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Cited by 281Telemedicine and Telehealth ImplementationDiabetes Management and EducationDiabetes Management and Research

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

Open access
Faruque, Labib Imran, Wiebe, Natasha, Ehteshami-Afshar, Arash, Liu, Yuanchen, Dianati-Maleki, Neda, Hemmelgarn, Brenda R., Manns, Braden J., Tonelli, Marcello·2017·Canadian Medical Association Journal
DOI 10.1503/cmaj.150885PMC PMC5334006
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Abstract

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 randomeffects meta-analysis, and heterogeneity was quantified using the I2 statistic. RESULTS: From 3688 citations, we identified 111 eligible RCTs (n = 23 648). 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.

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Crossref · 10.1503/cmaj.150885

Cites

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Claims the paper makes

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  • Findingown data

    In meta-regression, partially reported loss to follow-up was associated with a higher HbA1c (MD 0.30, 95% CI 0.11 to 0.48, p=0.003).

    “| Partially reported | 22 | 0.30 (0.11 to 0.48) | 0.003 |”
    Quote in the paperNot a substantial claim
  • Findingown data

    Choice of patient-to-provider platform did not significantly modify the effect of telemedicine on HbA1c.

    “Choice of patienttoprovider platform (smartphone application, Web portal, smart device, telephone) did not significantly modify the effect of telemedicine on HbA 1C .”
    Quote in the paperSubstantial claim
  • Findingown data

    Trials with partially reported loss to follow-up showed a smaller HbA1c difference than trials with fully reported or unreported loss to follow-up, with a difference in mean difference of 0.30% (95% CI 0.11 to 0.48).

    “Tri als that partially reported loss to followup (i.e., no stated reasons for loss to followup, or loss was reported for the whole trial and not by group) showed a smaller difference in HbA 1C than trials with fully reported loss to followup or trials that did not report loss to followup (difference in MD 0.30%, 95% CI 0.11% to 0.48%).”
    Quote in the paperNot a substantial claim
  • Findingnone given

    There was no evidence of selective reporting of quality-of-life subscores.

    “There was no evidence of selective reporting of subscores for quality of life.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Meta-regression suggested that telemedicine interventions facilitating medication adjustments were more effective in improving glycemic control than interventions that did not allow such adjustments.

    “The metaregression analyses suggested that telemedicine inter ventions that facilitated medication adjustments were more effec tive in improving glycemic control than interventions that did not al low such adjustements.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 26
  • May combine two claims. 44

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The literature search yielded 3688 unique citations, and 111 trials met the review's inclusion criteria.

    “Our literature search identified 3688 unique citations.After the screening of titles and abstracts, 517 potentially eligible studies were identified, of which 111 trials 21, met our inclusion criteria (Figure 1).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Providers included nurses (37%), care managers (10%), diabetes educators (11%), physicians (29%), allied health professionals (17%), clinical decision support systems (32%), and nonspecialized support (23%).

    “Providers were nurses (37%), care managers (10%), diabetes educators (11%), physicians (29%), allied health profes sionals (17%; including dietitians, nutritionists, physiologists, exer cise trainers, psychologists and pharmacists), clinical decision sup port systems (32%) and nonspecialized support (23%; including trained peers, members of research teams, counsellors and com munity health care”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Because blinding of participants is not feasible for telemedicine interventions, all trials were open label to participants, and every trial had at least one risk-of-bias element.

    “Because blinding of participants is not feasible for telemedicine interventions, all trials were open label to the participants; thus, every trial included at least 1 element of risk of bias.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There was no evidence that telemedicine reduced the risk of hypoglycemic episodes, with risk differences of 0.0% (95% CI -5.5 to 5.5, I2 = 63%) at 3 months or less and 3.1% (95% CI -7.9 to 14.2, I2 = 47%) at 4-12 months.

