Escolar Documentos
Profissional Documentos
Cultura Documentos
Review
172:3
R93R101
Department of Endocrinology and Metabolism, Beijing Anzhen Hospital, Capital Medical University, Beijing
Institute of Heart Lung and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing 100029,
China and 1Beijing Anzhen Hospital, Capital Medical University, The Key Laboratory of Remodeling-Related
Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases,
2 Anzhen Road, Chaoyang District, Beijing 100029, China
Correspondence
should be addressed
to H Tao
Email
vivientao@126.com
Abstract
Objective: To review the published literature on the effects of telecare intervention in patients with type 2 diabetes and
inadequate glycemic control.
Design and methods: A review of randomized controlled trials on telecare intervention in patients with type 2 diabetes,
and a search of electronic databases such as The Cochrane Library, PubMed, EBSCO, CINAHL, Science Direct, Journal of
Telemedicine and Telecare, and China National Knowledge Infrastructure (CNKI), were conducted from December 8 to 16,
2013. Two evaluators independently selected and reviewed the eligible studies. Changes in HbA1c, fasting plasma glucose
(FPG), post-prandial plasma glucose (PPG), BMI, and body weight were analyzed.
Results: An analysis of 18 studies with 3798 subjects revealed that telecare significantly improved the management of
diabetes. Mean HbA1c values were reduced by K0.54 (95% CI, K0.75 to K0.34; P!0.05), mean FPG levels by K9.00 mg/dl
(95% CI, K17.36 to K0.64; PZ0.03), and mean PPG levels reduced by K52.86 mg/dl (95% CI, K77.13 to K28.58; P!0.05)
when compared with the group receiving standard care. Meta-regression and subgroup analyses indicated that study
location, sample size, and treatment-monitoring techniques were the sources of heterogeneity.
Conclusions: Patients monitored by telecare showed significant improvement in glycemic control in type 2 diabetes when
compared with those monitored by routine follow-up. Significant reduction in HbA1c levels was associated with Asian
populations, small sample size, and telecare, and with those patients with baseline HbA1c greater than 8.0%.
European Journal of
Endocrinology
(2015) 172, R93R101
Introduction
In 2013, the estimated prevalence of diabetes among a
representative sample of Chinese adults was 11.6% and the
prevalence of pre-diabetes was 50.1% (1). The total number
of people with diabetes is projected to increase from 171
million in 2000 to 366 million in 2030 (2). These data
emphasize the importance of diabetes as a major global
health problem. The conventional diabetes management
www.eje-online.org
DOI: 10.1530/EJE-14-0441
Review
Methods
Eligibility criteria
Studies that met the following criteria were included in
the meta-analysis: i) RCTs with telecare as an intervention
(self-monitored transmission of glucometer data and
feedback by health professionals, or automatic medical
devices); ii) adult (R18 years) patients with a diagnosis of
type 2 diabetes; iii) comparison of standard therapies
(conventional outpatient clinic intervention, no special
health guidance of diabetes care by health professionals or
automatic medical devices); and iv) reported outcome of
HbA1c, with mean values and S.D. at baseline and at the
end of the study for each group. Only English language
papers were reviewed. Studies with mixed patient
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172:3
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Data extraction
Titles and abstracts of studies identified by the electronic
searches were reviewed independently by two investigators. If potentially eligible, the full text was retrieved
for further review. One investigator designed the standardized data extraction form and the other reviewed it for
completeness and accuracy. We have included abstracts
that described an RCT of telecare intervention in patients
with type 2 diabetes, with an outcome of HbA1c level.
When both investigators did not agree (e.g. inclusion
criteria or quality assessment), conflicts were resolved by
discussing with another investigator.
We reported the redundant publications only once.
For studies with more than one intervention group, we
regarded the most intensive intervention as the experimental one. Intensity was defined by the number of
telecommunication modes used, frequency of communication, and duration of intervention.
Extraction of literature and intervention information
include: references; country of origin; study duration;
number of participants at baseline and follow-up;
percentage of women participants; intervention of telecare
and control groups; and ways of telecare feedback
(e.g. telephone calls, automatic internet-based disease
management system, or short message service).
