Intensive remote monitoring versus conventional care in type 1 diabetes: A randomized controlled trial

Benefits, implementation and sustainability of innovative paediatric models of care for children with type 1 diabetes: a systematic review

BACKGROUND AND AIM

The evidence about the acceptability and effectiveness of innovative paediatric models of care for Type 1 diabetes is limited. To address this gap, we synthesised literature on implemented models of care, model components, outcomes, and determinants of implementation and sustainability.

METHODS

A systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Database searches of Medline, CINAHL, EMBASE and Scopus were conducted. Empirical studies focused on Type 1 diabetes paediatric models of care, published from 2010 to 2022 in English were included.

RESULTS

Nineteen extant studies reported on models and their associations with health and psychosocial outcomes, patient engagement with healthcare, and healthcare costs. Thirteen studies described multidisciplinary teamwork, education and capacity building that supported self-care. Four studies involved shared decision making between providers and patients, and two discussed outreach support where technology was an enabler. Fourteen studies reported improvements in health outcomes (e.g. glycaemic control), mostly for models that included multidisciplinary teams, education, and capacity building (11 studies), outreach support or shared care (3 studies). Four studies reported improvements in quality of life, three reported increased satisfaction for patients and carers and, and one reported improved communication. Four of five studies describing shared care and decision-making reported improvements in quality of life, support and motivation. Outreach models reported no negative outcomes, however, accessing some models was limited by technological and cost barriers. Eight studies reported on model sustainability, but only half reported implementation determinants; none reported applying a theoretical framework to guide their research.

CONCLUSION

Some health and psychosocial benefits were associated with newer models. To address knowledge gaps about implementation determinants and model sustainability, longitudinal studies are needed to inform future adoption of innovative models of care for children with Type 1 diabetes.

Telemedicine in Improving Glycemic Control Among Children and Adolescents With Type 1 Diabetes Mellitus: Systematic Review and Meta-Analysis

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.

Use of Telemedicine in Pediatric Services for 4 Representative Clinical Conditions: Scoping Review

Background

Telemedicine is becoming routine in health care. Postpandemic, a universal return to face-to-face consultations may risk a loss of some of the advantages of telemedicine. However, rapid implementation and adoption without robust evaluation of usability, efficacy, and effectiveness could potentially lead to suboptimal health outcomes and downstream challenges to providers.

Objective

This review assesses telemedicine interventions against international guidance and sufficiency of evidence to support postpandemic utilization in pediatric settings.

Methods

This scoping review was performed following searches on PubMed, Embase, and CINAHL databases on April 15, 2021, and May 31, 2022, and examined studies focused on telemedicine, remote consultation, video call, or remote patient monitoring in children (0-18 years) receiving outpatient care for diabetes, asthma, epilepsy, or renal disease. Exclusion criteria included studies published before 2011 as the technologies used have likely been improved or replaced, studies in adult populations or where it was not possible to disaggregate data for participants younger than 18 years as the focus of the review was on pediatric care, and studies not published in English. Data were extracted by 4 authors, and the data were corroborated by a second reviewer. Studies were examined for feasibility and usability, clinical and process outcomes, and cost-effectiveness.

Results

Of the 3158 studies identified, 56 were suitable for final inclusion and analysis. Data on feasibility or usability of interventions (48 studies) were overwhelmingly positive in support of telemedicine interventions, with common themes including convenience, perceived cost savings, and ease of use. However, use in preference to usual care was rarely explored. Clinical and process outcome data (31 studies) were mostly positive. Across all studies, there was limited measurement of standardized clinical outcomes, although these were more commonly reported in asthma (peak flow) and diabetes (glycated hemoglobin [HbA1c]). Implementation science data generally supported cost-effectiveness of telemedicine with a reduction of health care costs.

Conclusions

There is promising evidence supporting telemedicine in pediatric settings. However, there is a lack of evaluation of telemedicine in comparison with usual outpatient care for noninferiority of clinical outcomes, and this review highlights the need for a more standardized approach to evaluation of digital interventions.

