*Results from Telehealth DOI: http://dx.doi.org/10.5772/intechopen.101183*

#### **Figure 18.**

*Change in secondary cardiovascular outcomes of different telehealth strategies compared to usual care in adults with Type II diabetes by telehealth approach [49].*

## *4.5.2 Intervention strategies*

Most studies on telehealth are conducted on a selected group of patients that is considered homogeneous and outcomes are considered through statistical measures. One study investigated management of all patients with diabetes in a primary care setting [53], performing two weeks of monitoring daily blood glucose and blood pressure, repeated every 6 months following the UK national framework. Data from each patient was reviewed to assess whether their condition was well controlled,

and if not, intervention was used to manage the condition and establish correct control. The study identified three distinct patient groups: the well-controlled who required no intervention; patients requiring intervention to re-establish control; and patients in denial.

The well-controlled patients were aware of their condition, and managed their lifestyle and medication accordingly. They required no intervention. The daily measurements provided by the telemonitoring gave insight into the habits of the patients who required intervention and allowed directed and personalised intervention strategies, for example by identifying patients who did not follow diet at the weekend as part of a social activity, seen as a spike in daily glucose. The daily measurements also clearly identified patients who were in denial, frequently not taking any medication, and the data could be used to confront the patient in order to encourage change. Monitoring would continue until correct management was established. 37% of the patients were identified as needing intervention, resulting in a mean reduction in HbA1c of 3 mmol/mol and mean reduction in systolic blood pressure of 5 mmHg.

The short period of intervention was considered more effective than continuous monitoring of patients who were well managed. It was expected that patients would comply initially but then lapse after a period, when the monitoring would be repeated.

#### *4.5.3 Type I diabetes*

In Type I and insulin dependent Type II diabetes the goals for control of blood glucose are somewhat different. In addition to achieving a long term average, as indicated by HbA1c, within the target range, a patient with Type I diabetes must maintain their blood glucose within a target range at all times through injection of an appropriate amount of insulin to match their current blood glucose level, activity and ingestion of food. This requires frequent measurement of their blood glucose. Traditionally this has been through regular use of a finger prick and a glucose meter, usually measured before a meal to determine the required amount of insulin. Postprandial measurements may be taken to monitor correct management. Glucose meters typically store many measurements that may be uploaded to a monitoring service for review by the clinician and telehealth service.

One meta-analysis study [54] compares separately the outcome from studies that included Type I and Type II patients. The outcomes show improvement in mean change to HbA1c in each of the three categories that were studied, Type I and Type II, Type I, and Type II (**Figure 19**); the Type II group achieving the greatest change.

#### *4.5.4 Continuous glucose monitoring*

A recent development in telehealth is the introduction of devices that can be placed on the body to monitor blood glucose on a continuous basis. Improvements in biomaterials have extended the time that the sensor remains on the body to 10 days [55]. These devices can communicate their data to a monitoring application that may be used by the patient directly to monitor their blood glucose to determine insulin dose, and detect and provide an alert when the blood glucose level goes outside thresholds. Data may also be forwarded to others monitoring the patient that includes the parents of juvenile diabetes patients and the clinician.

Studies [56, 57] have shown that continuous glucose monitoring (CGM) can reduce HbA1c in Type II patients (**Figure 20**); although it is not clear if CGM produces improved reduction in HbA1c compared to other telehealth approaches.


#### **Figure 19.**

*Mean difference in the changes in HbA1c levels for telehealth and usual care [54].*

The most valuable use of CGM is in the management of Type I and insulin dependent Type II patients as it improves short-term control, provides alerts of high and low values (hyperglycaemia and hypoglycaemia). This reduces the number of times a finger prick is required, reducing scarring and the incorrect results from taking blood from over-used sites.


**Figure 20.**

*Mean difference in the changes in HbA1c levels for telehealth using CGM [56].*

### **4.6 Clinical benefits in patients with hypertension**

Hypertension is a disease in which a patient has an elevated level of blood pressure. It is normally managed using drug therapy. Telehealth has often been proposed as a method to manage patients with hypertension.

A meta-analysis [58] of the use of telehealth versus usual office management of hypertension shows a statistically significant reduction of both systolic (3.4 mmHg) (**Figure 21**) and diastolic (1.6 mmHg) (**Figure 22**) blood pressure in patients managed by telehealth, however the reduction is not of clinical significance.

Again this outcome may be explained by the target being to bring patients within a threshold. Given the range of patients between those well-managed, in need of intervention, and in denial, overall outcome may be small, but impact on a small number of patients may significant. Telehealth allows resource to be targeted to those in most need.

Telehealth in management of hypertension probably has greatest effect when used with the newly diagnosed, and allows rapid titration of medication to bring them below threshold, without need for frequent visits to the clinician, especially


**Figure 21.** *Mean difference in the changes in Systolic Blood Pressure [58].*

#### **Figure 22.**

*Mean difference in the changes in Diastolic Blood Pressure [58].*

valuable where the patient must travel a large distance. Once the patient becomes well-managed, the need for telehealth is significantly reduced and could be removed.

Telehealth has also found a place in diagnosing hypertension. The elevated blood pressure measured in the clinician office is a well-known phenomenon and can mask the presence of hypertension. Ambulatory blood pressure has been used in the past to confirm the diagnosis. Telehealth, monitoring daily blood pressure at home for a short period, has become accepted as an alternative method for diagnosis.

#### **4.7 Clinical benefits in pregnancy**

Several conditions can develop during pregnancy, including gestational diabetes and pre-eclampsia. In general, these conditions resolve postpartum, however it is important that they are monitored carefully until fully resolved. Usual care is frequent monitoring at the out-patient clinic of the maternity hospital, requiring travel with a new-born baby, and possibly other young children. Telehealth offers the means to undertake the monitoring at home.

#### *4.7.1 Gestational diabetes*

Gestational diabetes is a short term condition which may develop during pregnancy and will generally resolve postpartum. Good control of blood glucose is essential for correct development of the foetus, as high blood glucose severely impacts birth weight. Monitoring and management strategy is the same as Type II diabetes.

Conclusions from meta-analysis of the outcomes of studies of telehealth to manage gestational diabetes are mixed. One study [59] concludes glycaemic control (HbA1c, pre and postprandial blood glucose) to be similar between the telehealth and usual care groups, although face-to-face and unscheduled consultations were reduced. However, another study [60] determined significant improvement in glycaemic control in HbA1c (**Figure 23A**), pre-prandial blood glucose (**Figure 23B**) and 2 hour postprandial blood glucose (**Figure 23C**).

## *4.7.2 Pre-eclampsia*

Pre-eclampsia is a serious condition that usually develops late in pregnancy and will necessitate early delivery. It is associated with high blood pressure. The condition normally resolves quickly postpartum, and management is to check the blood pressure periodically until it returns to normal value. Telehealth has been used to monitor blood pressure in pre-eclampsia. Blood pressure may also be monitored during pregnancy in those at high risk of developing pre-eclampsia [61].

There are fewer reported outcomes for studies in pre-eclampsia than other uses of telehealth. The one systematic review [62] reports that telehealth is liked by participants, but there is little difference in mean blood pressure between telehealth and usual care. This is to be expected as telehealth is being used to replace visits to the clinic and provide convenience for the patient.