Review
Quality assessment
Results
Study selection
Statistical analyses
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Study characteristics
All the 18 eligible studies were published between 2000 and
2013, six of which were conducted in the USA, nine in
Korea, and one each in Iran, Poland, and Spain. The
shortest study lasted 3 months and the longest 60 months;
12 studies were of 612 months duration and two lasted
O12 months. The number of subjects in each study ranged
from 38 to 1665. To summarize, at baseline 3798 subjects
were enrolled through all studies and 2793 subjects
completed the studies. All studies shared a completion
rate of 73.54 and 72.66% in the telecare groups and 74.43%
in the standard care group. The mean age of all participants
ranged from 46 to 71 years. Ten studies (13, 14, 15, 16, 17,
18, 19, 20, 21, 22) limited inclusion criteria to participants
1240 records
identified through
searches
99 full-text articles
assessed for
eligibility
81 excluded.
42 deficient data of HbA1c
value.
20 no RCT.
Six redundant publications.
Five study design.
18 included in
meta-analysis
Five no English.
Three peer support programs.
Figure 1
Diagram of data extraction.
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Review
Meta-analysis
HbA1c at baseline had no significant heterogeneity between
the telecare and standard care groups (0.06; 95% CI, K0.03
to 0.15; PZ0.25). The telecare groups have demonstrated
a significant reduction in HbA1c from baseline to postintervention (K0.72; 95% CI, K0.81 to K0.63; P!0.05),
whereas the standard care groups showed smaller but
significant difference (K0.33; 95% CI, K0.62 to K0.04;
PZ0.03). Telecare was significantly different from standard
care (pooled HbA1c change from baseline: (K0.54; 95% CI,
K0.75 to K0.34; P!0.05), with statistical heterogeneity
to the variability in effect estimate (I2Z76%; Fig. 2).
For PPG, four studies (16, 18, 27, 28) presented outcome
data and the meta-analysis showed a significant reduction
in telecare group compared with standard care group
from baseline (K52.86 mg/dl; 95% CI, K77.13 to K28.58;
P!0.05). There were nine studies (13, 16, 18, 21, 23, 27,
28, 29, 30) with FPG data that could be pooled to metaanalysis, which indicated a small but significant difference
in FPG decline from baseline, favoring telecare intervention (K9.00 mg/dl; 95% CI, K17.36 to K0.64; PZ0.03).
Table 1
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Adverse effects
Two studies (15, 16) reported hypoglycemia episodes
during the trials. A study by Lim et al. (16) has shown
that the hypoglycemia by a minor proportion and
hypoglycemic events seemed to be higher in the telecare
group than in the standard care group, with no statistical
significance, whereas the major and nocturnal hypoglycemia were smaller in the telecare group (P!0.05).
The study by Kim et al. (15) has indicated that the total
number of symptomatic hypoglycemia episodes, the
incidence of asymptomatic hypoglycemia (10.6 vs
11.1%) and nocturnal hypoglycemia (12.8 vs 11.1%)
were similar in the telecare and standard care groups.
Subgroup analyses
To evaluate the potential source of heterogeneity, we
performed subgroup analyses that included feedback
References
Study
location
Duration
(months)
Recruited/
completed
Women
(%)
Telecare method
Control
(28)
(29)
(13)
(14)
(30)
(15)
(16)
(17)
(18)
(23)
(19)
(24)
(25)
(26)
(20)
(22)
(21)
(27)
Poland
Korea
Korea
USA
Korea
Korea
Korea
Iran
Korea
USA
USA
Spain
USA
Korea
USA
USA
Korea
Korea
6
30
3
3
3
3
6
3
3
12
12
12
60
3
6
12
3
12
100/95
80/71
71/64
120/114
73/?
100/92
154/144
61/60
50/38
280/248
213/163
328/297
1665/?
59/49
150/137
415/379
114/123
60/51
46.31
38.75
59.94
44.54
46.57
50
55.84
71.67
64
58.87
50.31
48.48
62.81
57.14
NR
40
40.35
56.87
Internet-based
Internet-based
Internet-based
Automated
Internet-based
Internet-based
Internet-based
Telephone
Telephone
Automated
Internet-based
Telephone
Internet-based
Telephone
Telephone
Internet-based
Internet-based
Internet-based
www.eje-online.org
Quality
C
C
B
B
C
B
C
B
B
A
A
A
B
B
B
A
C
B
Review
Study or subgroup
Telecare
Mean
S.D. Total
(31)
(29)
(13)
(14)
(30)
(15)
(16)
(17)
(18)
(23)
(19)
(24)
(25)
(26)
(20)
(22)
(21)
(27)
7.37
6.7
7.5
7.876
7.4
7.4
7.4
7.04
7.7
8.2
7.9
7.4
7.05
7.1
7.9
8.1
7.1
6.77
1.27
0.9
0.9
1.09
1.03
0.7
1
1.18
1
1.9
1.7
1.43
1.17
1.2
1.2
1.68
0.8
0.77
Standard care
Mean S.D.
