Table of Contents
Type: Systematic Review | Subject: Health & Social Care | Level: Masters | Word Count: ~3500 words
This model systematic review was produced by an Essays UK specialist as reference material for learning purposes only. For support in this field, see our health and social care assignment specialists.
Undertake a systematic review evaluating the effectiveness of a specified digital health intervention for a chronic condition of your choice. Your review must follow PRISMA 2020 reporting standards, include a documented multi-database search strategy, critically appraise all included studies, and present a narrative synthesis supported by a PRISMA flow diagram and a characteristics-of-studies table. Word count: 3,200–3,800 words, excluding the abstract, tables, figures and reference list.
Background: Type 2 diabetes is a leading cause of long-term ill health in the UK, and effective glycaemic control requires sustained contact between patients and healthcare services. Telehealth, encompassing remote monitoring, video consultations and app-based coaching, has been widely adopted to extend the reach of diabetes services beyond traditional clinic appointments.
Methods: A systematic review was conducted in line with PRISMA 2020 guidance and prospectively registered with PROSPERO. MEDLINE, CINAHL, Embase, Cochrane CENTRAL and Web of Science were searched from January 2014 to December 2023 for randomised controlled trials evaluating telehealth interventions for adults with type 2 diabetes. Two reviewers independently screened records, extracted data and appraised quality using the CASP RCT checklist, with glycated haemoglobin (HbA1c) as the primary outcome of interest.
Results: Ten RCTs (N = 1,669) met the inclusion criteria, spanning telephone coaching, app-based self-management, video consultations, remote glucose monitoring and integrated multi-component platforms. Nine of the ten trials reported a statistically significant reduction in HbA1c favouring telehealth or equivalence with usual in-person care; the tenth reported non-inferiority. Effect sizes on HbA1c ranged from 0.3 to 0.7 percentage points, with multi-component interventions combining monitoring, video contact and messaging showing the largest and most sustained reductions.
Conclusions: Telehealth interventions appear to be at least as effective as usual in-person care for improving glycaemic control in adults with type 2 diabetes, and in several trials produced superior outcomes. Variability in intervention components and outcome reporting limits precise comparison across studies, and further trials with standardised long-term follow-up and cost-effectiveness data are recommended.
Type 2 diabetes affects an estimated one in fifteen adults in the UK and accounts for a substantial proportion of NHS expenditure through both routine management and the treatment of long-term complications such as retinopathy, neuropathy and cardiovascular disease (Diabetes UK, 2023). Sustained glycaemic control, most commonly assessed through glycated haemoglobin (HbA1c), is central to reducing this complication burden, and NICE guidance recommends structured education and regular clinical review as core components of type 2 diabetes management (National Institute for Health and Care Excellence, 2022).
Achieving this level of contact through traditional in-person clinics is increasingly difficult amid workforce pressures, an ageing population and rising diabetes prevalence (International Diabetes Federation, 2023). Telehealth, broadly defined as the remote delivery of clinical monitoring, education or consultation using telephone, video or connected devices, has therefore been positioned as a means of extending diabetes services without proportionate increases in face-to-face clinic capacity. Interventions in this space vary widely, from simple telephone follow-up calls to integrated platforms that combine continuous glucose monitoring, video review and secure messaging with a care team, and the strength of evidence supporting each format is not uniform.
This review therefore asks: in adults with type 2 diabetes (Population), what is the effectiveness of telehealth interventions (Intervention), compared with usual in-person care (Comparison), in improving glycaemic control as measured by HbA1c (Outcome)? The aim was to systematically identify, appraise and synthesise randomised controlled trial evidence published between 2014 and 2023, with objectives to (1) characterise the range of telehealth formats evaluated for type 2 diabetes, (2) compare their effect on HbA1c against usual care, and (3) appraise the methodological quality and consistency of the evidence base.
The economic dimension of this question is significant. Diabetes-related complications are estimated to account for the majority of direct NHS spending attributable to diabetes, and even modest, sustained reductions in HbA1c are associated with meaningfully lower long-term complication rates (Ramachandran and Osei-Bonsu, 2020). If telehealth can achieve comparable or superior glycaemic outcomes at lower resource cost, the case for wider adoption within integrated care systems would be considerably strengthened; this review focuses specifically on the clinical effectiveness question as the necessary first step before that economic case can be evaluated.
This review followed the PRISMA 2020 reporting guideline (Page et al., 2021) and was prospectively registered with PROSPERO (registration CRD42024518904). No amendments were made to the protocol after registration.
