NIHR Signal Information delivered by telemedicine can improve diabetes control

Published on 14 February 2017

Telemedicine, such as text messaging or internet support systems used to communicate with patients, improves long-term blood sugar control in adults with type 1 or type 2 diabetes.

Telemedicine gave small reductions in HbA1c (a measure of overall diabetes control over 12 weeks) compared with usual care at all follow-up times. It was most effective in the short-term, reducing HbA1c by about 0.6% (6mmol/mol) by three months. There was less difference in the medium and long-term, around 0.3% (3mmol/mol) reduction up to one year or more. There was no effect on quality of life, mortality or risk of episodes of low blood sugar.

This review included 111 trials and 23,648 adults with type 1 or type 2 diabetes. A wide variety of interventions were categorised as telehealth. Texting or web portal ways of communicating were associated with slightly larger average effects. Few studies were performed in the UK.

Adding telemedicine to current UK practice for diabetes care may require additional funding and extra staff time so it is important to determine the interface that is most effective.

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Why was this study needed?

In 2013, over 3.2 million adults were diagnosed with diabetes in England (6% prevalence) and Wales (6.7% prevalence). Around 90% of these diagnoses are for type 2 diabetes.

In 2012, management of type 2 diabetes and its complications cost the NHS around £8.8 billion a year. Due to the growing burden of type 2 diabetes, this is estimated to increase to £15.1 billion by 2035.

Telemedicine involves delivery of health services through interfaces such as text messaging or Web portals. In this review it was defined as some electronic form of provider-to-patient communication. It has been shown to have benefits in managing several other chronic diseases.

Previous reviews have shown that telemedicine could improve blood sugar control in diabetes, but studies have varied in the delivery formats assessed. This systematic review aimed to update this knowledge, examining the effect of different forms of telemedicine when added to usual care.   

What did this study do?

The systematic review and meta-analysis identified 111 randomised controlled trials including 23,648 adults with type 1 or type 2 diabetes.

Telemedicine was delivered via telephone in most cases (59%), via clinical decision support systems in a third, and by Web portals or text messages in roughly 20% each. Nurses provided care in 37% of cases, doctors in 29% and non-specialised support staff in 23%.   Frequency of contact varied from daily to less than monthly.

The main outcome of interest was control of HbA1c. The authors aimed to identify which telemedicine formats were most effective.

Over a third of trials came from the United States with few UK-based. Common sources of bias were around patient allocation and outcome assessment.

What did it find?

  • Telemedicine gave modest reductions in HbA1c at all follow-up times. The mean difference (MD) compared to usual care was:
    • At 3 months or less: -0.57%, 95% confidence interval (CI) -0.74% to -0.40% (including 39 trials).
    • At 4-12 months: -0.28%, 95% CI -0.37% to -0.20% (including 87 trials).
    • At 12 months or more: -0.26%, 95% CI -0.46% to -0.06% (including 5 trials). Across all analyses there was significant variation in the results of the individual trials (heterogeneity), suggesting that the true size of the effects should be interpreted with some caution.
  • The researchers explored whether population characteristics or telemedicine delivery format could explain these differences. Text messaging and Web portals were associated with a greater effect than telephone-based systems (MD -0.28% [95% CI -0.52 to -0.05] for text and -0.35% [95% CI -0.56 to -0.14] for Web portal vs. telephone). Interventions where providers adjusted medication according to patient data gave greater improvements than trials without this component (MD -0.23%, 95% CI -0.42 to -0.05]). Asian trials also demonstrated greater effect than North American trials.
  • There was no evidence to suggest telemedicine enhanced quality of life, affected mortality or reduced the risk of low blood sugar (hypoglycaemic) episodes.

What does current guidance say on this issue?

NICE guidelines on the management of type 1 and type 2 diabetes provide recommendations around the frequency of monitoring of HbA1c, which is typically three to six monthly. For adults with type 1 diabetes, and most people with type 2 diabetes, the target HbA1c is 48 mmol/mol (6.5%) or lower. In type 2 diabetes, NICE recommend patients are involved in discussions around their individual target, taking into account adverse effects such as hypoglycaemia. Self-monitoring of blood sugar is recommended for type 1 diabetes, but only for type 2 in specific circumstances.

Both guidelines recommend telephone support, but neither mentions other forms of telemedicine.

What are the implications?

Earlier studies also support the idea that telemedicine could improve diabetes care. The UK government has plans to train NHS professionals to deliver healthcare using digital technology and to encourage the use of digital services.

