McPhee
Impact of Automated Calls
with Nurse Follow-up on RCTs
Diabetes Treatment Outcomes
in a Department of Veterans
Affairs Health Care System –
a randomized controlled trial
Piette, Weinberger, Mcphee,
Mah, Kraemer and Crapo
Do Automated Calls with
Nurse follow-up improve self
care and glycemic control
among vulnerable patients
with Diabetes?
RCT
Friedman et al.
A telecommunications system
for monitoring and counseling
patients with hypertension –
impact on medication
adherence and blood pressure
control.
Revere and Dunbar (2001)
Systematic
Review
Review of computer-generated
outpatient health behavior
interventions: clinical
encounters “in Absentia”
Table 5: Considered Judgment Table (con’t)
SIGN Directness of application
Conclusions Internal to Target Population of Clinical Impact Implementability
Quality Guideline
Automated Telephone Care Services
included: Findings cannot be
1) targeted and tailored self-care education directly applied due to
messages. patient factors: difference
2) Check patient health status, assessment in ethnicity factor and
on self care issues cultural factors. Asian
3) Nature of calls: Calls outbound, up to 6 + low-income group might
(1) Resources: NHG
tempted calls. Touch-tone keypads used to have a different health
Polyclinics have a main call
communicate. literacy level.
center. The main line
4) Frequency and duration: Biweekly basis.
telephone introduction is
5 to 8 minute assessment. Level of applicability for
automated, interacted with
5) Telephone nurse follow up involved. diabetes population only:
touch-tone phone pads.
60%
(2) In Singapore, most of the
Large due to the households have touch-tone
large number of telephones.
Automated Telephone Care Services
patients this
included:
“automated (3) Setting up the system
1) targeted and tailored self-care education Same as above for
telephone care” will require additional
and motivational messages to improve applicability.
will serve if course for the planning and
medication adherence.
implemented the usage of the telephone
2) Check patient health status, assessment ++ Level of applicability for
lines
on medication issues hypertension population
3) Nature of calls: Patient-initiated calls. only: 55% (due to elderly
(4) The implementation of
Touch-tone keypads used to communicate. subjects as focus)
this intervention is not
4) Frequency and duration: Weekly basis. 4
justifiable at the moment,
minute.
due to the unknown cost of
5) Reports transmitted to physicians.
setting up the system
comparison to the benefits.
Due to the inclusion of
1) Evidence that tailored interventions can
printed communications
more positively affect health behavior
and other forms of
change than targeted, personalized or
+ interventions besides
generic interventions.
automated telephone care.
2) More research studies need to compare
different tailoring protocols with another.
Level of applicability:
.
60%
 SIGN
Level of Physiological Self-Care Psychological Satisfaction Cost-
Author/ Title/ Type Internal Features
Application Outcomes Behavior outcomes with Care Effectiveness
Quality

Hersh, Helfand, Wallace, Kraemer,

Patricia, Shapiro and Greenlick Systematic + 70% all
Clinical outcomes resulting from 
Review 3 populations
telemedicine interventions: a systematic
review.

*Piette, Weinberger, Mcphee, Mah,

Kraemer and Crapo RCT 60% for
Do Automated Calls with Nurse follow- + diabetes  
up improve self care and glycemic control population
among vulnerable patients with only 
Diabetes?

**Piette, Weinberger and McPhee

The Effect of automated calls with 60% for
RCT + diabetes
telephone nurse follow-up on patient-    
centered outcomes of diabetes care: a population
randomized, controlled trial only

Piette, Weinberger, Kraemer and

McPhee RCT
Impact of Automated Calls with Nurse 60% for
Follow-up on Diabetes Treatment + diabetes     
Outcomes in a Department of Veterans population
Affairs Health Care System – a only
randomized controlled trial

Friedman et al. 55% for

A telecommunications system for hypertension
RCT ++ elderly
monitoring and counseling patients with     
hypertension – impact on medication population
adherence and blood pressure control. only

Kaplan, Farzanfar and Friedman

Personal relationships with an intelligent Evaluation
interactive telephone health advisor + 80% 
Study
system: a multi-method study using
surveys and ethnographic interviews
Table 6: Summary of Evidence for 5 Articles * and ** are the same study on same population
Recommendations for Practice
The specific evidence grade is given according to the SIGN grading system (2004). Grades for
levels of evidence and grades of recommendations are given according to (1) the type of study,
(2) quality of study and (3) risk of bias. The assignment of a level of evidence and associated
grade of recommendation should be agreed unanimously by the guideline development group. In
face of a difference in opinion of the grades of recommendation, the difference should be
formally recorded and the reasons for disagreement noted (SIGN, 2004). SIGN’s criteria for
grading the levels of evidence and assigning the grade of recommendation can be found in
Appendix C.

