Improving Diabetes Outcomes in Rural

Improving Diabetes Outcomes in Rural America Through Telehealth Solutions The United States is a nation characterized by deep socioeconomic divisions which are prompted by racial, ethnic and geographical patterns. In spite of the nation's relative affluence, indications persist in its public health outlook to suggest both the increasing permeation of epidemic health conditions precipitated by lifestyle tendencies and the lopsided distribution of healthcare access. The latter concern is of particular relevance to us as countless Americans suffering from a treatable condition are nonetheless incapable of accessing the healthcare facilities and professionals that can help them. With the condition of diabetes, which is fast proliferating today in the United States due to poor nutritional habits, negative lifestyle tendencies and cultural patterns encouraging both, its appearance in rural America has become especially problematic. This is because in America's rural regions, healthcare access tends to be lesser, conditions such as obesity and heart disease are more common and the education which is necessary to help people either prevent or treat diabetes is likely to be lacking or insufficient. It is thus that we undertake the study here, which is engaged to determine the value of newly evolving healthcare technologies in addressing this identified public health problem. The emergence of telehealth technologies through the online computer medium is opening these regions up to new treatment and educational opportunities. These could have a substantial impact on the length and quality of life for diabetes sufferers in rural America. This invokes the discussion here, both on the presence and problematic nature of diabetes in America's rural region and on how telehealth technologies are improving healthcare access both in a general sense and where diabetes is concerned. This is important because diabetes has become a definite epidemic in the United States. According to a study by Dabney & Gosschalk (2008), "the number of diagnosed cases has increased nearly 10-fold over the past 40 years and has nearly doubled in the past 10 years. Approximately 17 million Americans-6 percent of the population-are diabetic, with perhaps one-third of the cases being undiagnosed. Furthermore, a newly recognized condition called 'pre-diabetes' affects another estimated 16 million Americans." (Dabney & Gosschalk, 57) This denotes that diabetes is a significant public health problem which levies considerable costs on the public healthcare system. Given that diabetes-and especially its inexorable rise in prominence-is connected to lifestyle decisions and negative lifestyle habits, intervention on a wide based level is justified. This discussion focuses this imperative on those rural communities where for various geographical reasons often are at a significant disadvantage in terms of received proper healthcare. Access and education being the dual obstacles to treatment, the consideration of telehealth technologies as a way of focusing on diabetes issues specifically in the rural context is fielded here. The study by Dabney & Gosschalk provides a useful jumping off point in this discussion, indicating that "in this nationwide survey of state and local rural health leaders, diabetes was ranked third among the most frequently nominated rural health priorities after access and heart disease and stroke. There was substantial agreement on the rural priority status of diabetes relative to all other . . . functional areas." (Dabney & Gosschalk, 58) This illustrates that there is a clear need to take measures that can alter the current outlook for those in rural areas. To the point, we will therefore initiate a discussion on the apparent value and benefits of telehealth technologies and methods in a general sense. With the integration of internet technologies into everyday business functions, it seems an intuitive leap to consider the ways in which advancing communication and information tools might help to improve the quality and accessibility of healthcare which cutting down on the costs to the company and the laborer.

