Totten AM, Hansen RN, Wagner J, Stillman L, Ivlev I, Davis-O’Reilly C, Towle C, Erickson JM, Erten-Lyons D, Fu R, Fann J, Babigumira JB, Palm-Cruz KJ, Avery M, McDonagh MS, et al.
. Date of publication 2019 Apr 1;volume ():.
1. Telehealth for Acute and Chronic Care Consultations [Internet].
Totten AM(1), Hansen RN(1), Wagner J(1), Stillman L(1), Ivlev I(1),
Davis-O’Reilly C(1), Towle C(1), Erickson JM(1), Erten-Lyons D(1), Fu R(1), Fann
J(1), Babigumira JB(1), Palm-Cruz KJ(1), Avery M(1), McDonagh MS(1).
Rockville (MD): Agency for Healthcare Research and Quality (US); 2019 Apr. Report
No.: 19-EHC012-EF.
AHRQ Comparative Effectiveness Reviews.
Author information:
(1)Pacific Northwest Evidence-based Practice Center
OBJECTIVES: To conduct a systematic review to identify and summarize the
available evidence about the effectiveness of telehealth consultations and to
explore using decision modeling techniques to supplement the review. Telehealth
consultations are defined as the use of telehealth to facilitate collaboration
between two or more providers, often involving a specialist, or among clinical
team members, across time and/or distance. Consultations may focus on the
prevention, assessment, diagnosis, and/or clinical management of acute or chronic
conditions.
DATA SOURCES: We searched Ovid MEDLINE®, the Cochrane Central Register of
Controlled Trials (CCRCT), and the Cumulative Index to Nursing and Allied Health
Literature (CINAHL®) to identify studies published from 1996 to May 2018. We also
reviewed reference lists of identified studies and systematic reviews, and we
solicited published or unpublished studies through an announcement in the Federal
Register. Data for the model came both from studies identified via the systematic
review and from other sources.
METHODS: We included comparative studies that provided data on clinical, cost, or
intermediate outcomes associated with the use of any technology to facilitate
consultations for inpatient, emergency, or outpatient care. We rated studies for
risk of bias and extracted information about the study design, the telehealth
interventions, and results. We assessed the strength of evidence and
applicability, and then synthesized the findings using quantitative and
qualitative methods. An exploratory decision model was developed to assess the
potential economic impact of telehealth consultations for traumatic brain
injuries in adults.
RESULTS: The search yielded 9,366 potentially relevant citations. Upon review,
8,356 were excluded and the full text of 1,010 articles was pulled for review. Of
these, 233 articles met our criteria and were included—54 articles evaluated
inpatient consultations; 73, emergency care; and 106, outpatient care. The
overall results varied by setting and clinical topic, but generally the findings
are that telehealth improved outcomes or that there was no difference between
telehealth and the comparators across the settings and for the clinical
indications studied. Remote intensive care unit (ICU) consultations likely reduce
ICU and total hospital mortality with no significant difference in ICU or
hospital length of stay; specialty telehealth consultations likely reduce the
time patients spend in the emergency department; telehealth for emergency medical
services likely reduces mortality for patients with heart attacks; and remote
consultations for outpatient care likely improve access and a range of clinical
outcomes (moderate strength of evidence in favor of telehealth). Findings with
lower confidence are that inpatient telehealth consultations may reduce length of
stay and costs; telehealth consultations in emergency care may improve outcomes
and reduce costs due to fewer transfers, and also may reduce outpatient visits
and costs due to less travel (low strength of evidence in favor of telehealth).
Current evidence shows no difference in clinical outcomes with inpatient
telehealth specialty consultations, no difference in mortality but also no
difference in harms with telestroke consultations, and no difference in
satisfaction with outpatient telehealth consultations (low strength of evidence
of no difference). Too few studies reported information on potential harms from
outpatient telehealth consultations for conclusions to be drawn (insufficient
evidence). An exploratory cost model underscores the importance of perspective
and assumptions in using modeling to extend evidence, and the need for more
detailed data on costs and outcomes when telehealth is used for consultations.
For example, a model comparing telehealth to transfers and in-person
neurosurgical consultations for acute traumatic brain injury identified that the
impact of telehealth on costs may depend on multiple factors, including how
alternatives are organized (e.g., if the telehealth and in-person options are
part of the same healthcare system) and whether the cost of a telehealth versus
an in-person consultation differ.
CONCLUSIONS: In general, the evidence indicates that telehealth consultations are
effective in improving outcomes or providing services, with no difference in
outcomes; however, the evidence is stronger for some applications, and less
strong or insufficient for others. However, as specific details about the
implementation of telehealth consultations and the environment were rarely
reported, it is difficult to assess generalizability. Exploring the use of a cost
model underscored that the economic impact of telehealth consultations depends on
the perspective used in the analysis. The increase in both interest and
investment in telehealth suggests the need to develop a research agenda that
emphasizes rigor and focuses on standardized outcome comparisons that can inform
policy and practice decisions.
PMID: 31577401
