**4.5 Clinical benefits in patients with diabetes**

Diabetes is a disease in which a patient is unable to produce sufficient insulin to control the level of glucose in their blood. In Type I and insulin-dependent Type II, patients produce little or no insulin, and so must inject insulin to meet their need to maintain their blood glucose level with limits. The amount of insulin to be injected to maintain the level of blood glucose is determined by the patient by taking a measurement of their current blood glucose and calculating the amount of carbohydrate they about to ingest.

Type II patients may be able to manage their level of blood glucose by diet and exercise alone, or require an increasing level of oral therapy as their condition deteriorates until they will be required to inject insulin.

Telehealth has been applied to the management of patients with diabetes in many projects, including Type I, Type II and both forms. In addition, many approaches to telehealth have been used to facilitate early detection and diagnosis, monitor disease progression, and provide management. Methods include telemonitoring, teleconsultation, interventions delivered by computer, and combinations.

**Figure 16.** *Pulse oximetry in COPD patients [45].*

#### *4.5.1 Type II diabetes*

The primary outcome of studies is the level of Hb1Ac, which provides a measure of the long-term level of blood glucose. It is the primary means of routine management of patients with diabetes, with the aim to bring within a target range. Daily fasting glucose may also be measured as an outcome, with the aim to maintain within a target range. A secondary outcome is blood pressure, as it is important that this is well maintained in order to prevent complications of the disease, and this may be controlled in studies. Further secondary outcomes include lipid levels, which would include cholesterol and low density lipoprotein and high density lipoprotein also to prevent complications of the disease, and may also be controlled in a study.

One meta-analysis [49] analyses the outcome from each approach separately. The analysis (**Figure 17**) shows that each approach, other than telecasemanagement and telemonitoring that were marginal, achieved similar outcome that was a positive outcome for telehealth, although telecase-management with teleconsultation achieved a higher average outcome but with large variation. In part, this outcome can be explained because patients have the goal to reach a target within a specified range and once attained no further change is expected or required. This will limit the mean difference, which will also be influenced by the baseline.

The meta-analysis [49] also analyses each of the secondary outcomes by approach. Secondary outcomes were generally similar between telehealth and standard care; however this will be dependent on the protocol for intervention.

Other systematic reviews and meta-analysis agree with these outcomes: [50] reports a mean reduction of 0.17% in HbA1c in telehealth compared to usual care, especially for patients with mean baseline greater than 8.0%. However, there was no clinically significant reduction in LDL-cholesterol (LDL-c), body mass index (BMI), systolic (SBP) or diastolic blood pressure (DBP); [51] reports mean reduction between 0.2% and 0.64%, with a pooled mean of 0.39% in HbA1c; [52] reports mean reduction of 0.486% in HbA1c and some improvements in secondary outcomes such as diastolic blood pressure and body mass index (**Figure 18**).
