Telemedicine for the Management of Glycemic Control and Clinical Outcomes of Type 1 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Abstract

Importance: Telemedicine has been shown to be an efficient and effective means of providing care to patients with chronic disease especially in remote and undeserved regions, by improving access to care and reduce healthcare cost. However, the evidence surrounding its applicability in type 1 diabetes remains scarce and conflicting.Objective: To synthesize evidence and quantify the effectiveness of telemedicine interventions for the management of glycemic and clinical outcomes in type 1 diabetes patients, relative to comparator conditions.Data Sources: MEDLINE, EMBASE, Cochrane Library, Web of Science, PsycINFO, and CINAHL were searched for published articles since inception until December 2016.Study Selection: Original articles reporting the results of randomized controlled studies on the effectiveness of telemedicine in people with type 1 diabetes were included.Data Extraction and Synthesis: Two reviewers independently extracted data, assessed quality, and strength of evidence. Interventions were categorized based upon the telemedicine focus (monitoring, education, consultation, case-management, and peer mentoring).Main Outcome and Measure: Absolute change in glycosylated hemoglobin A1c (HbA1c) from baseline to follow-up assessment.Results: A total of 38 studies described in 41 articles were identified. Positive effects on glycemic control were noted with studies examining telemedicine, with a mean reduction of 0.18% at the end of intervention. Studies with longer duration (>6 months) who had recruited patients with a higher baseline HbA1c (≥9%) were associated with larger effects. Telemedicine interventions that involve individualized assessments, audit with feedback and skill building were also more effective in improving glycemic control. However, no benefits were observed on blood pressure, lipids, weight, quality of life, and adverse events.Conclusions and Relevance: There is insufficient evidence to support telemedicine use for glycemic control and other clinically relevant outcome among patients with type 1 diabetes.

Cost-effectiveness of Shared Telemedicine Appointments in Young Adults With T1D: CoYoT1 Trial

“…We found that if the QoL benefits were to persist over a lifetime, there would be a gain of 0.95 QALYs. The life-time base-case, subgroup, and sensitivity CEAs were all consistent with each other (eTables [11][12][13][14].…”

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies

“…Telemedicine has the potential to help reduce disparities in diabetes management especially in remote regions, by improving access to care and reducing health care costs as demonstrated in this study of older adults . While a recent meta‐analysis found a mean reduction in HbA1c of 0.18% with use of telemedicine, given the paucity of data available and heterogeneity of the studies included in the analysis, the findings are limited . When impact of telemedicine was investigated by subpopulation, its use was noted to be successful in adolescents with a mean difference in HbA1c of −0.32% between groups .…”

“…296 Importantly, those studies with longer duration (>6 months) and those that recruited individuals with higher baseline HbA1c values (≥9%) demonstrated greater benefit. 296 Thus, a cautious optimism can be used when considering application of this technology in the future.…”

Intensive remote monitoring versus conventional care in type 1 diabetes: A randomized controlled trial

“…A recent meta‐analysis of 13 randomized controlled trials including 4207 adults with T1D found that telemedicine was associated with a significant decline in HbA1c compared with usual care . However, findings among pediatric patients with T1D have been more equivocal, and no studies so far have included separate subgroup analyses of younger children and adolescents . This pilot study was conducted to assess the impact of a 6‐month intensive remote therapy (IRT) intervention for children and adolescents with T1D.…”

“…17 However, findings among pediatric patients with T1D have been more equivocal, and no studies so far have included separate subgroup analyses of younger children and adolescents. 18,19 This pilot study was conducted to assess the impact of a 6-month intensive remote therapy (IRT) intervention for children and adolescents with T1D. We hypothesized that real-time collection of data regarding insulin, blood glucose, and physical activity, in conjunction with rigorous outreach, would improve glucose control among these patients.…”