Patient Preference and Satisfaction with the Use of Telemedicine for Glycemic Control in Patients with Type 2 Diabetes: A Review

Figures & data

Table 1 Summary of Individual Studies

Study	Analytical Approach	Patients Characteristics	Type of Telemedicine	Satisfaction	Preference
Yip et al, 2002 (Hong Kong)^Citation17	Questionnaire	T2D patients recruited from diabetic center of a district hospital Age: 56 years Diabetes duration: 1.7 years	Telemedicine	61.9% patients reported high satisfaction with TM. They felt that TM was time saving and provided a consistent and high quality of education. Older patients had a higher satisfaction with TM. The lack of a perceived need to have assistance while using TM and the perceived ability of TM to meet healthcare needs were the most important predictors of satisfaction. Some patients perceived the need of assistance while using TM. There was some uncertainty on whether the diabetes nurse specialist understood or attended to the patient’s healthcare needs.
Long et al, 2005 (USA)^Citation18	Interview	T2D patients recruited from general practice Age: 69 years	Telecarer (Proactive call-center treatment suppose (PACCTS))	80% patients indicated expectations had been met totally, especially younger patients, 90% of them were satisfied with recommendations by telecarers. PACCTS improved knowledge of diabetes, control, and general well-being. Younger patients felt that they were more knowledgeable and in control.	Patients preferred staff to be knowledgeable, caring, and friendly. They preferred regular contact to reduce feelings of isolation. Personalized expert advice with pertinent questions could help patients in establishing realistic goals. They preferred personalized TM advice tailored to their lifestyles (eg, shift work or exercise regimen).
Wade'Vuturo et al, 2012 (USA)^Citation25	Focus groups or survey	T2D recruited from primary care clinic Age: 57.1 Diabetes duration: 8 years	Secure messaging (SM) within patient portal	Patients were satisfied with SM for their administrative purposes, time-saving component, and multiple communication options with quicker response. SM was able to retain messages for future reference. SM enhanced efficiency and quality of face-to-face visits and provided access to clinical care outside of traditional face-to-face visits. Patients were dissatisfied with SM, for not receiving response to patient-initiated message.	Patient assumed clinicians to be resistant to technology, to be interrupted by SM, and not be reimbursed by using SM. Patients preferred clinicians to recommend and talk about SM.
Rho et al, 2014 (South Korea)^Citation26	Survey	T2D patients who used telemedicine services Age: 79% >50 years	Web-based telemedicine with blood glucose and pressure devices	Patients reported high satisfaction with the compatibility, ease of use, intimacy, and usefulness of TM. Income level was an important variable for overall satisfaction.	Patients preferred tailored interactions for targeted users, eg, older, less experienced users.
Siminerio et al, 2014 (United States)^Citation16	Questionnaire	Rural T2D patients recruited from rural clinic Age: 62.4 years Diabetes duration: 12.4 years	Videoconferencing (Telemedicine for Reach, Education, Access, and Treatment (TREAT))	Patients were highly positive with video conferencing treatment. Nurse services improved patient’s engagement and their health was better than before receiving video conferencing.
Georgsson and Staggers, 2015 (USA)^Citation19	Satisfaction (System Usability Scale [SUS])	T2D recruited from metropolitan primary care clinic Age: 50–69 years Diabetes duration: 60% ≥5 years	mHealth SMS with web portal	Patient’s overall satisfaction was good, although they indicated usability of the app could be improved. Males, those with more IT experience and younger patients performed slightly better, they had higher satisfaction scores and SUS scores.
Ronda et al, 2015 (Netherlands)^Citation39	Questionnaire	81.8% T2D patients recruited from patient web portal Age: 59.7 years	Diabetes patient web portal	Patients indicated portal as easy to use and login, they were satisfied with the layout, as the overall information was comprehensible including meaning of laboratory values, abbreviations used, and reasons for clinic appointments. They appreciated the function to read information discussed during consultations and access to laboratory values and treatment goals at homes. Patients gave negative scores for portal in supporting lifestyle changes.	Patients preferred to add injected insulin units to the glucose diary, to receive updates with current medical information about diabetes and to use the portal for supporting diabetes care, like scheduling a clinic visit. They preferred reminder functions for upcoming visits, information on medications and side-effects, and automatic upload of readings from glucose meters.
Welch et al, 2015 (USA)^Citation40	Questionnaire	African American T2D patients recruited from urban community health center Age: 60.6 years Diabetes duration: 62.1% ≥5 years	Diabetes remote home monitoring device with electronic pillbox, blood glucose and pressure monitor	90% patients strongly agree with pillbox’s ease of use, helpfulness in organizing medications, ability to fit into routines, convenience of storage at home, and the ease of refilling. 88.8% and 84% patients were satisfied with BG meter and BP cuff. They “strongly agree” and “somewhat agree” for items assessing their happiness with device training, support from diabetes team, and the amount of time from nurse calls.
Andrews et al, 2017 (USA)^Citation35	Interview	Veterans Affairs men with persistent poorly controlled diabetes mellitus Age: 60 years Diabetes duration: Poorly controlled diabetes >1 year	Telemedicine/telehealth with advanced comprehensive diabetes care	5 out of 18 patients were willing to continue TM. They were more aware of glucose fluctuations and they monitored their conditions more frequently. TM provided accountability and motivation for self-monitoring, with personalized education from TH nurse to establish new routines. Some patients claimed that TM reporting did not fit into daily routines. The length of TM calls was extended by repetitive computerized recommendations and patients had to repeat entries when values were incorrect. Inconvenience and stress were encountered by patients while using TM interface. Other competing demands (comorbid illness, physical injuries, medication side-effects) limited patient’s engagement with intervention.	Patients preferred more flexibility in using TH, such as entering >1-day readings at a time rather than telemonitoring daily, or, report via alternate device for those whose work environment did not accommodate regular use of phones. They preferred omission of automated recommendations.
