Systematic Review And Meta-Analysis

1. Cellular Phone-Based Technologies for Monitoring Of Patients With Diabetes: a Systematic Review and Meta Analysis Systematic Review And Meta-Analysis Class 3 PhD João Fonseca Introdução à Medicina II

2. Overview Introduction Motivation Research question Aims Methods and Participants Systematic review and Meta-analysis Query Inclusion and Exclusion criteria Sampling methods Data collection Studies’ quality Statistical analysis and Results Diabetes and the chronic diseases Characteristics of the studies Secondary variables Outcomes Meta-analysis Discussion Main findings Limitations Critical comparison with other studies Conclusions

3. Introduction Motivation Research question Aims Methods and Participants Systematic review and Meta-analysis Query Inclusion and Exclusion criteria Sampling methods Data collection Studies’ quality Statistical analysis and Results Diabetes and the chronic diseases Characteristics of the studies Secondary variables Outcomes Meta-analysis Discussion Main findings Limitations Critical comparison with other studies Conclusions

4. Mobile phone based tecnhologies Chronic diseases 60% of all deaths [1] Slow progression Applied in management of diseases [3] Motivation Increasinginternationalinterest[2] [1]http://www.who.int/en/, available at 1-11-2007 [2] Pinnock Hilary, Slack Roger, Pagliari Claudia, Price David, Sheikh Aziz. Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study. Clinical and Experimental Allergy. May 2007. 37(5):794-802; Available at: www.pubmed.com 26-10-2007. [3] Ryan D, Cobern W, Wheeler J, Price D, Tarassenko L; Mobile Phone Technology in the Management of Asthma; Journal of Telemedicine and Telecare 2005; 11 Suppl 1:4Kollmann et al., 2007 [6]-6; Available at: www.pubmed.com 26-10-2007

5. Healthcare professional Communication of adapted treatment Quick communication of symptoms [4] Patient with diabetes Fig. 1_ The role of CPT in the monitoring of patients with chronic diseases [4] Morak J, Kollmann A, Schreier G; Feasibility and usability of a home monitoring concept based on mobile phones and near field communication (NFC) technology; Medinfo. 2007; 12 (Pt 1):112-6; Available at: www.pubmed.com 26-10-2007.

6. Diabetes High mortality High morbidity Increasing prevalence in society [5] Clear and structured article Focused article Selectionofonedisease [5] Amosa F.; Mccarty D. J.; Zimmet P., The rising global burden of diabetes and its implications: estimates and projections to the year 2010 ;Diabetic medicine ; 1997, vol.14, pp S7-S84, SUP5

7. Research question “Does cellularphonebasedtecnhologiesmonitoringimprove diabetes patients’ clinicaloutcomes?”

8. * To describe the proportion of published studies about CPT regarding major chronic diseases. Aims * To investigate if CPT improves patients’ medical state Glycosylated haemoglobin Fasting plasma glycemia

9. Introduction Motivation Research question Aims Methods and Participants Systematic review and Meta-analysis Query Inclusion and Exclusion criteria Sampling methods Data collection Studies’ quality Statistical analysis and Results Diabetes and the chronic diseases Characteristics of the studies Secondary variables Outcomes Meta-analysis Discussion Main findings Limitations Critical comparison with other studies Conclusions

10. Search Collect Summarize Evidence collected from articles Systematic review and Meta-analysis

11. ((monitoring) OR (telemonitoring)) AND ((cellular phone-based technologies) OR (mobile phone-based technologies) OR (cellular phone) OR (mobile phone)) AND ((chronic diseases) OR (chronic patients) OR (cancer) OR (nephrologic diseases) OR (kidney insufficiency) OR (asthma) OR (respiratory chronic diseases) OR (COPD) OR (diabetes) OR (cardiovascular disease)). Query