    “There was no evidence that telemedicine reduced the risk of hypoglycemic episodes (risk difference for hypoglycemic episodes ≤ 3 mo: 0.0%, 95% CI -5.5% to 5.5%, I 2 = 63%; and at 4-12 mo: 3.1%, 95% CI -7.9% to 14.2%, I 2 = 47%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Trial region and baseline HbA1c modified the effect of telemedicine on final HbA1c, whereas mean age, percent male, diabetes duration, BMI, insulin use, oral hypoglycemic therapy, and diabetes type did not.

    “Both trial region and baseline HbA 1C modified the effect of telemedicine on final HbA 1C , but mean age, percent male, diabetes duration, BMI, insulin use, use of oral hypoglycemic therapy and diabetes type did not.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The trials used a variety of patient-to-provider platforms, including Web portal (24%), customized smart device (14%), telephone (13%), smartphone application (8%), SMS (5%), email (3%), and other less common platforms.

    “The trials used a large variety of plat forms: Web portal (24%), customized”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Risk differences for severe hypoglycemia were not significant, with values of 0.0% (95% CI -4.2 to 4.2) at 3 months or less and -0.1% (95% CI -1.0 to 0.8, I2 = 0%) at 4-12 months.

    “Risk differences for severe hypogly cemia were also not significant (≤ 3 mo: 0.0%, 95% CI -4.2% to 4.2%; and at 4-12 mo: -0.1%, 95% CI -1.0% to 0.8%, I 2 = 0%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Telemedicine reduced HbA1c beyond 12 months by a mean difference of -0.26% (95% CI -0.46 to -0.06), with I2 = 58%, based on 5 trials and 1896 participants.

    “and > 12 mo: -0.26%, 95% CI -0.46% to -0.06%,I 2 = 58%).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The review did not find good evidence that telemedicine reduced hypoglycemia, quality of life, or mortality.

    “However, we did not find good evi dence that telemedicine reduced the risk of hypoglycemia, quality of life or mortality, although it is unlikely that benefits for the latter would have been observed given the short duration of the included trials.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Provider-to-patient platforms included telephone (59%), clinical decision support system (32%), Web portal (22%), SMS (16%), email (7%), videoconference (4%), and other less common platforms.

    “The platforms used were telephone (59%), clinical decision support system (32%; e.g., automated interactive voice [9%]), Web portal (22%), SMS (16%), email (7%), videoconference (4%), computer software (3%), customized”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All-cause mortality risk differences were nonsignificant at 3 months or less, 4-12 months, and beyond 12 months.

    “The risk differences were all nonsignificant, without evidence of heteroge neity (≤ 3 mo: 0.2%, 95% CI -0.6% to 0.9%, I 2 = 0%, 6 deaths; 4-12 mo: -0.2%, 95% CI -0.6% to 0.2%, I 2 = 0%, 68 deaths; and > 12 mo: -0.3%, 95% CI -1.6% to 1.0%, I 2 = 0%, 351 deaths).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Most interventions (94%) were interactive, allowing patient-provider communication in both directions.

    “Most (94%) of the interventions were interactive, whereby the patient could communicate with the provider, and the provider could communicate with the patient.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The contour funnel plot for HbA1c was asymmetrical, consistent with publication bias from more small studies favoring telemedicine.

    “The contour funnel plot of HbA 1C was asymmetrical, consistent with publication bias (more small studies favouring telemedicine) (Figure 4).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Frequency of contact and type of provider did not significantly modify the association.

    “Frequency of contact and type of pro vider did not significantly modify the association.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The Egger test bias estimate was significant, with bias -0.95 and p = 0.02.

    “The bias estimate from the regression analysis was signifi cant (Egger test: bias -0.95, p = 0.02).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Baseline mean HbA1c ranged from 6.4% to 10.9%, and mean HbA1c was 8% or greater in 71 trials (64%).

    “The range of meta bolic control at baseline varied substantially between trials (mean HbA 1C 6.4%-10.9%);however, the mean HbA 1C level in 71 (64%) of the trials was 8% or greater at baseline.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Three quality-of-life scores or subscores showed significant worsening: SF-36 physical functioning at 3 months or less (MD -3.98, 95% CI -0.62 to -7.34, I2 = 30%, 2 trials, n = 311), SF-36 social functioning at 3 months or less (MD -2.22, 95% CI -0.10 to -4.34, I2 = 0%, 2 trials, n = 311), and EQ-5D at 4-12 months (MD -0.01, 95% CI -0.01 to -0.01, 2 trials, n = 743).

