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Abstract：
BACKGROUND: Type 1 diabetes mellitus (T1DM) is the most common chronic autoimmune disease among children and adolescents. Telemedicine has been widely used in the field of chronic disease management and can benefit patients with T1DM. However, existing studies lack high-level evidence related to the effectiveness of telemedicine for glycemic control in children and adolescents with T1DM.
OBJECTIVE: This study aims to systematically review the evidence on the effectiveness of telemedicine interventions compared with usual care on glycemic control among children and adolescents with T1DM.
METHODS: In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Embase, Web of Science (all databases), and CINAHL Complete from database inception to May 2023. We included randomized controlled trials (RCTs) that evaluated the effectiveness of a telemedicine intervention on glycemic control in children and adolescents with T1DM. In total, 2 independent reviewers performed the study selection and data extraction. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Our primary outcome was glycated hemoglobin (HbA1c) levels. Secondary outcomes were quality of life, self-monitoring of blood glucose, the incidence of hypoglycemia, and cost-effectiveness. A random-effects model was used for this meta-analysis.
RESULTS: Overall, 20 RCTs (1704 participants from 12 countries) were included in the meta-analysis. Only 5% (1/20) of the studies were at high risk of bias. Compared to usual care, telemedicine was found to reduce HbA1c levels by 0.22 (95% CI -0.33 to -0.10; P<.001; I2=35%). There was an improvement in self-monitoring of blood glucose (mean difference [MD] 0.54, 95% CI -0.72 to 1.80; P=.40; I2=67.8%) and the incidence of hypoglycemia (MD -0.15, 95% CI -0.57 to 0.27; P=.49; I2=70.7%), although this was not statistically significant. Moreover, telemedicine had no convincing effect on the Diabetes Quality of Life for Youth score (impact of diabetes: P=.59; worries about diabetes: P=.71; satisfaction with diabetes: P=.68), but there was a statistically significant improvement in non-youth-specific quality of life (MD -0.24, 95% CI -0.45 to -0.02; P=.04; I2=0%). Subgroup analyses revealed that the effect of telemedicine on HbA1c levels appeared to be greater in studies involving children (MD -0.41, 95% CI -0.62 to -0.20; P<.001), studies that lasted <6 months (MD -0.32, 95% CI -0.48 to -0.17; P<.001), studies where providers used smartphone apps to communicate with patients (MD -0.37, 95% CI -0.53 to -0.21; P<.001), and studies with medication dose adjustment (MD -0.25, 95% CI -0.37 to -0.12; P<.001).
CONCLUSIONS: Telemedicine can reduce HbA1c levels and improve quality of life in children and adolescents with T1DM. Telemedicine should be regarded as a useful supplement to usual care to control HbA1c levels and a potentially cost-effective mode. Meanwhile, researchers should develop higher-quality RCTs using large samples that focus on hard clinical outcomes, cost-effectiveness, and quality of life.
OBJECTIVE: This study aims to systematically review the evidence on the effectiveness of telemedicine interventions compared with usual care on glycemic control among children and adolescents with T1DM.
METHODS: In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Embase, Web of Science (all databases), and CINAHL Complete from database inception to May 2023. We included randomized controlled trials (RCTs) that evaluated the effectiveness of a telemedicine intervention on glycemic control in children and adolescents with T1DM. In total, 2 independent reviewers performed the study selection and data extraction. Study quality was assessed using the Cochrane Risk of Bias 2 tool. Our primary outcome was glycated hemoglobin (HbA1c) levels. Secondary outcomes were quality of life, self-monitoring of blood glucose, the incidence of hypoglycemia, and cost-effectiveness. A random-effects model was used for this meta-analysis.
RESULTS: Overall, 20 RCTs (1704 participants from 12 countries) were included in the meta-analysis. Only 5% (1/20) of the studies were at high risk of bias. Compared to usual care, telemedicine was found to reduce HbA1c levels by 0.22 (95% CI -0.33 to -0.10; P<.001; I2=35%). There was an improvement in self-monitoring of blood glucose (mean difference [MD] 0.54, 95% CI -0.72 to 1.80; P=.40; I2=67.8%) and the incidence of hypoglycemia (MD -0.15, 95% CI -0.57 to 0.27; P=.49; I2=70.7%), although this was not statistically significant. Moreover, telemedicine had no convincing effect on the Diabetes Quality of Life for Youth score (impact of diabetes: P=.59; worries about diabetes: P=.71; satisfaction with diabetes: P=.68), but there was a statistically significant improvement in non-youth-specific quality of life (MD -0.24, 95% CI -0.45 to -0.02; P=.04; I2=0%). Subgroup analyses revealed that the effect of telemedicine on HbA1c levels appeared to be greater in studies involving children (MD -0.41, 95% CI -0.62 to -0.20; P<.001), studies that lasted <6 months (MD -0.32, 95% CI -0.48 to -0.17; P<.001), studies where providers used smartphone apps to communicate with patients (MD -0.37, 95% CI -0.53 to -0.21; P<.001), and studies with medication dose adjustment (MD -0.25, 95% CI -0.37 to -0.12; P<.001).
CONCLUSIONS: Telemedicine can reduce HbA1c levels and improve quality of life in children and adolescents with T1DM. Telemedicine should be regarded as a useful supplement to usual care to control HbA1c levels and a potentially cost-effective mode. Meanwhile, researchers should develop higher-quality RCTs using large samples that focus on hard clinical outcomes, cost-effectiveness, and quality of life.