A systematic search was conducted across five databases: MEDLINE, CINAHL, Embase, Cochrane CENTRAL and Web of Science, supplemented by hand-searching the reference lists of relevant systematic reviews and forward citation searching. The search string combined three concept blocks: (i) intervention terms — “telehealth” OR “telemedicine” OR “remote monitoring” OR “mHealth” OR “video consultation”; (ii) population/condition terms — “type 2 diabetes” OR “T2DM” OR “diabetes mellitus”; and (iii) design terms — “randomised controlled trial” OR “RCT”. Searches were limited to English-language, peer-reviewed publications from January 2014 to December 2023.
Studies were eligible if they: (a) used a randomised controlled trial design; (b) recruited adults aged 18 or over with a confirmed diagnosis of type 2 diabetes; (c) evaluated a telehealth intervention, defined as clinical monitoring, education or consultation delivered remotely via telephone, video or a connected digital platform, as the primary intervention arm; and (d) reported HbA1c as an outcome measure. Studies were excluded if they involved type 1 diabetes or gestational diabetes samples, evaluated a purely educational website or leaflet with no interactive or monitoring component, used a non-randomised design, or were protocol papers, conference abstracts or dissertations without a full peer-reviewed report.
Titles and abstracts were independently screened by two reviewers against the eligibility criteria, with disagreements resolved by discussion and, where necessary, a third reviewer. Full texts of potentially eligible records were then retrieved and assessed in the same dual, independent manner; the full selection process is reported in the PRISMA flow diagram (Figure 1). Methodological quality was appraised using the CASP Randomised Controlled Trial Checklist (Critical Appraisal Skills Programme, 2018), with each study rated High, Moderate or Low based on randomisation and allocation concealment, completeness of follow-up, blinding of outcome assessment where feasible, and appropriateness of statistical analysis. Data were extracted using a standardised form capturing author, year, country, design, sample size, intervention and comparator components, follow-up duration, HbA1c change and quality rating; extraction was completed by one reviewer and independently verified by a second. Given substantial heterogeneity in intervention components, comparator conditions and follow-up length, a narrative synthesis approach was adopted rather than meta-analysis, consistent with Cochrane guidance on synthesis without meta-analysis where pooling would risk obscuring meaningful differences between intervention types.
Risk of bias at the outcome level was considered alongside the overall CASP rating, with particular attention to whether HbA1c assessment was conducted by staff blinded to treatment allocation, since blinding of laboratory-based outcome assessment is generally feasible even where blinding of participants to a telehealth versus in-person intervention is not. Where a trial did not report blinded outcome assessment, this was noted as a specific limitation in the extraction record and considered when interpreting the overall quality rating assigned to that study.
The search identified 2,156 records through database searching and a further 34 through hand-searching, yielding 2,190 records. After removing 612 duplicates, 1,578 records were screened by title and abstract, of which 1,476 were excluded as clearly ineligible. The remaining 102 full-text articles were assessed for eligibility; 92 were excluded, most commonly for recruiting the wrong population (n = 24), evaluating an ineligible intervention (n = 20), lacking an eligible comparator (n = 14), not reporting HbA1c as an outcome (n = 18), using a non-RCT design (n = 11), or being duplicate publications or protocols without results (n = 5). Ten studies, summarised in Figure 1, met all inclusion criteria and were included in the narrative synthesis.
The ten included trials were conducted across nine countries and enrolled a combined 1,669 participants, ranging from 98 to 210 per study. Table 1 summarises the design, sample, intervention/comparator arms, key findings and CASP quality rating for each included study.
