Issue 48 | May - September 2017

79ISSUE 48
SCIENTIFIC JOURNAL, 3 ISSUES PER YEAR MAY - AUGUST 2017
Published by the Greek
Nursing Studies
Association (GNSA)
ISSUE
48
INDEXED IN SCOPUS, ΕΒSCO, CINAHL
ISSN 22413960
• Determinants of quality of life and stress among patients
with chronic renal disease
• CTs and MRIs in Cyprus: A market analysis
• Investigation of the results of Moral Distress in Job
satisfaction of Greek nurses Investigation of the results
of Moral Distress in Job satisfaction of Greek nurses
• Glycemic control of DM2 through Telemedicine
PUBLICATIONS
οcelotos

81ISSUE 48
Scientific Journal, 3 Issues per Year
Published by the Greek Nursing Studies Association (GNSA)
Nursing
Care AND Research
EDITOR-IN-CHIEF
Chryssoula Lemonidou, RN, MSc, PhD, Professor of Nurs-
ing, University of Athens
CO-EDITORS
Eleni Apostolopoulou, RN, PhD, Emeritus Professor of Nursing,
University of Athens
Ioannis Elefsiniotis, PhD, Associate Professor, Faculty of Nurs-
Panagiota Sourtzi, RN, MSc, PhD, Professor, Faculty of Nursing,
Olga Siskou, RN, M.Sc. Ph.D, Faculty of Nursing, University of
Athens, General Secretary of the Greek Nursing Studies As-
sociation
EDITORIAL BOARD
Lambros Anthopoulos, Emeritus Professor, Faculty of Nursing,
George Baltopoulos, PhD, Emeritus Professor, Faculty of Nurs-
Thalia Bellali, RN, MSc, PhD, Associate Professor of Nursing,
Technological Educational Institute of Thessaloniki
Konstantinos Birbas, PhD, Associate Professor, Faculty of Nurs-
Gerasimos Bonatsos, PhD, Professor, Faculty of Nursing, Univer-
sity of Athens
Charalambos Economou, Associate Professor, Department of
Sociology, Panteion University
Petros Galanis, RN, MPH, PhD, Center for Health Services Man-
agement and Evaluation, Department of Nursing, National &
Kapodistrian University of Athens
Margarita Giannakopoulou, MSc, PhD, Associate Professor,
Faculty of Nursing, University of Athens
Leonidas Grigorakos, Associate Professor, Faculty of Nursing,
Michael Igoumenidis, RN, M.Sc. Ph.D.
Dafni Kaitelidou, MSc, PhD, Associate Professor, Faculty of Nurs-
Ioannis Kaklamanos, PhD, Associate Professor, Faculty of Nurs-
Maria Kalafati, RN, MSc, PhD, Faculty of Nursing, University of
Athens
Athina Kalokerinou, RN, PhD, Professor of Nursing, Faculty of
Nursing, University of Athens
Stylianos Katsaragakis, Lecturer, Faculty of Nursing, University
of Peloponnese
Evangelos Konstantinou, RN, MSc, PhD, Associate Professor,
Faculty of Nursing, University of Athens
Vassiliki Matziou, RN, PhD, Professor, Faculty of Nursing, Uni-
versity of Athens
Pavlos Myrianthefs, PhD, Professor, Faculty of Nursing, Univer-
sity of Athens
Elisabeth Patiraki, RN, PhD, Professor, Faculty of Nursing, Uni-
versity of Athens
Sotiris Plakas, RN, MSc, PhD, General Hospital of Attika «Sism-
anoglion»
Antonios Stamatakis, Associate Professor, Faculty of Nursing,
EleniTheodossopoulou, Professor, Faculty of Nursing, Univer-
sity of Athens
StylianiTziaferi, Assistant Professor Faculty of Nursing, Univer-
sity of Peloponnese
VenetiaVelonaki, RN, M.Sc., Ph.D., Lawyer
INTERNATIONAL EDITORIAL BOARD
John Albarran, Principal Lecturer in Critical Care Nursing, Uni-
versity of the West of England, Bristol, UK
Maria Katopodi, PhD, Assistant Professor, University of Michi-
gan, USA
Katerina Labrinou, PhD, Assistant Professor in Nursing, Cyprus
University of Technology
Anastasia Mallidou, RN, MSc, PhD, Assistant Professor,
University of Victoria, Canada
Anastasios Merkouris, RN, MSc, PhD, Associate Professor of
Nursing, Faculty of Nursing, Cyprus University of Technology
Evridiki Papastavrou, PhD, Assistant Professor in Nursing,
Cyprus University of Technology
Elisabeth D.E. Papathanassoglou, RN, MSc, PhD, Associate
Professor, Faculty of Nursing, Cyprus University of
Technology
Julie Scholes, Professor of Nursing, University of Brighton,
Brighton, UK
Riita Suhonen, RN, PhD, Profes sor, University of Turku,
Department of Nursing Science, Turku, Finland

83ISSUE 48
Contents
NursingCare AND Research
Published by the Greek Nursing Studies Association (GNSA)
Publisher and Editor-in-Chief: Chryssoula Lemonidou
Address: 123, Papadiamantopoulou st., 115 27 - Athens, GREECE
Tel.: +30 210-7461485
e-mail: info@nursingstudies.gr
Technical publisher: Ocelotos publishing
Annual Subscriptions 2012 for Εlectronic Version
Public Services, Libraries, Companies, Organisations: € 30,00
Individual Subscriptions: € 20,00
© Copyright 2007 - 2014: All rights reserved. The reproduction of articles (or parts of them) is
prohibited without permission of the publisher and the writers.
Instructions to Authors��90
ORIGINAL PAPER
Determinants of quality of life and stress among
patients with chronic renal disease�� 101
Papadopoulos R., Galanis P., Papagianni A., Hronidis G., E. Freggidou,
Bilali A., Theodorou M.
ORIGINAL PAPER
CTs and MRIs in Cyprus: A market analysis�� 113
Kantaris M., Theodorou M., Angelopoulos G., Kaitelidou D.
ORIGINAL PAPER
Investigation of the results of Moral Distress in
Job satisfaction of Greek nurses Investigation
of the results of Moral Distress in Job satisfaction
of Greek nurses�� 129
Chatzoula M., Kafetsios K.
REVIEW
Glycemic control of DM2 through Telemedicine�� 145
Dikoudi A., Sourtzi P.
2017 • VOLUME ...... • ISSUE 48

