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Review

Z Huang and others

Effects of telecare intervention

172:3

R93R101

MANAGEMENT OF ENDOCRINE DISEASE

Effects of telecare intervention on glycemic

control in type 2 diabetes: a systematic review
and meta-analysis of randomized controlled
trials
Zhenru Huang, Hong Tao, Qingdong Meng and Long Jing1

European Journal of Endocrinology

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

2015 European Society of Endocrinology

Printed in Great Britain

model is difficult to use to cover all the patients. Telecare

(or telehealth or telemedicine) can mitigate barriers in
healthcare services. Integrating telecare technology (such
as telephone, internet-based disease management system,
short message service) and healthcare professionals has
promising results, especially in monitoring and supporting
the lifestyle changes of patients with chronic disease (3).
Published by Bioscientifica Ltd.

European Journal of Endocrinology

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Z Huang and others

Telecare intervention with feedback by health

professionals could improve the monitoring of glycemic
control in patients with type 1 diabetes, which has
been demonstrated by a meta-analysis of randomized trials
(4). However, there is a paucity of similar data in patients
with type 2 diabetes. Previous systematic reviews of telecare
intervention in type 2 diabetes have assessed the usage of
web-based systems (5, 6) or mobile phones (7, 8) separately
to monitor diabetes care. Some of the reviews have
considered telecare intervention contents, technologies,
and frequencies, but they did not consider adequately the
usage of combination technologies in practice, the nature
of feedback receipt in telecare, the ethnic differences, etc.
Some important issues that require further consideration
are as follows: i) the effective feedback receipt mechanism
in telecare (human calls, automated calls, or automated
text message reminders); ii) the type of diabetes, type 1 or
type 2 diabetes, which would benefit more from telecare in
terms of the improvement of HbA1c; iii) feasibility among
the Asian population. This is especially important in a
country like China, with a large population of diabetic
patients; however, there are few studies on telecare in the
monitoring of diabetes among the Chinese population;
and iv) the characteristics of patients with type 2 diabetes
who benefit from telecare to a maximum extent.
The objective of this study was to conduct a
qualitative and quantitative analysis of randomized
controlled trials (RCTs) from published literature to assess
the effectiveness of telecare in patients with type 2
diabetes and the effect on HbA1c, to identify effective
feedback receiving techniques in telecare, to improve
diabetes management, to provide future quantitative
analyses, and to establish further research needs.

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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Effects of telecare intervention

172:3

R94

populations (type 1 and type 2 diabetes) or without

diabetes treatment feedback were not included.

Search strategy and study selection

We have followed the preferred reporting items for
systematic reviews and meta-analyses guidelines (9). The
literature search was conducted from December 8 to 16,
2013 and the electronic databases such as The Cochrane
Library, PubMed, EBSCO, CINAHL, Science Direct, Journal
of Telemedicine and Telecare, and CNKI were searched.
For the search string, we have combined telemedicine
or telecommunications or remote consultation or
telehealth or rural health services or home care services
or home nursing or home care services or home
nursing or therapy, computer-assisted or web-based or
computer communication networks or information
technology or internet or web based or remote
consultation or rural health services, and diabetes in
the title, abstract, and keywords. The search was limited
to human subjects and English language. Additional
strategies included a search of related articles in PubMed
and the bibliographies of eligible studies.

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).

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Quality assessment

Results

The quality of data were ensured by selecting RCTs based

on randomization procedure and allocation concealment
(selection bias); withdrawals, dropouts, and intentionto-treat analysis (attrition bias); and masking of outcome
assessors (detection bias), the three main criteria specified
by Schulz et al. (10) and Jadad et al. (11) and their
colleagues. We have defined three categories as follows: all
quality criteria were met with a low risk of bias (A); at least
one of the quality criteria was only partly met with a
moderate risk of bias (B); and at least one criterion was not
met with a high risk of bias (C).