Parents' views about healthcare professionals having real-time remote access to their young child's diabetes data: Qualitative study

OBJECTIVES

We explored parents' views about healthcare professionals having remote access to their young child's insulin and glucose data during a clinical trial to inform use of data sharing in routine pediatric diabetes care.

RESEARCH DESIGN AND METHODS

Interviews with 33 parents of 30 children (aged 1-7 years) with type 1 diabetes participating in a randomized trial (KidsAP02) comparing hybrid closed-loop system use with sensor-augmented pump therapy. Data were analyzed using a qualitative descriptive approach.

RESULTS

Parents reported multiple benefits to healthcare professionals being able to remotely access their child's glucose and insulin data during the trial, despite some initial concerns regarding the insights offered into everyday family life. Key benefits included: less work uploading/sharing data; improved consultations; and, better clinical input and support from healthcare professionals between consultations. Parents noted how healthcare professionals' real-time data access facilitated remote delivery of consultations during the COVID-19 pandemic, and how these were more suitable for young children than face-to-face appointments. Parents endorsed use of real-time data sharing in routine clinical care, subject to caveats regarding data access, security, and privacy. They also proposed that, if data sharing were used, consultations for closed-loop system users in routine clinical care could be replaced with needs-driven, ad-hoc contact.

CONCLUSIONS

Real-time data sharing can offer clinical, logistical, and quality-of-life benefits and enhance opportunities for remote consultations, which may be more appropriate for young children. Wider rollout would require consideration of ethical and cybersecurity issues and, given the heightened intrusion on families' privacy, a non-judgmental, collaborative approach by healthcare professionals.

Impact of virtual care on health-related quality of life in children with diabetes mellitus: a systematic review protocol

INTRODUCTION

Diabetes mellitus is the most common endocrine disorder in children, and the prevalence of paediatric type 1 and type 2 diabetes continue to rise globally. Diabetes clinical care programs pivoted to virtual care with the COVID-19 pandemic-driven social distancing measures. Yet, the impact of virtual care on health-related quality of life in children living with diabetes remains unclear. This protocol reports on the methods that will be implemented to conduct a systematic review to assess the health-related quality of life and metabolic health impacts of virtual diabetes care.

METHODS AND ANALYSIS

We will search MEDLINE, Embase, EMCare, PsycInfo, Web of Science, and the grey literature for eligible studies. We will screen title, abstract, and full-text papers for potential inclusion and assess the risk of bias and the overall confidence in the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. A meta-analysis will be conducted if two studies report similar populations, study designs, methods, and outcomes.This systematic review will summarise the health-related quality of life outcomes for virtual diabetes care delivery models.

ETHICS AND DISSEMINATION

No ethics approval is required for this systematic review protocol as it does not include patient data. The systematic review will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021235646.

Feasibility and Impact of Remote Glucose Monitoring Among Patients With Newly Diagnosed Type 1 Diabetes: Single-Center Pilot Study

Background

Caregivers of children with newly diagnosed type 1 diabetes (T1D) maintain close contact with providers for several weeks to facilitate rapid adjustments in insulin dosing regimens. Traditionally, patient glucose values are relayed by telephone for provider feedback, but digital health technology can now enable the remote sharing of glucose data via mobile apps.

Objective

The aim of this study was to test the feasibility of remote glucose monitoring in a population of children and adolescents with newly diagnosed T1D and to explore whether remote monitoring alters habits for self-review of glucose data or perceived ease of provider contact in this population as compared to a nonrandomized control group.

Methods

Data were collected from families who chose to participate in remote monitoring (intervention group) as well as from patients receiving usual care (control group). The intervention group received Bluetooth-capable glucose meters and Apple iPod Touch devices. Patient-generated glucose data were passively relayed from the meter to the iPod Touch and then to both the electronic health record (EHR) and a third-party diabetes data platform, Tidepool. The principal investigator reviewed glucose data daily in the EHR and Tidepool and contacted the participants as needed for insulin dose adjustments during the time between hospital discharge and first clinic appointment. Families in the control group received usual care, which involved keeping written records of glucose values and contacting the diabetes team daily by telephone to relay data and receive treatment recommendations. A total of 40 families (20 for the intervention group and 20 for the control group) participated in the study. All families were surveyed at 1 month and 6 months regarding self-review of glucose data and ease of contacting the diabetes team.