Adu et al, 2018 (Australia, Europe, Asia, and US)^Citation32	Questionnaire and telephone interview	T2D (61.8%), mHealth user (48.8%) and non-user recruited online Age: 44.65 years Diabetes duration: 1–5 years	mHealth		Patients preferred apps with foods nutrient information (56.7%), glucose tracker (54.8%), physical activity tracker (47%), and health trend visual analytics (42.9%). They also preferred an app that provides general diabetes education (40.6%) or personalized education. Apps for social networking among people with diabetes had the lowest rating for usefulness. Factors for long-term engagement with apps were improved functionalities (new recipes, actionable goals with reminder), ability to turn off and attend to prompting at convenient time, consolidated features from peripheral devices, ability to save and display previous data, and provision of problem-solving suggestions.
Gabarron et al, 2018 (Norway)^Citation20	Questionnaire	T2D patients recruited through social media channels of the Diabetes Association Age: 40.2% 45–64 years	Tele-education (health-promotion intervention)	Patients rated quality of diabetes-related information on social media with an average rating of 62.0. The average satisfaction rate with the diabetes-related content on social media was 61.9.	Patients preferred content on tele-education that included research and innovation on diabetes and personal or technical aspects of self-management. Women preferred interviews or personal stories from other patients. Text format for tele-education was the most preferred format (almost all adults), followed by images (users 18–29 years old) and videos (users <18 years old). Patients preferred frequency of contact “more seldom” over “several times per day”.
Lee et al, 2018 (UK)^Citation12	Interview	T2D patients who are new and used telehealth for some time Age: 62.6 years Diabetes duration: 4–33 years	Telehealth	Overall, patients were satisfied, and they viewed TH as a monitoring service. TH was well received and preferred compared to traditional consultation as it was safer and improved access to care. There was no concern on TH use but they did not view TH as a complete substitute to traditional consultations, especially not for discussing serious health issues. They were satisfied with the simplicity of use of TH, but were concerned with repeated alerts and question restrictions. They highly valued TH for 24/7 presence, health monitoring, provision of advice, and address of concerns and health status. There was a reduced need to travel, with health status being confirmed at home and reduced need of using emergency/hospital services. TH was quick to contact patients through TV message or ringing. The TH reminders and re-enforcing messages were highly valued. Patients with mobility problems favored TH for easy access to doctor, time-saving, and decreased risk of contracting germs. The daily information increased patient’s knowledge while health trend analysis improved their self-reflection. This increased patient’s confidence in managing their condition and they became more careful with diet. Only 1 out of 10 patients concerned with privacy issues. Some patients were not satisfied with the continuity of care. Some patients got worried when their readings were out of range.	Patient’s concerns were dismissed after demonstration and explanation. Patients preferred delivery of consistent quality of care, better communication between telehealth care members, and prompt home visits by matrons. Patients preferred face-to-face consultation for more serious health concerns and with doctors whom they are familiar with.
Veazie et al, 2018 (USA)^Citation21	Review	T2D patients Age: 48–55 years	Mobile app	Patients were generally satisfied with mobile apps.
Baptista et al, 2019 (Australia)^Citation31	Survey	T2D patients recruited online Age: 58 years Diabetes duration: 10 years (14% diabetes app users, 61% lower socioeconomic area)	Mobile app		Patients preferred apps that track “as much as possible” for long time to see the “big picture”, with greater ability to personalize glucose level tracking using presentation that is easy to understand, with automated personalized diabetes coaching, with reminders including exercise reminders, with automated upload and linking of data to devices, with option to share with GPs and with integrated data sources (food diaries, physical activity, stress, mood, blood pressure, and clinical test results). They preferred readings to be analyzed and interpreted, with actionable recommendations including meal suggestions. Patients preferred provision of ongoing motivation, eg, visual reward with happy face sticker and they disliked simply being patronized. They also preferred support for stress management and well-being.
Jeffrey et al, 2019 (Australia)^Citation22	Interview	Rural T2D smartphone user recruited online with app and non-app user Age: 40% 60–69 years	Mobile app	App perceived to be useful and majority would recommend it. App-specific facilitators include being user-friendly (easy navigation, clear designs, intuitive), convenient (ease of glucose monitoring, inbuilt exercise technology, time taken to use) and features (BGL connectivity with glucometer, food calculator, visual graph trends of BGLs). User-specific facilitators include personal, social factors, and health or technical literacy. Many were open to the idea of using an app as there were more interactions with healthcare professionals. Recommendations by healthcare professionals were well received. Others stated that they would use app if their GP recommended it, especially the elderly. Healthcare professionals discussing app use with patients encouraged patient’s self-reflection on diabetes management. App-specific barriers included technological issues of app failing to work (connectivity and navigation issues) and initial setup issues such as different measurement units, cost of app, and font size. User-specific barriers included patient’s feeling of not needing an app. Some were used to the old way and felt that their diabetes was “not bad enough” and current care was sufficient. Some did not know about the available apps. Some patients had self-perception of poor technological literacy due to old age, negative attitudes, and lack of desire to learn. There were not enough GP recommendations, patients thought GP would not have time/interest, or unfamiliar with technology.	Patients preferred educational component as part of the app, preferred topics included diabetes-related complications and hypoglycemia. They preferred information from other sources rather than in-app educational features. Patients also preferred BGL monitoring with trends paired with dynamic tips. Additional self-management tasks such as blood pressure and weight monitoring, activity tracking and reminders for exercise and appointments could be included. Nutritional features including carbohydrate calculators, diabetes meal recipes and recommendations were welcomed. They also preferred an app that allows medication list to be uploaded and provides reminders for new prescriptions. Patients indicated weekly text messaging as an appropriate timeframe with a preference for customization features such as personalized diabetes information.
