ReviewTelemedicine interventions for gestational diabetes mellitus: A systematic review and meta-analysis
Introduction
The prevalence of Gestational Diabetes Mellitus (GDM) is estimated between 2% and 16% of all pregnancies [1]. The diagnosis of GDM typically occurs in week 24–28 of pregnancy, when routine oral glucose tolerance test (OGTT) screening is performed [1], [2]. Based on GDM management guidelines and recommendations, a ‘step–up’ approach is suggested to control hyperglycaemia [3], [4]. First line intervention involves dietary modification and physical activity [5], [6], [7] or an oral hypoglycaemic agent (OHA) [5]. In approximately half of cases, GDM is managed using insulin [2], [5], which requires intensive monitoring and regular insulin adjustment [2]. The additional demand placed on pregnant women beyond regular pre-natal care may lead to missed appointments and sub-optimal GDM management [4], [5], [6].
Suboptimal GDM control is associated with serious perinatal and neonatal complications including babies that are large for gestational age (LGA), greater chance for caesarean delivery, brachial plexus injury in the baby, preeclampsia, and gestational hypertension [4], [5], [8]. Nearly 50% of women with GDM develop type 2 diabetes within 8 years of delivery [9]. Furthermore, results of a systematic review and meta-analysis of associations between GDM and type 2 diabetes showed women with GDM had approximately 7.5 fold risk of developing type 2 diabetes compared to women with normoglycaemia during pregnancy [10].
Sustainable and innovative models of care that improve patient outcomes with minimal burden and disruptions on the patient are critical [11]. Fineberg argues that the key elements of sustainability are affordability for patients, healthcare service and government and acceptability by all stakeholders [12]. High cost and inefficient systems of care can be barriers to sustainability [12] of otherwise innovative health care provision. Hence cost benefits and/or savings are integral to sustainability of care.
Telemedicine refers to the use of information and communication technologies (ICT) to bridge the distance gap in the pursuit of sharing health information and delivering health care [13]. Interest in telemedicine is increasing as a potentially innovative and sustainable intervention approach to GDM management. Information sharing may occur between healthcare professionals or between healthcare professionals and patients. A distinction is often made between telemedicine (service delivery by doctors) and telehealth (service delivery by any healthcare professional) [14]. The World Health Organization (WHO) [14] has adopted an interchangeable use of telemedicine and telehealth. Another common term is telemonitoring in which patients remotely monitor their condition, relay data to their healthcare professionals for evaluation and feedback/action [13], [15], [16]. For the purpose of this review we adopted the broad definition of telemedicine/telehealth, including telemonitoring.
Systematic appraisals of telemedicine have been conducted for various diseases and population groups [15], [16], [17], [18], [19]. However we have not identified any reviews that specifically or exclusively appraised the use of telemedicine in GDM. Jana and Pare [16] reviewed the use of telemedicine in type 1 and 2 diabetes and reported “...significant reduction in HbA1c and complications, good receptiveness by patients and patient empowerment and education.” Other systematic reviews of telemedicine or telemonitoring have reported mixed results. A review of telemedicine in chronic disease management generally reported similar outcomes between telemedicine and controls [15] while reviews of the use of telemedicine in asthma (where it may reduce exacerbations and hospitalisation [17]) and in smoking cessation (where higher quit rates were found in favour of mobile phone-based interventions [18]) have been positive.
Few studies of telemedicine include cost assessment. In 2002, only 9% of telemedicine studies reportedly included cost evaluations and the results were generally inconclusive [19]. Nevertheless net cost savings have been reported in favour of telemedicine, largely attributed to avoided travel-associated costs [20], [21].
Despite the lack of systematic reviews of telemedicine in GDM, one quasi-controlled study that looked at telemedicine in managing diabetes in a mixed group of pregnant women with type 1 diabetes or GDM, showed acceptance levels of 85% and usage (weekly transmission of data) was 76% [22]. With mixed results in terms of effectiveness and costs, and yet rapid growth of telemedicine we conducted a systematic review of the literature and meta-analysis to examine the effect of telemedicine for GDM on glycaemic control, mother and infant perinatal outcomes, and GDM clinic utilisation, quality of life and costs.
Section snippets
Materials and methods
A systematic review and meta-analysis of randomised controlled trials (RCT) of telemedicine for GDM management was conducted. Telemedicine interventions included use of telephone, video-conferencing, mobile short message service (SMS), or web-based interfaces and other remote wireless relay systems.
Results
Our search yielded 721 articles. After screening for duplicates, relevant titles and abstracts, 14 full text publications were obtained for further screening. A further 10 publications were then excluded for the following reasons: comparison of two telemedicine interventions [27], presented pooled data for GDM and T2DM [28], outcomes were different from those we aimed to evaluate [29], [30], editorial commentaries [31], [32], methodology paper [33], different population group (pregnant women
Discussion
Our systematic review of RCTs on telemedicine for GDM showed that good quality trials in this area were few in number. The sample sizes in the individual studies were small ranging from 57 to 97 after attrition, for a maximum pooled sample of 154. Even with pooled data the sample was underpowered to detect any difference across clinical outcomes.
Our findings suggest that telemedicine reduced the need for face-to-face consultations and unplanned face-to-face consultations while achieving similar
Conclusion
Telemedicine has the potential to reduce GDM service utilisation while producing similar maternal and foetal outcomes as usual care. Its advantage may lie in the ability to deliver support and monitoring remotely for the convenience of pregnant women and reducing face-to-face and unscheduled consultations. Studies are limited and more trials that include cost evaluation are required.
Conflict of interest statement
All the authors declare no conflict of interest.
Author contributions
TR conceived the review topic, drafted the protocol, performed literature search, review data extraction, data analysis and authored the manuscript.
JF performed literature review, data extraction and contributed to manuscript authorship and editing.
IB performed literature review and contributed to manuscript authorship and editing.
MT provided secondary data analysis, contributed to manuscript authorship.
KG provided technical oversight, contributed to manuscript authorship and editing.
KL
Acknowledgements
We would like to acknowledge Dr Patty Chondros for her biostatistical advice during the early phase of conception of the review. We would like to thank Prof Doris Young and Prof Danny Liew for their feedback on the selection of outcomes. TR is supported by Australian Postgraduate Association (APA) scholarship, PhD top-up scholarship from Institute for Broadband Enabled Society (now Melbourne Networked Society Institute), University of Melbourne and a small project grant from Northern Health,
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