Results

Patient-generated glucose data were remotely accessible for 100% of the participants via Tidepool and for 85% via the EHR. Survey data indicated that families in the intervention group were more likely than those in the control group to review their glucose data using mobile health apps after 1 month (P<.001), but by 6 months, this difference had disappeared. Perceived ease of contacting the clinical team for assistance was lower for the intervention group after 6 months (when receiving usual care) in comparison to during the intervention period (P=.48) and compared with a control group who did not have exposure to remote monitoring (P=.03).

Conclusions

Remote glucose monitoring is feasible among pediatric patients with newly diagnosed T1D and may be associated with the earlier adoption of mobile health apps for self-management. The use of broadscale remote monitoring for T1D in the future will depend on improved access to Bluetooth-enabled mobile devices for all patients, improved interoperability of mobile health apps to enable data transfer on Android as well as Apple devices, and new provider workflows to handle large-scale panel management based on patient-generated health data.

Trial Registration

ClinicalTrials.gov NCT04106440; https://clinicaltrials.gov/ct2/show/NCT04106440

Integrating diabetes technologies with team-based primary care for type 2 diabetes: A pilot trial

This pilot trial studied a novel intervention that integrated diabetes technologies into team-based primary care for type 2 diabetes. We found clinically significant reductions in blood pressure, weight, and glucose. The latter two were statistically significant.

Parents' preferences for follow-up care in a type 1 diabetes paediatric population: a survey-based study in Quebec, Canada

OBJECTIVES

Examine variations in parent's preferences for their child's type 1 diabetes (T1D) follow-up care and the determinants of the preferred intensity of care. Clinical guidelines recommend multidisciplinary management of T1D, with follow-up visits with an endocrinologist at least every 3 months in the paediatric population. However, there could be heterogeneity in parents' needs, and preferences in terms of care management may deviate from clinical guidelines.

SETTING

Not applicable.

PARTICIPANTS

Parents who have a child living with T1D and who reside in Quebec, Canada.

INTERVENTION

In collaboration with a patient-partner (a parent of a child with T1D), we developed a survey to collect data from parents of children living with T1D. Our primary outcome of interest was the preferred time in months between two appointments. We ran a probit model to analyse longer time (over 3 months between appointments), compared with the standard of care (3 months or less).

RESULTS

Results suggest that about one-third (33%) of parents want to deviate from the guideline. Parents who want to increase the time between appointments are more experienced in the management of the disease and have higher costs than those who wish to follow the 3-month guideline. The number of years since the diagnosis is positively associated with a preference for a longer time between appointments, while the perceived useful of information provided during the consultation, and a parent having made a change in their professional life were negatively associated with a desire to space out appointments. The child's gender is not a significant factor in parents' preferences.

CONCLUSIONS

Adapting visit protocols could make the health system more efficient to respond to T1D patients and their parent's needs.

Parental expectations before and after 12-month experience with video consultations combined with regular outpatient care for children with type 1 diabetes: a qualitative study

AIM

To explore parents' expectations of the perceived barriers to and benefits of 1 year of monthly video consultations combined with regular outpatient care of children with type 1 diabetes.

METHODS

The Virtual Diabetes Outpatient Clinic for Children and Youth (VIDIKI) study was a controlled, multicentre, perennial study with 240 participants from northern Germany. Fifty-four qualitative interviews with parents were analysed using qualitative content analysis. Before the intervention, 30 interviews were conducted to assess parents' expectations, and after 1 year, 24 interviews evaluated the experienced benefits and barriers to video consultations.

RESULTS

Four main topics were identified from parents' responses to the video consultation. The main advantages of the video consultation compared with standard care were a higher frequency of contact for optimized insulin dosing and saving time; difficulties with internet connections were identified as the main barrier. A feeling of increased confidence with respect to insulin dosing was directly associated with telemedicine. Digital prescriptions and meeting the same diabetologist in both outpatient and telemedical care were mentioned as important improvements. The majority of interviewees preferred intervals of 4-6 weeks between video consultations.

