The Impact of Secure Messaging in the Treatment of Patients With Diabetes Within a Primary Care Setting: Protocol for a Scoping Review

Introduction

The prevalence of diabetes worldwide is expected to continue to rise. From 2010 to 2030, the prevalence of diabetes among individuals aged 20 to 79 years will likely increase from 6.4% to 7.7% worldwide and from 11.6% to 13.9% in Canada [1].

Diabetes is an endocrine disorder that arises from the body’s inability to produce insulin, effectively use it, or both, resulting in an unhealthy rise in blood sugar levels. Insulin is a hormone that is produced by the pancreas to regulate blood sugar. Consequences of unmanaged diabetes include pain, nerve damage, amputation, the failure of different organs, cardiovascular diseases, and more. Complications of this disease are very serious and can lead to death [2,3].

Canada’s public health care system spends billions of dollars annually in the treatment of chronic diseases, and this cost is rising due to population growth and improvements in screening, diagnosis, and care. Diabetes Canada estimated the direct cost of diabetes to the Canadian health care system to be about CAD $32 billion (approximately US $24 billion) in 2023 and predicted it to reach about CAD $39 billion (approximately US $29 billion) by 2028 [3]. The province of Alberta spends approximately twice as much money on patients with diabetes compared to the amount of money it spends on those without it [4].

The recent COVID-19 pandemic has acted as a catalyst for the adoption of virtual care technology and services around the world, including Canada. The Canadian government continues to invest in virtual care technology (eg, secure messaging technology, videoconferencing technology, and other tools), in addition to the billions of dollars already invested in digital health [5]. Virtual care is defined as “[a]ny interaction between patients and/or members of their circle of care occurring remotely, using any form of communication or information technology with the aim of facilitating or maximizing the quality of patient care.“ Secure messaging is a virtual care modality defined as “the asynchronous exchange of information between providers and patients, or between providers, through electronic platforms (e.g. texting, e-mail) that adhere to the standards of safety and privacy” [6]. Effective diabetes treatment involving the tracking and monitoring of diet, blood sugar, and physical activities that involve using technology together with active treatment is shown to be cost-effective in reducing complications. The provision of remote health care services by using a variety of virtual care tools is identified by Diabetes Canada as a delivery mechanism that can improve patient outcomes by providing timely and interdisciplinary care [3]. In contrast with other outcomes of conventional diabetes treatment, the use of virtual care offers benefits, such as improved access to services in rural or remote areas, reduced wait times, the avoidance of clinician and patient travel, cost efficiencies, and even reduced carbon emissions [3,7,8]. It is unclear to what extent the use of virtual care technology in health care helps to facilitate or maximize the quality of care for patients.

Our preliminary literature scan found many studies on the use of one or another form of digital health technology (telehealth, telemedicine, telemonitoring, videoconferencing, SMS text messages, electronic health records, etc) to improve diabetes management and patient outcomes, but only a small proportion are on the use of secure messaging for diabetes management. Similar findings were also suggested by a scoping review on the costs and benefits of eHealth applications that support the independent living of older adults [9]. A literature scan on virtual care evaluations, which was conducted by the Canadian Agency for Drugs and Technologies in Health in 2021, noted that studies tend to assess combined virtual care modalities (eg, video and telephone), making it difficult to provide informative evidence on the impact of a specific modality [10].

There is some evidence suggesting that the use of virtual care technology in the management of diabetes and other chronic diseases is associated with positive clinical outcomes that, in some cases, are comparable to those of in-person care [11-15]. Moreover, the use of asynchronous electronic communications tools is shown to improve primary care providers’ access to specialists, minimize unnecessary referrals, and reduce call volumes to providers [3,16-19]. However, negative impacts on clinicians' workloads and mixed inconclusive impacts on certain clinical outcomes (eg, blood pressure and cholesterol) and aspects of the quality of care have also been reported [11,15,19-22].