Practice Recommendation 1:
Adjunct automated telephone care in addition to usual care improves physiological outcomes
than usual care alone especially in hypertension and diabetes disease management.
Supporting evidence:
(a) Clinical outcomes resulting from telemedicine interventions: a systematic review (Hersh
et al, 2001). Level of evidence: 1+
(b) Do Automated Calls with Nurse follow-up improve self care and glycemic control among
vulnerable patients with Diabetes? (Piette et al, 2000). Level of evidence: 1+
(c) 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
(Piette, Weinberger, Kraemer and McPhee, 2001). Level of evidence: 1+
(d) A telecommunications system for monitoring and counseling patients with hypertension –
impact on medication adherence and blood pressure control (Friedman et al, 1996). Level
of evidence: 1+
Grade of Recommendation: B
Practice Recommendation 2:
There is some evidence that adjunct automated telephone care increases frequencies of self-care
behaviors especially glucose monitoring and foot inspection in diabetes population.
Supporting evidence:
(a) Do Automated Calls with Nurse follow-up improve self care and glycemic control among
vulnerable patients with Diabetes? (Piette et al, 2000), Level of evidence: 1+
(b) 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.
(Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+
Grade of Recommendation: B

Practice Recommendation 3:
There is some evidence that adjunct automated telephone care improves medication adherence in
diabetes and hypertension population.
Supporting evidence:
(a) Do Automated Calls with Nurse follow-up improve self care and glycemic control among
vulnerable patients with Diabetes? (Piette et al, 2000), Level of evidence: 1+
(b) A telecommunications system for monitoring and counseling patients with hypertension –
impact on medication adherence and blood pressure control (Friedman et al, 1996). Level
of evidence: 1+
Grade of Recommendation: B

Practice Recommendation 4:
There is limited consistent evidence that adjunct telephone care improves psychological
outcomes in patients with chronic diseases.
Supporting evidence:
(a) The Effect of automated calls with telephone nurse follow-up on patient-centered
outcomes of diabetes care: a randomized, controlled trial (Piette, Weinberger and
McPhee, 2000). Level of evidence: 1+
 (b) A telecommunications system for monitoring and counseling patients with hypertension –
impact on medication adherence and blood pressure control (Friedman et al, 1996). Level
of evidence: 1+
Grade of Recommendation: B

Practice Recommendation 5:
There is increased satisfaction with care especially in the summary scale and the quality of
outcomes for patients receiving adjunct telephone care compared to the patients receiving usual
care alone in diabetes population.
Supporting evidence:
(a) 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.
(Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+
(b) The Effect of automated calls with telephone nurse follow-up on patient-centered
outcomes of diabetes care: a randomized, controlled trial (Piette, Weinberger and
McPhee, 2000). Level of evidence: 1+
Grade of Recommendation: B

Practice Recommendation 5:
There is some evidence that satisfaction with care in patients receiving adjunct telephone care
with personal relationships formed.

Supporting evidence:
(a) Personal relationships with an intelligent interactive telephone health advisor system: a multi-
method study using surveys and ethnographic interviews (Kaplan, Farzanfar and Friedman,
2003). Level of evidence: 3
Grade of Recommendation: D
Practice Recommendation 6:
There is limited consistent evidence that adjunct telephone care is cost-effective in chronic
diseases management.
Supporting evidence:
a) 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.
(Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+
b) A telecommunications system for monitoring and counseling patients with hypertension –
impact on medication adherence and blood pressure control (Friedman et al, 1996). Level
of evidence: 1+
Grade of Recommendation: B

Practice Recommendation 7:
There is some evidence that tailored health behavior change model underlying adjunct
automated telephone care can produce better outcomes.
Supporting evidence:
a) 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.
(Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+
b) A telecommunications system for monitoring and counseling patients with hypertension –
impact on medication adherence and blood pressure control (Friedman et al, 1996). Level
of evidence: 1+
c) Review of computer-generated outpatient health behavior interventions: clinical
encounters “in Absentia” (Revere and Dunbar, 2001). Level of evidence: 1+
Grade of Recommendation: B
Practice Recommendation 8:
There is limited and consistency evidence of the nature of adjunct automated telephone care in
chronic diseases outpatient management, in regards of (1)duration (2)frequency (3)patient-
initiated or calls outbound etc.
Supporting evidence:
a) 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.
(Piette, Weinberger, Kraemer and McPhee, 2001), Level of evidence: 1+
b) A telecommunications system for monitoring and counseling patients with hypertension –
impact on medication adherence and blood pressure control (Friedman et al, 1996). Level
of evidence: 1+
c) Do Automated Calls with Nurse follow-up improve self care and glycemic control among
vulnerable patients with Diabetes? (Piette et al, 2000). Level of evidence: 1+
Grade of Recommendation: B