84
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85ISSUE 48
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87ISSUE 48
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Williams N. (2001). Patient resuscitation follow-
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Muller D, Harns P, Watley L. (1986). Nursing
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London: Harper Row.
Lewis T, Hell J. (1992). Rhabdomyolysis and
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National Institute for Clinical Excellence (2000)
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90
ABSTRACT
INTRODUCTION: Quality of life and stress
among patients with chronic renal disease af-
fect decisively clinical outcomes and clinical
course of these patients.
AIM:To evaluate quality of life and stress among
patients with chronic renal disease and to find
their determinants.
METHODOLOGY: A cross-sectional study was
conducted during January to March 2016.
Study population consisted of 130 patients with
chronic renal disease and 49 healthy people
without this disease as the control group. Qual-
ity of life short form (SF-12) and State Trait Anxi-
ety Inventory (STAI) were used in order to assess
quality of life and stress respectively.
RESULTS: According to multivariate linear re-
gression analyses, patients had worse quality of
life versus healthy in the following domains of
SF-12: physical functioning, physical role, physi-
cal pain, general health and physical health.
Also, decreased age was associated with bet-
ter quality of life in all domains of SF-12 except
mental health, while decreased stress was asso-
ciated with better quality of life in all domains of
SF-12. Patients had higher stress from a specific
situation than healthy people, while patients
and residents in rural areas had higher perma-
nent stress.
CONCLUSION: Patients with chronic renal dis-
ease had worse quality of life and more stress
than healthy and so appropriate interventions
are need in order to improve quality of life, de-
crease stress and improve clinical outcomes.
KEYWORDS: stress, quality of life, determi-
nants, chronic renal disease
ORIGINAL PAPER
Determinants of quality of life and stress
among patients with chronic renal disease
Papadopoulos R., MD Nephrologist, MSc, General Hospital of Imathia unit of Veria, Greece
Galanis P., RN, MPH, PhD, Center for Health Services Management and Evaluation, Department of
Nursing, National Kapodistrian University of Athens
Papagianni A., Health Visitor, MSc, General Hospital of Imathia unit of Veria
Hronidis G., RN, MSc, MSc, General Hospital of Imathia unit of Veria, Veria Greece
E. Freggidou, National Organism of health Care Services (EOPYY), Regional Department of Kilkis
Bilali A., RN, MSc, PhD, Children’s Hospital “P. A. Kiriakou”
Theodorou M., Professor, Open University of Cyprus
Corresponding Author:
Galanis P., e-mail: pegalan@nurs.uoa.gr

91ISSUE 48
ABSTRACT
OBJECTIVES: The purpose of this study was to
provide an analysis of the current and future
trends of CT and MRI activity in Cyprus. Cyprus is
leading in numbers of CT and MRI scanners per
100,000 inhabitants (3.4 CT and 2.1 MRI scan-
ners vs. 2.2 and 1.2 the EU mean respectively).
It can easily be argued that this market is fully
saturated; however no data exists to support
this claim.The only existing involves only public
sector activity showing disproportionately low
usage.
METHODS: Literature research, international
databases and field research were used. Fif-
teen interviews with key stakeholders were
conducted. This approach enhanced extraction
of as much as possible information which was
cross-checked with two or more interviewees.
RESULTS: Annual activity of MRI was estimated
around 50,000 examinations (89% private sec-
tor and 11% public) while the corresponding
activity of CT was approximately 123,000 exam-
inations (23% private and 77% public). The MRI
market is dominated by the private sector as
the public sector possesses only one MRI scan-
ner (leading to long waiting lists), whereas for
CT examinations the demand is met mostly by
the public sector. CONCLUSIONS:The diagnostic
imaging sector is unregulated, working without
monitoring and control mechanisms, referral
protocols and guidelines, leading among others
to clinically unjustified examinations. It is driven
mostly by prices and by referrals made by co-
operating doctors, who in some cases receive
a fee for this purpose. There are indications of
an overuse caused mainly by provider’s induced
demand.
KEYWORDS: CT, MRI, medical imaging, Cyprus
ORIGINAL PAPER
CTs and MRIs in Cyprus: A market analysis
Kantaris M., Research Associate, Open University of Cyprus
Theodorou M., Professor, Open University of Cyprus
Angelopoulos G., Research Associate, National and Kapodistrian University of Athens
Kaitelidou D., Assistant Professor, Open University of Cyprus
CorrespondingAuthor:
Kantaris M., Research Associate, Open University of Cyprus, PO Box 12794 2252 Latsia Nicosia, Cyprus.
kantarism@yahoo.com.

