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Journal ArticleDOI

Parental evaluation of a telemonitoring service for children with Type 1 Diabetes

TL;DR: A high number of parents appreciated the telemonitoring service and were confident that it could improve communication with physicians as well as the family’s own peace of mind.
Abstract: IntroductionIn the past years, we developed a telemonitoring service for young patients affected by Type 1 Diabetes. The service provides data to the clinical staff and offers an important tool to ...

Summary (3 min read)

Introduction

  • Technology for managing Type 1 Diabetes Mellitus (T1DM) has deeply evolved over time.
  • The patient is still responsible for adjusting his therapy considering external events (e.g. meals, physical exercise, stress, etc.) and large research efforts have been recently directed to develop an Artificial Pancreas (AP), a system for automating BGL control via closed-loop insulin modulation based on CGM readings [3, 4].
  • One of the main fears felt by parents is the occurrence of hypoglycemia episodes.
  • Thus the daily management of the disease negatively affects both children and parents: the former mainly face physical and emotional effects [6], while the latter, in addition to the emotional concern, suffer three different stress levels.

The Telemonitoring Service

  • The TM service, on which this manuscript focuses, is implemented as a web application that was made available to each parent, allowing him/her to oversee his/her child during the camp.
  • It offers a summary of the child conditions in the upper left panel by reporting the most relevant information: the last BGL reading, its trend and a hypo-/ hyper-risk assessment.
  • The central panel includes a chart with a number of physiological variables, including: glucose concentration measured by the CGM every 5 minutes, insulin delivery rates, meal intake, and risk assessments throughout the period displayed.
  • Alternate views, selectable through tabs, offer textual information not suitable for charting (e.g. settings, logs, messages, etc.).
  • The TM service was also used by the study team to monitor in real-time the trial, allowing a comprehensive data collection and analysis and providing a valuable support for therapy adjustments.

The Clinical Trial

  • Data analyzed in this paper were collected during a randomized crossover clinical trial assessing the effectiveness of BGL control achieved through the use of an AP in pediatric prepubertal patients.
  • Considering previous studies [20, 21, 22, 23], this was the first time that a closed-loop insulin therapy, based on the Modular Model Predictive Control algorithm [24, 25], was compared to the manually controlled therapy in prepubertal children.
  • As soon as the patients were admitted at the camp, they were randomly assigned to one of the two groups: one group used the AP in the first part of the study and the manually controlled therapy in the second, while the other group did the opposite.
  • Both study parts lasted for 3 days (72 hours) and were separated by a 1-day wash-out period.
  • The 31 children enrolled in the clinical trial were accompanied by 21 single parents and 10 parent couples.

The Survey Questionnaires

  • To assess the users’ perception of the service, two questionnaires were proposed to the parents attending the camp: a first one just before starting to use the AP system with the associated TM service and a second one after having experimented its use.
  • The main purpose of this questionnaire, was the definition of a baseline for the feelings related to the daily management of diabetic children and for the impact of the disease on the Perceived Quality of Life (PQL).
  • The post-study questionnaire, 27], aimed to capture the parents’ perception about the usefulness of the TM service.
  • Statistical Analysis on questionnaire data Questionnaire responses were analyzed using the R statistical tool [29].
  • Baseline vs. post-study comparisons of numerical values were performed using the Wilcoxon test for paired data.

Results

  • Overall 41 baseline and 38 post-study questionnaires were collected.
  • That difference is due to one child dropping out and some parents of children in the second arm leaving the camp soon after the closed-loop session and before questionnaires administration.

Baseline questionnaire analysis

  • Classification of the responses into positive (”Never” or ”Rarely”) or negative (”Sometimes”, ”Often”, ”Very Often”) tendencies revealed nearly equal distributions (49% positive tendency; 51% negative tendency).
  • Figure 2 provides a general overview of the positive responses, stratified according to four explanatory variables.
  • Responses provided by fathers and mothers did not show any statistically significant difference.
  • Finally, parents pointed out fatigue as one of the most severe consequences of managing diabetes every day, together with the continuous rapid change of their children’s health status (questions 1d and 1f).
  • In the second section, parents were asked to rate their PQL on a 0-100 scale.

Post-study questionnaire analysis

  • In the first section parents were asked to assess whether TM could improve the communication with the health care staff.
  • Overall the authors observed that in 85% of the responses they expressed their agreement, in 12% they expressed neutrality and only in 3% they expressed disbelief.
  • Concerning the willingness to pay, the median value is 200 euro/year, ranging from 0 to 3000 euro/year.
  • Parents were asked to repeat Section 1 of the baseline questionnaire after experiencing the TM service, indicating if its use could improve, worsen or was irrelevant for each of the 8 items previously answered.
  • Parents’ ”fatigue”, which emerged through the baseline questionnaire as the worst effect of diabetes management, was considered the most improvable item through a daily usage of the TM.