    “Three scores or subscores showed significant worsening (SF36 physical functioning ≤ 3 mo: MD -3.98, 95% CI -0.62 to -7.34,I 2 = 30%, 2 trials, n = 311; SF36 social functioning ≤ 3 mo: MD -2.22, 95% CI -0.10 to -4.34,I 2 = 0%, 2 trials, n = 311; and EQ5D at 4-12 mo: MD -0.01, 95% CI -0.01 to -0.01, 2 trials, n = 743).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The median mean age at baseline was 56 years, and the median mean BMI at baseline was 31.

    “The median mean age at baseline was 56 years, and the median mean BMI at baseline was 31.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The median number of study participants was 114, with a range of 10 to 2378.

    “The median number of study participants was 114 (range 10-2378) (Table 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Telemedicine reduced HbA1c at 4-12 months by a mean difference of -0.28% (95% CI -0.37 to -0.20), with I2 = 69%, based on 87 trials and 15,524 participants.

    “4-12 mo: -0.28%, 95% CI -0.37% to -0.20%,I 2 = 69% [Figure 3];”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Seventy-eight trials (70%) reported an appropriate randomization method, 30 (27%) reported adequate allocation concealment, 51 (46%) applied intention-to-treat, and 57 (51%) used public funding exclusively.

    “Seventyeight trials (70%) reported and described an appropriate method of randomization, but only 30 (27%) reported an adequate allocation concealment process.The intentiontotreat principle was applied in 51 (46%) of the trials.Public funding was exclusively used in 57 trials (51%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Other frequent intervention components were general diabetes education (76%), nutritional interventions (53%), exercise (49%), and blood pressure management (9%).

    “Other frequent compo nents of the interventions included general diabetes education (76%), nutritional interventions (53%), exercise (49%) and blood pressure management (9%).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    There was no gradient of effect, so no evidence that reporting versus not reporting loss to follow-up was a significant effect modifier.

    “Because there was no gradient of effect, there was no evidence that reporting versus not reporting loss to followup was a signifi cant effect modifier.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    SMS text messaging and Web portal were associated with greater benefit than telephone-based systems, with differences in mean difference of -0.28% (95% CI -0.52 to -0.05) for SMS versus telephone and -0.35% (95% CI -0.56 to -0.14) for Web portal versus telephone.

    “with both SMS text messaging and Web portal associated with greater benefit than telephonebased systems (difference in MD: SMS v. telephone -0.28%, 95% CI -0.52% to -0.05%; Web portal v. telephone -0.35%, 95% CI -0.56% to -0.14%).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Inclusion of interactive communication, exercise, general diabetes education, blood pressure management, or nutritional interventions did not modify the benefit of telemedicine on HbA1c.

    “Inclusion of interactive com munication, exercise, general diabetes education, blood pressure management or nutritional interventions did not modify the bene fit of telemedicine on HbA 1C .”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Interactive telecommunication initiated by providers occurred at least daily in 8%, weekly in 26%, every 2 weeks in 10%, monthly in 16%, and less often in 7%; frequency was not reported in 33% of trials.

    “Interactive telecommunica tion initiated by providers occurred in the following frequencies: at least daily (8%), weekly (26%), every 2 weeks (10%), monthly (16%) or less often (7%).Frequency of interaction was not reported in 33% of trials.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Telemedicine reduced HbA1c at 3 months or less by a mean difference of -0.57% (95% CI -0.74 to -0.40), with I2 = 75%, based on 39 trials and 3165 participants.

    “The MDs were all significant and favoured telemedicine, although there was large heterogeneity (≤ 3 mo: -0.57%, 95% confidence interval [CI] -0.74% to -0.40%,I 2 = 75%;”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Of the 111 included trials, 4 were published before 2000; 5 were cluster RCTs, 3 were crossover trials, and the remainder were parallel RCTs.