We find that literature on the impact of secure messaging in diabetes management tends to focus on discrete outcomes, such as biomedical outcomes, cost, adoption, patient satisfaction, and workflows, among others. We posit that there is a research gap on studies that assess the impact of secure messaging in primary care through a more holistic quality of care lens (ie, safety, effectiveness, efficiency, timeliness, and patient centricity, as defined by the Institute of Medicine [23]). A recent systematic review of patient portal functionalities and outcomes of patients with diabetes also identified similar gaps and the need for further studies to understand how the use of patient portals by patients with diabetes improves health outcomes [15].

To continue investing in virtual care services, health care policy makers need evidence on both the clinical outcomes and the health system outcomes to inform their decisions. The purpose of our scoping review is to explore what is known about the use of secure messaging in the treatment of diabetes within the primary care setting and how its impact has been assessed from the patient, health system, and quality of care perspectives.

Our scoping review will contribute to existing literature by examining the literature for evidence on the impact of secure messaging in the treatment of diabetes from a more holistic quality of care perspective that includes both clinical outcomes and health system outcomes.

Methods

Study Design

Our review will be based on the Arksey and O’Malley methodological framework for scoping reviews, which includes the following six steps: (1) identifying the research question; (2) identifying the relevant studies; (3) defining the study selection criteria; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) optionally consulting with peers for additional feedback and the validation of findings [24].

Our approach will result in the wide coverage of the literature. The decision to narrow down the literature will be made once the reviewers have a sense of the volume and general scope of the literature and gain familiarity with the literature and the field, after conducting the search [24]. The tools recommended by Levac et al [25] and the Joanna Briggs Institute [26-28], which are grounded on Arksey and O’Malley’s [24] earlier work, will be leveraged to conduct and report our scoping review in a structured way. These tools include the Population, Concept, and Context (PCC) framework and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines and checklist.

Stage 1: Identifying the Research Question

Our scoping review aims to address the following research questions:

1. How is secure messaging used in the treatment of diabetes within the primary care setting?
2. Which outcome measures are used?
3. What is the impact of using secure messaging on the quality of care?
4. What are the facilitators, risks, and challenges of adopting secure messaging for diabetes care?

Stage 2: Identifying Relevant Studies

The PCC framework was utilized to identify the main concepts of the research questions (Table 1). Initial iterative searches in MEDLINE were conducted by the principal investigator (AL) to identify relevant articles and subject headings.

Further iterative searches against MEDLINE were conducted in collaboration with a professional information specialist, resulting in a more refined search strategy that produced 4972 results (Multimedia Appendix 1). This search strategy was then submitted to a second information specialist for a peer review assessment and the validation of the quality and comprehensiveness of the search strategy, in accordance with the PRESS (Peer Review of Electronic Search Strategies) 2015 guideline [29]. Comments were reviewed, and adjustments were made to the strategy as deemed appropriate.

The intervention of interest is secure messaging use in the treatment of diabetes within primary care settings. The care settings will comprise noninstitutionalized and nonhospital settings. This aligns with the definitions of primary care by the World Health Organization [30] and Health Canada, whereby primary care is considered an “element within primary health care that focusses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury” [31].

Our strategy utilizes a combination of controlled vocabulary (eg, Diabetes Mellitus, Telemedicine, and Patient Portals) and free-text terms (eg, NIDDM, virtual consult, and secure email). Using the Ovid platform, we will search Ovid MEDLINE ALL, Embase, and APA PsycINFO. We will also search the Cochrane Library on Wiley, CINAHL on EBSCO, and PubMed. Vocabulary and syntax will be adjusted across the databases. No language or date limits will be applied, but animal-only records will be removed where possible. Results will be downloaded and deduplicated by using EndNote 9.3.3 (Clarivate Plc) and uploaded to Covidence (Veritas Health Innovation Ltd).

The reference lists of all included studies will also be hand searched to identify additional literature that may not be captured through the database search. Additional grey literature will also be identified through an existing network of reviewers, relevant journals, organizations, conferences, and a community of practices across the globe. EndNote software will be utilized to manage references.