Parental Evaluation of a Telemonitoring Service 5

  • The mean value was 78.39, which was significantly higher than in the baseline questionnaires (pvalue=0.0001).
  • PQL improvement was significantly correlated with responses to questions ”The authors family gives up a lot of things (e.g. travelling together for long periods)” (4a; pvalue=0.01), ”We give up seeing family and friends” (4g; p-value=0.01) and ”We do not have much desire to go out” (4h; p-value=0.05).the authors.the authors.
  • A stepwise multiple regression analysis identified improvements in 4a and 4g as the only independent factors positively affecting PQL (multiple R squared=0.32).
  • This is explained by the highest correlation found between questions 4a and 4h (p-value<<0.05).
  • Finally, comparing the sentiment analysis scores achieved by processing the comments in the free text sections in both questionnaires, the authors found a significant decrease of negative scores (median and quartiles of the difference between positive and negative scores: -1[-2;0] baseline; 1[0.75;2] post-study; p-value=0.028).

Discussion

  • Technology presently offers solutions supporting remote monitoring and patient education in the disease’s management [31, 32].
  • Studies focusing on the parents’ feelings identified three different stressful conditions: (a) low self-efficacy in helping with the disease, (b) the occurrence of hypoglycemia events, and (c) their responsibility in the overall management of diabetes [33].
  • This may be due to the increased serenity felt by parents if children are visited face-to-face.
  • To sum up, despite their study highlighted some skepticism about the usefulness of the TM service by some parents, it also showed their interest in using it as a means of improving the management of T1DM and the communication with the health care staff.
  • Due to this limitation, the perceived usefulness measured during this trial may not be directly correlated with the actual one.

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Parental Evaluation of a Telemonitoring
Service for Children with Type 1
Diabetes
Journal Title
XX(X):17
c
The Author(s) 2016
Reprints and permission:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/ToBeAssigned
www.sagepub.com/
E. Losiouk
1
*, G. Lanzola
1
*, S. Del Favero
2
*, F. Boscari
3
, M. Messori
4
, I. Rabbone
5
, R.
Bonfanti
6
, A. Sabbion
7
, D. Iafusco
8
, R. Schiaffini
9
, R. Visentin
2
, S. Galasso
3
, F. Di Palma
4
, D.
Chernavvsky
10
, L. Magni
4
, C. Cobelli
2
*, D. Bruttomesso
3
, S. Quaglini
1
*
Abstract
Introduction: In the past years, we developed a telemonitoring service for young patients affected by Type 1 Diabetes.
That service provides data to the clinical staff and offers an important tool to the parents, that are able to oversee in
real time their children. The aim of this work was to analyze the parents’ perceived usefulness of the service. Methods:
The service was tested by the parents of 31 children enrolled in a seven-day clinical trial during a summer camp. To
study the parents’ perception we proposed and analyzed two questionnaires. A baseline questionnaire focused on
the daily management and implications of their children’s diabetes, while a post-study one measured the perceived
benefits of telemonitoring. Questionnaires also included free text comment spaces. Results: Analysis of the baseline
questionnaires underlined the parents’ suffering and fatigue: 51% of total responses showed a negative tendency and
the mean value of the perceived quality of life was 64.13 in a 0-100 scale. In the post-study questionnaires about
half of the parents believed in a possible improvement adopting telemonitoring. Moreover, the foreseen improvement
in quality of life was significant, increasing from 64.13 to 78.39 (p-value=0.0001). The analysis of free text comments
highlighted an improvement in mood, and parents’ commitment was also proved by their willingness to pay for the
service (median=200 euro/year). Discussion: A high number of parents appreciated the telemonitoring service and
were confident that it could improve communication with physicians as well as the family’s own peace of mind.
Keywords
Home telecare; ehealth; Self care; Telemedicine; Telemetry
Introduction
Technology for managing Type 1 Diabetes Mellitus (T1DM)
has deeply evolved over time. Patients check their Blood
Glucose Level (BGL) concentration either taking finger
pricks or using minimally invasive subcutaneous sensors
for Continuous Glucose Monitoring (CGM) [1]. Insulin that
was once administered only through regular injections may
now be continuously delivered also in subcutaneous tissues
using wearable pumps [2]. Despite the advances in diabetes
technology, the patient is still responsible for adjusting his
therapy considering external events (e.g. meals, physical
exercise, stress, etc.) and large research efforts have been
recently directed to develop an Artificial Pancreas (AP), a
system for automating BGL control via closed-loop insulin
modulation based on CGM readings [3, 4].
In case of pediatric patients T1DM poses additional
challenges. The young age of those patients causes a great
concern in parents, especially when children are away from
home and manage the treatment on their own [5]. One of the
main fears felt by parents is the occurrence of hypoglycemia
episodes. Those may quickly develop as the result of a poor
management when the child is at school or practicing sports.
Thus the daily management of the disease negatively affects
both children and parents: the former mainly face physical
and emotional effects [6], while the latter, in addition to
the emotional concern, suffer three different stress levels.
At the lowest one the causes are the everyday activities
aimed at improving the children’s health care; the medium
stress level develops as the parents realize that T1DM is a
constant element affecting family life and decisions; finally
at the highest level is the traumatizing experience occurring
*
Authors equally contributed to this study.
1
Department of Electrical, Computer and Biomedical Engineering,
University of Pavia, Pavia, Italy
2
Department of Information Engineering, University of Padova, Padova,
Italy
3
Unit of Metabolic Diseases, Department of Internal Medicine-DIMED,
University of Padova, Padova, Italy
4
Department of Civil Engineering and Architecture, University of Pavia,
Pavia, Italy
5
Department of Pediatrics, University of Torino, Torino, Italy
6
Pediatric Department and Diabetes Research Institute, Scientific
Institute, Hospital San Raffaele, Milano, Italy
7
Regional Center for Pediatric Diabetes, Clinical Nutrition & Obesity,
Department of Life & Reproduction Sciences, University of Verona,
Verona, Italy
8
Department of Pediatrics, Second University of Napoli, Napoli, Italy
9
Unit of Endocrinology and Diabetes, Bambino Gesu’, Children’s
Hospital, Roma, Italy
10
Center for Diabetes Technology, University of Virginia, Charlottesville,
VA, USA
Corresponding author:
Eleonora Losiouk Department of Electrical, Computer and Biomedical
Engineering University of Pavia Via Ferrata 5, 27100 Pavia, Italy
Email: eleonora.losiouk01@ateneopv.it
Prepared using sagej.cls [Version: 2015/06/09 v1.01]