92
INTRODUCTION
Cyprus is the only member-state in the Europe-
an Union (EU) which does not have an integrated
public health care system of universal coverage.
Instead, the health system comprises of sepa-
rate public and private systems of almost simi-
lar size. The public system, which is financed by
the state budget, is highly centralized and tight-
ly controlled by the Ministry of Health (MoH). En-
titlement to receive free health services is based
on residency and income level and it is estimated
that only 80% of the population has coverage. It
is exclusively financed by the state budget, with
services provided through a network of hospitals
and health centres (Theodorou et al., 2012).
Currently, the public health care sector is more
akin to a hybrid system, with outdated structure
and organization, lack of modern and effective
management, serious shortcomings and diffi-
cult problems that cannot meet timely the ba-
sic needs of the beneficiaries. The system suffers
from long waiting lists for many services, includ-
ing diagnostic imaging, a situation that has been
worsened due to the recent economic crisis.
On the other side, the private sector works in a
rather unregulated environment and detached
from the control of the MoH and the Ministry of
Economics. It is financed mostly by out-of-pock-
et payments and to some degree by voluntary
health insurance (VHI), while providers are gen-
erally remunerated in a fee-for-service system.
It largely consists of independent providers, es-
tablished in urban areas, and working in solo and
group practices. Facilities are often physician-
owned or private companies with doctors usu-
ally as shareholders and to a large extend they
operate without a professional and effective
management. Private sector provides services to
those who can afford to pay for their treatment
from own resources or through private insurance
providers. It has an overcapacity of expensive
medical technology that is underutilized (Theo-
dorou et al., 2012).
According to the Mercer report (2013), the sec-
ond largest increase in the National Health Ex-
penditure of Cyprus during the period 2005-10
came from outpatient services which included
diagnostic imaging services, amounting to a 64%
increase from €244m in 2005 to €400m in 2010.
The same report projected that if there are no
changes in the current healthcare system, then
the total healthcare expenditure over the period
2016-2025 will see an increase at an average year-
ly rate of 4.2%. It was also forecasted that in 2020
the national healthcare expenditure will surpass
the 2011 level (€1,308m), the first year of reduc-
tion in national healthcare expenditure of Cyprus
due to the adverse economic conditions. Finally,
the private healthcare sector growth for the peri-
od 2016-2025 was forecasted at 4.9% per annum
whereas for the public sector at 3.3% per annum.
While outpatient care has consistently been the
second largest category with respect to health-
care expenditure in the public sector, it ranked
the largest in the private sector. Regarding out-
patient services and access to outpatient special-
ists the same report anticipated that NHS imple-
mentation in the future, with the introduction
of global budget approach and point system
mechanism, will have a significant impact on
outpatient specialists’ behaviour and this in ef-
fect will most likely influence access. The intro-
duction of family doctors as ‘gatekeepers’ is ex-
pected to ‘filter’ today’s uncontrolled and often
inappropriate access to outpatient specialists
such as radiologists and diagnostic imaging ser-
vice providers.
PURPOSE AND OBJECTIVES
It can be said that given no changes in the health-
care scene, the diagnostic imaging sector in Cy-
prus, being an integral part of outpatient and in-
patient care, could observe constant growth in
the coming years despite the negative impacts
of the economic crisis, which numbers show to
be easing out. That view, coupled with the uni-
versal and constant demand for improved diag-
nostic tools creates premise for reviewing the
current market of Advanced Diagnostic Imaging
- ADI (MRI and CT) in Cyprus.
Cyprus happens to be a leader in numbers of CT
and MRI scanners per 100,000 inhabitants (3.4 CT
and 2.1 MRI scanners vs. 2.2 and 1.2 the EU mean
respectively). At first glance it can be argued that
this market is fully saturated; however no data
exists to support this claim. The only existing da-
ta in Eurostat 2016 database involves only public
sector activity showing disproportionately low
usage.

93ISSUE 48
The purpose of this study was to provide an anal-
ysis of the current and future trends of the CT
and MRI market in Cyprus, which can be used as
a tool for strategic decision making in the field.
Subsequently, the study objectives questions
formulated in the form of research questions
were the following:
1. What are the CT and MRI facilities on the is-
land (locations, equipment features and tech-
nical characteristics)?
2. What is the CT and MRI clinical activity (num-
ber and type of examinations, capacity etc)?
Moreover, what kind of inferences could be
made regarding their appropriate and ration-
al usage?
3. What are the forces driving the CT and MRI
market (competition, contracting, pricing
etc)?
METHODOLOGY
The study followed a twofold methodologi-
cal process. Its first part consisted of an exten-
sive review of the relevant literature consisting
of policy, economic, technical and other relevant
reports (e.g. Mercer report, WHO reports, Euro-
pean Health Observatory and World Bank, OECD
and EU statistics) concerning ADI in Cyprus par-
ticularly the imaging modalities of CT and MRI.
This was followed by a field analysis which in-
cluded data collected from public services (e.g.
the Statistical Service of the Republic of Cyprus,
Ministry of Health, Ministry of Finance and the
Public Hospitals) as well as data collected from
private sources (e.g. private hospitals, diagnos-
tic imaging practices and health market experts).
As it happens with all the fields of healthcare
concerning the private sector in Cyprus, the field
of diagnostic imaging is a vastly undocumented
and unregulated area. At the same time the pri-
vate sector constitutes the overwhelming part
of diagnostic imaging market in Cyprus. In or-
der to obtain valid information regarding the
current situation and the nature and magnitude
of the activity in this particular area, key inform-
ants (medical radiations professionals e.g. radiol-
ogists, radiologic technologists, medical physi-
cists, general practitioners and specialists who
refer patients for diagnostic imaging investiga-
tions) and major stakeholders (local private pro-
viders e.g. shareholders and general managers of
private hospitals and diagnostic imaging centers,
policy makers from public authorities e.g. Minis-
try of Health, Health Insurance Organization) of
the sector were contacted. Fifteen personal in-
terviews were conducted, using unstructured
open-ended questions. This approach helped
us in the extraction of as much as possible infor-
mation on the matter which was in many cases
cross-checked with two or more key informants
during this process. Given the prevailing condi-
tions, it is envisaged that this approach lead to
the most reliable estimates and the most valid
conclusions regarding past and present activity
in this field of medical care in Cyprus.
FINDINGS
CT and MRI Facilities in Cyprus
Cyprus is a leading country in numbers of CT and
MRI scanners per 100, 000 inhabitants (Tables 1
2) (Eurostat, 2016). More specifically, Cyprus, Den-
mark Latvia, Bulgaria, Italy and Austria are in the
same group of EU countries having reported in
2013 at least 3 CT scanners per 100,000 inhabit-
ants, whereas Hungary and the UK had less than
1 per 100,000 inhabitants.
CT scanners MRI scanners Gamma cameras PET scanners
Angiography
units
n
per
100,000
n
per
100,000
n
per
100, 000
n
per
100,000
n
per
100,000
29 3.4 18 2.1 10 1.2 0 0.0 7 0.8
Table 1: ADI equipment in Cyprus and ratio per 100,000 inhabitants (2013)
Source: Eurostat, 2016

