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The prevalence of diabetes and the use of electronic health (eHealth) resources are increasing. People with diabetes need frequent monitoring and follow-up of health parameters, and eHealth services can be of great significance in this regard. However, little is known about the extent to which different kinds of eHealth tools are used, and how the use of eHealth is associated with the use of provider-based health care services among people with diabetes.
The primary objective of this study is to investigate the use of eHealth and its association with the use of provider-based health care services. The secondary objectives include investigating which eHealth services are used (apps, search engines, video services, social media), the relationship between socioeconomic status and the use of different eHealth tools, whether the use of eHealth is discussed in the clinical encounter, and whether such tools might lead to (or prevent) doctor visits and referrals.
We will conduct cross-sectional studies based on self-reported questionnaire data from the population-based seventh Tromsø Study. Participants will be diabetic patients aged 40 years and older. According to our estimates, approximately 1050 participants will be eligible for inclusion. Data will be analyzed using descriptive statistics, chi-square tests, and univariable and multivariable logistic regressions.
The grant proposal for this study was approved by the Northern Norway Regional Health Authority on November 23, 2015 (HST 1306-16). Recruitment of participants for the Tromsø Study started in 2015 and will continue throughout 2016. This particular project started on July 1, 2016.
This project may yield benefits for patients, health care providers, hospitals, and society as a whole. Benefits are related to improved prevention services, health, experience of care services, self-management tools and services, organizational structures, efficiency of specialist care use, allocation of resources, and understanding of how to meet the challenges from the increasing prevalence of diabetes. This project has potential for generalization to other groups with chronic disease.
Solutions based on information and communication technology for health information, self-management, and novel treatment strategies have developed rapidly in recent years. These solutions have not only become an option for patient self-management, but also potential aids to health care services in their struggle to keep up with the population’s increasing expectations of service. Of particular interest are patients with chronic diseases, such as diabetes mellitus (DM), who are in need of frequent monitoring and follow-up of health parameters.
The prevalence of diabetes is increasing. In 2014 approximately 422 million adults worldwide were living with diabetes [
Electronic health (eHealth) refers to “the transfer of health resources and health care by electronic means” [
The use of eHealth is reported to be positively associated with general practitioner (GP) visits (yes/no) [
The use of eHealth services often takes place without doctor involvement. A study from the United States found that only 31% of users of mobile health (mHealth; mobile and wireless communication technologies that aid in health and health care) prioritized their physician’s involvement [
Health care services and communication inequalities may contribute to inequalities in health, as it is well known that new interventions and treatments reach people in higher socioeconomic groups first [
Teams at the Norwegian Centre for E-health Research have been developing and studying Internet-based self-management tools for chronic diseases (including DM) for more than a decade, with the understanding that communication technologies hold great potential for making health services and diabetes care more effective and efficient. However, this potential has not been fully realized. Research on the combined use of consumer-based eHealth (as defined by the use of apps, search engines, video services, and social media) and provider-based health care, as well as the interaction between the use of these different sources of care, is scarce [
eHealth is an area of continuous and rapid development, and the use of eHealth services and their possible associations with health care utilization and socioeconomic position are likely to vary between regions, countries, diagnostic groups, health care services, and health care systems. Hence, research from different cultural and economic settings is important to achieve an overall epidemiological view and comprehensive understanding, as well as to identify vulnerable subgroups. Understanding the influence of eHealth on health care utilization in the large and growing group of patients with diabetes is important for patients, health care providers, administrators, policy makers, and society, in order to enable evidence-based planning for future eHealth and provider-based health care services, thereby providing better health outcomes.
The primary objective is to investigate the use of eHealth in Tromsø, Norway, and its association with the use of provider-based health care services. This study will peruse the following specific objectives:
1. To investigate which eHealth services are used.
2. To investigate whether the use of eHealth is associated with the use of primary and specialist health care services.
3. To investigate whether the use of eHealth might lead to or prevent doctor visits.
4. To investigate whether patients’ use of eHealth is discussed in clinical encounters.
5. To investigate whether the use of eHealth is associated with referrals to specialist care.
6. To investigate whether the use of eHealth is associated with SES.
7. To assess how knowledge gained from this study can be used to develop and implement eHealth solutions and changes in health care services, in order to increase DM patients’ chances of reaching their treatment goals.