Implementation
Before implementation of guidelines, using Iowa Model of evidence-based practice to promote
quality care, consideration if the research base if sufficient is important (Titler et al, 2001). In
this research review, the research base is definitely insufficient. There is limited evidence from
systematic reviews to demonstrate effectiveness of adjunct automated telephone care.1 RCT
done on hypertension population and 2 RCTs on diabetes population. Besides, RCT on
hyperlipidemia population has not been evaluated due to the article unavailability. A research on
adjunct automated telephone care to usual care should be done locally on these 3 populations,
gathering expert opinions and determining scientific principles before implementation of
guidelines.

Before the full implementation of guidelines, an action plan for piloting the evidence-based
practice has to be drawn. The action plan involves mainly identifying (1)practice setting,(2)staff
involved, (3)targeted patient population, (4)one or more units with a small number of patients
and (5)indicators that evaluate the process and outcomes of the pilot trial (Titler et al, 2001). A
team of dedicated people from different organization levels within an institute is necessary to
draw up the action plan, as different perspectives on the barriers for the whole implementation
process are necessary.

For this assignment, XXX polyclinics will be chosen as the unit for pilot change due to the
smallest amount of chronic diseases patients among the 9 polyclinics. The targeted patient
population will be patients with hypertension. For diabetes population, though the advantage of
using HbA1C% as an outcome indicator, which is less fluctuant and operator-dependent
compared to blood pressure, assessment of health status and education are longer due to a larger
number of items to cover (see Table 7). The reason for not considering hyperlipidemia
population is the lack of studies done around the population group.
Diabetes Hypertension
Disease knowledge Disease knowledge
Medication knowledge and side effects Medication knowledge and side effects
Diet – low carbohydrate, high fibre, low fat and low Diet – low fat and low salt
free sugar Self-care Behaviors
Self-care Behaviors - Blood pressure monitoring
- Glucose monitoring - Medication adherence
- Medication adherence - Diet adherence
- Diet adherence - Annual blood screening for cholesterol and kidney
- Foot inspection function
- Usage of screening services – eye screening, foot
screening, annually blood screening for cholesterol
and kidney function
Table 7: Education and Assessment components for Diabetes and Hypertension groups
The consideration of considering the number education and assessment components is important
when structuring the adjunct automated telephone care. Care managers, or expert nursing
opinions in hypertension disease management have to be considered or involved in structuring
the automated telephone care conversations and infrastructure. Telecommunications experts,
dietician, family physicians, care managers and policy administrators are people involved in the
team to structure the automated telephone care infrastructure. Another team will be formed to see
to the implementation process.

Strategies for promoting Change

Adopting a new practice into the practice area can be facilitated through mainly in the following
5 areas (Titler et al 2001). (1) organization support (2) education to staff on the usage of adjunct
automated telephone care and promoting this usage to patients involved (3) ownership of the new
practice by nurses and all affected disciplines from family physicians, to the administrative staff
of the polyclinics (4) perception by staff that the introduction of this adjunct automated telephone
care improves quality of care and (5) perception by staff that it is the right time to carry out this
change.

In the above 5 areas, the art of dealing with people and communication hold the key to success.
Viewing evidence-based practice, which is implementation of adjunct automated telephone care
in chronic disease management, as an innovation in this assignment, Rogers’ model of diffusion
of innovation can serve as a conceptual guide to design interventions to promote the rate and
extend of the evidence-based practice adoption (Titler and Everett, 2001 and Berwick, 2003).
According to this model, 2 important components affect the diffusion of “new practice”, the
nature of the “new practice” and the manner in which the “new practice” is communicated to the
members of the social system in other words the people involved.

Nature of the Innovation

Before adopting the adjunct automated telephone care, careful considerations of the nature of this
“new practice” on its credibility, localization of guidelines and use of practice prompts from both
the staff and the patients’ perspectives are important (Titler and Everett, 2001). The less complex
or more user-friendly this adjunct automated telephone care is and the more credible that this
practice can result in improvement of health status will ensure faster adoption and adherence.
Localization of guidelines is definitely necessary and might even be appropriate to adapt the
guidelines for each disease group, e.g. the difference in the frequencies of calls for patients with
different chronic diseases or in terms of their severity of illnesses. Finally practice prompts for
the new practice have to be simple to read and understandable for both patients and staff.
Publicity in terms of posters containing essential practice prompts with a “catchy slogan”, “Dial
for Health”, can be placed around the premise of the polyclinics for the patients. For the nurses,
decision making algorithms might be useful in selecting the patients to be under the adjunct
automated telephone care and the frequencies to instruct patients to call. Having computerized
prompting to the family physicians to send the patients to the nurse might also be useful. Finally,
user-friendly and easy to read pamphlets in all 4 languages have to be designed for patients to
bring home to facilitate usage.