12. Inclusion criteria Exclusion criteria * Articles published in the last 10 years * Articles containing original data * Cellular phone-based technologies (CPT)‏ * Articles about the application of CPT in patients * Articles regarding diabetes * Articles regarding comparison studies * Articles regarding the evolution of the clinical state of the patient * Articles in English, Spanish and French * Use of cellular-phone for interviewing patients about other issues unrelated to disease monitoring * Articles that describe technologies and their development Inclusion and Exclusion criteria

13. Sampling methods 33 14 3 Fig.2 – Distribution of articles repeated among databases

14. Readabstractof160(inclusionandexclusioncriteria) 9 with no abstract Readfull-textof21(inclusionandexclusioncriteria) 4 excluded(no controlgroupor no postestvalues) 2 answered Requestedby e-mail 1included 50 repeatedamongdatabases 2articlesincluded 80 excluded 6 with no full-text Systematicreview Meta-analysis 7 excluded 3 repeatedwithindatabases 5articlesincluded

15. * year of publication * Glycosylated haemoglobin Control/intervention * country of origin * type of study * Fasting plasma glycemia Control/intervention * n intervention * n controls Children : 0-14 Youth: 15-17 Adults: 18-65 Elderly: +65 * age group Data collection

16. Studies’ quality Table 1 - Quality Criteria used to evaluate the final articles included, adapted from “Extending the CONSORT Statement to Randomized Trials of Nonpharmacologic Treatment: Explanation and Elaboration”

17. Table 2 – Articles classification according to quality criteria

18. Introduction Motivation Research question Aims Methods and Participants Systematic review and Meta-analysis Query Inclusion and Exclusion criteria Sampling methods Data collection Studies’ quality Statistical analysis and Results Diabetes and the chronic diseases Characteristics of the studies Secondary variables Outcomes Meta-analysis Discussion Main findings Limitations Critical comparison with other studies Conclusions

19. Diabetes and chronic diseases Graphic 1 - Distribuition of chronic diseases among obtained articles. Total number of articles obtained regarding chronic diseases N= 81

20. Characteristics of the studies Table 3 - Included articles characteristics

21. Secondary variables Table 4 - Secondary variables

22. Outcomes Table 5 - Extracted variables

23. Meta-analysis Glycosilated haemoglobin Fig. 3 - Glycosilated haemoglobin forest plot

24. Fasting plasma glycemia Fig.4 - Fasting plasma glycemia forest plot

25. Introduction Motivation Research question Aims Methods and Participants Systematic review and Meta-analysis Query Inclusion and Exclusion criteria Sampling methods Data collection Studies’ quality Statistical analysis and Results Diabetes and the chronic diseases Characteristics of the studies Secondary variables Outcomes Meta-analysis Discussion Main findings Limitations Critical comparison with other studies Conclusions

26. Main findings Table 6 – Summary of obtained results

27. Clinical State: Measured in different ways Impossible to compare Adherence: Significant except for Diabetic diet Adherence seem to increase with the use of CPT QoL and Satisfaction with life: Significant This variable seem to increase with the use of CPT Table 7 – Summary of results obtained for secondary variables and studies quality classification

28. Glycosilated haemoglobin: Increases in Vahatalo et al., 2004 [10] (Quality 7) Decreases significantly in 4 of the studies Meta-analysis not significant, although decreases Measured in different ways Included studies are different Table 8 – Summary of results obtained for glycosilated haemoglobin

29. Fasting plasma glycemia: Measured in 3 studies Decreases not significantly in every studies Meta-analysis not significant, although decreases Table 9 – Summary of results obtained for fasting plasma glycemia

30. Clinical State: Measured in different ways Impossible to compare Adherence: Significant except for Diabetic diet Adherence seem to increase with the use of CPT QoL and Satisfaction with life: Significant This variable seem to increase with the use of CPT Fasting plasma glycemia: Measured in 3 studies Decreases not significantly in every studies Meta-analysis not significant, although decreases Glycosilated haemoglobin: Decreases significantly in 4 of the studies Meta-analysis not significant, although decreases