CONCLUSION

The higher frequency of contact with the diabetes team was considered a great relief by parents of children with type 1 diabetes. Apart from the time savings and flexibility in appointments, the most important advantages were the higher frequency of contact leading to short-term therapy adjustments and an increase in the ability to adjust therapy independently. (German Clinical Trials Registry No: DRKS00012645).

Use of Fitbit Devices in Physical Activity Intervention Studies Across the Life Course: Narrative Review

BACKGROUND

Commercial off-the-shelf activity trackers (eg, Fitbit) allow users to self-monitor their daily physical activity (PA), including the number of steps, type of PA, amount of sleep, and other features. Fitbits have been used as both measurement and intervention tools. However, it is not clear how they are being incorporated into PA intervention studies, and their use in specific age groups across the life course is not well understood.

OBJECTIVE

This narrative review aims to characterize how PA intervention studies across the life course use Fitbit devices by synthesizing and summarizing information on device selection, intended use (intervention vs measurement tool), participant wear instructions, rates of adherence to device wear, strategies used to boost adherence, and the complementary use of other PA measures. This review provides intervention scientists with a synthesis of information that may inform future trials involving Fitbit devices.

METHODS

We conducted a search of the Fitabase Fitbit Research Library, a database of studies published between 2012 and 2018. Of the 682 studies available on the Fitabase research library, 60 interventions met the eligibility criteria and were included in this review. A supplemental search in PubMed resulted in the inclusion of 15 additional articles published between 2019 and 2020. A total of 75 articles were reviewed, which represented interventions conducted in childhood; adolescence; and early, middle, and older adulthood.

RESULTS

There was considerable heterogeneity in the use of Fitbit within and between developmental stages. Interventions for adults typically required longer wear periods, whereas studies on children and adolescents tended to have more limited device wear periods. Most studies used developmentally appropriate behavior change techniques and device wear instructions. Regardless of the developmental stage and intended Fitbit use (ie, measurement vs intervention tool), the most common strategies used to enhance wear time included sending participants reminders through texts or emails and asking participants to log their steps or synchronize their Fitbit data daily. The rates of adherence to the wear time criteria were reported using varying metrics. Most studies supplemented the use of Fitbit with additional objective or self-reported measures for PA.

CONCLUSIONS

Overall, the heterogeneity in Fitbit use across PA intervention studies reflects its relative novelty in the field of research. As the use of monitoring devices continues to expand in PA research, the lack of uniformity in study protocols and metrics of reported measures represents a major issue for comparability purposes. There is a need for increased transparency in the prospective registration of PA intervention studies. Researchers need to provide a clear rationale for the use of several PA measures and specify the source of their main PA outcome and how additional measures will be used in the context of Fitbit-based interventions.

Telemetric Interventions Offer New Opportunities for Managing Type 1 Diabetes Mellitus: Systematic Meta-review

BACKGROUND

The prevalence of diabetes mellitus (DM) is increasing rapidly worldwide. Simultaneously, technological advances are offering new opportunities for better management of type 1 diabetes mellitus (T1DM). Telemetry, the remote acquisition of patient data via a telecommunication system, is a promising field of application in eHealth and is rapidly gaining importance.

OBJECTIVE

The aim of this study was to summarize the current evidences available on the effectiveness of telemetric approaches in T1DM management. This systematic meta-review examined different types of interventions of the technologies used in communication between health care professionals and patients as well as the key outcomes.

METHODS

We performed a systematic search in Web of Science Core Collection, EMBASE, Cochrane Library, MEDLINE via PubMed, and CINAHL databases in April 2020 with regard to the effectiveness of telemetric interventions for T1DM. We classified the interventions into 4 categories according to the technology used: (1) real-time video communication, (2) real-time audio communication, (3) asynchronous communication, and (4) combined forms of communication (real-time and asynchronous). We considered various study designs such as systematic reviews, clinical trials, meta-analyses, and randomized controlled trials and focused on the key outcomes. Additionally, a funnel plot based on hemoglobin A_1c (HbA_1c) values and different quality assessments were performed.

