MON-126 Telemedicine Interventions for Treatment of Diabetes Mellitus in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Abstract

Diabetes mellitus (DM) is associated with significant morbidity, mortality and poor quality of life. It also has substantial social and financial implications because over 75% of patients with DM live in low- and middle-income countries (LMIC). In this context, it is often opined that diabetes care can be improved by employing telemedicine interventions. The present systematic review and meta-analysis aims to estimate the clinical effectiveness of telemedicine in improving biochemical and treatment adherence outcomes related to DM and provide the certainty of evidence for these interventions. Using a pretested search strategy, nine academic databases were searched from their inception to August 2019: Web of Science, PubMed, Medline, Global Health Library, Cochrane Central Register of Controlled Trials (CENTRAL), New York Academy of Medicine (NYAM) and Popline. We only included RCTs and cluster RCTs testing the effectiveness of tele-medicine-based interventions in type 1, 2 and gestational diabetes in LMIC. Risk of bias in the included RCTs was assessed using the Cochrane tool for assessment of risk of bias in randomized controlled trials. A series of meta-analyses for each individual outcome was run using random effects analyses. Certainty of evidence for these interventions was assessed using the GRADE guidelines. A total of 22 studies describing 23 interventions were included. We identified five modes of interventions delivered using telephone calls (n=6), SMS (n=5), telemetry (n=5) web-based systems (n=3) and smartphone apps (n=3). Major strategies included health record keeping, follow ups, reminders, psychoeducation, glucose monitoring, monitoring prompts, alerts and online consultations Overall, a significant treatment effect was seen among outcomes of HbA1c (SMD=-0.30, 95% CI= -0.42 to -0.17, n=6548, I2= 80.21%) and fasting blood sugar levels (SMD=-0.17, 95% CI= -0.32 to -0.01, n=4709, I2=60.49%), self-efficacy (SMD= 1.94, 95% CI= 1.31 to 2.58, n=626, I2= 95.99) and treatment adherence (SMD= 1.16, 95% CI= 0.78 to 1.54, n=437, I2= 84.8%). A marginally significant effect was seen in improvement of knowledge regarding diabetes (SMD= 0.66, 95% CI= -0.006 to 1.33, n=1345, I2= 93.38%). No significant treatment effect was seen in outcomes of serum triglyceride levels (SMD= -0.02, 95% CI= -0.18 to 0.14, n= 1535, I2=2.98%), serum total cholesterol levels (SMD= -0.05, 95% CI= -0.20 to 0.09, n= 4862, I2=66.45%) and BMI (SMD= -0.03, 95% CI= -0.13 to 0.07, n= 5372, I2=41.78 %). Telephone calls and SMS based telemedicine interventions yielded the highest treatment effects when compared with telemetry and smartphone apps-based services. Although telemedicine was found to be effective in improving several DM related outcomes, the certainty of evidence was downgraded to very low due to substantial heterogeneity, publication bias and risk of bias.