Background
Methods
Search strategy
Selection procedures
Inclusion criteria
Data extraction
Methodological quality
Level of evidence | Descriptor |
---|---|
I | Systematic review of randomised controlled trials |
II | Randomised controlled trial |
III | Pseudo-randomised controlled trial, comparative study with or without concurrent controls |
IV | Case series with either post-test or pre-test/post-test outcomes |
Results
Quality criteria | Clark et al. [10] | Neubeck et al. [18] | Inglis et al. [8] | Martínez et al. [26] | Agarwal et al. [17] | Klersy et al. [23] | Chaudhry et al. [21] | Giamouzis et al. [22] | Seto [27] | Verberk et al. [20] | Louis et al. [24] | Maric et al. [25] | Omboni et al. [19] |
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Search methods used to find evidence stated
| 3 | 1 | 3 | 3 | 3 | 3 | 3 | 2 | 3 | 3 | 3 | 2 | 3 |
Search for evidence reasonably comprehensive
| 3 | 3 | 3 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 |
Criteria used for deciding which studies to include reported
| 3 | 3 | 3 | 2 | 3 | 2 | 2 | 3 | 3 | 3 | 2 | 3 | 3 |
Bias in the selection of studies avoided
| 3 | 3 | 3 | 2 | 3 | 3 | 2 | 3 | 3 | 3 | 2 | 3 | 3 |
Criteria used for assessing validity of included studies reported
| 3 | 3 | 3 | 3 | 2 | 2 | 2 | 1 | 1 | 1 | 1 | 1 | 1 |
Validity of included studies assessed appropriately
| 3 | 3 | 2 | 3 | 2 | 2 | 2 | 1 | 1 | 1 | 1 | 1 | 1 |
Methods used to combine the findings of studies reported
| 3 | 3 | 3 | 3 | 3 | 3 | 3 | 2 | 3 | 3 | 2 | 2 | 3 |
Findings of studies combined appropriately
| 3 | 3 | 3 | 3 | 3 | 3 | 3 | 2 | 3 | 3 | 2 | 2 | 2 |
Conclusions made by authors supported by analysis
| 3 | 3 | 3 | 3 | 3 | 3 | 2 | 3 | 3 | 2 | 3 | 2 | 3 |
Overall Quality Score
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7
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7
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6
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6
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5
|
5
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4
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3
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3
|
3
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3
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2
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2
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Citation | NHMRC level of evidence | Included studies | Total participants | Participants condition | Inclusion criteria | Intervention | Outcomes | Results | Conclusion |
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Agarwal et al. [17] | I | 37 | 9446 | Hypertension | • Published between 1966-2010 | Home BP monitoring compared to a control group. | • BP - diastolic, systolic and mean arterial • Medication use | Compared with clinic based measurements, home based BP monitoring; • Improved systolic BP (SMD −2.63 mmHg, 95% CI −4.24 to −1.02; 22 studies) • Improved diastolic BP (SMD - 1.68 mmHg, 95% CI −2.58 to −0.79 mmHg; 22 studies) • Improved mean arterial pressure (SMD −4.0 mmHg, 95% CI −6.22 to −1.79 mmHg; 3 studies) • Reduced medication use (RR 2.02, 95% CI 1.32 to 3.11; 10 studies) • Reduced therapeutic inertia (RR 0.82, 95% CI 0.68 to 0.99; 15 studies) • Led to no greater increase in medication (RR 0.94, 95% CI 0.75 to 1.19; 12 studies) | • Compared with clinic BP monitoring alone, home BP monitoring had the potential to overcome therapeutic inertia [no change in medication]. • Lead to a small but significant reduction in systolic and diastolic BP.• Hypertension management with home BP monitoring can be enhanced when used with telemonitoring. |
Neubeck et al. [18] | I | 11 | 3145 | Coronary Heart Disease | • English language • Published between 1990-2008 | Intervention involved home monitoring with 50% patient provider contact for risk factor modification and advice/counselling for CHD patients | • All-cause mortality • Modifiable risk factors including cholesterol (and associated measures), BP, BMI, Smoking Status, Physical Activity • Quality of life • Cost | Compared to the control group the evidence suggests that the intervention group had; • Reduced total cholesterol (WMD 0.37 mmol/L, 95% CI: 0.19 to 0.56, 9 studies) • Reduced low-density lipoprotein cholesterol (WMD 0.41 mmol/L, 95% CI: 0.36 to 0.56, 4 studies) • Reduced systolic blood pressure (WMD 4.69 mmHg, 95% CI 2.91 to 6.47, 7 studies) • Reduced risk of smoking (RR 0.83, 95% CI: 0.70 to 0.99, 7 studies) | • Telemonitoring interventions provided effective risk factor reduction and secondary prevention in patients with CHD. • Telemonitoring could increase the uptake of formal secondary prevention by those who do not access cardiac rehabilitation, and narrow the current gap between evidence and practice. |