摘要：
背景：1型糖尿病（T1DM）是儿童和青少年中最常见的慢性自身免疫性疾病。远程医疗已广泛应用于慢性病管理领域，可使T1DM患者受益。然而,现有研究缺乏与远程医疗对儿童和青少年T1DM患者血糖控制有效性相关的高水平证据.
目的：本研究旨在系统评价在儿童和青少年T1DM患者中，远程医疗干预与常规护理对血糖控制的有效性的证据。
方法：在本系统综述和荟萃分析中，我们搜索了PubMed,科克伦图书馆,Embase,WebofScience（所有数据库），从数据库开始到2023年5月，andCINAHL完成。我们纳入了随机对照试验（RCT），评估了远程医疗干预对儿童和青少年T1DM血糖控制的有效性。总的来说,2名独立评审员进行了研究选择和数据提取。使用Cochrane偏差风险2工具评估研究质量。我们的主要结果是糖化血红蛋白（HbA1c）水平。次要结果是生活质量，自我监测血糖，低血糖的发生率，和成本效益。该荟萃分析使用随机效应模型。
结果：总体而言，20项RCT（来自12个国家的1704名参与者）纳入荟萃分析。只有5%(1/20)的研究存在高偏倚风险。与常规护理相比，发现远程医疗可使HbA1c水平降低0.22（95％CI-0.33至-0.10；P<.001；I2=35％）。血糖的自我监测有所改善（平均差异[MD]0.54，95％CI-0.72至1.80；P=.40；I2=67.8％）和低血糖的发生率（MD-0.15，95％CI-0.57至0.27；P=.49；I2=70.7％），尽管这在统计学上并不显着。此外，远程医疗对青少年糖尿病生活质量评分没有令人信服的影响（糖尿病的影响：P=.59；对糖尿病的担忧：P=.71；对糖尿病的满意度：P=.68），但在非青年特定生活质量方面有统计学显著改善(MD-0.24,95%CI-0.45至-0.02;P=.04;I2=0%).亚组分析显示，在涉及儿童的研究中，远程医疗对HbA1c水平的影响似乎更大（MD-0.41，95％CI-0.62至-0.20；P<.001），持续<6个月的研究（MD-0.32，95％CI-0.48至-0.17；P<.001），提供者使用智能手机应用程序与患者沟通的研究（MD-0.37，95%CI-0.53至-0.21；P<.001），和药物剂量调整的研究（MD-0.25，95％CI-0.37至-0.12；P<.001）。
结论：远程医疗可降低儿童和青少年T1DM患者的HbA1c水平并改善其生活质量。远程医疗应被视为控制HbA1c水平的常规护理的有用补充和潜在的成本效益模式。同时,研究人员应该使用大样本开发更高质量的RCT，专注于艰难的临床结果，成本效益，和生活质量。
目的：本研究旨在系统评价在儿童和青少年T1DM患者中，远程医疗干预与常规护理对血糖控制的有效性的证据。
方法：在本系统综述和荟萃分析中，我们搜索了PubMed,科克伦图书馆,Embase,WebofScience（所有数据库），从数据库开始到2023年5月，andCINAHL完成。我们纳入了随机对照试验（RCT），评估了远程医疗干预对儿童和青少年T1DM血糖控制的有效性。总的来说,2名独立评审员进行了研究选择和数据提取。使用Cochrane偏差风险2工具评估研究质量。我们的主要结果是糖化血红蛋白（HbA1c）水平。次要结果是生活质量，自我监测血糖，低血糖的发生率，和成本效益。该荟萃分析使用随机效应模型。
结果：总体而言，20项RCT（来自12个国家的1704名参与者）纳入荟萃分析。只有5%(1/20)的研究存在高偏倚风险。与常规护理相比，发现远程医疗可使HbA1c水平降低0.22（95％CI-0.33至-0.10；P<.001；I2=35％）。血糖的自我监测有所改善（平均差异[MD]0.54，95％CI-0.72至1.80；P=.40；I2=67.8％）和低血糖的发生率（MD-0.15，95％CI-0.57至0.27；P=.49；I2=70.7％），尽管这在统计学上并不显着。此外，远程医疗对青少年糖尿病生活质量评分没有令人信服的影响（糖尿病的影响：P=.59；对糖尿病的担忧：P=.71；对糖尿病的满意度：P=.68），但在非青年特定生活质量方面有统计学显著改善(MD-0.24,95%CI-0.45至-0.02;P=.04;I2=0%).亚组分析显示，在涉及儿童的研究中，远程医疗对HbA1c水平的影响似乎更大（MD-0.41，95％CI-0.62至-0.20；P<.001），持续<6个月的研究（MD-0.32，95％CI-0.48至-0.17；P<.001），提供者使用智能手机应用程序与患者沟通的研究（MD-0.37，95%CI-0.53至-0.21；P<.001），和药物剂量调整的研究（MD-0.25，95％CI-0.37至-0.12；P<.001）。
结论：远程医疗可降低儿童和青少年T1DM患者的HbA1c水平并改善其生活质量。远程医疗应被视为控制HbA1c水平的常规护理的有用补充和潜在的成本效益模式。同时,研究人员应该使用大样本开发更高质量的RCT，专注于艰难的临床结果，成本效益，和生活质量。