94
Table 2: Comparison of ratios per 100,000 inhabitants in CT MRI scanners across ten European
countries (2013)
Country
CT scanners
ratio per 100,000 inhabitants
MRI scanners
ratio per 100,000 inhabitants
Bulgaria 3.4 0.7
Croatia 1.6 1.1
Cyprus 3.2 2.0
Greece 3.5 2.3
Hungary 0.8 0.2
Ireland 1.8 1.3
Italy 3.3 2.4
Lithuania 2.3 1.1
Poland 1.7 0.7
Portugal 2.1 0.7
Turkey 1.4 1.1
Source: Eurostat, 2016
According to Eurostat (2016) between 2008 and
2013 the ratio of availability of MRI scanners per
100,000 inhabitants dropped because of popu-
lation growth and stability in the number of MRI
scanners. Cyprus joined with Greece, Finland, Ita-
ly and Austria reporting at least 1.9 MRI scanners
per 100,000 inhabitants in 2013 (Eurostat, 2016).
Despite the fact that Cyprus was among the top
countries in MRI units, it reported one of the low-
est ratios in numbers of MRI scans (below 1,000
scans) per 100,000 inhabitants. Strangely enough
this ratio for Cyprus was higher in 2008 despite
the fact that Cyprus had an increase of approx-
imately 0.3 MRI scanners per 100,000 between
2008 and 2013. Regarding the number of MRI
scans, Cyprus reported the least intensive yearly
use, with just 349 scans carried out on average (in
2013), per MRI unit (Eurostat 2016). These findings
regarding MRI scans or MRI scanner usage in Cy-
prus prove that MRI scans carried out in the pri-
vate sector are not recorded anywhere.
The official data from Eurostat presents a para-
dox for Cyprus; while being a top country in num-
ber of MRI scanners there is a dramatically low
use of MRI scanners in proportion to the number
of MRI scanners it possesses. However this is in-
accurate since the only examinations presented
are these at the only MRI unit in the public sec-
tor which are then related in ratio with the total
number of MRI units in both the private and the
public sectors yielding a dramatically low and in-
accurate ratio.
Figures 1a and 1b present the numbers of CT and
MRI scanners in Cyprus (public and private sec-
tors) for the period 2005-2016. From these ta-
bles it is worth noting the close to doubling of
MRI scanners within just one year, from 2007 to
2008 coming from an unprecedented expansion
of the private sector while at the same time the
public sector was experiencing a halt in CTs and
MRIs for more than 10 years. At present there are
18 MRI units and 29 CT scanners in Cyprus.

95ISSUE 48
Figure 1a: Changes in CT scanner numbers 2005-2016 (Private Public sector)
Figure 1b: Changes in MRI scanner numbers 2005-2016 (Private Public sector)
Source: Eurostat (2016)
¹From the field research
Source: Eurostat (2016)
¹From the field research

96
According to the European Coordination Com-
mittee of the Radiological, Electromedical and
Healthcare IT industry (COCIR) (2014), Cyprus had
the highest percentage of ageing CT scanners
in 2013 and did significantly better with respect
to MRI units comparing to the rest of the Euro-
pean countries (Table 3). The figures of Cyprus
in this respect fail COCIR ‘golden rules’ stating
among others that ‘not more than 10% of age pro-
file should be older than 10 years’ and ‘at least 60%
of the installed equipment base should be younger
than 5 years’.
Although medical technology older than 10
years is considered outdated and difficult to
maintain and repair and at the same time may
be considered obsolete and inadequate, there is
a trend in the private sector in Cyprus to acquire
and commission used (second-hand) CT and MRI
scanners. The situation is still controlled for MRI
scanners as a few of them are reconditioned be-
fore they arrive in Cyprus while some others are
upgraded after some years in operation; howev-
er the figures are expected to get worse in the
near future. Concerning CT scanners, the situ-
ation is much worse since there were some re-
ally old scanners at the time (2013) both in the
public and private sectors. Since then two old CT
scanners of the public sector have been replaced
with new ones. However a number of ageing CT
scanners still exists in the private sector, mainly
in small private hospitals. These CT scanners are
significantly underutilized and are mainly kept as
backup and for covering their own needs.
There is no general guideline or benchmark re-
garding the optimum number of CT or MRI scan-
ners per population (OECD, 2016). In the case
where too few of these units exist, this may lead
to access problems. In the case however of too
many scanners, this may result to an overuse
caused either by artificial demand (provider’s in-
duced demand) or not properly clinically justified
examinations. Keyvanara et al., (2014) argued that
some of the services offered by physicians have
inducing properties. This means that physicians
know that patients do not have full and appropri-
ate information regarding their services; they in-
duce a demand to them. Moreover, it is plausible
that induced demand may well be caused by the
conditions applied for health care coverage and
services provision to individuals, groups or pop-
ulations or even by patients and users. Howev-
er the stronger evidence on induced demand are
related to the supplier and more specifically the
clinician induced demand (Noguchi and Shimi-
zutani, 2005; Keyvanara et al., 2014).
One should expect that the sharp increase in
both CT and MRIs scanners needed to be accom-
panied with appropriate evidence justifying their
use and sustainability. However this was not the
case in the Cypriot CT and MRI market. Our find-
ings from the field research indicate that this
steep expansion in CT and MRI scanners was car-
ried out with no consideration of key factors re-
lated to clinical justification and financial sustain-
ability of such a venture.
The case of Cyprus in this respect is an interesting
one, in the sense that in the public sector there
are huge waiting lists in terms of requests for MRI
examinations. This is firstly because the private
sector dominates in numbers of MRI units and
secondly because patient referrals are in their
vast majority public sector patients (beneficiar-
Table 3: Age profile of CT and MRI scanners in Cyprus (2013)
Age profile
CT scanners MRI scanners
Cyprus Europe Cyprus Europe
1-5 years ~30% ~50% ~50% ~40%
6-10 years ~40% ~40% ~30% ~40%
10+ years ~30% ~10% ~20% ~20%
Source: COCIR (2013)

97ISSUE 48
ies). Thus the existence of only one MRI unit in
the public sector that cannot meet the demand
for MRI examinations and the reluctance of the
public sector to refer to the private sector, has
caused for the accumulation of a large number of
MRI exams waiting to be carried out. As far as CT
examinations are concerned there are long wait-
ing lists in Nicosia and Paphos.
In the absence of referral protocols/guidelines for
clinicians, there is widespread belief that many
of these accumulated examinations, which are
translated into long waiting lists, are examina-
tions which are more than likely not to be nec-
essary. This may be partly due to the self-inter-
est of doctors (supplier induced demand) and
partly to the defensive medicine they practice.
Even though no literature exists linking directly
the absence of referral guidelines to induced de-
mand, it can be argued that the absence of clin-
ical guidelines and protocols could contribute
towards the preservation of conditions of unnec-
essary and irrational usage of CT and MRI units.
In any case it cannot go without mention that de-
spite the increase in the numbers of CT and MRI
examinations during the recent years and the ac-
cumulation of significant waiting lists, the public
sector more or less remained in a state of a con-
stant freeze.
The distribution of CT scanners and MRI units
across the public and private sectors is 6 (21%)
and 23 (79%) respectively for CT scanners and 1
(6%) and 17 (94%) respectively for MRI units. In Cy-
prus there are 14 (78%) closed-type and 4 (22%)
open-type MRI units in 2016. Figure 2 shows
distribution of MRIs in Cyprus by their magnet-
ic field strength (low, mid, high) and figure 3 the
CT scanner slice technology (Low-slice, medium-
slice and high-slice).
CT and MRI Activity
CT and MRI examinations carried out in the pub-
lic sector (Tables 4, 5 6) are recorded and can
be extracted from the Health and Hospital statis-
tics publication of the Statistical Service (Repub-
lic of Cyprus Statistical Service, 2016a). Moreover,
table 7 presents a few examples of CT and MRI
fees of the public sector for non-beneficiaries.
The cost of these fees corresponds to a range of
9-16% of the median monthly income (€1,509) for
2015 in Cyprus, and 28- 49% of the monthly min-
imum salary (€870) in Cyprus (Republic of Cyprus
Statistical Service, 2016b). A detailed description
of all the prices of the public sector for non-ben-
eficiaries for medical care is published in the Re-
public of Cyprus official gazette (Republic of Cy-
prus, 2013). The upsurge in CT examinations in
Figure 2: MRI equipment field strength
1
5%
3
17%
14
78%
Low (0.3T)
Mid (0.3-1.0 T)
High (1.0-3.0T)

