Telehealth for the Longitudinal Management of Chronic Conditions: Systematic Review

Abstract

Background: Extensive literature support telehealth as a supplement or adjunct to in-person care for the management of chronic conditions such as congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM). Evidence is needed to support the use of telehealth as an equivalent and equitable replacement for in-person care and to assess potential adverse effects.

Objective: We conducted a systematic review to address the following question: among adults, what is the effect of synchronous telehealth (real-time response among individuals via phone or phone and video) compared with in-person care (or compared with phone, if synchronous video care) for chronic management of CHF, chronic obstructive pulmonary disease, and T2DM on key disease-specific clinical outcomes and health care use?

Methods: We followed systematic review methodologies and searched two databases (MEDLINE and Embase). We included randomized or quasi-experimental studies that evaluated the effect of synchronously delivered telehealth for relevant chronic conditions that occurred over ≥2 encounters and in which some or all in-person care was supplanted by care delivered via phone or video. We assessed the bias using the Cochrane Effective Practice and Organization of Care risk of bias (ROB) tool and the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We described the findings narratively and did not conduct meta-analysis owing to the small number of studies and the conceptual heterogeneity of the identified interventions.

Results: We identified 8662 studies, and 129 (1.49%) were reviewed at the full-text stage. In total, 3.9% (5/129) of the articles were retained for data extraction, all of which (5/5, 100%) were randomized controlled trials. The CHF study (1/5, 20%) was found to have high ROB and randomized patients (n=210) to receive quarterly automated asynchronous web-based review and follow-up of telemetry data versus synchronous personal follow-up (in-person vs phone-based) for 1 year. A 3-way comparison across study arms found no significant differences in clinical outcomes. Overall, 80% (4/5) of the studies (n=466) evaluated synchronous care for patients with T2DM (ROB was judged to be low for 2, 50% of studies and high for 2, 50% of studies). In total, 20% (1/5) of the studies were adequately powered to assess the difference in glycosylated hemoglobin level between groups; however, no significant difference was found. Intervention design varied greatly from remote monitoring of blood glucose combined with video versus in-person visits to an endocrinology clinic to a brief, 3-week remote intervention to stabilize uncontrolled diabetes. No articles were identified for chronic obstructive pulmonary disease.

Conclusions: This review found few studies with a variety of designs and interventions that used telehealth as a replacement for in-person care. Future research should consider including observational studies and studies on additional highly prevalent chronic diseases.

Keywords: chronic obstructive; delivery of health care; diabetes mellitus, type 2; heart failure; pulmonary disease; systematic review; telemedicine; veterans.

Conflict of interest statement

Conflicts of Interest: AAL reports receiving funding from Otsuka and the PhRMA Foundation.

©Allison A Lewinski, Conor Walsh, Sharron Rushton, Diana Soliman, Scott M Carlson, Matthew W Luedke, David J Halpern, Matthew J Crowley, Ryan J Shaw, Jason A Sharpe, Anastasia-Stefania Alexopoulos, Amir Alishahi Tabriz, Jessica R Dietch, Diya M Uthappa, Soohyun Hwang, Katharine A Ball Ricks, Sarah Cantrell, Andrzej S Kosinski, Belinda Ear, Adelaide M Gordon, Jennifer M Gierisch, John W Williams Jr, Karen M Goldstein. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.08.2022.

Figures

Figure 1

Analytic framework to guide systematic review activities. CHF: congestive heart failure; COPD: chronic obstructive pulmonary disease; HbA1c: glycosylated hemoglobin; T2DM: type 2 diabetes mellitus.

Figure 2

Literature flowchart. *Search results from MEDLINE (4713) and Embase (3949) were combined. CHF: congestive heart failure; N/A: not applicable; OECD: Organisation for Economic Co-operation and Development.

Figure 3

Change in glycosylated hemoglobin levels between intervention and comparator arms across type 2 diabetes mellitus studies. MD: mean difference; ROB: risk of bias [30,32,34,35].

Figure 4

Risk of bias (ROB) assessment for included studies in congestive heart failure and type 2 diabetes mellitus [30,32-35].

Figure 5

Risk of bias (ROB) assessment across included studies on congestive heart failure and type 2 diabetes mellitus (N=5).