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      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

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          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.

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          Most cited references37

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          Type 1 diabetes prevalence increasing globally and regionally: the role of natural selection and life expectancy at birth

          Objective Prevalence of type 1 diabetes (T1D) disease is increasing worldwide. We aim to test correlation of T1D prevalence to the reduced natural selection measured by Biological State Index (Ibs). Research design and methods Country-specific estimates of T1D prevalence, life expectancy, obesity prevalence rate, urbanization rates, per capita sugars consumption and per capita gross domestic product (GDP) were obtained. Ibs and country-specific longevity (e50) increase for each country were self-calculated. These data were then matched to T1D prevalence by country for our ecological study among 118 countries. Countries were also grouped to study the associations in different regions. SPSS V.22 was used for correlation analysis. Results Worldwide, both Ibs and life expectancy at birth (Ibs proxy) were significantly correlated to T1D prevalence in Pearson r (r=0.713, p<0.001 and r=0.722, p<0.001, respectively) and Spearman's r (r=0.724, p<0.001 and r=0.689, p<0.001, respectively). T1D prevalence was not correlated to longevity increase measured as life expectancy at 50 years old. T1D prevalence was significantly associated with I bs (r=0.307, p<0.001) and newborn life expectancy (r=0.349, p<0.001) independent of per capita total sugar consumption, per capita GDP, urbanization and obesity prevalence in partial correlation. Globally, both life expectancy at birth and Ibs exponentially correlated to T1D prevalence. Pearson correlations generally existed in different country categorizations by geographic region, culture background and economic status. Conclusions Reduced natural selection may have contributed to the increasing T1D prevalence worldwide. T1D epidemiology study in total population may be the practical solution to identify the causes of increasing T1D prevalence.
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            A randomized controlled trial of the effect of real-time telemedicine support on glycemic control in young adults with type 1 diabetes (ISRCTN 46889446).

            To determine whether a system of telemedicine support can improve glycemic control in type 1 diabetes. A 9-month randomized trial compared glucose self-monitoring real-time result transmission and feedback of results for the previous 24 h in the control group with real-time graphical phone-based feedback for the previous 2 weeks together with nurse-initiated support using a web-based graphical analysis of glucose self-monitoring results in the intervention group. All patients aged 18-30 years with HbA(1c) (A1C) levels of 8-11% were eligible for inclusion. A total of 93 patients (55 men) with mean diabetes duration (means +/- SD) 12.1 +/- 6.7 years were recruited from a young adult clinic. In total, the intervention and control groups transmitted 29,765 and 21,400 results, respectively. The corresponding median blood glucose levels were 8.9 mmol/l (interquartile range 5.4-13.5) and 10.3 mmol/l (6.5-14.4) (P < 0.0001). There was a reduction in A1C in the intervention group after 9 months from 9.2 +/- 1.1 to 8.6 +/- 1.4% (difference 0.6% [95% CI 0.3-1.0]) and a reduction in A1C in the control group from 9.3 +/- 1.5 to 8.9 +/- 1.4% (difference 0.4% [0.03-0.7]). This difference in change in A1C between groups was not statistically significant (0.2% [-0.2 to 0.7, P = 0.3). Real-time telemedicine transmission and feedback of information about blood glucose results with nurse support is feasible and acceptable to patients, but to significantly improve glycemic control, access to real-time decision support for medication dosing and changes in diet and exercise may be required.
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              One-year efficacy and safety of Web-based follow-up using cellular phone in type 1 diabetic patients under insulin pump therapy: the PumpNet study.

              Conventional follow-up of type 1 diabetic patients treated with continuous subcutaneous insulin infusion (CSII) was compared with intensive coaching using the Web and the cellular phone network for retrospective data transmission and short message service (SMS). Thirty poorly controlled patients (HbA1c 7.5-10%) were enrolled in a bicenter, open-label, randomized, 12-month, two-period, crossover study. After a 1-month run-in period, 15 patients were randomly assigned to receive weekly medical support through SMS based upon weekly review of glucose values, while 15 patients continued to download self-monitored blood glucose (SMBG) values on a weekly basis without receiving SMS. After 6 months, patients crossed over to the alternate sequence for 6 additional months. Visits at the clinic were maintained every 3 months. Patients with long-standing inadequately controlled diabetes (24 +/- 13 years) were included. A non-significant trend to reduction in HbA(1c) (-0.25+/-0.94%, P<0.10) and mean glucose values (-9.2+/-25 mg/dl, P=0.06) during the 6-month SMS sequence was observed as compared with the no-SMS period. No safety issue (hypoglycemia, glucose variability) was reported. Adherence to SMBG was not affected by the trial. Quality of life analysis suggests a significant improvement in DQOL global score, as well as the DQOL satisfaction with life subscale, during the SMS sequence. Long-term telemedical follow-up of insulin pump-treated patients using a cellular phone-, SMS- and Web-based platform is feasible, safe, does not alter quality of life and associated with a trend toward improved metabolic control.
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                Author and article information

                Contributors
                Journal
                Front Pharmacol
                Front Pharmacol
                Front. Pharmacol.
                Frontiers in Pharmacology
                Frontiers Media S.A.
                1663-9812
                30 May 2017
                2017
                : 8
                : 330
                Affiliations
                [1] 1School of Pharmacy, Monash University Malaysia Bandar Sunway, Malaysia
                [2] 2Faculty of Pharmacy, UCSI University Kuala Lumpur, Malaysia
                Author notes

                Edited by: Iñaki Gutiérrez-Ibarluzea, Basque Office for Health Technology Assessment (OSTEBA), Spain

                Reviewed by: Anna Chapman, Monash University, Australia; Sihem Ait-Oudhia, College of Pharmacy, University of Florida, United States

                *Correspondence: Shaun W. H. Lee, shaun.lee@ 123456monash.edu

                This article was submitted to Pharmaceutical Medicine and Outcomes Research, a section of the journal Frontiers in Pharmacology

                Article
                10.3389/fphar.2017.00330
                5447671
                28611672
                a83e9b46-d24e-4027-a37e-e558eb8bff43
                Copyright © 2017 Lee, Ooi and Lai.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 13 March 2017
                : 16 May 2017
                Page count
                Figures: 1, Tables: 1, Equations: 0, References: 47, Pages: 8, Words: 0
                Funding
                Funded by: Kementerian Sains, Teknologi dan Inovasi 10.13039/501100003200
                Award ID: 03-02-10-SF0238
                Categories
                Pharmacology
                Mini Review

                Pharmacology & Pharmaceutical medicine
                telemedicine,type 1 diabetes,management,meta-analysis,systematic review

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