Study selection

Statistical analyses

European Journal of Endocrinology

Effects of telecare intervention

Meta-analyses of the primary outcomes (absolute changes

in HbA1c before and after interventions) were performed
out by the DerSimonianLaird method, using a
randomized effects model, weighted mean difference
(WMD). Secondary outcome data, including mean change
in the BMI, body weight, fasting plasma glucose (FPG), and
2-h post-prandial plasma glucose (PPG), were pooled in
meta-analysis. Heterogeneity was assessed by the
Cochrans Q and I2 statistics, with the Z-score (Q-test)
and c2 statistics set at P!0.10. I2 statistic analysis
attributed the percentage variation across studies to
heterogeneity rather than chance, and its values of 25,
50, and 75% represented low, moderate, and high
heterogeneity respectively (12). Wherever applicable and
appropriate (I2O50%), efforts were made to explain
possible sources of heterogeneity among the studies by
subgroup analysis. A funnel plot and the Beggs adjusted
rank correlation test for primary outcomes (HbA1c)
assessed publication bias. As overall analysis showed
high heterogeneity, sensitivity analyses were conducted
by omitting one study and re-evaluating the pooled
standardized effect sizes. Meta-analysis was carried out
using the Review Manager (RevMan) version 5.2.
The exact effects of some intervention characteristics or
demographics on the association with the change in HbA1c
level were analyzed through meta-regression. We ran a
random-effects meta-regression using the standardized
mean difference estimates of HbA1c. For each metaregression model, the adjusted R2 indicated the proportion
of between-study variance explained by the covariates.
Significant clinical and/or studies variables (P!0.05) in
univariate models were also combined into multivariate
meta-regression analyses. Meta regression was performed
using the metan command in STATA version 12.

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From 1240 citations, 99 publications were identified as

potentially eligible studies, and full texts were retrieved
and assessed. Out of the 99 identified citations, 18 met the
inclusion criteria (Fig. 1).

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

800 excluded based on

abstracts.
208 did not report HbA1c
values.
159 unrelated to telecare
intervention.
133 review or comment.

899 records after

duplicates removed

117 wrong population.

107 others (unrelated
illness, introduction of
telecare techniques, etc.)
62 no RCTs.
14 wrong/no comparator.

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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Effects of telecare intervention

with baseline HbA1c O6.5%. The mean baseline HbA1c in

the studies included in the meta-analysis ranged from 7.3
to 9.9%. Most studies reported improvement in HbA1c.
Four studies (19, 22, 23, 24) scored A for quality, nine
(13, 14, 15, 17, 18, 20, 25, 26, 27) scored B, and five (16, 21,
28, 29, 30) scored C. Studies included in the systematic
review are listed in Table 1.

European Journal of Endocrinology

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

172:3

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The pooled reduction in FPG from baseline in the telecare

and standard care groups were K10.23 and 4.51 mg/dl
respectively. Outcome data about BMI were provided in four
studies (16, 18, 21, 28) and used for meta-analysis, finding no
significant difference between telecare and standard care
groups (K0.59 kg/m2; 95% CI, K1.52 to 0.34; PZ0.21).
There were four studies (16, 20, 21, 22) that included weight
change data; meta-analysis also showed that the telecare
was not significantly different from standard care at endpoint (1.01 pounds; 95% CI, K3.31 to 5.33; PZ0.65).

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

Characteristics of randomized controlled trials included in the meta-analysis.

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

Clinic visit every 2 months

Conventional office visits
General diabetes education
Clinic visit every 23 months
No scheduled clinic visits
Clinic visit at 4th and 8th week
No scheduled clinic visits
No scheduled clinic visits
Visit every 3 months
No scheduled clinic visits
No scheduled clinic visits
No scheduled clinic visits
No scheduled clinic visits
No scheduled clinic visits
Monthly care coordination
Reminders of laboratory tests
No scheduled clinic visits
1 or 2 visits during 6 months

NR, not reported; SMS, short messaging service.

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Quality

C
C
B
B
C
B
C
B
B
A
A
A
B
B
B
A
C
B

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Z Huang and others

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

Total (95% CI)

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).