98
the public sector (over 80%) for the period 2006-
2014 cannot be attributed to a single reason. Two
main reasons may be the need to meet growing
health needs and the supplier -induced demand.
The degree of impact of these two factors sep-
arately and in combination cannot be estimat-
ed for this period due to the absence of referral
guidelines and audits.
The activity of the private sector with respect to
CT and MRI examinations is clearly unrecorded
and uncharted. Although the recording of such
examinations is a requirement under Europe-
an and national legislation, no central recording
system of collection is in place, in order to make
this information readily available to researchers,
regulators and other groups, stakeholders or in-
dividuals with vested interest. Taking under con-
sideration this absence of information as well as
the time constrains, this particular type of infor-
mation had to be extracted by contacting vari-
ous key informants and experts in the field of di-
agnostic medical imaging in Cyprus.
Based on this approach it was estimated that the
annual activity of MRIs is approximately 50,000
examinations (89% private and 11% public) while
the corresponding activity of CTs to be approx-
imately 123,000 examinations (23% private and
77% public) This estimation (figure 4) is slightly
higher than the EU mean, showing an underuti-
lisation of the diagnostic imaging in private sec-
tor (Eurostat, 2016). The figures were estimated
by compiling 2014 data from Ministry of Health
regarding the public sector and data collected
for the private sector for the needs of this study.
Consequently this picture of the private sector
should be evaluated as a rough overall indica-
tion since there are no official statistics. The lev-
el of uncertainty on these figures cannot be cal-
culated.
Looking at these figures it is obvious that the MRI
market is dominated by the private sector while
the CT market by the public sector. This is primar-
ily due to the fact that the public sector possess-
es only one MRI scanner whereas for CT examina-
tions that in their vast majority concern referrals
of public sector beneficiaries served by the six CT
scanners of the public sector that appear to meet
the demand at a fairly satisfactory level. This por-
trayal indicates an underutilisation of CT scanner
in the private sector. Looking closer at these fig-
ures regarding the private sector it can be not-
ed that there is a concentration in MRI activity of
more than 70% at 7 private providers while the
remaining 11 are operating well below their ca-
pacity potential. The positioning of ADI servic-
es inside hospitals/medical centers that provide
wide range of healthcare services such as inpa-
tient, ambulatory, ancillary and supportive care
services creates better conditions for the greater
use of the CT scanners and MRI units.
Figure 3: CT scanner slice technology
19
66%
9
31%
1
3%
Low-slice (64)
Medium-slice (64 slices)
High-slice (64 slices)

99ISSUE 48
Table 4: CT and MRI examinations, public sector 2006-2014
Table 5: CT and MRI examinations by hospital (district), public sector 2014
2006 2007 2008 2009 2010 2011 2012 2013 2014
CT 51,887 55,702 67,842 75,157 83,536 85,709 91,184 96,265 94,491
MRI -- 116 6,500 5,660 5,191 6,261 6,207 5,939 5,535
Source: Statistical Service, Republic of Cyprus (2014)
Nicosia
General
Larnaca
General
Famagusta
General
Limassol
General
Paphos
General
CT 31,574 15,792 5,837 28,566 12,722
MRI 5,535 -- -- -- --
Table 6: CT and MRI exams by public hospital, inpatient (IP) and outpatient (OP), 2014
Table 7: Examples of Public Sector prices to non-beneficiaries for CT and MRI exams
Source: Official gazette, Republic of Cyprus (2013)
Nicosia General
Larnaca
General
Famagusta
General
Limassol
General
Paphos
General
IP OP IP OP IP OP IP OP IP OP
CT 16,210 15,364 433 15 359 556 5 281 5 117 23 449 4 420 8 302
MRI 724 4 811 -- -- -- -- -- -- -- --
Examination Fee to non-beneficiaries
MRI of the Knee €256
MRI of the Brain €376
MRI Angiography – Cervical €376
MRI – administration of IV contrast €51
MRI – administration of anaesthetic €51
CT of the Chest €171
CT Coronography €427
CT Brain €136 – with IV contrast €256
CT Colonoscopy €427

100
Figure 4: Number CT and MRI examinations (per 100,000 inhabitants) in 2014:
EU mean, Cyprus-- public sector only Cyprus – Study estimate
The competition, particularly in MRI, has become
rather fierce since 2005, following the installation
of many more units. Today the price of the exam-
ination is probably the most decisive factor for
the patients, a factor which seems to drive com-
petition. The price for a rather common and sim-
ple MRI examination (e.g. MRI of the knee) can to-
day be as low as €190 whereas ten years ago it
was nearly double this amount. This is attribut-
ed mainly to two factors: (a) the entrance of new
‘players’ with older units hence lower deprecia-
tion costs and (b) the gradual deterioration of the
economy during the recent years that has limited
consumers purchasing power and exerted pres-
sure over the market to lower its prices.
Waiting times for CT MRI
examinations in the public sector
For the last 6-8 years MRI examinations in the
public sector pose one of the biggest problems
in terms of waiting times, forcing some patients
to visit the private sector. The situation regarding
CT examinations is much better where the con-
tracting with the private sector is mainly used for
covering in case of accumulated emergency cas-
es or unexpected breakdowns.
Table 8 shows the waiting times for MRI and CT
examinations as at April 2016. It is estimated that
approximately 21 MRI examinations are carried
out on a daily basis at the MRI unit of the pub-