There is need to establish which telemedicine interface or format is best, and whether the interventions improve outcomes at a reasonable cost. Texting and web platforms seem promising and potentially cheaper than telephone services as staff time could be minimised.

Technology moves quickly and the latest mobile apps will now need evaluation. These are already more popular than some of the technologies available when these trials were undertaken.

Citation and Funding

Faruque LI, Wiebe N, Ehteshami-Afshar A, et al. Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials.  
Canadian Medical Association Journal. 2016. [Epub ahead of print].

The work was funded by a team grant to the Interdisciplinary Chronic Disease Collaboration from Alberta-Innovates-Health Solutions; two Alberta Heritage Foundation for Medical Research Population Health Scholar Awards, the Roy and Vi Baay Chair in Kidney Research and Alberta Health with the Universities of Alberta and Calgary. The funding agencies did not have a role in the study conception, study analysis or writing of the manuscript.

Bibliography

NICE. Guidance on type 1 diabetes in adults: diagnosis and management. NG17. London: National Institute for Health and Care Excellence; 2015.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2016.

NICE. Type 2 diabetes: prevention in people at high risk. PH38. London: National Institute for Health and Care Excellence; 2012.

DH. New plans to expand the use of digital technology across the NHS. London: Department of Health; 2016.

Why was this study needed?

In 2013, over 3.2 million adults were diagnosed with diabetes in England (6% prevalence) and Wales (6.7% prevalence). Around 90% of these diagnoses are for type 2 diabetes.

In 2012, management of type 2 diabetes and its complications cost the NHS around £8.8 billion a year. Due to the growing burden of type 2 diabetes, this is estimated to increase to £15.1 billion by 2035.

Telemedicine involves delivery of health services through interfaces such as text messaging or Web portals. In this review it was defined as some electronic form of provider-to-patient communication. It has been shown to have benefits in managing several other chronic diseases.

Previous reviews have shown that telemedicine could improve blood sugar control in diabetes, but studies have varied in the delivery formats assessed. This systematic review aimed to update this knowledge, examining the effect of different forms of telemedicine when added to usual care.   

What did this study do?

The systematic review and meta-analysis identified 111 randomised controlled trials including 23,648 adults with type 1 or type 2 diabetes.

Telemedicine was delivered via telephone in most cases (59%), via clinical decision support systems in a third, and by Web portals or text messages in roughly 20% each. Nurses provided care in 37% of cases, doctors in 29% and non-specialised support staff in 23%.   Frequency of contact varied from daily to less than monthly.

The main outcome of interest was control of HbA1c. The authors aimed to identify which telemedicine formats were most effective.

Over a third of trials came from the United States with few UK-based. Common sources of bias were around patient allocation and outcome assessment.

What did it find?

  • Telemedicine gave modest reductions in HbA1c at all follow-up times. The mean difference (MD) compared to usual care was:
    • At 3 months or less: -0.57%, 95% confidence interval (CI) -0.74% to -0.40% (including 39 trials).
    • At 4-12 months: -0.28%, 95% CI -0.37% to -0.20% (including 87 trials).
    • At 12 months or more: -0.26%, 95% CI -0.46% to -0.06% (including 5 trials). Across all analyses there was significant variation in the results of the individual trials (heterogeneity), suggesting that the true size of the effects should be interpreted with some caution.
  • The researchers explored whether population characteristics or telemedicine delivery format could explain these differences. Text messaging and Web portals were associated with a greater effect than telephone-based systems (MD -0.28% [95% CI -0.52 to -0.05] for text and -0.35% [95% CI -0.56 to -0.14] for Web portal vs. telephone). Interventions where providers adjusted medication according to patient data gave greater improvements than trials without this component (MD -0.23%, 95% CI -0.42 to -0.05]). Asian trials also demonstrated greater effect than North American trials.
  • There was no evidence to suggest telemedicine enhanced quality of life, affected mortality or reduced the risk of low blood sugar (hypoglycaemic) episodes.

What does current guidance say on this issue?

NICE guidelines on the management of type 1 and type 2 diabetes provide recommendations around the frequency of monitoring of HbA1c, which is typically three to six monthly. For adults with type 1 diabetes, and most people with type 2 diabetes, the target HbA1c is 48 mmol/mol (6.5%) or lower. In type 2 diabetes, NICE recommend patients are involved in discussions around their individual target, taking into account adverse effects such as hypoglycaemia. Self-monitoring of blood sugar is recommended for type 1 diabetes, but only for type 2 in specific circumstances.