The potential represented by telemedicine, still modestly unexplored, bears a great deal of undiscovered opportunity for rural residents in need of access to medical attention that is quick, affordable and reliable. By placing live medical care and pertinent medical information at the computer user's fingertips, the process of telecommunication removes many of the fundamental obstacles to receiving healthcare. Among these, telemedicine eliminates the need for and cost of transportation, significantly diminishes the amount of time required by employees to obtain medical care, compensates for a decided shortage of healthcare professionals and, ultimately, reduces many of the inherent costs in an office visit. As a result of the relative cheapness of the basic required equipment for access to online healthcare, this has been widely touted as a sensible avenue for exploration as a means to advancing opportunities for healthcare to many venues and geographic locations where such had previously been unavailable. For our considerations here, the traditional medical or home facility will serve as a hypothetical venue where, though, it has not been traditionally present, medical access may through online strategies become a reality. "The adoption of PC-based desktop medical teleconferencing is tracking closely after the more widespread use of desktop videoconferencing (DVC) for business" (B2B Media, 1) As this relates to telemedicine, it seems apparent that very little physical adaptation needs to be made in order to participate in a growing network of online healthcare users and providers. The abilities which it gives patients and doctors to connect from remote locations by way of any modestly equipped PC terminal makes telemedicine a route to the expansion or supplement of our abilities to contend with radiological, pathological and even cardiological challenges. In fact, "depending on how it is defined, telemedicine can involve the use of imaging and diagnostic equipment to gather data from a patient, computer hardware and software to record data, communication lines or satellites to send the data from one location to another, and computer equipment at the receiving end for a physician or specialist to interpret the data." (Weldon, 4) This suggests a range of potential uses for telemedicine that is broad and still subject to continued exploration and experimentation. Therefore, in attempting to intervene with the above-noted pattern of rural diabetes spread, researchers have found that telemedicine approaches are far more manageable and affordable than the construction of new hospital facilities or the expansion of existing ones. Indeed, for those who are truly immobilized by the nagging health concerns either relevant to or consequent of diabetes at an advanced age, such facilities which still provoke unwanted strain on the system. By contrast, "without leaving the office or clinic, doctors and nurses can make personal "visits" to patients at home, using state-of-the-art technology that simultaneously transmits voice and video combined with clinical data streams from medical peripherals such as blood pressure monitors, stethoscopes, and glucose meters - all over standard telephone lines." (Moore, 1) Telehealth has also come to serve as a blanket term for the delivery of information and information services. Again, the recurrent issue of poor nutritional and lifestyle habits in the spread of diabetes implicates the need for just such a delivery. The increased presence of terminals for access of such information in the homes of diabetes sufferers can contribute to improved lifestyle habits and lowered mortality due to insufficient self-treatment. According to the article by Templeton (2007), this can be a path to overcoming some of the key informational problems which make rural areas most vulnerable to conditions like diabetes. Templeton indicates that such "problems include poverty, lack of healthy food and, worst of all, lack of doctors, pharmacists, dietitians, psychologists and diabetes educators." (Templeton, 1) These are problems which are directly associated with the conditions often inherent to rural life in the United States, where economic inequality pervades and carries with it a wide scope of social symptoms. Chronic health conditions are among the most prominent of these symptoms, owing to the negative cycle of persistent poverty and its related lifestyle tendencies. For those living with diabetes in rural areas, chances of mortality are made considerably higher by this reality and a lack of concrete resources denotes the need for far-reaching healthcare solutions that are simultaneously cost-effective. This is underscored by Bull's (1993) prescient observation of the persistent patterns facing rural America. Bull reports that "according to W.R. Lassey, a contributing author to The Elderly In Rural Society, "Poor rural older people suffer from what might be referred to as the 'poverty-illness syndrome'--that is, they are poor, which ... limits their access to medical services while subjecting them to many of the risk factors associated with the higher incidence of chronic disease. Because of their chronic diseases, they are often unable to improve their incomes. Geographic and social isolation limit their ability to escape from either poverty or (ill) health.'" (Bull, 1) This suggests a condition in which the problems of poverty produce healthcare obstacles which can become self-perpetuating. The prospects of telehealth to resolve this are immense according to currently applied research, which has put into practice the prospect both for the distribution of information and of health services through telecommunication means. Reporting on these efforts, Moore (2005) indicates that "one of the most interesting and promising outcomes of telehealth programs has been the increase in patient participation and self- care. Because patients have an active role in their care plan and are in more frequent contact with their healthcare provider, they gain a better understanding of their condition and become more compliant in their care." (Moore, 1) This speaks directly to the challenges in healthcare relating to diabetes, which is a condition that can best be controlled through effective personal