2 Journal Title XX(X)
whenever any complication develops in children [7]. Parents
may also feel guilty about the appropriateness of the care
they are giving to their children [8] and get anxious or even
depressed for that situation [9].
Telemedicine, that is being increasingly adopted for the
provision of medical services to outpatients [10, 11, 12], may
be leveraged for mitigating the abovementioned problems
[13]. In this paper we evaluate the parents’ perception
of a telemedicine service, notably a telemonitoring one
(TM), that is able to oversee in real time the physiological
parameters of their children when they are not under their
direct control, such as when they are away from home or
overnight. This kind of service has been offered to parents
of T1DM children enrolled in a clinical trial accomplished
during a summer camp held in 2015 [14] and aimed at
controlling BGL through the use of an AP system on
children.
Methods
The Telemonitoring Service
The TM service, on which this manuscript focuses, is
implemented as a web application that was made available to
each parent, allowing him/her to oversee his/her child during
the camp. The TM main screen is shown in Figure 1. It offers
a summary of the child conditions in the upper left panel
by reporting the most relevant information: the last BGL
reading, its trend and a hypo-/ hyper-risk assessment. The
central panel includes a chart with a number of physiological
variables, including: glucose concentration measured by the
CGM every 5 minutes, insulin delivery rates, meal intake,
and risk assessments throughout the period displayed. It
is possible to choose which variables to display using
the checkboxes above the panel. The chart also depicts
information about devices’ functioning (e.g. closed-loop,
open-loop, etc.). Alternate views, selectable through tabs,
offer textual information not suitable for charting (e.g.
settings, logs, messages, etc.). The TM service was also used
by the study team to monitor in real-time the trial, allowing a
comprehensive data collection and analysis and providing a
valuable support for therapy adjustments. Both these features
were illustrated to the parents.
The TM service was inspired by some authors’ previous
experiences [15]. It was first developed to enforce safety
on diabetes patients [16] undergoing a therapy administered
through the AP. After an initial tuning phase on inpatients
[17], the TM service has been used throughout several
experiments enrolling patients at their domiciles [18, 19].
The Clinical Trial
Data analyzed in this paper were collected during a ran-
domized crossover clinical trial assessing the effectiveness of
BGL control achieved through the use of an AP in pediatric
prepubertal patients. Considering previous studies [20, 21,
22, 23], this was the first time that a closed-loop insulin
therapy, based on the Modular Model Predictive Control
algorithm [24, 25], was compared to the manually controlled
therapy in prepubertal children. The trial was performed at
a summer camp in Bardonecchia, a small village located in
the Northern part of Italy. It lasted for 8 days enrolling 31
patients aged 5 to 9 years selected by pediatric diabetologists
practicing at 5 different major centers in Italy.
As soon as the patients were admitted at the camp, they
were randomly assigned to one of the two groups: one group
used the AP in the first part of the study and the manually
controlled therapy in the second, while the other group did
the opposite. Both study parts lasted for 3 days (72 hours)
and were separated by a 1-day wash-out period. The clinical
results of the study can be found in [14]. The 31 children
enrolled in the clinical trial were accompanied by 21 single
parents and 10 parent couples. The TM service was available
only during the AP segment of the study, i.e. only for 3 days.
The Survey Questionnaires
To assess the users’ perception of the service, two
questionnaires were proposed to the parents attending the
camp: a first one just before starting to use the AP system
with the associated TM service and a second one after having
experimented its use.
Baseline questionnaire The main purpose of this question-
naire, that is reported in the Appendix and has been partially
inspired by a previous work [5], was the definition of a
baseline for the feelings related to the daily management of
diabetic children and for the impact of the disease on the
Perceived Quality of Life (PQL).
Post-study questionnaire The post-study questionnaire,
that is also available in the Appendix and has been partially
inspired by previous works [26, 27], aimed to capture the
parents’ perception about the usefulness of the TM service.
Besides questions concerning the parents experience and
their willingness to use the TM service in the future, the
post-study questionnaire also asked parents to consider the
responses previously provided in the baseline questionnaire
and to revise those affected by the use of the TM service.
The Likert scaling method [28] was adopted for some of the
questions.
Statistical Analysis on questionnaire data
Questionnaire responses were analyzed using the R statistical
tool [29]. Center, parents’ gender, children’s gender and
children’s age were investigated as explanatory variables
of the questionnaires’ scores. Kruskal-Wallis and Wilcoxon
tests were used to check differences among the groups
identified according to the four variables above. In case of
a statistically significant analysis of variance, Wilcoxon test
was executed on each pair of groups. The analyses were
conducted both on the responses provided to each question
and on the sum of the responses to questions belonging to the
same section. All the possible responses for multiple-choice
questions followed the same ordinal scale weighted with a
numerical score ranging from 1 (very negative feeling) to 5
(very positive feeling). Spearman’s correlation analysis was
used for identifying the relationship between two numerical
variables. Baseline vs. post-study comparisons of numerical
values were performed using the Wilcoxon test for paired
data. A stepwise multiple regression analysis was used to
identify possible independent predictors of PQL.
Finally, we used the SentiStrength tool [30] to analyze
free text comments reported in the questionnaires through
Prepared using sagej.cls

