ReviewDoes telemedicine improve treatment outcomes for diabetes? A meta-analysis of results from 55 randomized controlled trials
Introduction
The increasing prevalence of diabetes and its associated costs has become a daunting health challenge in the world. In 2013, 381.8 million adults in 219 countries and territories had diabetes, and the number has been projected to rise to 591.9 million in 2035 [1]. Concurrent with this trend is the escalating economic burden of the disease. Global health expenditure to treat and prevent diabetes and its complications will increase from 232 billion US dollars in 2007 to exceed 302 billion by 2025 [2]. Thus, identifying effective approaches to promoting diabetes self-management at home and reducing hospital admissions or readmissions has become increasingly important to control expenditures associated with diabetes [3].
Over the last two decades, telemedicine—defined as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status” [4]—has been increasingly used in diabetes control and management. Relative to conventional care, telemedicine allows for more constant and close monitoring of blood glucose and medication adherence by patients. It also reduces the need of in-person visits for those patients who do not have easy access to health care providers due to either distance to clinics or due to transportation issues.
A growing number of randomized controlled trials (RCTs) have assessed the effectiveness of telemedicine on diabetes management compared with usual care. While some studies highlighted the effectiveness of telemedicine to attain blood glucose control [5], [6], [7], other studies did not show significant differences in glucose control for patients intervened by telemedicine compared to other patients [8], [9], [10]. So far, systematic reviews and meta-analysis of findings from these studies are limited and existing review studies have often been restricted by modest sample sizes, lack of adherence to standardized methodology for meta-analysis, or inadequate attention to heterogeneity across studies [11], [12], [13], [14].
In this systematic review and meta-analysis study, we aim to assess the effectiveness of telemedicine programs, compared to conventional, non-telemedicine care, in diabetes management. We further examined the performance of telemedicine in diabetes management by type of diabetes, age group of patients, duration of trial, and primary telemedicine approaches used (remote monitoring or teleconsultation). The analysis is conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [15].
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Data sources and searches
We systematically searched published RCTs that investigated the effect of telemedicine interventions on HbA1c levels in patients with type 1 or type 2 diabetes based on information from PubMed, Scopus and Embase until August 8, 2014. The search terms used were “telehealth”, “telemedicine”, “eHealth”, “mHealth”, “short message system (SMS)” “smartphone”, and “diabetes”.
We excluded studies that were conference proceedings, abstracts, non-English publications, trials that included patients with
Study selection and characteristics
The study selection process is detailed in Fig. 1. The initial database search resulted in 1992 articles after removing duplicates. Of these articles, 1887 studies were excluded because they were either not RCTs or did not include health outcomes. Full-text review was conducted for 105 studies. Of these articles, 56 were excluded due to the following reasons: focusing on gestational diabetes; health outcomes did not include HbA1c; the study did not include a usual care group; or data necessary
Discussion
The objective of this study was to systematically investigate whether telemedicine programs are more effective in diabetes management than conventional, non-telemedicine care. Based on an analysis of findings from 55 RCTs, our results indicated that patients served by telemedicine programs experienced a more substantial reduction in HbAlc levels compared to patients not served by telemedicine programs. This reinforces the evidence on the overall effectiveness of telemedicine in diabetes
Limitations
Heterogeneities across the included 55 RCTs posed a challenge to our meta-analysis. While the subgroup analyses helped assess the robustness of our findings to the risk of biases both within and across studies, unobserved confounding factors may significantly impact our findings. For example, when we conducted the subgroup analysis by patient age groups and duration of telemedicine intervention, we did not control for potential differences in baseline HbA1c across the subgroups. Meta-regression
Conclusions
Compared to conventional, non-telemedicine care, telemedicine interventions are in general more effective in improving treatment outcomes for diabetes patients, especially for those with type 2 diabetes. There is also preliminary evidence of the decreasing impact of telemedicine in diabetes management overtime. Despite its higher cost and technological sophistication relative to teleconsultation, remote patient monitoring was not associated with better clinical outcomes for patients with
Author contributions
Dejun Su and Jim Stimpson conceived the paper idea. Junmin Zhou and Megan Kelley led the effort in compiling the literature and conducting the meta-analysis. All authors including Dejun Su, Junmin Zhou, Megan Kelley, Tzeyu Michaud, Mohammad Siahpush, Kim Jungyoon, Fernando Wilson, Jim Stimpson, and Jose Pagan substantively participated in the research design, presentation of results, and writing of the paper.
Conflict of interest
The authors have no conflict of interest to declare.
Acknowledgement
We would like to thank librarians at the University of Nebraska Medical Center library for their support and assistance during the literature search.
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