Technology and Health Care 23 (2015) 161169 161

DOI 10.3233/THC-140888
IOS Press

Effectiveness of a telemedicine programme

for patients with metabolic syndrome

Jess Lpez-Torresa, , Joseba Rabanalesb , Mara Jos Simarroc and

on behalf of the PITES-ALBACETE Group1
a University Health Centre, Albacete Zone IV, Castilla-La Mancha Health Service, Albacete, Spain
b Cuenca Faculty of Nursing, University of Castilla-La Mancha, Spain
c Villarrobledo Health Centre, Castilla-La Mancha Health Service, Albacete, Spain

Received 26 October 2014

Accepted 3 December 2014

Abstract.
BACKGROUND: There is a high prevalence of metabolic syndrome in Western societies, and it is therefore an example of
chronic disease whose follow-up could be enhanced by telemedicine.
OBJECTIVE: The objective of this study was to assess the effectiveness of a telemedicine programme for the follow-up and
control of patients with metabolic syndrome in a primary-care setting.
METHODS: Semi-experimental study in which 82 patients with metabolic syndrome were included in a telemedicine pro-
gramme and compared to 82 patients routinely followed up at health-care facilities. The programme consisted of the teletrans-
mission of analytical parameters via the PITES technological platform for chronic and dependent patients. Other study variables
were lifestyle, treatment compliance, perceived health status and satisfaction with the programme.
RESULTS: Follow-up showed that 68 patients (82.9%) continued in the programme after 6 months and 45 (54.9%) after one
year, with a mean stay of 39.7 weeks. Comparison of the parameters obtained for the telemedicine and control-group patients
indicated that the former registered significantly lower mean values for systolic blood pressure (125.5 10.6 SD vs. 136.7
12.0 SD), diastolic blood pressure (81.0 6.3 SD vs. 84.0 6.8 SD), total cholesterol (177.4 34.5 SD vs. 202.4 31.7 SD)
and cLDL (106.0 28.1 SD vs. 121.3 30.6 SD). By the end of follow-up, the health status scores of the patients monitored
by telemedicine had risen significantly (69.2 vs. 64.2; p = 0.04), and 86.6% stated that they were satisfied.
CONCLUSIONS: Telemedicine allows for better control of some of the defining parameters of metabolic syndrome than is
achieved by routine clinical practice. Teletransmission is viable and satisfactory, and constitutes a novel contribution to the
clinical management of these patients.

Keywords: Metabolic syndrome, telemedicine, primary health care

Corresponding author: Jess Lpez-Torres, Centro de Salud Universitario Zona IV, c/ Seminario n 4, 02006 Albacete,
Spain. Tel.: +34 967510094; E-mail: jesusl@sescam.org.
1
PITES-ALBACETE Group: Fernando Andrs, Carmen Carrasco, Mara Jos Carretero, Roco Pilar Elicegui, Francisco
Escobar, Rafael Fernndez, Emiliano de la Fuente, Jos Daniel Gmez, Francisco Javier Lpez, Jess Lpez-Torres, Rafael
Muoz, Beatriz Navarro, Beln de la Ossa, Llanos Panads, Ignacio Prraga, Joseba Rabanales, Victoria Romero, Mara Jos
Simarro, Humberto Soriano, Inmaculada Tejero, Rus Torrecillas.

0928-7329/15/$35.00 
c 2015 IOS Press and the authors. All rights reserved
162 J. Lpez-Torres et al. / Effectiveness of a telemedicine programme for patients with metabolic syndrome

