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Telecare for Patients with Type 1 Diabetes and Inadequate Glycemic Control

Response to Montori et al.

From the Institute for Diabetes Research, City Hospital Munich-Schwabing, Muenchen, Bavaria, Germany

Address correspondence to Eberhard Biermann, MD, Institute for Diabetes Research, City Hospital Munich-Schwabing, Koelnerplatz 1, Muenchen, 80804, Germany. E-mail: eberhard.biermann{at}lrz.uni-muenchen.de

The insightful study of Montori et al. (1) raises the question of whether telecare can close the gap between the necessary and frequent interventions by health care professionals in order to lower the HbA_1c of patients. We would like to comment on the control group and meta-analysis in their study.

Telecare can be embedded into different achievable scenarios, where the left-most cornerstone considers a control group and where conventional care means no intervention (A). The right-most cornerstone is to replace face-to-face interventions by telecare with the same frequency and quality as in the control group (B). In reality, the typical group defining "conventional care" would be situated between these two cornerstones. Due to regional differences, the private situation, and, particularly, the distance to the next specialist, the patients would not be able to achieve the necessary frequency of face-to-face visits that they would if the doctor’s office were next door (C).

In a comparative study, medical outcome (HbA_1c) and costs would be different depending on whether strategy A or B or something in between was adopted. A cost-effectiveness study is particularly mandatory in strategy B, where the primary outcome parameter would be cost and the secondary parameter HbA_1c.

In a randomized cost-effectiveness study (2), we adopted strategy B in order to isolate the effect of telecare and not any effect attributable to the frequency of interventions. A similar study by Chase et.al (3) is also situated closely to strategy B. Both studies came to the conclusion that telecare can save costs while maintaining the quality of care (HbA_1c).

In another recent study (4), we tried to adopt an approach that better simulates a patient’s "real-life" (C) by having the patients in the control group being educated first in hospital and then returning to their private practitioners. We believe that due to the different goals of the studies and the different control groups, a meta-analysis would ultimately draw equivocal or false conclusions.

In conclusion, we would suggest adding the method of whether a cost-effectiveness analysis or an outcome analysis has been performed to a further meta-analysis in telecare. However, the use of excellent tools such as intention-to-treat analysis and the high degree of transparency makes the report of Montori et al. groundbreaking and a critical starting point for further studies in this field.

References

1. Montori VM, Helgemoe PK, Guyatt GH, Dean DS, Leung TW, Smith SA, Kudva YC: Telecare for patients with type 1 diabetes and inadequate glycemic control: a randomized controlled trial and meta-analysis. Diabetes Care 27:1088–1094, 2004[Abstract/Free Full Text]
   
2. Biermann E, Dietrich W, Rihl J, Standl E: Are there time and cost savings by using telemangement for patients on intensified insulin therapy? A randomised, controlled trial. Comput Methods Programs Biomed 69:137–146, 2002[Medline]
   
3. Chase HP, Pearson JA, Wightman C, Roberts MD, Oderberg AD, Garg SK: Modem transmission of glucose values reduces the cost and need for clinic visits. Diabetes Care 26:1475–1479, 2003[Abstract/Free Full Text]
   
4. Biermann E, Rihl J, Standl E: Outcome and efficiency of restoration of metabolic control of insulin dependent diabetics by telemonitoring (Abstract). Diabetologia 47(Suppl. 1):A348, 2004
   

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				V. M. Montori, G. H. Guyatt, S. A. Smith, and Y. C. Kudva Telecare for Patients With Type 1 Diabetes and Inadequate Glycemic Control: Response to Biermann et al. Diabetes Care, January 1, 2005; 28(1): 229 - 230. [Full Text] [PDF]

This Article Extract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Biermann, E. Articles by Standl, E. Search for Related Content PubMed PubMed Citation Articles by Biermann, E. Articles by Standl, E. Related Collections Related Letter Social Bookmarking                What's this?