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Effective Health Care Program

Telehealth for Acute and Chronic Care Consultations

Systematic Review Draft

Open for comment through Jun 26, 2018

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Purpose of Review

To evaluate the effectiveness of telehealth consultations for inpatient, emergency, and outpatient care.

Key Messages

  • Remote intensive care unit (ICU) consultations likely reduce ICU mortality and ICU length of stay (LOS); specialty telehealth consultations likely reduce the time patients spend in the emergency department; 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 telehealth consultations may: reduce inpatient LOS and costs; may improve outcomes and reduce costs for emergency care due to fewer transfers; and may reduce outpatient visits and costs due to travel (low strength of evidence in favor of telehealth).
  • Current evidence reports no difference in overall hospital LOS with remote ICUs, 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 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 as well as outcomes when telehealth is used for consultations.

Structured Abstract

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 1997 to November 2016. 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 included in 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 synthesized the findings using 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 7,714 potentially relevant citations. Upon review, 7,071 were excluded and the full text of 643 articles was pulled for review. Of these, 145 articles met our criteria and were included—31 articles evaluated inpatient consultations, 33 emergency care, and 81 outpatient care.

The overall results varied by setting and clinical topic, but generally found telehealth either better or no different than comparators on some outcomes. Remote intensive care unit (ICU) consultations likely reduce ICU mortality and ICU length of stay (LOS); specialty telehealth consultations likely reduce the time patients spend in the emergency department; 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 telehealth consultations may reduce inpatient LOS and costs; may improve outcomes and reduce costs for emergency care due to fewer transfers; and may reduce outpatient visits and costs due to travel (low strength of evidence in favor of telehealth). Current evidence reports no difference in overall hospital LOS with remote ICU consultations, 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 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, the 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 several factors (e.g., how alternatives are organized, that is, if the telehealth and in-person options are part of the same health care system) in addition to any difference in cost of a telehealth versus an in-person consultation.

Conclusions. In general, the evidence supports the effectiveness of telehealth consultations; however, the evidence is stronger for some applications, and less strong or insufficient for others. Exploring the use of a cost model underscored that the economic impact of telehealth consultations depends on the perspective used in the analysis. Future research should focus on better measuring harms or unintended consequences, and collecting data on the costs and economic impacts from different perspectives (e.g., health care systems, payers, patients, or society).