The results of this review add to the growing body of evidence that emerging IT may assist with improving health outcomes related to diabetes. Information technology appears to be a developing tool to improve the process of care for type 2 diabetes patients, as indicated by the significant improvements in health care utilization. Nonetheless, there were mixed results regarding declines in HbA1c levels and the other clinical outcomes (i.e., lipids). Although these findings are consistent with the reviews in type 1 diabetes in terms of psychological and biological outcomes,6
a formal metaanalysis conducted by Montani et al.,34
which also focused mainly on type 1 diabetes, supports the hypothesis that computer-based systems can effectively improve metabolic control.
By mode of delivery, internet interventions had a positive impact on patient-centered outcomes, but generally did not evaluate health care utilization and clinical outcomes. Telephone interventions had a positive impact on primary care visits. Computer-assisted integration of clinical management had a positive effect on most of the health care utilization outcomes. Although several interventions produced large declines in HbA1c, there was no clear pattern by mode and many studies reported no significant change in HbA1c.
The results of this study should be interpreted with several limitations in mind. First, only published studies were reviewed; this introduces the possibility of a publication bias. Second, the heterogeneity of the studies weakened any general inferences and prevented a metaanalysis, which could have allowed for a more quantitative assessment. Finally, only articles written in the English language were reviewed. However, broad inclusion/exclusion criteria were used to increase the likelihood of capturing relevant studies, including a hand search of Diabetes Care and a related articles search for completeness. Furthermore, double review was conducted to minimize errors and increase accuracy in data abstraction. Finally, to our knowledge, this is the first IT review to address type 2 diabetes specifically.
A recent review conducted by Farmer et al.35
evaluated the feasibility, acceptability, and effectiveness of telemedicine used to support blood glucose self-monitoring via transmission of results through a remote server, with automated or clinician feedback. Results showed that telemedicine was deemed feasible and acceptable, but evidence for its effectiveness in improving diabetes management was not considered robust. Although the review's primary focus and inclusion/exclusion criteria led to a pool of studies that differed from this review, the results are consistent with our findings related to telemedicine interventions and HbA1c.
This review provides several implications for future research in IT use in diabetes. First, there needs to be improvement in the quality of studies and reporting of results. Based on this review, we strongly recommend that future studies (1) favor RCT designs that enable comparisons with a concomitant control group with less biased assessment of the effectiveness of these interventions; (2) study the long-term (>1 year) effects of these interventions; (3) address and report on the costs associated with the intervention and the resulting cost-effectiveness; and (4) include representative numbers of ethnic minorities and underserved populations and determine whether these interventions are equally effective in these groups. Second, studies should consider participants' perceptions of IT as diabetes self-management as IT will likely remain an integral component of care that depends on the acceptance of the patient. In addition, internet-assisted interventions, which generally focused on patient education, should evaluate HbA1c, health care utilization, and costs associated with the intervention.
Overall, financial support for further research in this area seems promising as the studies in this review were funded by a number of sources including: the National Institutes of Health, National Library of Medicine, professional organizations, and private foundations.
In conclusion, our review suggests that computer-assisted interactive IT could be an important tool and should be evaluated more closely for its potential to improve diabetes care.