• Telephone based telemonitoring – 9 studies | |||||||||
• Internet based telemonitoring – 2 studies | |||||||||
Omboni et al. [19] | I | 12 | 5044 | Hypertension | • English language • Published between inception - 2010 | Home BP monitoring with data being automatically transferred compared to control group. | • Change in BP (diastolic, systolic and normalisation) • Medication | Compared to controls the overall effect of home BP monitoring was; • Improved office systolic BP (5.64 mm Hg, 95% CI: 7.92 to 3.36 mm Hg, 11 studies) • Improved office diastolic BP (2.78 mm Hg, 95% CI: 3.93 to 1.62 mm Hg, 11studies) • Improved ambulatory systolic BP (2.28 mm Hg, 95% CI: 4.32 to 0.24 mm Hg; 3 studies) • Improvement in BP control (RR 1.31, 95% CI: 1.06 1.62, 5 studies) | • Home blood pressure telemonitoring may represent a useful tool to improve blood pressure control but well-designed large-scale trials are still needed to demonstrate its clinical usefulness. |
Verberk et al. [20] | I | 9 | 2662 | Hypertension | • English language • No restriction on dates reported | Home BP transmitted via telephone, internet, modem or mail. | • BP - diastolic, systolic • Medication | • Increased use of antihypertensive medications (WMD +0.22, 95% CI: +0.02, +0.43, 5 studies) Compared with usual care, home based BP monitoring; • Reduced systolic BP (5.19 mmHg, 95% CI 2.31 to 8.07; 9 studies) • Reduced diastolic BP (2.11 mmHg, 95% CI 0.52 to 3.69; 9 studies) • There was no significant difference between groups in the number of patients that reached their target blood pressure (3 studies) | • Telecare led to a greater decrease in systolic and diastolic blood pressure than usual care. For systolic blood pressure, this decrease was greater in trials without treatment modification. |
Citation | NHMRC level of evidence | Included studies | Total participants | Inclusion criteria | Intervention | Outcomes | Results |
---|---|---|---|---|---|---|---|
Chaudhry et al. [21] | I | 9 | 3582 | • English language • Published between 1966-2006 | Nurse-led telephone symptom monitoring (no meta analysis) – 5 studies Automated monitoring of signs & symptoms – 1 study Automated physiological monitoring – 1 study Comparisons of two or more methods of telemonitoring (no meta-analysis) – 2 studies | • All cause and HF mortality • All cause and HF admissions • Cost | • Reduced all-cause hospitalisation (47%) (1 study) • Reduced HF hospitalisations (2 studies) (20-50% reduction) • No significant difference in HF hospitalisations (2 studies) • Reduced emergency room visits (95% CI 0.36-0.80)(1 study) • Reduced mortality (1 study) • Reduced health care costs ($1000 less per patient) (1 study) • No significant difference in all-cause hospitalisations (1 study) • Reduced mortality (56% - 95% CI 0.22-0.85) (1 study) • Reduced HF hospitalisations (1 study) (40% - 95% CI 0.45-0.82) • Reduced health care costs ($276705 less 6-month cumulative readmission charges in the intervention group) (1 study) • Both physiologic monitoring and regular nurse telephone calls showed improved mortality and hospitalisation rates compared to usual care (1 study). • No between group differences in mortality and hospitalisation rates between physiologic monitoring and regular nurse telephone calls (12.7% vs 15.9%) (1 study). • Both video conferencing and nursing support by telephone showed reduced 6-month HF readmission charges compared to usual care (1 study). • No between group differences in 6-month HF readmission charges were seen between video conferencing and nursing support by telephone (1 study). |