1. Introduction

Telemedicine can be defined as the use of information and communication technologies for the transfer
of medical information for diagnostic, therapeutic and educational purposes [1]. Telemedicine means
medicine at a distance, using technological resources that optimise health care by saving time and costs,
and enhancing accessibility [2].
Despite an evident willingness to incorporate telemedicine into health care and the fact that
telemedicine-related activity has increased, telemedicine still enjoys little more than a token presence
in clinical and health-care activity [3], probably due to the lack of conclusive scientific proof of its
usefulness [4], both medical (clinical benefits) and economic (improved cost-benefit).
Yet telemedicine could come to exert increasingly more influence on certain areas, such as the follow-
up of patients with chronic diseases [5]. Insofar as cardiovascular risk factors are concerned, its useful-
ness in highly prevalent diseases such as diabetes and arterial hypertension has been demonstrated: in
the case of diabetes [6,7], by improving both the degree of control of the diseases and diabetes educa-
tion, among other aspects; and in the case of arterial hypertension [8,9], by similarly improving control
of patients blood pressure figures, degree of adherence to treatment and degree of satisfaction. It is for
this reason that, among patients who present with several cardiovascular risk factors, as is the case of
those diagnosed with metabolic syndrome, telemedicine could result in better control of blood pressure,
glycaemia and lipid levels, and, by extension, contribute to reducing cardiovascular risk. This clinical
condition has a high prevalence in Western societies (1 out of every 5 adults) and constitutes a clear
example of chronic disease whose follow-up could be enhanced by telemedicine, through affording the
dual opportunity of improving the degree of control while providing patients with medical advice and
health education [7,10].
The aim of this study was thus: to assess the effectiveness of a telemedicine programme in the follow-
up and control of patients with metabolic syndrome in a primary-care setting; and, at the end of one year,
to evaluate these patients acceptance and degree of satisfaction.

2. Methods

We conducted a semi-experimental study with a comparison group at 6 health centres in the province
of Albacete, an area situated in south-east Spain, with a population of 402,837. In the study, 82 pa-
tients aged under 65 years and diagnosed with metabolic syndrome were included in a telemedicine
programme and then compared to 82 patients who were likewise diagnosed with metabolic syndrome
but underwent the standard follow-up undertaken in routine clinical practice in primary care. With a
statistical power of 90% and a 95% confidence level, a sample of this size made it possible to detect
differences of 6 mm Hg in systolic blood pressure (expected standard deviation (SD): 11.8 mm Hg) and
17 mg/dL in total cholesterol (expected SD: 33.5 mg/dL) between the two groups. All the participants
fulfilled 3 or more of the following ATP III criteria (National Cholesterol Education Programme-Adult
Treatment Panel III [11]): elevated abdominal obesity (waist circumference more than 102 cm in men
and 88 cm in women); triglyceride figures of 150 mg/dL or more; cHDL of under 40 mg/dL in men and
50 mg/dL in women; systolic blood pressure of 130 mm Hg or more and/or diastolic blood pressure of
85 mm Hg or more (or on antihypertensive medication); and elevated fasting glucose of 100 mg/dL or
more (or undergoing hypoglycaemia treatment).
The telemedicine programme consisted of the periodic teletransmission (weekly or quarterly) of ana-
lytical and clinical parameters by patients via a technological platform for chronic and dependent patients
 J. Lpez-Torres et al. / Effectiveness of a telemedicine programme for patients with metabolic syndrome 163

Patients asked to participate in the Patients asked to participate in the

telemedicine programme control group
(N = 132) (N = 85)

21 patients failed to meet the inclusion criteria. 3 patients failed to meet the inclusion criteria
29 patients refused to participate

Patients included in the telemedicine Patients included in the control group

programme (N = 82) (N = 82)

37 patients withdrew from the

telemedicine programme

Patients assessed after 12 months Patients assessed after 12 months

(N = 45) (N = 82)

Comparison of clinical and analytical parameters

at start and end of follow-up

Fig. 1. Study flow diagram.