European Journal of Endocrinology

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 =

Effects of telecare intervention

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

0.06 (0.62, 0.50)

0.70 (1.22, 0.18)
0.30 (0.79, 0.19)
0.05 (0.35, 0.45)
0.90 (1.76, 0.04)
0.40 (0.71, 0.09)
0.40 (0.80, 0.00)
1.56 (2.35, 0.77)
1.30 (2.01, 0.59)
0.10 (0.57, 0.37)
0.60 (1.27, 0.07)
0.05 (0.27, 0.37)
0.29 (0.49, 0.09)
1.50 (2.20, 0.80)
0.70 (1.12, 0.28)
0.23 (0.58, 0.12)
0.50 (0.84, 0.16)
1.63 (2.13, 1.13)

100.0%

0.54 (0.75, 0.34)

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

negative effect sizes reflect improvement in glycemic control

controlled trials of telecare vs standard care in patients with

and positive effect sizes reflect deterioration in glycemic

type 2 diabetes. Effect size is the pre- to post-intervention;

control.

methods, duration of follow-up, study location, baseline

HbA1c, quality of literature, and sample size (Table 2).
Feedback methods were classified into three categories:
i) human calls (interactive telephones with human intervention conducted by a healthcare provider or researcher);
ii) automated calls (automated telephone of prerecorded
voice message from call center); and iii) automated text
(including automated internet text messages and SMS). We
set studies of automated calls apart from human calls as the
sensitivity analysis showed that the studies of automated
calls influenced significantly the pooled results. The
heterogeneity decreased to an insignificant level within
each subgroup when pooling the WMD of HbA1c, which
indicated that feedback methods of telecare did explain
the heterogeneity. Despite the usage of different telecare
technologies, the phone-based SMS and the internet-based
text messages in telecare showed no significant difference in
the reduction of HbA1c (PZ0.75, I2Z0%). The human calls
subgroup was associated with the greatest effect size (K1.13;
95% CI, K1.51 to K0.75; P!0.05), wheareas the automated
calls showed no improvement (K0.01; 95% CI, K0.32 to
0.29; PZ0.94). We believed that human calls, by directly
communicating with patients, might improve the selfmanagement of diabetes. However, the human calls

subgroup had the smallest sample size, which may have

emphasized the pooled effect.
We divided HbA1c data acquisition time into 3, 6, 9,
12, and 15 months subgroups, and the differences in
subgroup analyses were not significant (PZ0.53, I2Z0%).
These pooled results have suggested that study duration
could hardly explain the study heterogeneity. Compared
with the standard care groups, the telecare groups attained
significant reduction in HbA1c (P!0.05) at each time
point. A sensitivity analysis of data from the studies by
Graziano & Gross (14), Rodriguez-Idigoras et al. (24), and
Yoon & Kim (27) altered significantly the pooled estimate
of change in HbA1c within the respective subgroups, and
hence, they were excluded from subgroup analysis. This
could be attributed to the fact that Graziano & Gross (14)
have used automated calls to execute telecare intervention
and attained few reductions; Rodriguez-Idigoras et al.s
(24) study had low baseline levels of HbA1c values
(7.62%), and Yoon & Kims (27) study had the smallest
sample size with the greatest effect size.
Significant heterogeneity was found among subgroups
divided by study location (P!0.05, I2Z87%), which was
more obvious than that of the total pooled result (I2Z76%).
Although decreased significantly in each subgroup,

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Table 2

AUTHOR COPY ONLY

Effects of telecare intervention

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Subgroup analysis of reduction in HbA1c.