lifestyle habits and a sound treatment of one's body. Being able to take proper routine measures to monitor, medicate and treat one's self can be facilitated through telehealth consultation, reducing the need for travel and doctor visits for those who might be less mobile due to age and infirmity. The importance of reducing hospital visits for both cost to healthcare and strain on the patient can be especially appealed to where diabetes is concerned. The chronic nature of the condition and the related ability of the patient to control certain aspects of the condition through proper behavior and lifestyle habits make this a prime context for telehealth implementation. So is this suggested by a study from 2005 where, "in phase 1, over 1,650 patients with diabetes were randomized to telehealth or normal care. Telehealth solutions as described above were placed in patients' homes. Participants received Internet service, training in equipment use, and maintenance support. Patients check their blood sugar, blood pressure, and other factors that affect diabetes. Through interaction with their clinical teams, the patients learn more about diabetes and receive recommendations and instructions on how to manage their disease." (Moore, 1) This bevy of methods would underscore the suitable nature of diabetes to improvement of outreach through such technologies. Where the rural communities impacted by the condition are concerned, this can be especially critical in lengthening and improving the lives of diabetes patients. The difficulty or impossibility to traveling to proper healthcare facilities for treatment can have a significant impact on mortality rates in these areas. The correlation between conditions such as obesity or advanced age and the presence of diabetes suggests that the strain of excessive healthcare travel should be reduced as much as possible. The above noted experiment and its results suggests telehealth to be well-suited to addressing this matter. This is further supported by Versweyveld's (2005) findings, which would engage in an investigation of telehealth's prospects for the improvement of clinical diabetes in the rural south. The south of the United States is a particularly vulnerable area, emerging in much of the research on both diabetes' spread and the value in bringing new telehealth measures to rural regions. Accordingly, the Versweyveld study reports on a pilot program conducted in 2004 both in Greenville and Jackson, Mississippi. The article denotes that "the programme joined UTHSC's telehealth programme with a pilot clinical diabetes management programme from UMMC. Five hundred visits a month at UMMC and one hundred visits per month at Greenville have improved all diabetic outcomes significantly. The reach of the programme and high quality of care has far exceeded national and Mississippi norms." (Versweyveld, 1) These positive outcomes demonstrate the opportunity in producing facilities as points of access but without the typical expenses and distances which are a factor in making regular physician or hospital visits. This manifests as both an improved opportunity for treatment for the patient and in a reduced healthcare burden on state and municipality in the face of rising diabetes prominence. The investment in the technologies, facilities and educational campaigns which could promote and realize such a program would produce considerable gains in the economically strained area of American healthcare. Indeed, through the pilot program upon which Versweyveld reports, the research conducted here is given reinforcement to markedly and consistently positive outcomes. The application of such suggested telehealth solutions, though rarely suggested as a total replacement for necessary physician, specialist or emergency room visits. However, for a chronic and treatable condition such as diabetes, rural regions are particularly suited to what is offered by telemedicine technologies. Indeed, this form of consultation far exceeds in health outcome prospects the total absence of consultation often facing elderly rural poor populations. Versweyveld reports, "'the addition of telehealth connectivity has proven to be of great benefit to the outcomes and sustainability of the programme results, significantly improving the health status of diabetics and easing the burden of projecting university medical centre teaching and expertise into a site 150 miles away from both institutions', stated Karen Fox, Ph.D. assistant dean for University of Tennessee Health Sciences Center. 'The results of the Greenville pilot project have been a resounding success to date, duplicating or improving upon all outcomes of the standard diabetic care model and far exceeding the outcomes of local Delta care.'" (Versweyveld, 1) This positive finding underscores a theme of fundamental importance beyond the relative absence of good and qualified facilities. The shortfall of qualified professionals and practitioners in rural areas means that there is an unequal distribution of knowledge, ability and qualification in the healthcare system. Teleconferencing through local clinic facilities would offer direct access to some of the best professionals in all aspects of diabetes treatment. In essence, this allows physicians, therapists, nutritionists and pharmacists all to be in many places at once, rather than demanding the impossible task of distant transportation for many rural diabetes sufferers who may be poor, elderly or both. Telehealth solutions offer the prospect of an improved quality of life and an improved life expectancy for diabetes sufferers in rural areas otherwise typically isolated from quality care or any care at all. And optimistically, we may also view these findings as a suggestion that the improved distribution of information might change lifestyle habits as they are passed from one generation to the next. Telehealth distribution in rural areas could well serve as one way amongst the needed many to stem the tide of the rising diabetes epidemic. At present, evidence already exists to endorses the implementation of telehealth programs in rural areas, with the opportunities self-apparent in diabetes treatment helping to open the door to treatment solutions in all manner of rural healthcare needs.