known by its Spanish acronym as PITES (Plataforma de Innovacin en nuevos servicios de Telemedic-
ina y e-Salud Innovation Platform for New Telemedicine and E-health Services), developed at the
Carlos III Institute of Health Telemedicine Unit (Madrid). Using a broadband Internet connection, this
platform enabled data to be transmitted from patients homes and graphically visualised for subsequent
monitoring by their general practitioners and analysis by the research team. All users underwent prac-
tical, face-to-face instruction until proper management was ensured. The programme was co-ordinated
by a qualified professional team made up of specialised health care staff and a software technician.
Depending on their respective cardiovascular risk factors, all patients included in the telemedicine
programme were taught to record weekly readings of their blood pressure (home self-monitoring with
an OMROM M6 Comfort Upper Arm Accurate Blood Pressure Monitor) and capillary glycaemia (us-
ing a CardioChek Home Blood Testing Device), and quarterly readings of their lipid profile (home
self-monitoring with a CardioChek total cholesterol, cHDL, cLDL and triglyceride analyser) and waist
circumference (self-measurement with a flexible, unstretchable tape measure). In addition, the research
team e-mailed fortnightly recommendations on healthy lifestyles and habits to the patients, embracing
specific recommendations on diet, physical exercise, use of medication, and toxic habits. Among the
patients in the control group, the clinical parameters were obtained from computerised clinical histories.
At the commencement of the study, all the participants were interviewed to obtain information on socio-
demographic variables, toxic habits, level of physical activity (active, partially active or inactive), use of
medication, adherence to preventive care guidelines and drug treatment (Morisky-Green questionnaire).
At the start and end of follow-up, the patients included in the telemedicine programme were asked to use
the EQ-5D questionnaire [12] and a visual analogue scale to rate their health status, with scores ranging
from 0 (worst health status imaginable) to 100 (best health status imaginable). Similarly, patients were
also asked at the end of follow-up about their degree of satisfaction with the programme.
164 J. Lpez-Torres et al. / Effectiveness of a telemedicine programme for patients with metabolic syndrome

Table 1
Patient characteristics. NS: difference not statistically significant
Characteristics Telemedicine group Control group p
No. (%) No. (%)
Sex
Men 61 (74.4) 49 (59.8) 0.04
Women 21 (25.6) 33 (40.2)
Age
3450 years 37 (45.1) 35 (42.7) NS
5165 45 (54.9) 47 (57.3)
Cardiovascular risk factors
Abdominal obesity, dyslipidemia, hypertension and hyperglycaemia 33 (40.2) 26 (31.7) NS
Abdominal obesity, dyslipidemia and hypertension 18 (22.0) 22 (26.8)
Abdominal obesity, dyslipidemia and hyperglycaemia 12 (14.6) 8 (9.8)
Abdominal obesity, hypertension and hyperglycaemia 11 (13.4) 20 (24.4)
Dyslipidemia, hypertension and hyperglycaemia 8 (9.8) 6 (7.3)
Chronic use of medication
Yes 77 (93.9) 79 (96.3) NS
No 5 (6.1) 3 (3.7)
Therapeutic compliance
Good compliance 56 (68.3) 61 (74.4) NS
Poor compliance 20 (24.4) 17 (18.3)
Not shown 6 (7.3) 6 (7.3)
Smoking habit
Smoker 22 (26.8) 22 (26.8) NS
Non-smoker 60 (73.2) 60 (73.2)
Alcohol consumption
Risk drinker 15 (18.3) 20 (24.4) NS
Non-risk drinker 67 (81.7) 62 (75.6)
Physical activity
Active 23 (28.0) 20 (24.4) NS
Partially active 29 (35.4) 35 (42.7)
Inactive 30 (36.6) 27 (32.9)

The study fulfilled the requirements of the Helsinki Declaration and was approved by the Clinical
Research Ethics Committee of the Albacete University Teaching Hospital. All participants gave their
written informed consent.
After the data-processing, exploratory analysis and variable-categorisation or -transformation stages
had been completed, we performed a descriptive analysis of the study subjects, including both those in
the telemedicine programme and those in the control group, calculating distributions of frequencies and
measures of central trend and dispersion together with their 95% confidence intervals. The two groups
were then compared using tests for comparison of proportions (Chi-squared likelihood ratio) and means
(Students T-test) from independent groups, with a significance level of 0.05. The Wilcoxon signed-ranks
test for related samples was used to compare mean values in a single group. Data-analysis was performed
using the SPSS v. 19.0 statistics programme.