Subgroups

European Journal of Endocrinology

Z Huang and others

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

Effect size (%)

I2 (%)

K1.13 (K1.51, K0.75)

K0.01 (K0.32, 0.29)
K0.36 (K0.47, K0.24)

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

K0.71 (K0.96, K0.46)

0.02 (K0.25, 0.30)
K0.28 (K0.48, K0.09)

56
0
38

0.01
0.74
0.15

!0.05

K0.33 (K0.53, K0.13)

K0.70 (K1.03, K0.36)

46
81

0.09
!0.05

!0.05

K0.14 (K0.36, 0.08)

K0.78 (K1.14, K0.41)
K0.47 (K0.67, K0.26)

13
85
0

0.33
!0.05
0.41

!0.05

K1.45 (K1.75, K1.14)

K0.30 (K0.43, K0.17)

0
32

0.68
0.13

!0.05

heterogeneity was still significant in the Asian population.

Asians showed the greatest reduction in HbA1c, which
might be associated with three aspects. First, all studies
carried out in Asia had smaller samples (38111 participants, average 68.4 per study) than the other two
continents. Second, the studies carried out in Asia had
more frequent human calls, once or twice per week, in the
telecare groups. Third, the characteristics of different racial
groups (North Africans, Asians, and Europeans) might have
an impact on the way how people responded to telecare
intervention in an unforeseen manner.
We have classified the 18 studies into three subgroups
based on to their HbA1c levels at baseline (7.07.99, 8.0
8.99, and 8.9910.0%). The pooled effect size was K0.54
(95% CI, K0.75 to K0.43; P!0.05), and there was no
significant heterogeneity in subgroup differences (PZ0.21,
I2Z35.9%). The 7.07.99% group showed the least effect;
when we combined the other two subgroups as 8.0
10.0%, the baseline HbA1c level of O8.0% was associated
with significant reduction compared with those !8.0%
(0.74 vs 0.33), with significant subgroup differences
(P!0.05, I2Z70.5%). Our result was comparable with
that obtained by Liang et al. (7) (0.6 vs 0.4).
Among the 18 RCTs included, nine that scored B for
quality achieved the greatest reduction in HbA1c level,
whereas studies that scored A indicated the least

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P value for heterogeneity P value for heterogeneity

in subgroups
between subgroups

reduction. Significant heterogeneity was found in the

subgroup of rank B (P!0.05, I2Z85%) and among
subgroups (P!0.05, I2Z79.9%). It was challenging to
interpret this result; we speculated that it was mainly due
to a different baseline HbA1c level, ethnicity, feedback
method, publication bias, etc.
Significant heterogeneity among subgroups grouped
by sample size (%60 or O60 subjects) has been found
(P!0.05, I2Z97.8%), with a pooled estimate of K0.54
(95% CI, K0.75 to K0.34) (P!0.05). Compared with
studies with a sample size of more than 60, studies with
a smaller sample size achieved greater reduction in the
HbA1c level (K1.45 vs K0.33). This difference was greater
than that obtained by Liang et al. (7) (K0.8 vs K0.4).
However, the meta-analysis by Liang et al. involved
patients with types 1 and 2 diabetes, which was a major
confounding factor that made our results incomparable.
Our results indicated that a small sample size increased the
effect size, and we need more RCTs with large samples in
the future, especially in Asia.

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

Standardized mean difference

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Z Huang and others

Effects of telecare intervention

2
0.2

0.4

Standard error of standardized mean difference

Figure 3
Beggs funnel plot analysis of publication bias. Eggers test:

European Journal of Endocrinology

PZ0.001.

with the change in the HbA1c level were quantified

through meta-regression. In univariate analysis, study
location, sample size, and feedback methods were associated significantly with changes in HbA1c. Hence, these
variables were combined into multivariate meta-regression
analyses, explaining nearly 100% of the variance among
studies (adjusted R2Z100%, I2Z41.82%, PZ0.0062).