Clark et al.[10] | I | 14 | 4264 | • English language • Published between 2002-2006 | Telemonitoring – 4 studies Structured telephone support – 9 studies Telemonitoring and structured telephone support – 1 study | • All-cause admissions • HF admissions • Quality of life • Acceptability • Cost • All-cause mortality | • Both interventions were associated with a statistically significant 20% reduction in all-cause mortality (RR 0.80, 95% CI: 0.69 to 0.92; 14 studies) |
• A decrease in all-cause mortality was more pronounced with telemonitoring (RR 0.62, 95% CI: 0.45 to 0.85; 4 studies) than with structured telephone support (RR 0.85, 95% CI: 0.72 to 1.01; 9 studies) • HF related hospitalisation was significantly reduced by 20% through remote monitoring programmes (RR 0.79, 95% CI 11%-31%). • None of the 8 studies that reported all cause admission to hospital reported a statistically significant result. The pooled estimates also did not show significant benefit. • 3/6 trials that investigated quality of life reported a significant and substantial improvement. • 3/4 trials of structured telephone support reported lower healthcare costs. • 4 trials reported acceptability of the intervention to patients. | |||||||
Giamouzis et al. [22] | I | 12 | 3,877 | • English language • Published between 1991 and November 2011 • Follow-up of at least 6 months • At least 1 device to measure and transmit physiological data | Intervention involved recording physiological data by portable devices, and transmitting data remotely to a server. | • CVD related mortality • All-cause mortality • Hospitalisation/Readmissions • Cost | Compared to controls the telemonitoring groups had: • Reduced hospitalisation rates that reached statistical significance (3 studies) • Reduced hospitalisation rates without reaching statistical significance (4 studies). • Statistically significant reduced all-cause mortality (3 studies). • Fewer reported deaths, however these results were not statistically significant (5 studies) • Evidence for costs associated with telemonitoring were mixed with two studies finding cost reductions and one study finding increased costs. • In four studies there were more re-hospitalisations in telemonitoring groups compared to usual care groups, but these findings were either not statistically significant or significance was not reported. |
Inglis et al.[8] | I | 25 | 8323 | • Published between 1999 – 2008 | Telemonitoring (transfer of daily data) – 11 studies Structured Telephone support – 16 studies Both interventions – 2 studies | • HF and all-cause admissions • Quality of life • Acceptability • Cost • All-cause mortality • Length of stay | • Telemonitoring reduced all-cause mortality (RR 0.66, 95% CI: 0.54–0.81; 11 studies) • Structured telephone support showed a non-significant trend towards reduced all-cause mortality (RR 0.88 95% CI: 0.76– 1.01; 15 studies) • Both telemonitoring (RR 0.79, 95% CI: 0.67–0.94; 4 studies), and structured telephone support (RR 0.77, 95% CI 0.68–0.87; 13 studies) reduced chronic heart failure related hospitalisations • Both interventions improved quality of life, reduced costs, and were acceptable to patients • 1/6 studies reported a statistically significant reduction in length of stay, with a further 2 studies reporting a non-significant reduction |
Klersy et al. [23] | I | 21 | 5715 | • Published before September 2009 • RCTS reporting hospitalisation and LOS data | Either structured telephone monitoring or technology assisted monitoring – collectively referred to as remote patient monitoring. | • Hospitalisations • LOS • Cost • Quality of life | • Remote patient monitoring was associated with significantly fewer hospitalizations for HF (incidence rate ratio: 0.77, 95% CI 0.65–0.91, P < 0.001) (18 studies) • Remote patient monitoring was associated with significantly fewer hospitalizations for any cause (incidence rate ratio: 0.87, 95% CI: 0.79–0.96, P = 0.003) (18 studies) • LOS was not different between remote patient monitoring and usual care for either HF hospitalisations (95% CI 20.12–0.13, P = 0.88) or all-cause hospitalisation (95% CI 20.18–0.02, P = 0.83) (12 studies). • RPM reduced costs between 300 to 1000 euros • RPM was associated with a gain of 0.06 quality-adjusted life years – 0.02 due to reduced mortality and 0.04 due to reduced hospitalisation |
Louis et al. [24] | III1