Parental Evaluation of a Telemonitoring Service 3
Figure 1. The main screen of the TM service.
Sentiment Analysis. This is a branch of text mining dealing
with the computational processing of opinion, sentiment, and
subjectivity expressed in natural language.
Results
Overall 41 baseline and 38 post-study questionnaires were
collected. That difference is due to one child dropping out
and some parents of children in the second arm leaving
the camp soon after the closed-loop session and before
questionnaires administration. Parents were both fathers
(n=16) and mothers (n=25) of female (n=11) and male
(n=20) diabetic children from five to nine years old (5yrs=3;
6yrs= 4; 7yrs=10; 8yrs=10; 9yrs=4; median=7.5yrs; 1st-3rd
quartile=6.98-8.24yrs). Families came from five different
locations in Italy: Milano (n=8), Napoli (n=4), Roma (n=3),
Torino (n=10) and Verona (n=6).
Baseline questionnaire analysis
We first analyzed Section 1 to understand how the parents’
life is affected by the disease of their child. Classification
of the responses into positive (”Never” or ”Rarely”) or
negative (”Sometimes”, ”Often”, ”Very Often”) tendencies
revealed nearly equal distributions (49% positive tendency;
51% negative tendency). Figure 2 provides a general
overview of the positive responses, stratified according to
four explanatory variables.
Families coming from different locations seemed to feel
different levels of burden, as illustrated in Figure 3. The
median score of all questions in Section 1 (encompassing
8 questions totaling [0-40]) varies from 21 in Verona to
32 in Milano and the analysis of variance on the total
score showed a p-value of 0.009. Responses provided by
fathers and mothers did not show any statistically significant
difference. Children’s gender also did not affect parents’
responses, while children’s age turned out to be positively
and significantly correlated with the total score of the
responses, as shown in Figure 4. Finally, parents pointed
out fatigue as one of the most severe consequences of
managing diabetes every day, together with the continuous
rapid change of their children’s health status (questions 1d
and 1f).
Figure 2. Baseline questionnaire, Section 1: percentages of
responses expressing a positive tendency (i.e. ”Never” or
”Rarely”) stratified according to explanatory variables.
In the second section, parents were asked to rate their
PQL on a 0-100 scale. The mean PQL value was 64.13
and no statistically significant differences were found among
Prepared using sagej.cls