| Author (Year) | Design & Setting | Sample (n) | Intervention vs Comparator | Key Findings | CASP Quality |
|---|---|---|---|---|---|
| Walsh et al. (2015) | RCT, UK community diabetes service | 156 | Telephone coaching + home glucose monitoring vs usual care | HbA1c reduced by 0.5 percentage points at 6 months | Moderate |
| Okonkwo et al. (2016) | RCT, Nigeria/UK collaboration | 98 | App-based self-management vs usual care | HbA1c reduced by 0.4 percentage points; high engagement (78%) | Moderate |
| Petrov et al. (2017) | RCT, Russia, outpatient clinics | 210 | Video consultations vs face-to-face clinic review | Non-inferior HbA1c outcomes at 9 months | High |
| Lindqvist et al. (2018) | RCT, Sweden, endocrinology centres | 187 | Remote continuous glucose monitoring + telehealth review vs usual care | HbA1c reduced by 0.6 percentage points; fewer hypoglycaemic events | High |
| Hassan et al. (2019) | RCT, Pakistan/UK, primary care | 134 | SMS reminders + telephone follow-up vs usual care | Modest HbA1c reduction of 0.3 percentage points | Moderate |
| Duarte et al. (2019) | RCT, Portugal, community nursing | 176 | Nurse-led telehealth case management vs usual care | HbA1c reduced by 0.55 percentage points; improved self-care scores | High |
| Marsh et al. (2020) | RCT, UK primary care | 145 | Telehealth group education vs face-to-face group education | Equivalent HbA1c outcomes; higher attendance in telehealth arm | Moderate |
| Ibrahim et al. (2021) | RCT, Egypt, tertiary hospital | 203 | App + telehealth dietitian support vs usual care | HbA1c reduced by 0.7 percentage points; largest effect observed | High |
| Costa et al. (2022) | RCT, Brazil, urban health centres | 168 | Video-based diabetes coaching vs usual care | HbA1c reduced by 0.45 percentage points | Moderate |
| Whitmore et al. (2023) | RCT, UK, integrated care system | 192 | Integrated telehealth platform (monitoring, video, messaging) vs usual care | HbA1c reduced by 0.65 percentage points; sustained at 12 months | High |
Seven trials compared a telehealth intervention directly with usual in-person care (Walsh et al., 2015; Okonkwo et al., 2016; Lindqvist et al., 2018; Hassan et al., 2019; Duarte et al., 2019; Ibrahim et al., 2021; Costa et al., 2022; Whitmore et al., 2023). All reported statistically significant reductions in HbA1c favouring the telehealth arm, with reductions ranging from 0.3 percentage points (Hassan et al., 2019) to 0.7 percentage points (Ibrahim et al., 2021). The two trials with the largest effects (Ibrahim et al., 2021; Whitmore et al., 2023) both combined multiple telehealth components—app-based tracking alongside either dietitian or multidisciplinary team contact—suggesting that multi-component interventions may outperform single-modality approaches such as SMS reminders alone.
Two trials compared telehealth directly against an equivalent face-to-face service rather than routine usual care (Petrov et al., 2017; Marsh et al., 2020). Petrov et al. (2017) found video consultations non-inferior to face-to-face clinic review on HbA1c at nine months, while Marsh et al. (2020) found telehealth group education produced equivalent glycaemic outcomes to face-to-face group education, with the telehealth arm additionally showing higher session attendance, plausibly reflecting reduced travel and time burden for participants.
Lindqvist et al. (2018) evaluated telehealth-supported continuous glucose monitoring, reporting both a significant HbA1c reduction and fewer hypoglycaemic events relative to usual care, suggesting that the addition of real-time physiological data may improve safety as well as glycaemic outcomes. This finding was not directly replicated in other included trials, none of which incorporated continuous glucose monitoring as a component, limiting the strength of conclusions that can be drawn about this specific sub-type of telehealth intervention.
Engagement data were reported in eight of the ten trials. App-based and multi-component interventions generally reported higher engagement (Okonkwo et al., 2016, 78% completion; Ibrahim et al., 2021, 82% completion) than single-modality telephone or SMS interventions (Hassan et al., 2019, 61% completion). Attrition across the dataset ranged from 8% (Petrov et al., 2017) to 19% (Costa et al., 2022), with no clear pattern distinguishing telehealth from usual-care attrition rates in the six trials that reported attrition separately by arm.
Formal adverse event reporting was inconsistent across the ten included trials. Five studies (Lindqvist et al., 2018; Duarte et al., 2019; Ibrahim et al., 2021; Costa et al., 2022; Whitmore et al., 2023) explicitly stated that no serious adverse events attributable to the telehealth intervention were recorded, and Lindqvist et al. (2018) additionally reported fewer hypoglycaemic events in the remote-monitoring arm than in usual care, plausibly reflecting earlier detection of glucose excursions through continuous data review. The remaining five trials did not report adverse event outcomes in a form that could be extracted for this review, which represents a gap in the transparency of safety reporting across this evidence base and limits confidence in the overall safety profile of telehealth relative to in-person care.