    “Of the 111 included trials, 4 were published before 2000.Five were cluster RCTs, 3 were crossover trials, and the remainder were parallel RCTs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    After removing the three outlier trials, the Egger bias estimate was not significant, with bias -0.68 and p = 0.07.

    “When the 3 outlier trials were removed, the bias estimate was not significant (bias -0.68, p = 0.07).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Excluding three outlier trials did not materially change the primary outcome but reduced heterogeneity to a mean difference of -0.24% (95% CI -0.31 to -0.16), with I2 = 58%.

    “Exclusion of these 3 trials did not materially affect our results for the primary outcome (HbA 1C at 4-12 mo), but it did reduce heterogeneity (-0.24%, 95% CI -0.31% to -0.16%,I 2 = 58%).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Many interventions (45%) adjusted medication based on data received.

    “Many of the interventions (45%) adjusted medication based on the data received.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Blinding of outcome assessors was present in 20% of trials.

    “However, we assessed for blinding of outcome assessors (present in 20% of trials).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Results were similar when HbA1c control was dichotomized at thresholds of 6.4%-6.5%, 7%-7.5%, 8%, or 9%, and when pooling the last time point from every available trial.

    “Findings were similar when control of HbA 1C was dichotomized at various thresholds (6.4%-6.5%,7%-7.5%,8% or 9%) and when we pooled results from the last time points from every available trial”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    European and North American trials had similar mean differences, with a difference in mean difference of -0.08% (95% CI -0.27 to 0.11).

    “European (n = 26) and North American trials (reference group, n = 47) reported simi lar MDs (difference in MD -0.08%, 95% CI -0.27% to 0.11%);”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Pooled mental and physical component summaries of SF-36 and SF-12 from 7 trials (n = 1333) had mean differences of 0.55 (95% CI -0.83 to 1.92; I2 = 29%) and 0.06 (95% CI -1.01 to 1.13; I2 = 0%), respectively.

    “We pooled the mental health and physical health component summaries of the SF36 and SF12 instruments from 7 trials (n = 1333): MD 0.55 (95% CI -0.83 to 1.92; I 2 = 29%) and 0.06 (95% CI -1.01 to 1.13; I 2 = 0%), respectively.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Forty-one trials (37%) were conducted in the United States, 14 (13%) in Korea, and 7 (6%) each in Canada and Australia; 6 or fewer were conducted in each remaining country.

    “Fortyone trials (37%) were done in the United States, 14 (13%) in Korea and 7 (6%) each in Canada and Australia; 6 or fewer were done in each of the remaining countries.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Reviewers disagreed on 7% of articles, with a kappa value of 0.82.

    “Disagreements occurred with 7% of the articles (κ value = 0.82).”
    Quote in the paperNot a substantial claim

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    Study design and conductown data

    Disagreements between reviewers were resolved by a third reviewer.

    “Disagreements between the reviewers were resolved by meeting with a third reviewer (N.W.).”
    Quote in the paperNot a substantial claim

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    Study design and conductown data

    Two reviewers independently assessed risk of bias and resolved disagreements with a third reviewer.

    “Two reviewers (L.F. and a research assistant) assessed the trials independently and resolved any disagreements by meeting with a third reviewer (N.W.).”
    Quote in the paperNot a substantial claim

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    Study design and conductnone given

    The analysis planned a priori to examine associations between population characteristics, intervention characteristics, risk-of-bias items, and telemedicine effect on HbA1c for characteristics reported in at least five trials.

    “We planned a priori to examine the association between popu lation characteristics, intervention characteristics, riskofbias items (as specified earlier) and the effect of telemedicine on HbA 1C for characteristics reported in 5 or more trials.”
    Quote in the paperNot a substantial claim

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    Study design and conductcitation

    The review was reported according to an accepted guideline.