4 Journal Title XX(X)
Figure 3. Baseline questionnaire, Section 1: total scores
according to the five centers.
Figure 4. Baseline questionnaire, Section 1: correlation
between total score and children’s age.
groups. With a borderline statistical significance (p=0.07),
fathers showed a more positive attitude with respect to
mothers.
At univariate regression analysis, the responses to the
following questions were identified as significant predictors
of PQL: ”Our family gives up a lot of things (e.g. travelling
together for long periods)” (1a; p-value=0.015), ”In taking
care of my son I do not have enough time for other
family members” (1b; p-value=0.008), ”I feel like I’m living
on a roller coaster: in crisis when my son is sick, calm
when he feels good” (1d; p-value=0.01), ”I feel tired”
(1f; p-value=0.006) and ”We give up seeing family and
friends” (1g; p-value=0.03). However, a stepwise multiple
regression analysis including parents’ and children’s gender
together with children’s age, revealed that only ”fatigue”
and ”having a male child” are retained in the model as
significant independent aspects that affect PQL (multiple R
squared=0.29).
Post-study questionnaire analysis
In the first section parents were asked to assess whether
TM could improve the communication with the health care
staff. Overall we observed that in 85% of the responses they
expressed their agreement, in 12% they expressed neutrality
and only in 3% they expressed disbelief.
Considering the four explanatory variables, only the chil-
dren’s age seemed to affect parents’ responses: the smooth-
ing curve obtained with a locally-weighted polynomial
regression in Figure 5 shows higher scores when children
enter the school-age.
Figure 5. Post-study questionnaire, Section 1: total score
according to children’s age.
According to the parents the possible advantages of
using the TM are: ”Improves remote control by sending
notifications about emergencies (e.g., by sending alarms in
case of hypoglycemia events)”, ”Improves the exchange of
medical information between patient and family members”,
”Improves family’s serenity when someone is away from
home” and ”Allows physicians and hospital to take care of
their patients in a better way” (median=5, on the ordinal
scale 1-5), followed by ”Substitutes paper material for
communicating the clinical data”, ”Decreases the costs due
to visits, controls and phone calls to the hospital” and
”Decreases worries” (median=4) and ”Decreases the number
of controls required in the hospital” (median=3).
Concerning the willingness to pay, the median value is 200
euro/year, ranging from 0 to 3000 euro/year. Considering the
explanatory variables, no statistically significant differences
were found, except for the towns (p-value= 0.005), with
Verona and Napoli being the locations with the lowest
willingness to pay. Independently from the amount of money
that parents were willing to pay, all of them expressed their
desire to use TM.
The fourth section was focused on understanding which
aspect of diabetes management could be improved by the
TM. Parents were asked to repeat Section 1 of the baseline
questionnaire after experiencing the TM service, indicating
if its use could improve, worsen or was irrelevant for each
of the 8 items previously answered. None of the parents
said that using TM could worsen the management, 49.65%
expressed a potential improvement, while 50.35% said that
the TM was deemed to have no impact. However, parents’
”fatigue”, which emerged through the baseline questionnaire
as the worst effect of diabetes management, was considered
the most improvable item through a daily usage of the TM.
In the last section, we again asked the parents to provide
an estimate of their PQL if the TM was regularly available
Prepared using sagej.cls

