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      Mapping the Evidence on the Effectiveness of Telemedicine Interventions in Diabetes, Dyslipidemia, and Hypertension: An Umbrella Review of Systematic Reviews and Meta-Analyses


      , MSc, MSc, Dipl Soz arb/Soz päd 1 , , , BA 2 , , MD, MBA, PhD 1 , 3 , 4 , , BA, MA 5

      (Reviewer), (Reviewer)

      Journal of Medical Internet Research

      JMIR Publications

      telemedicine, diabetes mellitus, hypertension, dyslipidemia, review, GRADE approach, treatment outcome

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          Telemedicine is defined by three characteristics: (1) using information and communication technologies, (2) covering a geographical distance, and (3) involving professionals who deliver care directly to a patient or a group of patients. It is said to improve chronic care management and self-management in patients with chronic diseases. However, currently available guidelines for the care of patients with diabetes, hypertension, or dyslipidemia do not include evidence-based guidance on which components of telemedicine are most effective for which patient populations.


          The primary aim of this study was to identify, synthesize, and critically appraise evidence on the effectiveness of telemedicine solutions and their components on clinical outcomes in patients with diabetes, hypertension, or dyslipidemia.


          We conducted an umbrella review of high-level evidence, including systematic reviews and meta-analyses of randomized controlled trials. On the basis of predefined eligibility criteria, extensive automated and manual searches of the databases PubMed, EMBASE, and Cochrane Library were conducted. Two authors independently screened the studies, extracted data, and carried out the quality assessments. Extracted data were presented according to intervention components and patient characteristics using defined thresholds of clinical relevance. Overall certainty of outcomes was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool.


          Overall, 3564 references were identified, of which 46 records were included after applying eligibility criteria. The majority of included studies were published after 2015. Significant and clinically relevant reduction rates for glycated hemoglobin (HbA 1c; ≤−0.5%) were found in patients with diabetes. Higher reduction rates were found for recently diagnosed patients and those with higher baseline HbA 1c (>8%). Telemedicine was not found to have a significant and clinically meaningful impact on blood pressure. Only reviews or meta-analyses reporting lipid outcomes in patients with diabetes were found. GRADE assessment revealed that the overall quality of the evidence was low to very low.


          The results of this umbrella review indicate that telemedicine has the potential to improve clinical outcomes in patients with diabetes. Although subgroup-specific effectiveness rates favoring certain intervention and population characteristics were found, the low GRADE ratings indicate that evidence can be considered as limited. Future updates of clinical care and practice guidelines should carefully assess the methodological quality of studies and the overall certainty of subgroup-specific outcomes before recommending telemedicine interventions for certain patient populations.

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          Most cited references57

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          Effect of mobile phone intervention for diabetes on glycaemic control: a meta-analysis.

            To assess the effect of mobile phone intervention on glycaemic control in diabetes self-management. We searched three electronic databases (PubMed, EMBASE and Cochrane Library) using the following terms: diabetes or diabetes mellitus and mobile phone or cellular phone, or text message. We also manually searched reference lists of relevant papers to identify additional studies. Clinical studies that used mobile phone intervention and reported changes in glycosylated haemoglobin (HbA(1c) ) values in patients with diabetes were reviewed. The study design, intervention methods, sample size and clinical outcomes were extracted from each trial. The results of the HbA(1c) change in the trials were pooled using meta-analysis methods.   A total of 22 trials were selected for the review. Meta-analysis among 1657 participants showed that mobile phone interventions for diabetes self-management reduced HbA(1c) values by a mean of 0.5% [6 mmol/mol; 95% confidence interval, 0.3-0.7% (4-8 mmol/mol)] over a median of 6 months follow-up duration. In subgroup analysis, 11 studies among Type 2 diabetes patients reported significantly greater reduction in HbA(1c) than studies among Type 1 diabetes patients [0.8 (9 mmol/mol) vs. 0.3% (3 mmol/mol); P=0.02]. The effect of mobile phone intervention did not significantly differ by other participant characteristics or intervention strategies.   Results pooled from the included trials provided strong evidence that mobile phone intervention led to statistically significant improvement in glycaemic control and self-management in diabetes care, especially for Type 2 diabetes patients. © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.
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            Diabetes and Hypertension: A Position Statement by the American Diabetes Association

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              9. Cardiovascular Disease and Risk Management:Standards of Medical Care in Diabetes—2018

              The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

                Author and article information

                J Med Internet Res
                J. Med. Internet Res
                Journal of Medical Internet Research
                JMIR Publications (Toronto, Canada )
                March 2020
                18 March 2020
                : 22
                : 3
                [1 ] Department for Prevention and Care of Diabetes Faculty of Medicine Carl Gustav Carus Technische Universität Dresden Dresden Germany
                [2 ] Master Program Health Sciences / Public Health at the Institute and Policlinic of Occupational and Social Medicine Faculty of Medicine at the University Clinic Carl Gustav Carus Technische Universität Dresden Dresden Germany
                [3 ] Paul Langerhans Institute Dresden Helmholtz Center Munich University Hospital and Faculty of Medicine, Technische Universität Dresden Dresden Germany
                [4 ] German Center for Diabetes Research (DZD e V) Neuherberg Germany
                [5 ] Research Association Public Health Saxony / Center for Evidence-Based Healthcare Faculty of Medicine Carl Gustav Carus Technische Universität Dresden Dresden Germany
                Author notes
                Corresponding Author: Patrick Timpel patrick.timpel@ 123456tu-dresden.de
                ©Patrick Timpel, Sarah Oswald, Peter E H Schwarz, Lorenz Harst. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 18.03.2020.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.



                telemedicine, diabetes mellitus, hypertension, dyslipidemia, review, grade approach, treatment outcome


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