    “The review was reported according to an accepted guide line.32”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] 32. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting system atic reviews and metaanalyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Publication bias was assessed using the Egger test and a contour-enhanced funnel plot.

    “We assessed publication bias using the Egger test 44 and by visual inspection of the contourenhanced funnel plot.45”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [44] 44. Egger M, Davey Smith G, Schneider M, et al. Bias in metaanalysis detected by a sim ple, graphical test. BMJ 1997;315:62934.

      Not checked in the free run.

    • cites [45] 45. Peters JL, Sutton AJ, Jones DR, et al. Contourenhanced metaanalysis funnel plots help distinguish publication bias from other causes of asymmetry. J Clin Epidemiol 2008;61:9916.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two reviewers independently screened titles and abstracts of all unique citations.

    “Two reviewers (N.W. and L.F.) independently screened the titles and abstracts of all unique citations.”
    Quote in the paperNot a substantial claim

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    Study design and conductcitation

    Risk of bias was assessed with the Cochrane Collaboration's tool plus additional items known to be associated with bias.

    “We assessed risk of bias using the Cochrane Collaboration's tool 33 and included other items (funding, intention to treat and interim analysis) also known to be associated with bias.[34][35][36][37][38][39][40]”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [33] 33. Higgins JPT, Altman DG, Sterne JAC. Chapter 8: Assessing risk of bias in included studies. In: Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration; 2011.

      Not checked in the free run.

    • cites [34] 34. Jüni P, Altman DG, Egger M. Assessing the quality of randomised controlled tri als. In: Egger M, Davey Smith G, Altman DG, editors. Systematic reviews in health care. 2nd ed. London (UK): BMJ Books; 2001.

      Not checked in the free run.

    • cites [35] 35. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of ran domized clinical trials: is blinding necessary? Control Clin Trials 1996;17:112.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Data from eligible trials were extracted by one reviewer and checked by another using a standardized extraction sheet.

    “Data from eligible trials were extracted by 1 reviewer (L.F.) and checked by another reviewer (Y.L.) using a standardized extraction sheet.”
    Quote in the paperNot a substantial claim

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    Study design and conductown data

    Two independent reviewers assessed full texts using an inclusion/exclusion form based on a priori criteria.

    “Two independent reviewers (L.F. and a research assistant) assessed them using an inclusion/exclusion form based on a priori selection criteria for eligibility.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Effects on HbA1c diminished but were sustained over time.

    “We were also able to show that effects on HbA 1C diminished but were sustained over time”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The meta-regression findings are vulnerable to the ecological fallacy and limited statistical power because they use summary data rather than individual participant data.

    “Third, as with all metaregression analyses using summary data rather than individual participant data, our findings are vulnerable to the ecological fallacy (i.e., findings at the population level do not always translate correctly to individuals) and from limited sta tistical power.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    Weaknesses of the review include limitations of the constituent trials: small sample size, lack of blinding, and relatively short duration.

    “Weaknesses of our systematic review include limitations of the constituent trials (small sample size, lack of blinding and rela tively short duration).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Because all quality-of-life findings were nonsignificant, there was no evidence that telemedicine enhanced quality of life.

    “Because all of these findings were nonsignificant, 157 there was no evidence to suggest that telemedicine enhanced quality of life.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [157] 157. Samsa G, Edelman D, Rothman ML, et al. Determining clinically important dif ferences in health status measures: a general approach with illustration to the Health Utilities Index Mark II. Pharmacoeconomics 1999;15:14155.

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Variation in the interventions and populations studied may have contributed to the observed heterogeneity and may explain why some trials found positive effects of telemedicine while others found no benefit.

    “The variation may have con tributed to the observed heterogeneity, and it may explain why some trials found positive effects of telemedicine and others found no benefit.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    The effect on HbA1c appears clinically relevant and comparable to improvements associated with some oral antidiabetic agents (0.5%-1.25%), psychosocial interventions (0.6%, 95% CI -1.2 to -0.1), or quality improvement strategies (0.42%, 95% CI 0.29 to 0.54).