3. Results

Initially, 132 patients were asked to take part in the telemedicine programme: of these, 21 failed to
fulfil the inclusion criteria (15.9%) and 29 refused to participate in the study (22.0%) (Fig. 1). A control
group was then selected by asking 85 patients to participate, 3 of whom were excluded for failing to
meet the inclusion criteria. The final sample thus consisted of 164 patients, 82 in the telemedicine group
 J. Lpez-Torres et al. / Effectiveness of a telemedicine programme for patients with metabolic syndrome 165

Table 2
Comparison of clinical and analytical parameters between telemedicine patients and those belonging to the control group. SD:
standard deviation. CI: confidence interval. NS: difference not statistically significant
Parameters Telemedicine group Control group p
No. of Mean value 95% No. of Mean value 95%
patients (SD) CI patients (SD) CI
Systolic blood pressure (mm Hg) 70 125.5 (10.6) 122.5128.0 76 136.7 (12.0) 134.0139.5 < 0.001
Diastolic blood pressure (mm Hg) 70 81.0 (6.3) 79.682.6 76 84.0 (6.8) 82.485.5 0.009
Total cholesterol (mg/dL) 61 177.4 (34.5) 168.5186.2 61 202.4 (31.7) 194.2210.5 < 0.001
HDL cholesterol (mg/dL) 47 44.9 (9.6) 42.147.7 49 48.3 (8.1) 46.050.7 NS
LDL cholesterol (mg/dL) 60 106.0 (28.1) 98.7113.2 60 121.3 (30.6) 113.3129.2 0.005
Triglycerides (mg/dL) 61 175.0 (95.3) 150.6199.5 61 150.6 (81.5) 129.7171.4 NS
Capillary glycaemia (mg/dL) 64 120.9 (33.3) 112.6129.3 60 132.7 (39.8) 122.4143.0 NS
Waist circumference (cm) 62 113.2 (11.8) 110.2116.2

Table 3
Comparison of clinical and analytical parameters between telemedicine patients and those belonging to the control group, in
men and women. SD: standard deviation. NS: difference not statistically significant
Men Women
Parameters Telemedicine Control p Telemedicine Control p
group mean group mean group mean group mean
value (SD) value (SD) value (SD) value (SD)
Systolic blood pressure (mm Hg) 126.3 (9.9) 136.9 (12.4) < 0.001 122.7 (12.9) 136.4 (11.7) 0.001
Diastolic blood pressure (mm Hg) 81.4 (6.3) 84.1 (7.2) 0.04 80.0 (6.0) 83.7 (6.3) NS
Total cholesterol (mg/dL) 176.6 (35.0) 199.6 (32.8) 0.004 179.9 (33.9) 205.9 (30.5) 0.01
Cholesterol HDL (mg/dL) 42.9 (9.1) 47.1 (8.8) NS 49.4 (9.7) 50.2 (6.7) NS
Cholesterol LDL (mg/dL) 102.8 (27.4) 121.0 (29.2) 0.005 116.3 (29.0) 121.5 (33.0) NS
Triglycerides (mg/dL) 181.6 (92.4) 163.6 (96.7) NS 153.2 (105.1) 134.2 (54.4) NS
Capillary glycaemia (mg/dL) 116.3 (23.1) 141.3 (40.7) 0.001 133.7 (50.9) 120.7 (36.0) NS
Waist circumference (cm) 113.2 (11.8) 109.5 (10.3)