Total
47 7.43
35
7.4
32
7.8
61 7.823
28
8.3
47
7.8
49
7.8
30
8.6
20
9
124
8.3
56
8.5
146 7.35
355 7.34
25
8.6
64
8.6
186 8.33
57
7.6
25
8.4
1387
2=0.14;
2=69.93,
Heterogeneity:
df=17 (P<0.00001);
Test for overall effect: Z=5.12 (P<0.00001).
1.49
1.3
1.1
1.14
1.89
0.8
1
1.88
1.2
1.9
1.8
1.38
1.54
1.3
1.3
1.81
1
1.04
48
36
32
58
23
45
48
30
18
124
51
151
372
24
73
193
54
26
1406
I2 =
Weight
(%)
Mean difference
IV, random, 95% CI
5.1
5.4
5.6
6.2
3.4
6.9
6.2
3.7
4.2
5.7
4.4
6.8
7.5
4.2
6.1
6.6
6.7
5.5
100.0%
76%.
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Mean difference
IV, random, 95% CI
0
1
2
2
1
Favours (telecare) Favours (standard care)
Figure 2
Telecare vs standard care: meta-analysis of randomized
control.
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Review
Table 2
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Subgroups
Studies (n)
Feedback ways
Human calls
5
Automated calls
2
Automated text
9
Duration of follow-up (months)
3
8
6
7
9
2
12
6
15
1
Study location
Asia
10
Europe
2
North America
6
Baseline HbA1c
!8.0%
7
R8.0%
11
Quality of literature
Rank A
4
Rank B
9
Rank C
5
Sample size (n)
%60
5
O60
13
I2 (%)
38
0
0
(K0.99,
(K0.71,
(K1.44,
(K0.56,
(K1.06,
46
17
31
67
None
K0.73
K0.53
K0.92
K0.29
K0.50
K0.47)
K0.34)
K0.40)
K0.02)
0.06)
0.17
0.63
0.75
!0.05
0.07
0.3
0.23
0.01
None
0.11
56
0
38
0.01
0.74
0.15
!0.05
46
81
0.09
!0.05
!0.05
13
85
0
0.33
!0.05
0.41
!0.05
0
32
0.68
0.13
!0.05
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Meta-regression analyses
In addition, the exact effects of feedback ways, duration of
follow-up, study location (or continent), baseline HbA1c,
quality of literature, and sample size on the association
Review
2
0.2
0.4
Figure 3
Beggs funnel plot analysis of publication bias. Eggers test:
PZ0.001.
Risk of bias
Publication bias was assessed by Beggs funnel plot and
Eggers test (Fig. 3). Significant publication bias towards
positive outcomes in the included studies was observed
(Eggers PZ0.001).
Conclusions
We carried out a meta-analysis of 18 original RCTs and
showed that the telecare reduced significantly the HbA1c
level (K0.54; 95% CI, K0.75 to K0.34; P!0.05), FPG
(K9.00 mg/dl; 95% CI, K17.36 to K0.64; PZ0.03), and
PPG (K52.86 mg/dl; 95% CI, K77.13 to K28.58; P!0.05)
vs the standard care group. No significant differences in
BMI, body weight, and hypoglycemic events were found
between intervention and control groups. Therefore, we
recommend the usage of telecare for long-term management of patients with type 2 diabetes worldwide,
especially in Asia. Subgroup analysis and meta-regression
analysis revealed three important clinical signs. First,
variables of study location, sample size, and feedback
ways were significantly associated with changes in HbA1c
in the univariate analysis; second, studies that observed
greater reduction in HbA1c were those associated with
172:3
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Review
Declaration of interest
The authors declare that there is no conflict of interest that could be
perceived as prejudicing the impartiality of the review.
Funding
This study was supported by Research Fund for the Clinical Medical Project
of Chinese Medical Association (13050880473), scientific research fund
program of training high-level talents in Beijing Health System (2013-3008), and Research Fund of the Capital Health Research and Development
of Special (2014-2-1054).
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172:3
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concept and review design and revised the review; Q Meng provided
feedback on the review drafts and methodological quality, and revised the
review; L Jing provided advice on data analyses and interpreting results.
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