Both guidelines recommend telephone support, but neither mentions other forms of telemedicine.

What are the implications?

Earlier studies also support the idea that telemedicine could improve diabetes care. The UK government has plans to train NHS professionals to deliver healthcare using digital technology and to encourage the use of digital services.

There is need to establish which telemedicine interface or format is best, and whether the interventions improve outcomes at a reasonable cost. Texting and web platforms seem promising and potentially cheaper than telephone services as staff time could be minimised.

Technology moves quickly and the latest mobile apps will now need evaluation. These are already more popular than some of the technologies available when these trials were undertaken.

Citation and Funding

Faruque LI, Wiebe N, Ehteshami-Afshar A, et al. Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials.  
Canadian Medical Association Journal. 2016. [Epub ahead of print].

The work was funded by a team grant to the Interdisciplinary Chronic Disease Collaboration from Alberta-Innovates-Health Solutions; two Alberta Heritage Foundation for Medical Research Population Health Scholar Awards, the Roy and Vi Baay Chair in Kidney Research and Alberta Health with the Universities of Alberta and Calgary. The funding agencies did not have a role in the study conception, study analysis or writing of the manuscript.

Bibliography

NICE. Guidance on type 1 diabetes in adults: diagnosis and management. NG17. London: National Institute for Health and Care Excellence; 2015.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2016.

NICE. Type 2 diabetes: prevention in people at high risk. PH38. London: National Institute for Health and Care Excellence; 2012.

DH. New plans to expand the use of digital technology across the NHS. London: Department of Health; 2016.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials

Published on 2 November 2016

Faruque, L. I.,Wiebe, N.,Ehteshami-Afshar, A.,Liu, Y.,Dianati-Maleki, N.,Hemmelgarn, B. R.,Manns, B. J.,Tonelli, M.

Cmaj , 2016

BACKGROUND: Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care. We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care. METHODS: We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes. Two independent reviewers selected the studies and assessed risk of bias in the studies. The primary outcome was glycated hemoglobin (HbA1C) reported at 3 time points (</= 3 mo, 4-12 mo and > 12 mo). Other outcomes were quality of life, mortality and episodes of hypoglycemia. Trials were pooled using random-effects meta-analysis, and heterogeneity was quantified using the I2 statistic. RESULTS: From 3688 citations, we identified 111 eligible RCTs (n = 23648). Telemedicine achieved significant but modest reductions in HbA1C in all 3 follow-up periods (difference in mean at </= 3 mo: -0.57%, 95% confidence interval [CI] -0.74% to -0.40% [39 trials]; at 4-12 mo: -0.28%, 95% CI -0.37% to -0.20% [87 trials]; and at > 12 mo: -0.26%, 95% CI -0.46% to -0.06% [5 trials]). Quantified heterogeneity (I2 statistic) was 75%, 69% and 58%, respectively. In meta-regression analyses, the effect of telemedicine on HbA1C appeared greatest in trials with higher HbA1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment. Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia. INTERPRETATION: Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA1C but not other clinically relevant outcomes among patients with diabetes.

The new HbA1c units (mmol/mol) have replaced the older unit (%) used in this Canadian study. An HbA1c of 6.5% is equivalent to 48mmol/mol and is the threshold sometimes used for diagnosing diabetes. For further values in the ranges used in this study:

  • 7.0% is equivalent to 53mmol/mol
  • 7.5% is equivalent to 58mmol/mol
  • 8.0% is equivalent to 64mmol/mol
  • 8.5% is equivalent to 69mmol/mol
  • 9.0% is equivalent to 75mmol/mol

The HbA1c test measures how much haemoglobin in the blood has become glycated (chemically bonded with glucose) and gives an estimate of overall glucose control over the preceding 12 weeks.

Expert commentary

Educational information is available for patients in a wide variety of formats, including printed information; group based structured education and telephone helplines. The internet is a modality to deliver/receive information that might provide a useful modality to reach geographically or socioeconomically isolated groups. The small improvements in HbA1c levels noted among people with diabetes, coupled with the postulated benefits such as cost-efficacy and convenience due to the potential for 24-hour access, could be very attractive indeed to patients.

Dr Samuel Seidu, Honorary Lecturer and Primary Care Research Fellow in Diabetes, Leicester Diabetes Centre