    “Nonetheless, the effect on HbA 1C appears clinically relevant and is comparable to improvements associated with some oral antidiabetic agents (0.5%-1.25%), 158 psychosocial interventions (0.6%, 95% CI -1.2% to -0.1%) 159 or quality improvement strategies (0.42%, 95% CI 0.29% to 0.54%) 160 among patients with diabetes.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [158] 158. Sherifali D, Nerenberg K, Pullenayegum E, et al. The effect of oral antidiabetic agents on A1C levels: a systematic review and metaanalysis. Diabetes Care 2010;33:185964.

      Not checked in the free run.

    • cites [159] 159. Armour TA, Norris SL, Jack L Jr, et al. The effectiveness of family interventions in people with diabetes mellitus: a systematic review. Diabet Med 2005; 22:1295305.

      Not checked in the free run.

    • cites [160] 160. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a metaregression analysis. JAMA 2006;296:42740.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    The use of SMS text messaging may be feasible to communicate with and motivate patients, which could result in positive outcomes.

    “The use of SMS text messaging may be feasible to communicate and motivate patients, which could result in positive outcomes.134”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [134] 134. Shetty AS, Chamukuttan S, Nanditha A, et al. Reinforcement of adherence to prescription recommendations in Asian Indian diabetes patients using short message service (SMS) -a pilot study. J Assoc Physicians India 2011;59:7114.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    The lower apparent magnitude of benefit with longer follow-up may reflect reduced adherence to the intervention.

    “The lower apparent magnitude of benefit with longer followup may reflect reduced adherence to the intervention.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The wide variation in telemedicine interventions likely contributed to some of the observed heterogeneity, which was only partly explained by meta-regression.

    “This wide variation in inter ventions likely contributed to some of the observed heterogeneity, which was only partly explained by metaregression.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A previous meta-regression analysis of quality improvement strategies reported that medication adjustment by nurse or pharmacist was associated with an improvement of 0.23% (95% CI 0.05 to 0.42).

    “This finding is consistent with medication adjustment by nurse or pharmacist (0.23%, 95% CI 0.05% to 0.42%) reported in a previous metaregression analysis of quality improve ment strategies, including case man agement.160”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [160] 160. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a metaregression analysis. JAMA 2006;296:42740.

      Not checked in the free run.

56 of 56

  • The paper relies on this without support.

    Telemedicine may be helpful for providing care to people with diabetes, especially those unable to travel to health care facilities because of large distances or disabilities.

    “It may also be helpful for providing care to people with diabetes, especially those unable to travel to health care facilities owing to large distances or disabilities.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The included studies exhibited substantial heterogeneity (I2=94%).

    “The included studies exhibited substantial heterogeneity (I²=94%), a common finding in telemedicine reviews, where heterogeneity typically ranges from 65% to 99% [17,22,86,93].”

    From Clinical Improvements From Telemedicine Interventions for Managing Type 2 Diabetes Compared With Usual Care: Systematic Review, Meta-Analysis, and Meta-Regression (2026) · cites this paper as [93]

    The Effect on HbA1C section reports substantial heterogeneity, but not I²=94%: it gives I²=69% for the primary 4–12-month analysis, 75% at ≤3 months, and 58% at >12 months. Table 4 also identifies 69% as the heterogeneity in the primary analysis. Page numbers were not available in our copy. (LLM, conf=0.88)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured

  • Three reviews reported that text-messaging or SMS feedback was equally effective in improving HbA1c compared to a teleconference or telephone appointment with healthcare professionals.

    “3 reviews [28, 31, 43] reported that interventions as simple as text-messaging or SMS feedback were equally effective in improving HbA1c, compared to a teleconference or telephone appointment with healthcare professionals.”

    From Effect of virtual care in type 2 diabetes management – a systematic umbrella review of systematic reviews and meta-analysis (2025) · cites this paper as [31]

    The Meta-regression analysis reports that provider-to-patient SMS text messaging was associated with a significantly greater HbA1c benefit than telephone-based systems, not an equal benefit. The paper does not establish a separate comparison with teleconference appointments. (LLM, conf=0.89)

    Checked by a reasoning model — may be wrong.