Lee et al, 2019 (Malaysia)^Citation23	Interview	T2D patients recruited from primary care Age: 51.9 years Diabetes duration: 5.6 years	Telemedicine	Overall, patients reported a positive response toward TM.	Elderly preferred to record blood glucose manually, as they could interact with doctors. They preferred someone to show them how to use TM. Younger patients preferred more guidance and education on how to use TM platform. Data sharing, while it could improve monitoring by TM staff, caused anxiety over privacy issues. Face-to-face information was preferred as patients felt that it was more personal.
Rodriguez-Fortúnez et al, 2019 (Spain)^Citation24	Questionnaire	Urban T2D elderly recruited from primary care Age: 60.3 years Diabetes duration: ≥1 year	Telemedicine	70.5% patients were satisfied with the use of TM. They perceived that TM was able to reduce healthcare resource use including visits to the healthcare professionals, emergency room, and pharmacy, and time per visit. 72.5% patients claimed that they would participate again in another TM study. Patients felt that TM improved their T2D management aspects including disease knowledge, non-adherence issues, lifestyle changes, glycemic control, prevention of hypoglycemia, and quality-of-life. Patients with prior experience of using TM had a more positive perception of the benefits of TM and the most highly valued content was medication-related information.	Patients preferred online TM platforms to be supervised by healthcare professionals, which allows for synchronous communication with the medical team. This could be in the form of a mobile app or SMS/WhatsApp messages. Patients indicated that TM could be improved by the provision of more explanations, more interaction with medical team, less time required for recording/transferring data, better content, more devices available, increased access to devices, extra interaction with other patients, and better app design. Most common search on TM was T2D-related complications.
Torbjornsen et al, 2019 (Norway)^Citation29	Interview	T2D patients recruited from primary healthcare setting Age: 61 years Diabetes duration: 1–5 years	Mobile phone-based diabetes diary app	User acceptability diverged. Patients found it easier to follow healthy lifestyle and thus better glucose control. Using the app was no effort to patients with easy accessibility to app with easy notetaking, automatic transmission and organization of readings using graphs. Patients could understand test results and causality. They were able to understand their conditions, and thus felt in control and were able to make decisions about self-management. Having readings on smartphone acted as reminders for some patients to ask diabetes-related questions during consultation with healthcare personnel. Some patients claimed that diabetes diary required hard work to manually enter measurements. The constant reminder could be stressful, and patient’s poor health might limit their ability to perform physical activities. They were sometimes dissatisfied with lack of usability of the smartphone (technical problems, smartphone size, extra costs with data traffic and multiple devices). Patients found it burdensome to interpret data patterns and perceived app was of no interest to GP. Some thought that self-management using app was a minor topic.	Patients preferred a more usable technology, freedom of choice, features of reminders and automatic tracking. The ability to send data to healthcare personnel was a strong incentive to establish routine. Patients preferred interpretative support from app such as additional knowledge about how to control BGL, extra educational content in the app, such as a manageable menu and more detailed feedback on physical activity. Patients appreciated getting app at an earlier stage of the disease to gain more benefits from interactions with staff. They preferred to discuss the findings with healthcare personnel, make future health-related plans, and obtain verifications of their interpretation. Patients hoped to receive more support from healthcare personnel on medication usage, to understand how to stabilize blood glucose, and exchange data within the app with healthcare personnel between consultations, in order to challenge themselves on maintaining a healthy lifestyle. Patients preferred more frequent telephone contact between visits.
Buysse et al, 2020 (Belgium)^Citation30	Questionnaire	12% T2D patients recruited online Age: 37.5 years	Telemedicine tele-education with data transmission with personal message	Patients were satisfied with the tele-education and would recommend it. The reasons for adding tele-component were “a wish for a new boost” in therapy, improving personal time management, and to receive more frequent feedback and contact. They were satisfied on receiving positive feedback on time agreed upon. Some patients however were highly content with traditional face-to-face treatment.	Patients indicated that tele-education should not be based on fixed moments as at times patients were in need of more frequent feedback. Further research should focus on the possible influence of life changes and more feedback via tele-education, and consequently on the provision of mobile platforms adaptable to patient’s life changing situations.
Gordon et al, 2020 (USA)^Citation27	Telephone interviews	T2D patients recruited from rural community-based outpatient clinics Age: 66 years	Clinical video telehealth (CVT)	Patients expressed satisfaction with better access to appointments, shorter travel time, and less time in the waiting room. Patients were concerned about: 1) errors in care because of perceived difficulty completing the physical exam; 2) perceptions that providers paid less attention to them; 3) barriers to speaking up and asking questions; and 4) difficulty establishing a provider–patient relationship.	Patients preferred having extra CVT personnel in the room, eg, nurse, as another set of ears. Patients preferred clinicians to provide “webside manner” and enough eye contact.

