Telemedicine in Patients With Type 1 Diabetes Mellitus.
Telemedicine in Patients With Type 1 Diabetes Mellitus.
Management of patients with type 1 Diabetes Mellitus has been changing rapidly in recent
 years, due in part to the introduction of new technologies such as Apps that recommend
 insulin boluses, or the use of continuous blood glucose sensors. This fact also entails a
 change in the care the investigators provide to these patients, facilitating virtual
 interaction without the need for the patient to go to the consultation, but having all the
 information necessary to modify treatment doses. There are no studies that compare the
 influence on glycemic control of conventional management with respect to virtual visits.

 The investigators have proposed a randomized cohort study, with the aim to compared the
 changes in glycated hemoglobin in a group of patients with DM1 of the reference area of the
 "Hospital Comarcal de l´Alt Penedès" followed by telemedicine respect to the usual management
 in presential consultation.
Classic management of patients with type 1 diabetes (T1D) by endocrinologists consisted of
 carrying out a visit every 3-6 months in which HbA1c, microalbuminuria and a notebook with a
 variable number of annotated controls had been reviewed. In an accelerated way, the
 management of T1D has clearly been modified with the irruption of new technologies. Devices
 such as insulin bolus calculators, continuous glucose sensors, or continuous insulin pumps
 have been appeared and improved. In last months, continuous glucose monitors (CGM) for
 patients with T1D have been included in public funding in some cases. This fact is also
 associated with a considerable increase in the number of patient data, and new parameters to
 analyzed have appeared, with the same importance as HbA1c. Thus, percentage of time in
 optimal glycemic range, percentage of time in hypoglycemia, coefficient of variation of
 glycemia, or the mean glycemia are new parameters that the investigators have now been
 included in the follow-up.

 The handling of such amount of data has mainly two repercussions: on the one hand, if these
 data are well analyzed it is easier to make changes in the treatment, which can conduce to a
 better disease management such as an improvement in metabolic control or a reduction in
 hypoglycemia number events. On the other hand, in routine clinical practice it has been found
 that the fact that patients have higher number of data raises more doubts about theirs
 treatment and other aspects of their disease, which motivate a greater number of
 consultations, usually telephone or unscheduled, generating a greater delay in the
 consultation, occupying spaces assigned to the emergency room or in time slots assigned to
 other patients.

 In this way, telemedicine could be very useful in T1D management. These new devices allow
 data to be downloaded on secure digital platforms that make it possible for the doctor to
 have all the patient's blood glucose data without the presential visit of patient to
 hospital. Some of these platforms also allow safe communication channels between doctors and
 patients (teleconference, chats). The main benefit that telemedicine can provide is that
 allow doctors have a very narrow control, unacceptable in routine practice, which allows to
 interpreted the large volume of data that is generated and to do treatment recommendations,
 which can improve the metabolic control of the patient.

 To date there are few studies on telemedicine in T1D. In this regard, a systematic review
 reported promising data in terms of HbA1c reduction in 3-6 months interventions, although it
 do not allow a robust conclusion due to the heterogeneity of the intervention in included
 studies, the absence of a control group and the small number of patients included2.

 Furthermore, the benefits of telemedicine in management of T1D may go beyond the improvement
 of metabolic control. It must be considered that most T1D patients are young people of
 working age and that in some areas such as "l´Alt Penedès" there is an important geographical
 dispersion.

 Thus, telemedicine could reduce trips to hospital with benefits on quality of life and reduce
 indirect costs such as travel costs, lost working hours, etc. In this sense, the Coyote
 study, carried out in the United States with a sample of 40 T1D subjects between 18-25 years
 of age, demonstrated that telemedicine was capable of improving the quality of life and
 saving 6 hours on average between travel to hospital, medical visit and return to work or
 university1. It should be noted that this study, which is considered a benchmark in its
 field, did not have a control group nor did it study changes in metabolic control.

 On the other hand, being able to establish virtual contact channels between the patient and
 the doctor with a quick response from the doctor can be reflected in a reduction in the
 number of unexpected visits or contacts with the Emergency Department. Finally, it must be
 considered that virtual visits, although they are more frequent than face-to-face ones, are
 shorter and therefore the total time that doctor spends with the patient does not have to be
 superior to conventional management.

 Hypothesis: Use of telemedicine in patients with T1D allows a closer control of their disease
 that results in a improve of metabolic control without increasing the number of face-to-face
 visits.
Inclusion Criteria:

 -  Patients with T1D over 18 years of age

 -  Duration of T1D greater than 6 months

 -  Access to smartphones

 -  In those patients with CGM, the minimum time for handling the sensor before
 randomization will be 2 months.

 Exclusion Criteria:

 -  Inability to handle smartphones or Apps to manage T1D.

 -  Admission due to acute decompensation of TD1 in previous 3 months, presence of more
 than one severe monthly hypoglycemia, or any other circumstance that requires frequent
 visits and intensive diabetes education

 -  Inability to sign the informed consent