Parental Evaluation of a Telemonitoring Service 5
in their daily life. The mean value was 78.39, which was
significantly higher than in the baseline questionnaires (p-
value=0.0001).
PQL improvement was significantly correlated with
responses to questions ”Our family gives up a lot of
things (e.g. travelling together for long periods)” (4a; p-
value=0.01), ”We give up seeing family and friends” (4g;
p-value=0.01) and ”We do not have much desire to go out”
(4h; p-value=0.05). A stepwise multiple regression analysis
identified improvements in 4a and 4g as the only independent
factors positively affecting PQL (multiple R squared=0.32).
This is explained by the highest correlation found between
questions 4a and 4h (p-value<<0.05).
Finally, comparing the sentiment analysis scores achieved
by processing the comments in the free text sections in both
questionnaires, we found a significant decrease of negative
scores (median and quartiles of the difference between
positive and negative scores: -1[-2;0] baseline; 1[0.75;2]
post-study; p-value=0.028).
Discussion
Technology presently offers solutions supporting remote
monitoring and patient education in the disease’s manage-
ment [31, 32]. The aim of our study was to evaluate how a
TM service could help parents of children affected by T1DM
in managing the disease, reassuring them and improving their
PQL.
Responses provided to the baseline questionnaire gave
a general overview of the parents’ feeling about diabetes.
Studies focusing on the parents’ feelings identified three
different stressful conditions: (a) low self-efficacy in helping
with the disease, (b) the occurrence of hypoglycemia events,
and (c) their responsibility in the overall management of
diabetes [33]. Moreover, the level of responsibility of family
members, and the burden of their stress, is inversely related
to the child’s age, since the younger the patient is, the more
attention he requires. This was confirmed by our analysis,
since parents of young children actually declared a more
negative attitude in coping with diabetes. The borderline
result about the more positive attitude of fathers with respect
to mothers is in line with other studies [34], possibly
suggesting that fathers are less emotionally involved since
they are usually busier and spend more time outside.
Besides acquiring the baseline of parents’ feelings
before the intervention, we also had to select an
outcome for measuring the users’ perception of our
TM. A previous review concerning telemedicine systems
identified the following possible outcomes: BGL monitoring,
improvements in glycemic control, patient satisfaction and
improvements in self-management [35]. We selected the
parents’ satisfaction as the main outcome for evaluating the
TM considering that those are responsible for enacting the
children’s treatment. BGL monitoring and glycemic control
were discarded as they were the primary outcomes of the
underlying clinical trial, the goal of which was to assess
the efficacy of an AP running in closed-loop in comparison
with the manually controlled therapy. Even self-management
was unsuitable since the therapy was managed by the AP
and closely supervised by the clinical and bioengineering
staff. The parents’ satisfaction was assessed through the
administration of a post-study questionnaire as already done
in previous studies [36, 37, 38].
Results showed that most of the parents believed in a
possible improvement for what concerns the interaction with
the healthcare staff, while half of them also believed on
an enhancement in their personal serenity. Neutrality and
disbelief also conveyed some skepticism about the possible
reduction in control visits and their associated costs. This
may be due to the increased serenity felt by parents if
children are visited face-to-face. The parents of the oldest
children appreciated TM more than others. The reason
may be found in the greater wish of independence and
self-management shown by grown-up children, and by the
consequent need for parents to find an alternative way to
stay updated with their children’s status without being too
obtrusive [35]. This is supported by responses indicating that
parents were highly confident about the support provided
by TM to the family own serenity when children are away.
Moreover, we found a correlation between the appreciation
of the TM shown by the parents and the school age. As a
matter of fact, in Italy education starts when children are
6 years old, and as soon as children start going to school
they also begin to use the technology (e.g. smartphone apps)
as a means of staying in touch with the family. This in
turn leads parents to better appreciate the TM potential for
reporting on the disease status of their children, highlighting
the advantages of the service.
To sum up, despite our study highlighted some skepticism
about the usefulness of the TM service by some parents, it
also showed their interest in using it as a means of improving
the management of T1DM and the communication with
the health care staff. The interest in the service was also
emphasized by the responses of 61% of the parents willing
to pay a fee for it. Given that the Italian national healthcare
service grants most services for free, this is an indirect
proof of the perceived usefulness of the TM. The parents’
positive attitude towards the TM matches their satisfaction
and confidence in the AP technology, as emerged from a
specific investigation performed through the administration
of questionnaires and structured interviews during the same
camp [39].
Finally, the main limitation affecting our study is that
parents were provided with the TM for a very short period
of time in an unusual context of use, such as a clinical trial
performed at a resort village. Due to this limitation, the
perceived usefulness measured during this trial may not be
directly correlated with the actual one. Thus a next step could
envision extending the TM use over a longer time frame,
as in a home trial, to test the system in a context closer to
the real life exploiting electronic means for questionnaire
administration [40].
Acknowledgements
The authors would like to thank all the people that took part
in the clinical trial. Among those: Roberta Calore and Yenny
Leal as camp engineers; Alfonso Galderisi, Valeria Vallone,
Davide Tinti, Andrea Rigamonti, Marco Marigliano, Angela
Zanfardino and Novella Rapini as camp physicians; Alda
Troncone as camp psychologist and Angelo Avogaro as chief
of the Padova unit. Moreover, the authors thank the patients
Prepared using sagej.cls

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Journal ArticleDOI
TL;DR: In this paper, the authors reviewed which questionnaires are commonly used tools in telemedicine services that can help to evaluate different aspects Selecting the ideal questionnaire for this purpose may be challenging for researchers.
Abstract: Questionnaires are commonly used tools in telemedicine services that can help to evaluate different aspects Selecting the ideal questionnaire for this purpose may be challenging for researchers This study aims to review which questionnaires are used to evaluate telemedicine services in the studies, which are most common, and what aspects of telemedicine evaluation do they capture The PubMed database was searched in August 2020 to retrieve articles Data extracted from the final list of articles included author/year of publication, journal of publication, type of evaluation, and evaluation questionnaire Data were analyzed using descriptive statistics Fifty-three articles were included in this study The questionnaire was used for evaluating the satisfaction (49%), usability (34%), acceptance (115%), and implementation (2%) of telemedicine services Among telemedicine specific questionnaires, Telehealth Usability Questionnaire (TUQ) (19%), Telemedicine Satisfaction Questionnaire (TSQ) (13%), and Service User Technology Acceptability Questionnaire (SUTAQ) (55%), were respectively most frequently used in the collected articles Other most used questionnaires generally used for evaluating the users’ satisfaction, usability, and acceptance of technology were Client Satisfaction Questionnaire (CSQ) (55%), Questionnaire for User Interaction Satisfaction (QUIS) (55%), System Usability Scale (SUS) (55%), Patient Satisfaction Questionnaire (PSQ) (55%), and Technology Acceptance Model (TAM) (35%) respectively Employing specifically designed questionnaires or designing a new questionnaire with fewer questions and more comprehensiveness in terms of the issues studied provides a better evaluation Attention to user needs, end-user acceptance, and implementation processes, along with users' satisfaction and usability evaluation, may optimize telemedicine efforts in the future

54 citations

Journal ArticleDOI
TL;DR: The intervention for a proactive approach to symptoms monitoring in curatively treated head and neck cancer patients resulted feasible and acceptable by both patients and oncologists.

