The Impact of Supported Telemonitoring on Glycemic Control in People with Type 2 Diabetes: the Telescot Diabetes Pragmatic Multicenter Randomized Controlled Trial

Talk Code: 
EP1B.03
Presenter: 
Brian McKinstry
Co-authors: 
Sarah H Wild, Janet Hanley , Stephanie C Lewis, John A McKnight, C. Lucy B McCloughan, Paul L Padfield, Richard A Parker, Mary Paterson, Hilary Pinnock, Aziz Sheikh,
Author institutions: 
Usher institute The University of Edinburgh, Edinburgh Napier University

Problem

Good control of glycaemia and blood pressure (BP) reduces complications in people with diabetes. Self-monitoring of blood glucose among people with type 2 diabetes not treated with insulin does not appear to be effective in improving glycaemic control. We investigated whether professional telemonitored review of self-monitored glucose results in improved glycaemic control in people with poorly controlled type 2 diabetes.

Approach

We performed a randomized, parallel, investigator-blind controlled trial with centralised randomization in family practices in four regions of the United Kingdom among 321 people with type 2 diabetes and glycated haemoglobin (HbA1c) >58 mmol/mol. The supported telemonitoring intervention involved self-measurement and transmission to a secure website of twice weekly morning and evening glucose for review by family practice clinicians. The control group received usual care, with at least annual review and more frequent reviews for people with poor glycaemic or blood pressure control in the context of incentives in family practice based on a sliding scale of financial rewards for achieving glycaemic and blood pressure control targets. HbA1c assessed at nine months was the primary outcome. Intention-to-treat analyses were performed.

Findings

160 people were randomized to the intervention group and 161 to the usual care group between June 6, 2011 and July 19, 2013. HbA1c data at follow-up were available for 146 people in the intervention group and 139 people in the control group. The mean (SD) HbA1c at follow-up was 63.0 (15.5) mmol/mol in the intervention group and 67.8 (14.7) mmol/mol in the usual care group. Mean HbA1c was 5.60 mmol/mol (95% CI 2.38 to 8.81 mmol/mol, p=0·0007) lower among people in the intervention group when compared with usual care after adjustment for minimisation strata and baseline differences. No differences were identified between groups in weight, treatment pattern, in adherence to medication or quality of life. There were few adverse events and these were equally distributed between the intervention and control groups. There was a greater number of telephone calls between practice nurses and patients in the intervention compared with control group (rate ratio 7.50 (95% CI 4.45 to 12.65) but no other differences between groups in use of health services were identified between groups.

Consequences

Supported telemonitoring resulted in clinically important improvements in control of glycaemia in patients with type 2 diabetes in family practice. However Key limitations include potential lack of representativeness of trial participants and uncertainty about the mechanism, the duration of the effect and the optimal length of the intervention. Implementation trials are now required to determine if the advantages found in this trial are maintained when implemented at scale.

Submitted by: 
Brian McKinstry
Funding acknowledgement: 
Chief Scientist Office of the Scottish Government