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2nd Concertation Meeting. Evidence in telemedicine: a literature review. Brussels, September 8, 2011 Reinhard Prior, Scientific Coordinator, HIM. Telemedicine vs eHealth. Telemedicine "Medicine at a Distance". 1892. - PowerPoint PPT Presentation

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  • 2nd Concertation MeetingBrussels, September 8, 2011

    Reinhard Prior, Scientific Coordinator, HIMEvidence in telemedicine: a literature review

  • Telemedicine vseHealth

  • Telemedicine

    "Medicine at a Distance"

  • Alexander Graham Bell inaugurating the first telephone line from New York to Chicago, 18921892

  • Safety?Clinical effectiveness?Patient perspectives? Economic aspects?Organisational aspects?Socio-cultural,ethical and legal aspects?The MAST domains1911

  • 2011

  • More chronic disease Sophisticated medical protocols Clinical guidelines to be followed Budget restrictions

  • 2011 Evidenced based medicine

    HTA

    MAST et al.

  • What is the current evidence?

  • Levels of EvidenceCochranereviews

  • Evidence by numbersTotal number of publications: 13504Medline Search for "Telemedicine or Telemonitoring" (5.9.11)TM + Meta-Analysis: 50TM + Randomized controlled trial: 756 TM + Systematic review: 110 TM+ Cochrane review: 4TM + Trial: 1269

  • Consolidated standards of reporting trials 25 item checklist

    Flow diagramwww.consort-statement.org

  • J Am Med Inform Assoc, July 29, 2011

  • 32 / 3784 papers analyzed

    43 % : Objectives not clearly defined34%: Sample size calculation missing29%: Outcomes not clearly identified62%: Adverse events not reported80%: Information on long-term implementation missing

    Only 40% were of superior quality (> 3 Jadad points)

    Augestad et al, 2011

  • Archibald Leman Cochrane

    (1909-1988)

  • "28000 health care professionals from over 100 countries work together to help health care providers, policy makers, patients and carers to make well informed decisions based on the best available research evidence by systematic reviews of RCTs"

  • 2000: General review on telemedicine versus face to face patient care"Establishing systems for patient care using telecommunications technologies is feasible, but there is little evidence of clinical benefits. The studies provided variable and inconclusive results for other outcomes such as psychological measures, and no analysable data about the cost effectiveness of telemedicine systems. The review demonstrates the need for further research and the fact that it is feasible to carry out randomised trials of telemedicine applications. Policy makers should be cautious about recommending increased use and investment in unevaluated technologies".

  • 2010: Asthma (21 RCTs analyzed)"Telehealthcare interventions are unlikely to result in clinically relevant improvements in health outcomes in those with relatively mild asthma, but they may have a role in those with more severe disease who are at high risk of hospital admission. Further trials evaluating the effectiveness and cost-effectiveness of a range of telehealthcare interventions are needed."

  • July 2011: COPD (10 RCTs analyzed) 70% reduction in ermergency room visits 54% reduction in hospital admissions No difference in death rate"Telehealthcare in COPD appears to have a possible impact on the quality of life of patients and the number of times patients attend the emergency department and the hospital. However, further research is needed to clarify precisely its role since the trials included telehealthcare as part of more complex packages."

  • August 2010: CHF (25 RCTs analyzed, 16 telephone support, 9 telemonitoring)34 % mortality reduction for telemonitoring (!)

    Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and CHF-related hospitalisations in patients with CHF; they improve quality of life, reduce costs, and evidence-based prescribing.

  • November 2010

  • November 2010

  • Single, but large studies may be more appropriate to avoid invalid conclusions even from high quality meta-analyses

  • Current directions in CHF:

    1: Still more studies (TIM-HF II)

    2: Subgroup analysis

    Which patients do benefit?

    Which components of the interventions are most effective?

    Which level of technology is appropriate?

  • Lancet, Feb 10, 2011

  • 40% reduction in hospitalisation

  • Thank you!

  • ExplanatoryPragmaticQuestion?Efficacycan the intervention work?Effectivenessdoes the intervention work when used in normal practice?SettingWell resourced, ideal settingNormal practiceParticipantsHighly selected. Poorly adherent participants and those with conditions which might dilute the effect are often excludedLittle or no selection beyond the clinical indication of interestInterventionStrictly enforced and adherence is monitored closelyApplied flexibly as it would be in normal practiceOutcomesOften short term surrogates or process measures (e.g. change in blood pressure)Directly relevant to participants, and health care authorities (e.g. quality of life, cost analysis). Relevance to practiceIndirectlittle effort made to match design of trial to decision making needs of those in usual setting in which intervention will be implementedDirecttrial is designed to meet needs of those making decisions about treatment options in setting in which intervention will be implemented

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