Communication of Innovation
The 2nd component is the communication of innovation. Methods of communication include
educating, use of opinion leaders, change champions, core groups and outreach visits (Titler and
Everett, 2001).

The aim of the education intervention is to educate the staff involve in using the automated
telephone care and obtaining patients’ reports from the adjunct automated telephone care service.
Besides that, educating staff in “selling” the practice to the patients and encourage their usage
will be part of the learning objectives of the teaching session. The decision on the instructor,
learning materials, education strategies, number of students, venue and duration of teaching
session has to be carefully considered. Printed materials in form of “visuals”, e.g. small tabletop
cards or bookmarks with the instructions for usage are strongly encouraged.

Careful selection of opinion leaders, change champions and core groups is important for the
success of practice adoption. The process of change is difficult and resistance against change will
definitely be present. Opinion leaders, change champions and core groups have to consist of
people that are dedicated to make things work and believe in the implementation of the new
practice. All of them should not only have the passion in raising the quality of care but also
working with people. In summary, opinion leaders, change champions and core group have to
people who belong to the early adopters group in order to move the diffusion of practice
(Berwick, 2003).

Evaluation
Process Evaluation
Titler (2002) commented that process evaluation include (1) measuring implementation and
adherence to the practice by the written evidenced-based practice standard (2) noting the barriers
the staff encountered in the practice (3) differences in opinions among the health care providers
and (4) difficulty and carrying out the steps of the practice originally designed. Using Rogers’
diffusion of innovation model when considering the indicators to evaluate process, the process
evaluation can be divided into mainly 2 parts evaluating the rate of adoption (adherence) and the
extent of adoption (Titler and Everett, 2001). The following are some of the indicators for
process evaluation:
Proportion of patients documented in the medical records to have being educated on the use of
the adjunct automated telephone care.
• Proportion of patients that use the adjunct automated telephone care.
• Proportion of doctors that referred patients to the nurses for adjunct telephone care
introduction and education.
• Survey among the nursing staff and family physicians on the usage of the adjunct
automated telephone care covering the following:
 satisfaction on this automated telephone care in improving their patients’
outcomes
 self-reported stage of adoption and degree of adherence
 barriers to adoption and adherence of practice

Outcome Evaluation
Outcome indicators measured should be those initially set to change when introducing the
adjunct automated telephone care, which in this case, the most importantly is patients’ with
chronic diseases physiological, psychological outcomes and self-care behaviors (Titler, 2002).
Next, the cost-effectiveness or “savings” from which this new practice can bring. It is therefore
important to collect pre-implementation and post-implementation data for comparison. Using
consistency and reliable measuring tools throughout the 9 polyclinics is a criterion for just
comparison. The following are the outcome indicators for evaluation:
Hypertension Population
Physiological Data
• Systolic and Diastolic blood pressure
• Weight and BMI
Self-Care Behaviors
• Medication adherence
• Annual blood check
• Low salt and low fat diet adherence
Diabetes Population
Physiological Data
• HbA1C%
• Serum blood glucose
• Weight and BMI
Self-Care Behaviors
• Medication adherence
• Foot inspection
• Diet adherence – low CHO, low sugar, low fat and high fiber
• Usage of specialty services – foot screening, eye screening and annual blood test
Hyperlipidemia Population
Physiological Data
• Low-density lipoprotein levels
• High-density lipoprotein levels
• Triglycerides
 • Weight and BMI

Self-Care Behaviors
• Medication adherence
• Low-fat diet adherence
Psychological Data for all 3 Populations
• Depression Score
• Self-efficacy scoring
• Satisfaction with Care survey
• Quality of Life Survey
Cost Analysis

Conclusion
Adjunct automated telephone care has limited evidence in clinical benefits. The decision to
implement or even do a pilot project has to be carefully balanced against the cost of building the
telecommunication infrastructure. From the writing of this assignment, it has only made the point
clearer that passion for commitment and a team effort is needed to have an evidence-based
culture in the workplace. Only a team effort with a dedicated purpose can not only provide
holistic view of the whole process of evidence-based practice from deciding the topic, to
literature review, doing systematic review, drawing out the guidelines, piloting the change,
implementing the change and evaluating the process and outcome.
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