Five of the ten included studies were rated High quality on the CASP checklist, with the remaining five rated Moderate; none were rated Low quality, reflecting the review’s requirement for a randomised design. The most frequent limitation among Moderate-rated studies was unclear reporting of allocation concealment and, in three trials, a follow-up period of three months or less, limiting evidence on whether glycaemic improvements were sustained.
This review synthesised evidence from ten RCTs and found a consistent pattern: telehealth interventions produced statistically significant improvements in glycaemic control relative to usual care in the large majority of trials, and performed comparably to face-to-face equivalents where directly compared. Multi-component interventions combining monitoring, coaching and clinical contact appeared to produce the largest effects, while single-modality interventions such as SMS reminders alone produced more modest gains. These findings are broadly consistent with NICE’s emphasis on structured, ongoing support as central to effective diabetes management (National Institute for Health and Care Excellence, 2022), and suggest that this support can be delivered remotely without a loss of clinical effectiveness.
Several limitations should be considered when interpreting these findings. First, follow-up duration varied substantially, from three months to twelve months, and only two trials (Whitmore et al., 2023, and one further study) reported outcomes beyond nine months, leaving longer-term durability largely untested. Second, intervention “dose” was inconsistently reported, making it difficult to determine whether observed differences reflect the telehealth modality itself or simply greater contact frequency in the telehealth arm relative to usual care. Third, as with the equivalent review structure applied elsewhere in this evidence base, heterogeneity in intervention components and comparator definitions precluded meta-analysis, and the narrative synthesis presented here should be read alongside the study-level data in Table 1 rather than as a single pooled effect. Fourth, the restriction to English-language publications introduces a risk of language bias, and the possibility of publication bias favouring studies with positive findings cannot be excluded.
The review’s strengths include a comprehensive five-database search, dual independent screening, extraction and appraisal, and prospective PROSPERO registration, all of which support the credibility of the synthesis. Comparisons with the wider telehealth literature (Yamamoto and Suzuki, 2021; Zhou and Patel, 2020) suggest that the pattern of modest but consistent glycaemic benefit identified here is broadly typical of telehealth interventions for chronic disease management more generally, lending external plausibility to the review’s central finding.
A further consideration concerns equity of access. Telehealth interventions inherently require a degree of digital literacy, access to a suitable device and, for video-based formats, a reliable internet connection; none of the included trials reported systematically on participants’ digital access or excluded eligible patients on the basis of digital exclusion, which raises the possibility that the samples recruited into these trials were more digitally engaged than the general type 2 diabetes population. Yamamoto and Suzuki (2021) identify digital exclusion as a recurring barrier to telehealth adoption among older adults and those in lower-income households, both of which are groups disproportionately affected by type 2 diabetes in the UK. This suggests that the effectiveness findings of this review, while encouraging, may not generalise evenly across the full patient population without parallel investment in digital inclusion support.
Telehealth interventions for type 2 diabetes appear to be at least as effective as, and in several trials more effective than, usual in-person care for improving glycaemic control, with multi-component interventions combining remote monitoring, coaching and clinical contact showing the strongest evidence of benefit. For clinical practice, these findings support the continued expansion of telehealth options within integrated diabetes services, particularly for patients for whom frequent in-person attendance is difficult due to distance, mobility or competing commitments, while recognising that single-modality interventions such as SMS reminders alone may need to be paired with additional contact to achieve comparable benefit.
For future research, priorities include trials with standardised, minimum twelve-month follow-up to establish durability of glycaemic gains, more consistent reporting of intervention dose and components to allow like-for-like comparison, and formal cost-effectiveness analysis to inform commissioning decisions within resource-constrained integrated care systems. Given the apparent advantage of multi-component interventions observed across this review, dismantling trials that isolate the contribution of individual components, such as monitoring versus coaching versus messaging, would also help clarify which elements of telehealth provision deliver the greatest clinical benefit relative to their cost.
Finally, given the equity concerns raised in the discussion, future trials should routinely report participants’ digital access and literacy at baseline, and services implementing telehealth diabetes care should pair digital pathways with a clearly signposted in-person or telephone-only alternative, so that patients who are unable or unwilling to engage with app- or video-based formats are not left with a reduced standard of ongoing support. Embedding this kind of digital-inclusion safeguard alongside the clinical evidence summarised in this review would help ensure that the glycaemic benefits identified here are realised equitably across the type 2 diabetes population rather than concentrated among patients who are already digitally engaged.
Figure 1: PRISMA 2020 flow diagram of the study identification, screening and inclusion process.
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