31. Limitations and Critical comparison with other studies Small number of studies Sensitivity of the query? Too restrictive exclusion criteria? Requested articles? Data bases explored? Small number of published articles (recent area of interest)? Published articles have low quality? Quality of the studies Studies of short duration No control group Ways of measuring Low number of participants Paré et al., 2007 [12] (Systematic review) Bigger number of studies Criteriaapplied less restrictive (older articles) Different databases explored Conclusions Glycosilated haemoglobin and Fasting plasma glycemia decrease No meta-analysis found

32. Conclusions There is no cure, only regular treatments Other chronic diseases are even less studied 31% of all articles report to diabetes Necessity of more studies and with more quality No meta-analysis found Older population Changes in the way of life Increasing number of patients with chronic diseases Increasing costs for the National Health System Increase of the adherence, clinical state and quality of life even if slightly Systematic review pointing the same conclusions Inconclusive results because of the small number of studies Increasing mortality

33. Class 3 Susana Carrilho Fernando Sá Diogo Miguel Alexandra Azevedo Ana Pessoa Ana Lisboa Ana Luísa Graça Pedro Lopes Ana Luísa Padilhó Joana Carvalho Maycoll Vieira Pedro Souteiro Sara Coelho

34. References [1]http://www.who.int/en/, availableon 1-11-2007 [2] Hilary Pinnock, Roger Slack, Claudia Pagliari, David Price, Aziz Sheikh; Understandingthepotential role of mobile phone-basedmonitoringonasthmaself-management: qualitativestudy; Clinical and Experimental Allergy. 2007 May; 20077(5):794-802; Available at: www.pubmed.com 26-10-2007. [3] Ryan D, Cobern W, Wheeler J, Price D, Tarassenko L; Mobile Phone Technology in the Management of Asthma; Journal of Telemedicine and Telecare 2005; 11 Suppl 1:4Kollmann et al., 2007 [6]-6; Available at: www.pubmed.com 26-10-2007 [4] Morak J, Kollmann A, Schreier G; Feasibility and usability of a home monitoring concept based on mobile phones and near field communication (NFC) technology; Medinfo. 2007; 12 (Pt 1):112-6; Available at: www.pubmed.com 26-10-2007. [5] Amosa F.; Mccarty D. J.; Zimmet P., The rising global burden of diabetes and its implications: estimates and projections to the year 2010 ;Diabetic medicine ; 1997, vol.14, pp S7-S84, SUP5 [6] Kollmann A, Riedl M, Kastner P, Schreier G, Ludvik B. Feasibility of a mobile phone-based data service for functional insulin treatment of type 1 diabetes mellitus patients. J Med Internet Res. Dez 2007; 31;9(5):e36. [7] Kim HS. Impact of Web-based nurse's education on glycosylated haemoglobin in type 2 diabetic patients; J ClinNurs; Jul 2007; 16(7):1361-6. [8] Kim HS; A randomized controlled trial of a nurse short-message service by cellular phone for people with diabetes; Int J Nurs Stud; Jul 2007; 687-92. [9] Benhamou, P, Melki, V, Boizel R, et al. One-year efficacy and safety of Web-based follow-up using cellular phone in type 1 diabetic patients under insulin pump therapy: the PumpNet study. Diabetes & Metabolism. Jun 2007; 33(2): 220-226. [10] Vahatalo, M.A., Virtamo, H.E., Viikari, J.S., Ronnemaa, T.; Cellular phone transferred self blood glucose monitoring: Prerequisites for positive outcome;Practical Diabetes International; 2004; 21 (5); 192-194. [11] Ladyzynski P, Wojcicki J, Krzymien J, et al. Teletransmission system upporting intensive insulin treatment of out-clinic type 1 diabetic pregnant women: Technical assessment during 3 years’ application. The International Journal of Artificial Organs. 2001. 24(3). [12] Paré G., Jaana M., Sicotte C.; Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base; J Am Med Inform Assoc. May–Jun 2007; 14(3): 269–277.