    Experimental — accuracy not yet measured

  • Heterogeneity in telemedicine reviews typically ranges from 65% to 99%.

    “The included studies exhibited substantial heterogeneity (I²=94%), a common finding in telemedicine reviews, where heterogeneity typically ranges from 65% to 99% [17,22,86,93].”

    From Clinical Improvements From Telemedicine Interventions for Managing Type 2 Diabetes Compared With Usual Care: Systematic Review, Meta-Analysis, and Meta-Regression (2026) · cites this paper as [93]

    The Effect on HbA1C section reports large heterogeneity in this telemedicine review (I² = 75%, 69%, and 58%). It supports the general point that heterogeneity can be substantial, but not the claim that telemedicine reviews typically range from 65% to 99%; this review reports a value below that range and does not establish a typical range across reviews. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The majority of the evidence (72%) originates from high-income countries, with the United States contributing the highest proportion (28%).

    “Consistent with previous findings [87,93], the majority of the evidence (72%) originates from high-income countries, with the United States contributing the highest proportion (28%).”

    From Clinical Improvements From Telemedicine Interventions for Managing Type 2 Diabetes Compared With Usual Care: Systematic Review, Meta-Analysis, and Meta-Regression (2026) · cites this paper as [93]

    The Results report that the United States contributed the largest share of the 111 included trials, but give its share as 41 trials (37%), not 28%. The paper does not report the claimed 72% figure for high-income countries, although its country breakdown is consistent with a majority coming from them. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Messages generated using automated algorithms may offer a more feasible and less expensive solution.

    “Messages generated using automated algorithms may offer a more feasible and less expensive solution [31].”

    From Effect of virtual care in type 2 diabetes management – a systematic umbrella review of systematic reviews and meta-analysis (2025) · cites this paper as [31]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Baseline HbA1C is called an effect modifier despite a nonsignificant result

    Major

    The results say baseline HbA1C modified the effect of telemedicine, but Table 4 reports p = 0.3 and a confidence interval spanning zero for that association.

  • Follow-up duration is given in years where the trial durations are in months

    Minor

    Table 4 labels the follow-up range as 2.6-24 years, yet the paper includes trials reporting outcomes at three months or less. The stated minimum of 2.6 years cannot describe those trials.

2 of 2

Cites

Flagged first, then by citations

83 of the 187 references couldn’t be matched to a known paper.

Research works printed but not linked: 76

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Cited by

Sorted by citations

Related

Authors
Faruque, L. I., Wiebe, N., Ehteshami-Afshar, A., Liu, Y., Dianati-Maleki, N., Hemmelgarn, B. R., Manns, B. J., & Tonelli, M.
Affiliations
University of Alberta (CA)
ORCID
Venue
Canadian Medical Association Journal
Publisher
CMA Impact Inc.
Published
2016-10-31
Volume
189
Issue
9
Pages
E341-E364
ISSN
  • 0820-3946 (ISSN-L)
  • 1488-2329
DOI
10.1503/cmaj.150885
PMC
PMC5334006
OpenAlex
W2546067499
Cited by
281
References
187
Citations by year
2026: 14 · 2025: 25 · 2024: 33 · 2023: 29 · 2022: 46 · 2021: 46 · 2020: 32 · 2019: 25 · 2018: 18 · 2017: 12 · 2016: 1
FWCI
2.76
Type
journal article
Language
en
Open access
Locations
  • Canadian Medical Association Journal (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
Keywords
telemedicine, diabetes mellitus, HbA1c, glycemic control, diabetes management, web portal, text messaging, medication adjustment, quality of life, hypoglycemia, mortality
MeSH terms
Communication, Diabetes Mellitus, Glycated Hemoglobin, Humans, Hypoglycemia, Quality of Life, Randomized Controlled Trials as Topic, Telemedicine, Disease Management, Internet, Text Messaging

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-30.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-30.

Statistics and arithmetic are recomputed, not judged.

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