Abbreviations: SMS, short message service; T2D, type 2 diabetes; TH, telehealth; TM, telemedicine; IT, information technology; app, application; BGL, blood glucose level; GP, general practitioner; UK, United Kingdom; US; United States; BG, blood glucose; BP, blood pressure; SM, secure messaging.

Figure 1 PRISMA flow diagram for literature search process.

Table 2 Affinity Matrix

Major Themes	Study Reference Number	Frequency
Patient satisfaction
Round the clock access and monitoring	[^Citation12,Citation22,Citation23,Citation25,Citation29^–^Citation32]	8
Access to different healthcare providers	[^Citation12,Citation22,Citation24,Citation25,Citation27,Citation29]	6
Time-saving	[^Citation12,Citation17,Citation24,Citation25,Citation27]	5
Patient preferences
Education and empowerment	[^Citation12,Citation17,Citation20,Citation22^–^Citation24,Citation26,Citation29^–^Citation31,Citation35,Citation39]	12
Support team	[^Citation16,Citation18,Citation20,Citation24,Citation27,Citation29,Citation31,Citation32,Citation40]	9
Flexibility	[^Citation18,Citation20,Citation22,Citation24,Citation29^–^Citation31,Citation35]	8
mHealth the choice	[^Citation22^–^Citation24,Citation29^–^Citation32]	7
Physician endorsement	[^Citation22,Citation25,Citation29]	3

Figure 2 Preferences for telemedicine among people with type 2 diabetes.

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