We thank Biermann et al. (1) for their kind remarks about the clarity and importance of our research and for proposing a novel taxonomy of telecare interventions by purpose: as a supplement to usual care (A in their taxonomy) or as a replacement of face-to-face visits (sometimes called nonvisit encounters; B or C in their taxonomy).
Two of the trials included in our meta-analysis used, to some extent, telecare as replacement. In their 6-month trial, Chase et al. (2) added telecare encounters to usual care and replaced the face-to-face visit at 3 months with a telecare nonvisit encounter. Biermann et al. (3) replaced all ad hoc visits with telecare encounters but kept face-to-face visits at 2, 4, 6, and 8 months for patients allocated to both telecare and control. These two replacement trials found no significant difference between telecare and control; however, this is not enough to claim that telecare visits are similar or superior (i.e., not inferior) to face-to-face visits.
To determine noninferiority, one needs to evaluate the magnitude of the smallest reduction in HbA1c that is still consistent with the trial data, i.e., the lower limit of the confidence interval (4). Data from the two trials of telecare as replacement were consistent with differences in HbA1c as large as 0.7% in favor of usual care. Thus, evidence of noninferiority from each of these trials alone is inconclusive.
Following the suggestions of Biermann et al. (1), we evaluated a subgroup effect across trials in our meta-analysis by telecare purpose (replacement versus supplement). There was no difference (test for interaction, P = 0.44) in pooled treatment effects between trials of telecare as replacement (pooled random-effects estimate 0.5% [95% CI 0.0–1.0%]) and as supplement (0.2% [−0.4–0.8%]). Therefore, the results of our meta-analysis (0.4% [0.0–0.8%]) apply to both types of trials, are not misleading, and suggest that telecare may be noninferior to usual care when it supplements usual care or when it replaces some visits.
We agree that a systematic assessment of costs with attention to the opportunity costs of implementing telecare and to the resulting freed-up resources available to patients who are most likely to benefit from face-to-face visits rather than telecare is critical when considering new technologies. Unfortunately, to our knowledge, a formal cost-effectiveness analysis of telecare as a supplement or replacement to usual care is not available.