| 24 | Not reported accurately | • English language • Published between 1966-2002 | Home monitoring using specialised devices in conjunction with a telecommunication systems. | • All-cause mortality • HF admissions • Length of stay • Quality of life • Acceptability • Compliance • Cost • ED presentations | • Observational studies suggested that telemonitoring: • Reduced hospitalisation (10 studies) and readmission rates (2 studies) • Reduced length of stay (4 studies) • Reduced ED presentations (2 studies) • Reduced inpatient costs (1 study) • Was acceptable to patients (3 studies), patients were highly satisfied (>86%)(2 studies) and improved quality of life (1 study). Compared with usual care telemonitoring RCTs: • Reduced hospitalisation (2 studies) and readmission rates (1 study) • Reduced mortality (1 study) |
• Reduced length of stay (1 study) | |||||||
• Improved quality of life and high patient satisfaction (1 study) | |||||||
Maric et al. [25] | IV2
| 56 | -- | • English language • Published before August 2007 | Device-based technologies - 16 studies Telephone touch-pads - 12 studies Video-consultation-based studies - 3 studies Website-based telemonitoring - 5 studies Combined modalities - 21 | • Hospitalisation • Quality of life • Medication • Cost • Length of stay | • Decreased hospitalizations (8 studies) • Improved QOL (5 studies) • Fewer re-hospitalizations and combined events (1 study) • Reduced time to target drug dosage (1 study) • No significant changes (1 study) • Change in mood (1 study) • Improved QOL (1 study) • Reduced hospital length of stay (1 study) • Increased hospital length of stay (1 study) • Decreased hospitalizations (7 studies) • Reduced costs (6 studies) |
Martínez et al. [26] | IV3
| 42 | Not reported accurately | ||||
• English and Spanish language • Published between 1951-2004 | Home monitoring of HF patients using peripheral devices for measuring and automatically transmitting data. | • Cost • Acceptability • Health status • Hospital admissions • Length of stay • Quality of life • Feasibility/viability | • Compared to the control groups the evidence suggests that telemonitoring; • Improved quality of life (12 studies) • Reduced length of hospitalisation (12 studies) • Reduced mortality (4 studies) • Reduced costs (9 studies) • Reduced unattended emergencies (1 study) • Equipment easy to use (5 studies) | ||||
Seto [27] | III4
| 10 | 586 | • English language • Published between inception – April 2010 | Telemonitoring systems with a component of home physiological measurements. | • Cost | • 9/10 studies analysed direct healthcare system costs. 1/10 study investigated direct patient costs. • All the studies found cost reductions from telemonitoring compared to usual care, ranging between 1.6% and 68.3% • Cost reductions were predominantly attributed to reduced hospitalisation expenditures. • A 3.5% lower direct patient costs was identified, related to patient travelling. • 55% of patients were willing to pay $20 to use telemedicine and 19% were willing to pay $40. |
Synthesis of reviews of hypertension & CVD management
Blood pressure
Medication use
Synthesis of reviews of heart failure management
Hospital admission
Length of stay
Mortality
Reference | Intervention | Results |
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Chaudhry et al. [21] | Automated monitoring of signs & symptoms | 56% reduced mortality (1 study) |
95% CI 0.22-0.85 | ||
Clark et al. [10] | Telemonitoring – 4 studies | 20% reduction in all-cause mortality (RR 0.80, 95% CI: 0.69 to 0.92; 14 studies) |
Structured telephone support – 9 studies | Decrease in all-cause mortality more pronounced with telemonitoring (RR 0.62, 95% CI: 0.45 to 0.85; 4 studies) than with structured telephone support (RR 0.85, 95% CI: 0.72 to 1.01; 9 studies) | |
Telemonitoring and structured telephone support – 1 study | ||
Giamouzis et al. [22] | Telemonitoring | Statistically significant reduced all-cause mortality (3 studies). |
Inglis et al. [8] | Telemonitoring (transfer of daily data) – 11 studies | Telemonitoring reduced all-cause mortality (RR 0.66, 95% CI: 0.54–0.81; 11 studies) |
Structured Telephone support – 16 studies | Structured telephone support showed a non-significant trend towards reduced all-cause mortality (RR 0.88 95% CI: 0.76– 1.01; 15 studies) |