101ISSUE 48
lic sector while another 21 MRI examinations are
added to the waiting lists also on a daily basis.
The absence of effective follow-up and updat-
ing of these lists creates reliability problems. The
reliability of these waiting times is a matter that
requires analysis and further investigation since
many of these patients waiting might have al-
ready paid out-of-pocket to have their examina-
tions in the private sector. Moreover there should
be a number of patients waiting too long for very
serious conditions who have already died. Lastly,
this data on waiting times does not provide nec-
essary detail to help make comparisons with ac-
ceptable waiting time targets in other countries.
The efforts of the public sector for restraining the
growth of the waiting lists focus on the imple-
menting of clinical referral protocols across the
board in order to control and monitor the refer-
ral of CT and MRI examinations, the collaboration
with other government departments such as the
department of Social Insurance in order to avoid
for example any unnecessary examinations for is-
suing invalidity certificates and the grouping of
patients with certain conditions requiring spe-
cialized diagnostic examinations to be covered
by the private sector through the procedure for
tender requests.
Contracting of private sector with pub-
lic sector
The long waiting lists for MRI and CT examina-
tions force the public sector to make announce-
ments for tender requests for the provision of
services from the private sector.
According to national legislation tenders low-
er than €15,000 are briefly reviewed and execut-
ed relatively quickly in order to meet current ac-
cumulating needs. At present there are ten such
tenders running (under €15,000); five for MRI ser-
vices and five for CT services. Each of these ten-
ders is intended for each one of the five districts
of Cyprus (excluding the Turkish occupied Kyre-
neia district). These tenders are awarded to ten-
derers who already meet predetermined crite-
ria related to technological and human resources
requirements. There are also plans by the Minis-
try of Health (MoH) to openly announce a much
more expensive (in the range of 1 million Euros)
and detailed tender, in an attempt to respond to
the ever so growing waiting list of MRI examina-
tions. Such a tender was in fact announced in the
past, but was cancelled because all candidate
tenderers failed to provide in full all the informa-
tion required for the successful submission of the
tender proposal.
During the last few months of 2015 the waiting
for MRI examinations hit a high of approximate-
ly 13,770 accumulated pending examinations. An
initiative of the MoH took advantage of an un-
foreseen surplus of the central government and
announced a three-month plan for mitigating
this problem of long waiting lists in MRI exam-
inations. Nine private providers (5 in Nicosia, 1
in Limassol, 2 in Larnaca and 1 Paphos) accept-
ed to participate in this plan which reportedly
Table 8:Waiting times for CT scans MRI in public hospitals (April 2016)
General Hospital
CT scans MRI
Waiting time
No of cases in
the list
Waiting time
No of cases in the
list
Nicosia 3 months 250 8 months 5 147
Limassol 2 months 1200 Non applicable Non applicable
Paphos 3,5 months 40 Non applicable Non applicable
Larnaca 20 days 200 Non applicable Non applicable
Famagusta 10 days 60 Non applicable Non applicable
Source: Ministry of Health

102
achieved by the end of December 2015 to car-
ry out more than 13,000 MRI examinations. This
plan was terminated on the last day of 2015 since
the surplus financing of the plan was only avail-
able for 2015. Since then the MRI waiting rose
again to the figures presented in table 4.9, and
for this reason the Ministry announced new call
for tender requests, which are underway.
The idea of grouping patients will probably in-
volve at a first phase those with multiple sclerosis
and thalassaemia and is anticipated to be an ef-
ficient method of contractual agreement of the
public with the private sector. There are approx-
imately 1,200 multiple sclerosis and 800 thalas-
saemia cases that are expected to benefit from
this scheme. It appears that the ultimate goal is
through such schemes to give nearly all MRI ex-
aminations to the private sector.
At present, the price that the public sector re-
imburses the private sector is €135 for every
MRI examination and €150 for every CT exami-
nation, despite the fact that public sector has a
set price for an MRI examination for non-benefi-
ciaries of the public system in the range of €300-
350 (including the intravenous (IV) contrast). This
low price was achieved because the tender pro-
cedure obliges the public sector to set as reim-
bursement the lowest price ever offered by a can-
didate tenderer. In this case a candidate tenderer
in his attempt to present the most economical-
ly attractive tender, had calculated the price for
every MRI examination to be €135 and since then
this specific value applies for all tenders.
Trends and Challenges of the Cypriot CT
and MRI Market
The underlying forces that compel consumers to
pay for ADI services such CT and MRI scans are
similar to those in other western societies. Market
drivers such as the growing ageing population
age and the growing demand for imaging diag-
nostic tools of advanced technology determine
market activity (European Society of Radiology,
2010). An additional factor that triggers the de-
mand, even if there is no adequate documenta-
tion, is the demand induced by providers, espe-
cially medical specialties which refer patients to
diagnostic centres. The absence of control in a
completely unregulated market on the one hand
and the lack of medical protocols on the other,
exacerbate the situation (Mitchell, 2007).
It is obvious that the absence of an integrated
National Health System (NHS) affects the mar-
ket in various ways. Phenomena and problems
such as unregulated market, lack of quality assur-
ance and referral systems, induced demand prac-
tices, high prices, out-of-pocket payments, long
waiting lists etc., would have different extent and
weight and could more easily be handled in a
well-organized health system. In the current sys-
tem, the majority of the public health beneficiar-
ies choose to pay for imaging services in the pri-
vate sector due to the shortcomings of the public
sector. A significant number of patients opt for
out-of-pocket private sector imaging services
while another not insignificant number of pa-
tients are privately insured with individual or col-
lective (work-based) insurance schemes which
cover for diagnostic imaging services. It was on-
ly just recently that this behaviour has begun to
overturn mainly because of the economic crisis
and the financial burden imposed on consumers
to use private healthcare services making out-of-
pocket payments.
The absence of control over the private sector
by the state in conjunction with the lack of na-
tional guidelines and protocols regarding the re-
ferral of patients for diagnostic imaging inves-
tigations create favourable conditions for the
excessive use of such services as well as the crea-
tion of artificial demand, based on the perceived
need of the consumer and the opinion of each
treating physician or group of physicians (norma-
tive need). In other words, it is relatively easy for
a patient who feels necessary to have an imag-
ing examination to obtain a referral by a private
sector physician based only on his or hers per-
ceived need. Moreover a private sector physician
can easily request an imaging examination with-
out considering all alternative options available.
It can be said that this kind of behaviour can also
be seen in the public sector where the long wait-
ing times especially for MRI investigations are in
a way the symptom as a result of the lack of clin-
ical guidelines and referral protocols and the in-
effective control and monitoring for this particu-
lar activity.
Many private sector providers that operate in
this ADI market environment have emerged in