and 82 in the control group. Follow-up showed that 68 patients (82.9%) continued in the programme
after 6 months and 45 (54.9%) after one year, with a mean stay of 39.7 weeks (SD: 17.9). The main
reasons for withdrawal were patients refusal to continue in the telemedicine programme and technical
incidents connected with the system. During the follow-up period, overall self-monitoring compliance
among patients included in the programme was 62.5% for blood pressure, 65.6% for glycaemia, 50.5%
for lipid parameters, and 52.6% for waist circumference, with the mean number of determinations per
patient being 32.5 (SD: 16.4), 2.5 (SD: 1.3), 31.5 (SD: 17.1) and 2.6 (1.5) respectively.
The baseline characteristics of all the patients are shown in Table 1 and the mean levels of the clinical
parameters obtained across the study period are shown in Table 2. When the parameters obtained in the
telemedicine patients were compared to those yielded by the control group, the former were observed to
have registered significantly lower mean values in terms of systolic blood pressure (125.5 10.6 SD vs.
136.7 12.0 SD), diastolic blood pressure (81.0 6.3 SD vs. 84.0 6.8 SD), total cholesterol (177.4
34.5 SD vs. 202.4 31.7 SD) and cLDL (106.0 28.1 SD vs. 121.3 30.6 SD), with no statistically
significant differences in evidence for triglyceride, glycaemia and cHDL figures. On stratifying by sex
(Table 3), mean glycaemia figures were also significantly lower in the case of the men included in the
telemedicine programme (116.3 23.1 SD vs. 141.3 40.7 SD); in the case of women, however, no
statistically significant differences were observed in mean glycaemia, diastolic blood pressure, cLDL
and triglyceride values.
By the end of the follow-up period, the telemedicine patients self-perceived health status scores had
risen significantly with respect to baseline (69.2 13.2 SD vs. 64.2 14.7 SD; p = 0.04). After one
166 J. Lpez-Torres et al. / Effectiveness of a telemedicine programme for patients with metabolic syndrome

year of taking part in the telemedicine programme, 73.3% said that they were satisfied and 13.3% that
they were very satisfied with it; 40.0% felt that their health had improved and 90.0% rated the informa-
tion received as useful or very useful, though 36.7% of them acknowledged that they had experienced
technical difficulties.

4. Discussion

The results obtained show the feasibility of using electronic means, not only for the continuous mon-
itoring of patients diagnosed with metabolic syndrome, but also for periodically providing such patients
with preventive guidelines. This experience constitutes a health-care innovation in these types of pa-
tients, and one that proved both viable and satisfactory for the persons involved. The results indicate that
there is a high likelihood of telemedicine being more clinically effective than standard clinical practice.
Moreover, telemedicine could be advantageous in terms of accessibility, patient comfort and speed of
dispatch of information. The principal limitation to the use of telemedicine might lie in its great techno-
logical dependence and the need for collaboration on the part of the patient, which requires some basic
knowledge about the management of these new tools [13].
In reality, there are few studies on the evidence of clinical benefits afforded by telemonitoring or
teleassistance programmes in the case of cardiovascular risk factors. In line with our results, different
studies on the use of telemedicine in the field of arterial hypertension [8,1418] report favourable data in
terms of the degree of control of blood pressure, though these results should be approached with caution,
given that these studies were frequently conducted on a small number of patients and that the follow-
up period was excessively short [19]. Among hypertensive patients, the traditional follow-up system,
based on regular medical visits, entails a small number of blood pressure readings, so that telemedicine,
aside from reducing the number of visits, also makes for a greater number of readings [20], which are
probably of higher quality on being free of the white-coat effect. It is evident that telemedicine improves
knowledge of blood pressure levels in the patients usual environment [21]. Logically, the fact that this
involves the application of new methods of diagnosis and follow-up of hypertensive patients means that
some matters remain unresolved, i.e., whether the beneficial effect lasts over time or begins to wane
after the initial stage. In future, a telephonic link-up to the electronic sphygmomanometer will make it
possible for the treatment to be managed on the basis of ambulatory measurements rather than at the
consulting room [19]. As in our results, in the case of glycaemic control the use of telemedicine in
patients with diabetes could prove more controversial, the reason being that, while some studies [22]
report improvements in metabolic control, others [23] have failed to observe differences with respect to
medical visits to the outpatient facility or physicians practice.
Telemedicine applications should be addressed in future research by means of randomised clini-
cal trials [3]. Due, however, to the experimental difficulties of successfully achieving random patient
allocations, adequate-sized samples and double-blind procedures, alternative methods are proposed,
such as that applied in this study, based on a semi-experimental design and the use of administrative
databases [24]. As a consequence, the evidence available to date may perhaps be insufficient to decide,
in the majority of cases, whether telemedicine applications have an acceptable cost-effectiveness ra-
tio [2527]. A review of telemedicine studies undertaken by Wootton in 2012, in which positive results
were observed in 108 out of a total of 141 controlled trials, underscores the importance of in-depth re-
search into aspects such as cost-effectiveness and longer-term follow-up [28]. Accordingly, the costs and
benefits of telemedicine vis--vis other health care alternatives must still be assessed [29]. Furthermore,
it should be borne in mind that studies which address telemedicine do not necessarily have to prove that
 J. Lpez-Torres et al. / Effectiveness of a telemedicine programme for patients with metabolic syndrome 167