Stage 3: Defining the Study Selection Criteria

Based on the research questions and objectives, the inclusion and exclusion criteria shown in Table 2 will be used to initially guide the review. The further refinement of these criteria will occur in an iterative manner as the reviewers gain a better understanding of the scope of available literature. In alignment with the PCC framework, the initial inclusion criteria will include those for the population (patients with diabetes), concept (secure messages), and context (primary and community care settings). The use of secure messaging for patient-provider, caregiver-provider, and provider-provider communications will be included. The initial exclusion criteria will be patients with gestational diabetes, other virtual or digital health interventions, and institutionalized or hospital settings.

Stage 4: Charting the Data

The review team consists of the following three reviewers: the principal investigator (AL), the supervisor (DM), and the cosupervisor (TS). Due to its convenience, Covidence will be used by the reviewers to independently screen the articles, based on the inclusion and exclusion criteria, in the following two steps: (1) title and abstract review and (2) full-text review of the full-text articles and documents. To be more inclusive and reduce the risk of excluding relevant studies, any articles that reviewers are unsure of during the title and abstract scan will be moved forward to the full-text review stage.

Data extraction will be conducted outside of Covidence, using a charting form (Multimedia Appendix 2) that we initially created based on Arksey and O’Malley’s [24] recommendations, which include the following elements: author(s), year of publication, study location, intervention type, comparator (if any), duration of the intervention, study populations, aims of the study, methodology, outcome measures, and important results.

Two reviewers will pilot the data extraction form on the first 30 articles to identify the need for modification. The review team will further revise the form, as needed, during the data extraction process as new relevant data types and themes are encountered.

Stage 5: Collating, Summarizing, and Reporting the Results

The review team will utilize the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) chart and PRISMA-ScR checklist [27] to report their findings in a clear, transparent way (Multimedia Appendix 3 [28] and Multimedia Appendix 4 [27]).

A narrative summary of findings will be developed based on the elements of the data extraction form and guided by the context of the research question and study objectives. Throughout the course of the review, if other criteria or elements are uncovered, the authors will decide on other additional formats (eg, graphs, tables, and diagrams) for presenting the study findings.

Stage 6: Peer Consultation for Feedback and Validation

At different stages, experts will be consulted to review and provide feedback. In stage 2, prior to executing the final search, the search strategy will undergo a peer review by a qualified librarian to ensure relevance and achieve more holistic search results. Other experts within the field will also be drawn from our networks to ensure that relevant findings are captured and reported in a clear manner. In stages 3 to 5, experts will also be consulted to suggest additional literature and provide feedback on the data extraction form.

The experts we consult will include researchers and practitioners within the digital health field and decision makers from publicly funded payer organizations.

Ethical Considerations

Neither ethics approval nor participant consent is required, as our scoping review will not include human or animal participants. Data will be collected from published literature.

Results

The systematic literature search of databases has been conducted, and the title and abstract review is planned to commence in early September 2022.

An article of the scoping review findings will be submitted for publication in a peer-reviewed journal. The final version of findings and the full-text article will be shared with a panel and wider stakeholder organizations.

Discussion

Overview

Our scoping review will explore what is known about the use of secure messaging in the treatment of diabetes within the primary care setting. The review will contribute to knowledge on this topic by examining how the impact of secure messaging has been assessed from the patient, health system, and quality of care perspectives. To our knowledge, this has not been the focus of previous reviews [11,15,22,23].

The findings of the scoping review will inform health care policy makers’ decisions on virtual care services.

Strengths and Limitations

Our scoping review will use an established framework and a comprehensive systematic search to identify and review existing literature on the use of secure messaging in the treatment of diabetes to date. The search strategy is peer-reviewed, and the grey literature search and the review will be informed and guided via consultation with experts. Although the findings will be useful in understanding the state of the literature and potential research gaps, the study does not aim to conduct a full assessment of the quality of the evidence in the literature uncovered.