103ISSUE 48
the last decade. One distinct category of those
private providers is that of physicians and other
clinicians who collaborate by referring their pa-
tients to specific ADI providers. Some of them
are also major shareholders in these small or
large private hospitals where the ADI facilities
are found. There can also be physicians with their
own private practices who are shareholders in a
certain ADI facility or simply ‘join forces’ in sup-
porting these facilities. In this way the financial
viability of these facilities is supported and up to
an extent ensured, with the creation of a strong
network of referring clinicians (many of whom
with a direct interest for these facilities’ econom-
ic sustainability and profitability). A second dis-
tinct category involves the traditional and long-
established providers who have been in the field
for many years enjoying the trust and respect of
patients and consumers for their capacity to offer
quality diagnostic imaging examinations, and for
these reasons they constitute the first choice for
many patients. One last distinct category of pri-
vate sector providers is that of the relatively new
entrants in the market of diagnostic imaging that
caused an ‘upset’ in the market by focusing on
the pricing parameter, offering the lowest prices
of the market for almost all the types of imaging
examinations.
The lowering of prices by new entrants intro-
duced a new dimension in the market’s competi-
tion. The lowering in prices was made financially
more feasible since such providers have installed
older and second-hand MRI units requiring low-
er starting and operating expenses. Today the at-
tention of consumers lies with the price and this
has caused all providers to lower their prices or
offer discounts. Regarding MRI, the prices have
been reduced by €100-150, depending on the ex-
amination.
Regardless the provider category, there is in ex-
istence an informal system of ‘premium grant-
ing’ to clinicians referring their patients to the
various ADI providers of the private sector. This
premium granting to referring clinicians is com-
monly referred to as ‘provision of medical servic-
es’ and is basically a payment of 10-30% commis-
sion on the price of the examination, depending
on the type of examination requested. Although
this activity does not appear to be illegal, it can
be argued that it damages fair competition as it
introduces a form of financial incentive for the re-
ferring clinicians and this can often not be in the
patients’ best interest.
CONCLUSIONS
Cyprus has too many MRI and CT units in relation
to the population and needs. The legal frame-
work although existent and detailed, in practice
allows flexibility and looseness. The absence of
specific legislation regarding MRI units and the
granting of permission for the installation and
the monitoring of the safe operation of such
units has created conditions for their contraindi-
cated installation.
Taking this under consideration, it can be in-
ferred that this particular imaging segment is sat-
urated. This is because currently there is no mon-
itoring and control over the clinical activity of the
private sector, there are no referral protocols be-
ing utilised and that consequently creates condi-
tions for the rise in ‘induced demand’ in both pri-
vate and public sectors. The likelihood for the
existence of ‘artificial demand’ is also reinforced
by the current environment of premium granting
and/or sponsorship of referring physicians.
The complete lack of activity data, forced us to
look for ways of measuring, at least, the CT and
MRI activity, conducting a field research via vis-
its to diagnostic centres, using personal contacts
and key informants. Despite the practical difficul-
ties, enough data was gathered on the activity of
the private sector, although some was based on
estimates by market experts. Nevertheless, we
eventually collected crude data from all private
hospitals and private centers that have CT and
MRI units, which in a sufficient degree of reliabil-
ity and validity reflected the magnitude of this
market. Based on this approach we found the an-
nual activity of MRI to be approximately 50,000
examinations (89% private and 11% public) while
the corresponding activity of CT to be approxi-
mately 123,000 examinations (23% private and
77% public).
The market of ADI seems currently to be driven
by the prices as well as by the establishment of
‘alliances’ and the creation of physician referral
networks. Despite the fact that these units oper-
ate well below their capacities, they still remain in
the market without presenting any loss.

104
At present the contracting possibilities with the
public sector (particularly in MRI) seem to be very
important for private sector providers. However
this is an issue that needs to be looked at under
the prism of the reforms in health care and the
implementation of the NHS. Alongside with the
NHS implementation the future political devel-
opments should also be assessed. The north part
of the island is occupied by Turkey since 1974 and
not controlled by the Republic of Cyprus. There
is no official data on the number of CT and MRI
units found at the occupied part. It is believed
that there are at least six MRI units in the occu-
pied part of Cyprus. It is also known that a PET/CT
unit operates there once or twice per week us-
ing radiopharmaceuticals brought illegally from
southern Turkey.
The possibility of the installation of a PET/CT
could be considered as a more appealing and vi-
able venture having in mind its growing impor-
tance and application in medical imaging di-
agnosis. According to unofficial data there are
currently approximately 5 public sector bene-
ficiaries per month who undergo a PET/CT scan
abroad (Israel, Greece or the UK) and an addi-
tional monthly estimated number of five private
sector patients who pay out-of-pocket to have a
PET/CT examination abroad. Thus, it is estimated
that at present there are at least ten Cypriot pa-
tients having a PET scan abroad each month for
diagnosis, staging or treatment follow-up pur-
poses. This leaves a small window of opportuni-
ty for PET imaging in Cyprus in the future since
the potential availability of such imaging modali-
ty in Cyprus, could increase the number in PET re-
ferrals since costs would be lower and awareness
of both patients and healthcare professionals
on the benefits of this examination would grow.
There are plans however for the installation of
such a unit in the near future in Cyprus at Asga-
ta, near Limassol, where the new ‘German oncol-
ogy centre’ is expected to commence operations
in the end of 2017.
FUNDING
No funding was available.
COMPETING INTERESTS
The authors declare that they do not have
conflicting interests.
REFERENCES
COCIR (2014), ‘Medical imaging equipment age pro-
file and density: Cocir executive summary’, COCIR
Cyprus Statistical Service, Health and Hospital Statis-
tics, (2014) http://www.mof.gov.cy/mof/cystat/sta-
tistics.nsf/All/39FF8C6C587B26A6C22579EC002D5
471/$file/HEALTH_HOSPITAL_STATS-2014-300316.
pdf?OpenElement
European Society of Radiology, (2010), The Future role
of Radiology in Healthcare, Insights Imaging, Jan
1:pg2-11
Eurostat (2016), ‘Healthcare resource statistics – tech-
nical resources and medical technology’, http://
ec.europa.eu/eurostat/statistics-explained/index.
php/Healthcare_resource_statistics technical_re-
sources_and_medical_technology#Availability_of_
medical_technology, Accessed on May 5, 2016
Keyvanara M, Karimi S, Khorasani E, Jazi MJ, (2014), Ex-
perts’ perceptions of the concept of induced de-
mand in healthcare: A qualitative study in Isfahan,
Iran, Journal of Education and Health Promotion,
3:pg27
Mercer (2013), ‘Actuarial study of Cyprus national
health expenditure and national health system,
Health Insurance Organization’, Marsh and McLen-
nan companies
Ministry of Finance, Cyprus (2016), Asymmetric in-
formation in Cyprus health market, Ministry of Fi-
nance of the Republic of Cyprus.
Mitchell JM, (2007), The prevalence of physician self
referral arrangements after stark II: evidence from
advanced diagnostic imaging, Health Affairs,
26(3):pg415-424
Noguchi H Shimizutani S. (2005) Supplier-induced
demand in Japan’s at-home care industry: Evi-
dence from micro-level survey on care receivers,
http://www.esri.go.jp/en/archive/e_dis/abstract/e_
dis148-e.html , Accessed on August 23 2017
OECD (2014) Health at a Glance: Europe 2014, OECD
Publishing. http://dx.doi.org /10.1787/health_
glance_eur-2014, Accessed on May 5, 2016
OECD (2016), ‘Health at a glance 2015, OECD indica-
tors’, http://apps.who.int/medicinedocs/documents/
s22177en/s22177en.pdf, Accessed on May 5, 2016
Republic of Cyprus Statistical Service (2016a), Health
Statistics 2014, Series I, report No. 35, March 2016.
http:// www.mof.gov.cy/cystat , Accessed on May 5,
2016
Republic of Cyprus Statistical Service (2016b), Av-
erage Monthly Earnings 2010-2015, http://www.

