4.1 Telemedicine was less effective in reducing fasting blood glucose in patients with diabetes
From the result of meta-analysis, there was no statistically significant difference of fasting blood glucose levels between the experimental group and the control group. Angeles 's study(31)also showed that compared with the usual group, the meta-analysis of fasting blood glucose after intervention of 3 months, 6 months and 12 months was not statistically significant. In a study of type 2 diabetes(20), 120 people were included in the intervention group, it was found that the difference between the intervention group and the control group was not statistically significant. However, Han Yun et al(23) figure out that significant differences in fasting blood glucose levels at the 3th ,6th and 12th months after intervention, and the fasting blood glucose levels in the intervention group were significantly lower than those in the control group. Perhaps, the reason for the difference may be related to the duration of diabetes and the severity of the disease in participants of the intervention group. (31).
4.2 Duration effect of telemedicine on glycosylated hemoglobin in patients with diabetes
Our result shows there was significant difference in glycosylated hemoglobin after intervention of 12 months, but there was no significant difference in glycosylated hemoglobin between the intervention group and the control group after 6 months. Therefore, we supposed that changes in glycosylated hemoglobin may have time effects.
Our results are similar to Viana et al(32),they performed a meta-analysis of glycosylated hemoglobin with telecare intervention, a total of 1,782 people were included in the study, the length of most studies was 6 months, and they also found no significant improvement in glycosylated hemoglobin. Moreover, we also find the long-term duration of intervention has positive effects on the control of glycosylated hemoglobin, the consequence is similar to the meta-analysis of Lee and Timpel et al. Lee et al figure out that telemedicine system can be positive in type 1 diabetes patients after intervention (33), the telemedicine system used in most trials were relatively simple and involved data transmission of blood glucose data with feedback, it turned out that the studies lasted at least 6 months in duration or longer, and that the effect of telemedicine was more obvious. Furthermore, Timpel et al(34) pointed out the great benefit in glycosylated hemoglobin reduction after telemedicine intervention, especially the communication and interactive functions of telemedicine, they find that digital health education was statistically significant in the long-term intervention duration of 12 months. Some of the original RCTs also reflects the time effects. Wakefield et al(35) conducted original research, the intervention group included home remote monitoring and nursing management over 6 months, the result shows that the difference between the intervention group and the control group was significant at 6 months, but if the intervention was withdrawn 6 months after the intervention, the glycosylated hemoglobin indicators of the intervention group and the control group will gradually tend to be consistent. Similar results also reflected in the study of Stelios Fountoulakis et al(17), telemonitoring which combined with a management and feedback system based on transmitted data has been proven effective in rapidly reducing glycosylated hemoglobin, the results showed significant reductions in glycosylated hemoglobin at both 3 months and 6 months compared with baseline, and the slightly attenuated at 6 months after its discontinuation. In the five-year follow-up study by shea et al(21), a total of 1665 people were recruited, the telemedicine group regularly implemented home unit management, nurse case management, and remote consultation activities, follow-up examinations were conducted at 1-year intervals, finally, the intervention group had net improvement in glycosylated hemoglobin compared with usual group.
In conclusion, most studies have shown that telemedicine has a positive effect on the management of diabetes, but the best time to intervene is different, from our study we found that telemedicine has a positive effect at 12 months. Telemedicine is a process of long-term intervention and will be more effective over time, this improvement could be attributed to better compliance due to a more frequent contact by using telemedicine(17).
4.3 Blood pressure can be improved by telemedicine intervention
The results of our meta-analysis showed that there was significant difference in systolic blood pressure and diastolic blood pressure after intervention of 6 months. Many studies have found that blood pressure can be improved by telemedicine intervention, although the duration of the intervention in many studies was different.
Our results of the study are similar to Verberk et al(36), it was a meta-analysis included nine randomized clinical trials, their research showed that the systolic blood pressure and diastolic blood pressure of the intervention group are significantly decreased by using telecare, this measure not only controls blood pressure effectively, but also enables patients to adhere to treatment. Another system review figure out that home remote monitoring does a better job of controlling blood pressure than other approaches, they selected some articles that examined populations of patients with hypertension, it is worth noting that in most cases the studies found a significant drop in blood pressure in the first 3 months of remote monitoring(37). However, an RCT study(38)which involved 387 participants, the interventions were instructed by trained nurses, such as blood pressure monitoring, answer questions, link device to the participant’s home, both systolic blood pressure and diastolic blood pressure were found to have significance after 12 months of intervention.
Most articles in RCTs have confirmed the positive effect of telemedicine on blood pressure, it can help support doctors and nurse for closer, continuous follow-up of patients with hypertension, although the duration of the intervention was different. (39-41)
4.4 Integration of telemedicine studies in patients with rheumatoid arthritis
Rheumatoid arthritis is one of the most prevalent chronic inflammatory diseases. The main symptoms of rheumatoid arthritis include rheumatoid nodules, pulmonary involvement or vasculitis, and systemic comorbidities(42). Patients with rheumatoid arthritis have a longer disease duration, it can cause joint deterioration and functional disability, eventually leading to unfavorable disease outcomes and seriously affected the activity of daily life(43). Therefore, the long-term management of rheumatoid arthritis patients with telemedicine as the main intervention method is developed gradually.
The main intervention in Ferwerda 's research(18) is a cognitive behavioral methods to manage the patients with rheumatoid arthritis. The results showed the effectiveness of Internet-based tailored cognitive behavioral interventions for rheumatoid arthritis patients with psychological risks. Yuqing Song(22) conducted a RCT study to observe the impact of telemedicine education on drug compliance and disease activity of rheumatoid arthritis patients, the results showed that it has not improved symptoms of patients by using remote medical education, but it can enhance the medication compliance of patients. Both articles(18, 22) showed that telemedicine could promote positive behaviors in patients with rheumatoid arthritis, the positive behaviors influence of telemedicine is benefit for rheumatoid arthritis patients, Optimistically, By searching the relevant literature, telemedicine will have the opportunity to become an important tool in the management of patients with rheumatoid arthritis, at the same time, there are some uncertainties in the application of the Internet for rheumatoid arthritis patients.(44), so we still need more RCT study to prove the effect of telemedicine on rheumatoid arthritis, which will be a key point for the future research.
4.5 The advantages and disadvantages of telemedicine
Nowadays, the technology of telemedicine is frequency to be used. Telemedicine technology has also been applied to various fields of medicine, and some diseases can be treated and cared at home (1). telemedicine can provide long-term care and treatment for people with chronic diseases through the website or other telecommunication equipment, which is helpful to reduce the risk of virus spread in period of COVID-19 global pandemic. Many articles have confirmed telehealth and telemedicine technologies have the potential to increase access to healthcare services and make full use of medical resource , it could also help to change the treatment plan in time and improve the service quality.(45). Telemedicine has also been be considered as a cost-effective methods for the management of chronic diseases(46). However, there still has a big barrier for the patient who has difficulty and anxiety to use computer or mobile especially for elderly people.(47).