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

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Asians, baseline HbA1c O8.0%, small sample size, and

human calls-based intervention; and third, telecare based
on automated calls-based showed no positive effect on
reducing the HbA1c level.
Compared with the study by Montori et al. (4), metaanalysis of telecare for patients with type 1 diabetes, our
study showed greater reduction in HbA1c (K0.54 vs
K0.4). Our meta-analysis differed from that by Montori
et al. in two aspects: inclusion of different types of
diabetes, and inclusion of a small sample size (2056
subjects) in their studies. This indicated that imbalance
among the two groups could easily occur despite the
randomization and may have exaggerated the effect.
Another similar meta-analysis (31) studied the impact
of telemedicine interventions in adolescents with type 1
diabetes, and found that the telecare group had a greater
but not significant difference in reduction of HbA1c by
K0.12 (95% CI, K0.35 to 0.11) compared with the
standard care group. In conclusion, telecare intervention
seems to be more useful for patients with type 2 than
type 1 diabetes in reducing HbA1c levels.
The meta-analysis by Liang et al. (7) about the effect of
mobile phone intervention for type 2 diabetes indicated
changes in HbA1c levels of K0.81 (95% CI, K1.11
to K0.50), and our result was K0.67 (95% CI, K0.99
to K0.36). It is necessary to point out that mobile phone
intervention meant intervention using the mobile
phones with or without internet for diabetes self-management, and hence, we pooled data from 12 studies (14, 15,
16, 17, 18, 20, 21, 23, 24, 26, 27, 30) that used a similar
intervention. Compared with the study by Liang et al., we
consider that our results had several strengths. First, we
searched more databases and enrolled only RCTs with
more participants. Second, we conducted both subgroup
analysis and meta-regression analyses to verify our views.
Third, we have identified carefully redundant or duplicate
publications (27, 32, 33, 34, 35, 36) and reported them
only once. Although telecare communication was conducted using the mobile phones, it is inappropriate to
include different feedback ways (human calls, automated
calls, and SMS) in the same category of telecare intervention, as the human calls have shown significantly greater
pooled reduction in HbA1c than the others.
Our study had the following limitations: i) most of the
studies enrolled did not report allocation concealment, due
to the nature of the intervention, and it was hard to achieve
double blinding, which influenced the assessment of
quality evaluation; ii) funnel plots of the studies indicated
significant publication bias; iii) most of the studies did not
introduce researchers and patient adherence to the telecare

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Z Huang and others

intervention plan; iv) for subgroups classified by duration

of follow-up, only two studies were of 9 months duration,
and the one study of 15 months duration, which might
have influenced the reliability of the pooled estimate; and
v) some studies failed to report the measures of variation
for several continuous outcomes (BMI, PPG, body weight,
blood pressure, LDL, etc.).
The results of this analysis revealed that patients who
will benefit from telecare were as follows. One study (37)
indicated that in women a greater frequency of blood
glucose transmission resulted in a greater reduction in the
HbA1c level. Similar to our results, Salzsieder & Augstein (38)
have also suggested that patients with baseline HbA1c
greater than 8% achieved a greater reduction in the HBA1c
level at the end of the intervention. Bujnowska-Fedak et al.
(28) have found that older patients with type 2 diabetes,
educated, those with recently detected diabetes, and homebased patients benefited the most from telemonitoring.
There was a positive association between education and
ability to use the telemonitoring system without help
(PZ0.045). Our meta-analysis suggests that ethnic variations altered the effect of telecare intervention, and Asian
subjects benefited more than North American and European
populations in terms of a reduction in the mean HbA1c level.
However, this conclusion might be inappropriate because
only two studies from Europe were included in contrast with
ten from Asia. One systematic review (39) revealed that every
1% absolute reduction in HbA1c required 23.6 h of contact
between the diabetes educator and patient. A few studies
have reported that telecare intervention can be linked with
medical insurance, although the problem that Medicare
lags behind Medicaid in reimbursement remains yet to
be resolved. More studies of cost-effectiveness analysis of
telecare intervention are warranted in the future.

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).

Author contribution statement

Z Huang contributed to the literature search, concept and review design,
review write-up, and feedback on the review drafts; H Tao provided

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Effects of telecare intervention

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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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Received 30 May 2014

Revised version received 13 September 2014
Accepted 16 September 2014

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