105ISSUE 48
mof.gov.cy/mof/cystat/statistics.nsf/economy_
finance_13main_en/economy_finance_13main_
en?OpenFormsub=3sel=1 , Accessed on August
29 2017
Theodorou M, Charalambous C, Petrou C, Cylus J
(20120, Health Systems in Transition : Cyprus Health
System Review, European Observatory on Health
Systems and Policies.
The Official Gazette of the Republic of Cyprus (2013)
Republic of Cyprus, ‘Fees for healthcare services (in
Greek)’,
The World Bank (2016), ‘Data: Cyprus’ http://data.
worldbank.org/country/cyprus#cp_prop, Accessed
on May 5, 2016

106
ABSTRACT
BACKGROUND: Most of the clinical situations
that health professionals called to manage re-
quire moral judgments. The nurses, as they have
more contact with patients and their family than
the other health professionals, often find them-
selves in front of moral and vague challenges,
which could lead them to moral distress.
OBJECTIVES: Aim of the present study is the in-
vestigation of the levels of moral distress and its
relation to job satisfaction in nurses of a general
hospital.
METHODS: Using survey methods approach,
it was asked throughout nursing hospital staff
completing questionnaires about demographic
factors, moral distress and job satisfaction Ad-
vanced statistical analysis was completed to look
at relationships between the variables.
RESULTS: In the study were participated 268
of nurses, midwives and assistant’s nurses. Data
analysis did show low levels of moral distress
(M=61.3, SD= 37.4). There was no significant cor-
relation between moral distress, job satisfaction,
and demographic characteristics.
CONCLUSION: Although this survey reported
low levels of moral distress and no correlation
with job satisfaction, further investigation is
needed in the future about nurses’moral distress
in hospitals and institutions cross country, as the
present study was the first that was attempting
in Greek nurses.
KEYWORDS: Moral distress, job satisfaction, mo-
rality, nurses
ORIGINAL PAPER
Investigation of the results of Moral
Distress in Job satisfaction of Greek nurses
Investigation of the results of Moral
Distress in Job satisfaction of Greek nurses
Chatzoula M., Midwife MSc, A’ Obstetric and Gynecological clinic, Aristotle University of Thessaloniki,
General Hospital Papageorgiou
Kafetsios K., Associate Professor of Psychology Department, School of Social, Economic Political
Sciences, University of Crete
CorrespondingAuthor:
Chatzoula M., Tripoleos 7, Sikies Thessaloniki, 56626, m8xenia@gmail.com

107ISSUE 48
ABSTRACT
INTRODUCTION: Type 2 diabetes mellitus (DM-
II) has been recognized as a major cause of pre-
mature death worldwide. Self-management is
one of the most important skills that patients
with this disease need to obtain. The goal of im-
proving the self-management of DM-II has led
to the development and implementation of nu-
merous telemedicine programs in order to im-
prove self-care.
PURPOSE:The purpose of this systematic review
was to study the effect of telemedicine on self-
management of the disease.
REVIEW METHOD:The review included research
studies published in the period 2005-2015, com-
ing from search databases Medline / Pubmed,
Scopus, Cinahl with the words“diabetes mellitus
type 2”,“self-management”,“telehealth / e-health
“,”Telemedicine“,”technology“.
RESULTS: 24 randomized studies were included.
The majority of these showed that glycemic con-
trol was statistically significantly improved in the
interventiongroupscomparedtocontrolgroups.
In addition, self-management of DM-II was
strengthened after telemedicine interventions.
Telemedicine interventions targeting more than
one biometric parameter have been shown to be
far more effective than simple self-monitoring of
blood glucose control in enhancing patient self-
management. In addition, the strong theoretical
background, the use of other technologies and
the longer the duration of the intervention have
proved to be also successful strategies.
CONCLUSION: Large multicentre studies are
necessary to make safe conclusions about the
utility and efficiency of telemedicine applica-
tions in self-management of chronic diseases
such as DM-II.
KEY WORDS: Type 2 diabetes mellitus, self-man-
agement, telemedicine / e-health, telemedicine,
technology
Glycemic control of DM2 through
Telemedicine
Dikoudi A., R.N., M.Sc. in Community Nursing, Diabetes Mellitus and Obesity,
Sourtzi P.,, Proffesor, Department of Nursing, National and Kapodistrian University of Athens
Corresponding author:
Dikoudi A., Email: nastaziantikoudi@gmail.com
REVIEW

108
Vatatzi 55, 114 73 Athens, Greece
ΤEL. : 210 6431108
E-MAIL: ekdoseis.ocelotos@gmail.com
www. ocelotos. gr

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