This review sought to collect and interpret the evidence base on home telehealth in managing type 1 diabetes. We looked at three areas:
- Patients: How is home telehealth used in care management for people with type 1 diabetes? Do patients like it? How clinically effective is it?
- Providers: What is the impact of home telehealth on health human resources? What are the roles of nurses, general practitioners, and specialists in its delivery? How do providers characterize their experiences with home telehealth?
- System: How is home telehealth incorporated into the care continuum? What is the economic impact of incorporating home telehealth into the management of type 1 diabetes? What policies need to be in place for home telehealth to be successful?
In order to answer these questions, we conducted a systematic search for literature published from 2005 to 2010. This search retrieved 12 studies that met our inclusion criteria. The quality of the evidence was generally strong. A final search for publications from 2011 to 2012 found 1 additional study. Though findings from this study were incorporated into the review, be aware that material from the 2011-2012 period was screened and analyzed in a slightly different way than the studies retrieved in our original search.
Number and Location
A search of literature published from 2005-2010 located 12 studies of home-based telehealth for management of type 1 diabetes in an adult population. The goal of most interventions was improved blood glucose control through remote monitoring and/or self-management support.
9 studies were located in Europe. Spain and the United Kingdom featured particularly prominently (Gomez et al., 2008; Jansa et al., 2006; Rigla et al., 2008; Rossi et al., 2010; and Everett & Kerr, 2010; Farmer et al., 2005; Rossi et al., 2010, respectively). Other study sites included Italy (Rossi et al., 2009, 2010; Vespasiani et al., 2009), France (Benhamou et al., 2007), Norway (Wangberg, 2008), and the United States (Albisser et al., 2007; Cox et al., 2008;). No Canadian studies were identified.
A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 additional study that met our inclusion criteria and filled gaps left by the first rounds of searching (Charpentier et al., 2011). This study was analyzed in a slightly different way than the studies retrieved in our original search, and its findings were incorporated into this review in a limited fashion. For more details, please see Methods.
The Oxford 2011 Levels of Evidence were used to assess the strength of the evidence base. Studies were placed on a scale running from Level 1, considered the highest level of evidence, through to Level 5. Levels are based primarily on study design. Studies were also assigned scores for quality of execution and reporting. Low execution/reporting scores resulted in downgrading.
The Oxford 2011 Levels of Evidence are intended to provide guidance rather than absolute judgments, and do not obviate the need for careful appraisal of local needs and context. The quality of studies within a given level can vary, as can their applicability to select populations. Furthermore, this system is not suitable for all forms of assessment. In the text that follows, the Oxford 2011 Levels of Evidence are used only when discussing clinical outcomes.
The evidence base for home telehealth in the management of type 1 diabetes was moderately strong. A Level 2 evidence rating was earned by 6 studies (Benhamou et al., 2007; Farmer, 2005; Jansa et al., 2006; Rossi, 2010; Vespasiani, 2008; Wangberg, 2008). These studies used randomization, concurrent comparison groups, and prospective measurement of exposure and outcomes. Another 6 merited a Level 3 rating, indicative of a non-randomized controlled cohort design (Albisser, 2007; Benhamou, 2010; Cox, 2008; Gomez et al., 2008; Rigla et al., 2008; Rossi, 2009). The remaining study, initially Level 4 evidence, was downgraded to Level 5 due to limitations of reporting and execution, including a conflict of interest disclosure (Everett & Kerr, 2010).
Execution and reporting scores were generally satisfactory, but rarely outstanding. Exceptions were Benhamou et al. (2007) and Farmer et al. (2005), which were notably thorough and rigourous.
Duration of intervention was between 6 and 12 months in just over half of the studies retrieved, and roughly 1-2 months in most of the remaining studies.
And on the qualitative side . . .
Our search retrieved only 1 qualitative article of relevance to type 1 diabetes (Armstrong & Powell, 2009). The study was based in England and designed to evaluate patient experiences with an online intervention called Virtual Clinic. The Virtual Clinic platform was designed to provide easy access to support for patients with diabetes. It included a secure patient-provider messaging feature, access to other online resources, and a discussion board for peer support. The article reports on qualitative data gathered through a pre-test session (n=5), a focus group (n=5), and individual interviews (n=5). All patients used insulin pumps.
Population Characteristics: Demographics
Most studies reported a mean participant age between 35 and 55 – considerably younger than the mean age observed in studies of the other chronic diseases discussed in this synthesis. The relatively early age of onset of type 1 diabetes may account both for this and for the comparative paucity of information on co-morbidities and complications in authors’ descriptions of their target populations. Gender distribution was fairly even.
Few studies provided more than basic demographics and clinical status in describing their target population. Race was reported in 1 study (Cox et al., 2008), and education level in 3 (Cox et al., 2008; Rossi et al., 2010; Wangberg, 2008). Computer literacy rates and community characteristics (i.e., rural vs. urban) were not described in any studies, although inclusion criteria occasionally required participants to be familiar with the technologies being used. Due to the infrequency with which non-clinical information was reported, no conclusions can be drawn regarding the relative efficacy of interventions in diverse patient populations.
Population Characteristics: Clinical Characteristics
The inclusion criteria of 6 studies referred to hemoglobin A1c (HbA1c) levels (Albisser et al., 2007; Benhamou et al., 2007, 2010; Everett & Kerr, 2010; Farmer et al., 2005; Jansa et al., 2006) frequently stipulating a recent value of 8% or above. Mean baseline HbA1c in the 9 studies that reported this figure ranged from 7.6-9.3, indicating that populations with sub-optimal glycemic control are usually the target of telehealth interventions for type 1 diabetes.
Patients who managed their diabetes using continuous subcutaneous insulin infusion (‘insulin pumping’) were the target group in 3 studies (Benhamou et al., 2007; Everett & Kerr, 2010; Rigla et al., 2008), while 2 specifically excluded these patients (Albisser et al., 2007; Jansa et al., 2006).
 For a comprehensive overview of this system, please refer to Jeremy Howick, Iain Chalmers, Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, and Hazel Thornton. “Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document)”.
Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653
 Systematic reviews of randomized trials; n-of-1 trials.
 Mechanism-based reasoning.