28 citations

Journal ArticleDOI
TL;DR: Factors such as age, ethnicity, technological literacy, beliefs and previous utility of technology of the patients have to be addressed before implementing TM in primary care.
Abstract: Tele-monitoring (TM) is remote monitoring of individuals via info-communication technology, enabling them and their relatives or care-providers to recognize their health status conveniently. TM will be successful only if the individuals, often patients with medical conditions, are willing to accept and adopt it in their daily lives. This study aimed to determine the prevalence of willingness of patients with type 2 diabetes mellitus (T2DM) and/or hypertension towards the use of TM, and the factors influencing their uptake. A cross-sectional survey was conducted at two public primary care clinics (polyclinics) in north-eastern Singapore, where TM had not been implemented. After the patients with T2DM and/or hypertension consented after fulfilling the eligibility criteria, they were first introduced to the concept of TM using pictogram and explanation by the investigators. Data on their demography, clinical parameters, technological literacy and acceptance of TM based on the Health Information Technology Acceptance Model (HITAM) were subsequently collected, computed, analyzed, followed by regression analyses to identify the factors associated with their willingness to use TM. Among 1125 eligible multi-ethnic Asian patients approached, 899 of them completed the assisted questionnaire survey, yielding a response rate of 79.9%. Their mean age was 58 ± 8 years, females 51.3% and Chinese 69.3%. Overall, 53.0% of the patients were willing to use TM. Personal beliefs on technology (OR = 3.54, 95%CI = 2.50–4.50, p < 0.001), prior technology utility (OR = 3.18, 95%CI = 1.57–6.42, p = 0.001), Patient’s requirements to be accompanied (OR = 1.48, 95% CI = 1.054–2.082, P = 0.03) Cost considerations (OR = 2.96, 95% CI = 2.257–3.388, P < 0.01) and technological literacy (OR = 2.77, 95%CI = 2.05–3.38, p < 0.001) were associated with willingness to use TM. Slightly over half of the patients were willing to use TM. Factors such as age, ethnicity, technological literacy, beliefs and previous utility of technology of the patients have to be addressed before implementing TM in primary care.

23 citations

Journal ArticleDOI
26 Apr 2018
TL;DR: A wearable integrated system for everyday fetal monitoring during the last weeks of pregnancy that can open a new perspective on the continuous monitoring of fetus development by enhancing the performance of regular examinations, making treatments really personalized, and reducing hospitalization or ambulatory visits.
Abstract: Prenatal monitoring of Fetal Heart Rate (FHR) is crucial for the prevention of fetal pathologies and unfavorable deliveries. However, the most commonly used Cardiotocographic exam can be performed only in hospital-like structures and requires the supervision of expert personnel. For this reason, a wearable system able to continuously monitor FHR would be a noticeable step towards a personalized and remote pregnancy care. Thanks to textile electrodes, miniaturized electronics, and smart devices like smartphones and tablets, we developed a wearable integrated system for everyday fetal monitoring during the last weeks of pregnancy. Pregnant women at home can use it without the need for any external support by clinicians. The transmission of FHR to a specialized medical center allows its remote analysis, exploiting advanced algorithms running on high-performance hardware able to obtain the best classification of the fetal condition. The system has been tested on a limited set of pregnant women whose fetal electrocardiogram recordings were acquired and classified, yielding an overall score for both accuracy and sensitivity over 90%. This novel approach can open a new perspective on the continuous monitoring of fetus development by enhancing the performance of regular examinations, making treatments really personalized, and reducing hospitalization or ambulatory visits.

17 citations


Cites background from "Parental evaluation of a telemonito..."

  • ...in wireless transmission, the remote management of chronic diseases has become a reality, and studies prove that patients are willing to adopt it [2]....

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References
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Journal ArticleDOI
TL;DR: Reviewers point to a continuing need for larger studies of telemedicine as controlled interventions, and more focus on patients' perspectives, economic analyses and on teleMedicine innovations as complex processes and ongoing collaborative achievements.