RESULTS

We identified 17 (6 high quality and 9 moderate quality) eligible publications: randomized controlled trials (n=9), systematic reviews and meta-analyses (n=5), cohort studies (n=2), and qualitative publications (n=1). Of 12 studies, 8 (67%) indicated a (significant or nonsignificant) reduction in HbA_1c levels; 65% (11/17) of the studies reported overall (mildly) positive effects of telemetric interventions by addressing all the measured outcomes. Asynchronous interventions were the most successful for patients diagnosed with T1DM, but no technology was clearly superior. However, there were many nonsignificant results and not sustained effects, and in some studies, the control group benefited from telemetric support or increased frequency of contacts.

CONCLUSIONS

Based on the currently available literature, this systematic meta-review shows that telemetric interventions cause significant reduction in HbA_1c levels and result in overall positive effects in T1DM management. However, more specified effects of telemetric approaches in T1DM management should be analyzed in detail in larger cohorts.

Telehealth in type 1 diabetes

PURPOSE OF REVIEW

The role of telehealth in the care of people with type 1 diabetes (T1D) has expanded dramatically during the coronavirus pandemic, and is expected to remain a major care delivery modality going forward. This review explores the landscape of recent evidence for telehealth in T1D care.

RECENT FINDINGS

Telemedicine for routine T1D care has shown equivalence to standard in-person care, with respect to glycemic control, while also increasing access, convenience, and satisfaction. Telehealth use promotes increased engagement of adolescents with T1D. Telehealth platforms have successfully been used in the care of microvascular complications and to support mental health related to diabetes. Machine learning and advanced decision support will increasingly be used to augment T1D care, as recent evidence suggests increasing capabilities to improve glycemic control. A spectrum of digital connected care services are emerging to support people with diabetes with daily management of diabetes. Finally, policy and systems are required that promote data interoperability, telemedicine provision, and reimbursement to support the ongoing growth of telehealth in T1D.

SUMMARY

A developing field of evidence supports use of telehealth in T1D. As this care modality scales, it has the potential to increase access to high-quality diabetes care for many people with T1D.

Outcomes of monthly video consultations as an add-on to regular care for children with type 1 diabetes: A 6-month quasi-randomized clinical trial followed by an extension phase

OBJECTIVE

To explore the outcomes of monthly video consultations for children with diabetes.

METHODS

The Virtual Outpatient Diabetes Clinic for Children and Youth (VIDIKI) was a 6-month multicenter controlled clinical trial followed by an extension phase. The 240 participants (1-16 years), all using a CGM, were quasi-randomized by residence location to the intervention group (IG) or the waitlist-control group (WG). The IG started immediately after enrollment with monthly video consultations as an add-on to regular care, while the WG received regular care for 6 months before starting the intervention. The extension phase lasted between 12 months and 2 years, depending on the enrollment date. Linear regression was applied to model the primary outcome of HbA1c after 6 months and other metabolic and psychosocial outcomes.

RESULTS

After covariate adjustments, the HbA1c at 6 months-corresponding to the controlled treatment phase-was 0.11% lower in the IG than that in the WG (95% CI -0.31 to 0.09, P = .277). For the total study sample, a significant HbA1c improvement was found after 12 months of video consultations, which increased further until month 15. The diabetes burden of the main caregivers was lower, and parental treatment satisfaction was significantly higher in the IG than that in the WG.

CONCLUSIONS

The VIDIKI study found no significant HbA1c difference between IG and WG after 6 months in the controlled phase, but there was a decreased diabetes burden and increased treatment satisfaction for the parents. In the longitudinal perspective, a significant HbA1c improvement was found after 12 and 15 months.

One Drop App With an Activity Tracker for Adults With Type 1 Diabetes: Randomized Controlled Trial

BACKGROUND

In 2017, mobile app support for managing diabetes was available to 64% of the global population of adults with diabetes. One Drop's digital therapeutics solution includes an evidence-based mobile app with global reach, a Bluetooth-connected glucometer, and in-app coaching from Certified Diabetes Educators. Among people with type 1 diabetes and an estimated hemoglobin A_1c level≥7.5%, using One Drop for 3 months has been associated with an improved estimated hemoglobin A_1c level of 22.2 mg/dL (-0.80%). However, the added value of integrated activity trackers is unknown.