it is better from the standpoint of clinical effectiveness: it should suffice to show that the effectiveness
of telemedicine is, at least, equal to that of routine practice, since it will inevitably entail some benefits
in terms of quality of life and wellbeing for the patient.
In addition to the fact that the results obtained highlight certain aspects of telemedicines clinical ef-
fectiveness in relation to routine clinical practice, stress should be laid on the patients generally good ac-
ceptance of the programme and their high degree of satisfaction with it, despite the technical difficulties
reported. Among both hypertensive and diabetic patients, previous studies have shown that telemedicine
users express a high degree of satisfaction, consider the system useful, and perceive themselves as having
an enhanced capability to manage the disease on their own [15,30].
The main limitations of this study are those inherent in a semi-experimental design, in which the par-
ticipants are not randomly allocated to each group. It was a somewhat complex project, which entailed
incorporating a new health-care modality into clinical practice and giving all the participants appropriate
training in the management of electronic media. By way of further limitations on the results, mention
should also be made of the proportion of withdrawals, which was different in the two groups and was in-
fluenced by the duration of the study, as well as the selection of patients, who might not be representative
of persons of a more advanced age or those confronting major difficulties when it comes to managing
electronic media. Hence, in terms of the external validity of the conclusions, the results might not be
directly extrapolatable to any other setting. Furthermore, it is known that determinations in capillary
blood consistently yield lower levels than do those in plasma [31], something that may have contributed
to total cholesterol or glycaemia figures, among others, being underestimated in patients included in the
telemedicine programme.
A great future undoubtedly awaits the development of telemedicine in different settings, and specifi-
cally in family medicine where it could favour equity by promoting accessibility for all patients, regard-
less of their health status, place of residence or level of resources. At the same time, it could facilitate
the work of professionals, not only in the field of health care, but also in that of health education and
prevention. The main recipients should be multi-disease patients with chronic diseases and negligible
possibilities of mobility and travel, thereby bringing the patient, primary-care physician and hospital
specialist closer together [5]. Even so, there are still many obstacles to the generalisation of telemedicine
in the primary-care setting. Resistance is not exclusively confined to the professionals whose degree
of commitment and involvement can be very variable depending on a wide range of factors [32] inas-
much as telemedicine also requires acceptance by patients, sufficient training and the availability of the
necessary technological means.

5. Conclusions

After a follow-up period of one year, a telemedicine programme has shown that telemedicine al-
lows for better control of some of the analytical parameters that define the metabolic syndrome than is
achieved by routine clinical practice. The teletransmission of information by patients and the dispatch
to them of preventive care guidelines by health professionals proved viable and highly satisfactory.
Home-based monitoring and transmission of analytical and clinical parameters specific to the metabolic
syndrome is currently feasible and constitutes a novel contribution to the clinical management of such
patients.
168 J. Lpez-Torres et al. / Effectiveness of a telemedicine programme for patients with metabolic syndrome

Acknowledgements

This study was funded by the Carlos III Institute of Health (Instituto de Salud Carlos III) (Subpro-
gramme for Research Projects in Health Technology and Health Service Assessment) (Ruling of 16
October 2009, Order of 20 March 2009, Official Government Gazette (Boletn Oficial del Estado No.
71).

Conflict of interest

The authors declare that they have no competing interests.

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