923 citations

Journal ArticleDOI
01 Nov 2011-Diabetes
TL;DR: The artificial pancreas (AP), known as closed-loop control of blood glucose in diabetes, is a system combining a glucose sensor, a control algorithm, and an insulin infusion device that has proved the feasibility of external glucose control and stimulated further technology development.
Abstract: The artificial pancreas (AP), known as closed-loop control of blood glucose in diabetes, is a system combining a glucose sensor, a control algorithm, and an insulin infusion device. AP developments can be traced back 50 years to when the possibility for external blood glucose regulation was established by studies in individuals with type 1 diabetes using intravenous glucose measurement and infusion of insulin and glucose. After the pioneering work by Kadish (1) in 1964, expectations for effectively closing the loop were inspired by the nearly simultaneous work of five teams reporting closed-loop control results between 1974 and 1978: Albisser et al. (2), Pfeiffer et al. (3), Mirouze et al. (4), Kraegen et al. (5), and Shichiri et al. (6). In 1977, one of these realizations (3) resulted in the first commercial device—the Biostator (7; Fig. 1), followed by another inpatient system, the Nikkiso STG-22 Blood Glucose Controller, now in use in Japan (8). FIG. 1. The Biostator (courtesy of William Clarke, University of Virginia). Although the intravenous route of glucose sensing and insulin infusion is unsuitable for outpatient use, these devices proved the feasibility of external glucose control and stimulated further technology development. Figure 2 presents key milestones in the timeline of AP progress. FIG. 2. Key milestones in the timeline of AP progress. EU, Europe; IP, intraperitoneal; NIH, National Institutes of Health; SC, subcutaneous. In 1979, landmark studies by Pickup et al. (9) and Tamborlane et al. (10) showed that the subcutaneous route was feasible for continuous insulin delivery. Three years later, Shichiri et al. (11) tested a prototype of a wearable AP, which was further developed in subsequent studies (12,13). In the late 1980s, an implantable system was introduced using intravenous glucose sensing and intraperitoneal insulin infusion (14). This technology was further developed, leading to clinical trials and …

532 citations


"Parental evaluation of a telemonito..." refers background in this paper

  • ...) and large research efforts have been recently directed to develop an Artificial Pancreas (AP), a system for automating BGL control via closed-loop insulin modulation based on CGM readings.(3,4) In the case of pediatric patients T1DM poses additional challenges....

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Journal ArticleDOI
TL;DR: Each area of parent functioning associated with pediatric parenting stress is amenable to behavioral intervention aimed at stress reduction or control and improvement of parent psychological and child-health outcomes.
Abstract: Objective Parents of children with type 1 diabetes are crucial to promoting positive disease adaptation and health outcomes among these youngsters, yet this success may come at some consequence to parents' own well-being. Little research has examined the stress faced by parents, or explored the psychological and behavioral correlates of their stress. Methods One hundred and thirty-four parents of children with type 1 diabetes completed measures of diabetes self-efficacy, responsibility for diabetes management, fear of hypoglycemia, and a recently developed measure of pediatric parenting stress (the Pediatric Inventory for Parents [PIP]; R. Streisand, S. Braniecki, K. P. Tercyak, & A. E. Kazak, 2001). Results Bivariate analyses suggest that pediatric parenting stress is multifaceted; the frequency of parenting stress is negatively related to child age and family socioeconomic status and positively related to single parent status and regimen status (injections vs. insulin pump). Difficulty of parenting stress is negatively related to child age and positively related to regimen status. In multivariate analyses, a significant portion of the variance in stress frequency (32%) and difficulty (19%) are associated with parent psychological and behavioral functioning, including lower self-efficacy, greater responsibility for diabetes management, and greater fear of hypoglycemia. Conclusions Each area of parent functioning associated with pediatric parenting stress is amenable to behavioral intervention aimed at stress reduction or control and improvement of parent psychological and child-health outcomes.

330 citations


"Parental evaluation of a telemonito..." refers background in this paper

  • ...Studies focusing on the parents’ feelings identified three different stressful conditions: (a) low self-efficacy in helping with the disease; (b) the occurrence of hypoglycemia events; and (c) their responsibility in the overall management of diabetes.(33) Moreover, the level of responsibility of family members, and the burden of their stress, is inversely related to the child’s age, since the younger the patient is, the more attention he requires....

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Journal ArticleDOI
TL;DR: The findings of the study highlight the importance of identifying family and/or community resources that may provide mothers with support that could reduce some of the tremendous stress and burden of responsibility experienced after diagnosis of diabetes.

228 citations

Frequently Asked Questions (1)
Q1. What are the contributions mentioned in the paper "Parental evaluation of a telemonitoring service for children with type 1 diabetes" ?

The aim of this work was to analyze the parents ’ perceived usefulness of the service. To study the parents ’ perception the authors proposed and analyzed two questionnaires. A baseline questionnaire focused on the daily management and implications of their children ’ s diabetes, while a post-study one measured the perceived benefits of telemonitoring.