OBJECTIVE

We conducted a pragmatic, remotely administered randomized controlled trial to evaluate One Drop with a new-to-market activity tracker against One Drop only on the 3-month hemoglobin A_1c level of adults with type 1 diabetes.

METHODS

Social media advertisements and online newsletters were used to recruit adults (≥18 years old) diagnosed (≥1 year) with T1D, naïve to One Drop's full solution and the activity tracker, with a laboratory hemoglobin A_1c level≥7%. Participants (N=99) were randomized to receive One Drop and the activity tracker or One Drop only at the start of the study. The One Drop only group received the activity tracker at the end of the study. Multiple imputation, performed separately by group, was used to correct for missing data. Analysis of covariance models, controlling for baseline hemoglobin A_1c, were used to evaluate 3-month hemoglobin A_1c differences in intent-to-treat (ITT) and per protocol (PP) analyses.

RESULTS

The enrolled sample (N=95) had a mean age of 41 (SD 11) years, was 73% female, 88% White, diagnosed for a mean of 20 (SD 11) years, and had a mean hemoglobin A_1c level of 8.4% (SD 1.2%); 11% of the participants did not complete follow up. Analysis of covariance assumptions were met for the ITT and PP models. In ITT analysis, participants in the One Drop and activity tracker condition had a significantly lower 3-month hemoglobin A_1c level (mean 7.9%, SD 0.60%, 95% CI 7.8-8.2) than that of the participants in the One Drop only condition (mean 8.4%, SD 0.62%, 95% CI 8.2-8.5). In PP analysis, participants in the One Drop and activity tracker condition also had a significantly lower 3-month hemoglobin A_1c level (mean 7.9%, SD 0.59%, 95% CI 7.7-8.1) than that of participants in the One Drop only condition (mean 8.2%, SD 0.58%, 95% CI 8.0-8.4).

CONCLUSIONS

Participants exposed to One Drop and the activity tracker for the 3-month study period had a significantly lower 3-month hemoglobin A_1c level compared to that of participants exposed to One Drop only during the same timeframe. One Drop and a tracker may work better together than alone in helping people with type 1 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03459573; https://clinicaltrials.gov/ct2/show/NCT03459573.

A Systematic Review of Pediatric Telediabetes Service Models

Telediabetes may improve patient access to clinicians who specialize in the management of pediatric diabetes. Due to the diversity of telehealth modes, many different service models for pediatric telediabetes have been developed. This review describes pediatric telediabetes service models identified in the literature, investigates the reported changes in HbA1c of these interventions, and describes enablers and barriers to implementing a telediabetes service. Evaluation of current literature may inform the development and sustainability of telehealth services for pediatric diabetes management. Twenty-nine studies met inclusion criteria and were reviewed. This review has demonstrated that pediatric telediabetes can be delivered by remote monitoring and real-time videoconference modes. Overall, pediatric telediabetes increased interactions between patients and clinicians, improved access to specialized care, and facilitated increased diabetes monitoring. In some contexts, telediabetes also improved short-term glycemic control. Key enablers reported for telediabetes services were integration with existing workflows, dedicated staff, clinician and patient training, appropriate data security, technology with good usability, and the availability of technical support. Barriers included increases in patient responsibilities and clinician workload, and technical issues with equipment and software.

Analysis of longitudinal adherence data: Hitting the target with consistency

Typical descriptions of partial adherence summarize to what extent a patient follows a prescribed treatment plan. Another aspect of adherence relates to how consistently a patient behaves. We distinguish these two notions as "adherence target" and "adherence consistency." Most research on adherence focuses on the former concept, but the latter can be a useful idea in assessing patients' compliance. Quantifying these two notions goes beyond typical summaries of center and spread, because they may be related to each other. That is, the mean is often related to the standard deviation via the variance function. Our approach defines a parameter that measures consistency separate from the adherence target. For exponential dispersion or quasi-likelihood families, the parameter corresponds to the dispersion parameter. Assessing adherence consistency to medical treatment requires longitudinal data, which can be collected with new technology. Two examples from pediatric medicine demonstrate that detangling the notion of consistency from the adherence target is useful.