Based on previous research and the authors’ experiences, the following hypotheses have been generated:
1. The use of eHealth is positively associated with one or more GP visits during a year.
2. The use of eHealth is not associated with the use of emergency departments.
3. The use of eHealth does not have any impact on the frequency of doctor visits.
4. It is more common for eHealth users not to discuss the use of eHealth in the consultation than to discuss it.
5. The use of eHealth is associated with an increase in GPs’ referrals to specialist services.
6. The use of eHealth is positively associated with the use of outpatient specialist services.
7. The use of eHealth is inversely associated with hospital admissions.
8. The use of eHealth is positively associated with higher SES.
These hypotheses will be tested using data from the Tromsø Study, which will be analyzed using descriptive statistics, chi-square tests, and logistic regressions.
Population-based health surveys have been conducted in Tromsø, Norway since 1974. We plan to retrieve questionnaire data from the seventh cross-sectional Tromsø Study (Tromsø 7), conducted in 2015-2016. Data will be available at the beginning of 2017. We have participated in the design of the survey, which for the first time includes self-reported data on the use of eHealth. Tromsø 7 also includes data on referrals, the use of primary and specialist health services, self-rated health, diseases and symptoms, use of medication, as well as demographic and socioeconomic data. The following question will be particularly important in our study:
Tromsø is the largest city in Northern Norway with 75,762 inhabitants (as of January 1, 2016). All residents aged 40 years and over (approximately 33,000 persons) were invited to participate in Tromsø 7; more details about Tromsø 7 are available at the Tromsø Study website [
The study design will be cross-sectional. Data will be analyzed using descriptive statistics, chi-square tests, and univariable and multivariable logistic regressions. The following variables will be available for adjustment in the multivariable regression models: age, gender, marital status, education, income, employment status, duration of the GP-patient relationship, frequency of GP visits, patients’ assessment regarding doctor visits due to the use of eHealth, if eHealth information has been discussed with the doctor, self-rated health, chronic diseases, and the Euro Quality of Life Group five dimensions scoring scale [
The grant proposal for this protocol was approved by the Northern Norway Regional Health Authority on November 23, 2015 (HST 1306-16). Tromsø 7 has been approved by the Regional Committee for Medical and Health Research Ethics (REK; 2014/940). Recruitment of participants started in March 2015 and is currently ongoing. Written informed consent was obtained from all participants. Data will be available for analyses at the beginning of 2017. This project has been presented to the REK, which found that an application was not required according to the Norwegian Health Research Act (2015/1779/REK nord). This particular project started on July 1, 2016.
We expect that our eight hypotheses will be confirmed during the conduct of the studies. For patients, the expected benefits of the project will be improved prevention services and prospects for improved health, improved experience of care services, and improved support for self-management tools and services. For health care providers, benefits will include improved organizational structures, tools, and services for diabetes care. Expected benefits for hospitals will be a more efficient use of specialist care, and allocation of resources for other activities. For society, benefits will include better understanding of how to meet the challenges from the increasing prevalence of diabetes, and better utilization of novel health technologies. This project has the potential to be generalized to other groups with chronic diseases.
diabetes mellitus
electronic health
general practitioner
mobile health
Regional Committee for Medical and Health Research Ethics
socioeconomic status
type 1 diabetes mellitus
type 2 diabetes mellitus
We thank the people of Tromsø, Norway for contributing data to this study, the University of Tromsø - The Arctic University of Norway, who initiated and organized the Tromsø 7 Study, and the Northern Norway Health Authorities who provided funding for this research.
All authors contributed to the design and conduct of the study. AHH drafted the protocol and the manuscript. All authors contributed with improvements and critical revisions, and approved the final version for publication.
None declared.