Appendix X: Telehealth research/evidence base · Appendix X: Telehealth research/evidence base A search of the recent literature and research was conducted by the Cornwall Health

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Appendix X: Telehealth research/evidence base A search of the recent literature and research was conducted by the Cornwall Health Library reviewing Medline, Embase, Cinahl

databases from the last search undertaken for the 2016 service review to the current date. The search question was: “what is the

evidence base for the clinical and/or cost effectiveness of Telehealth (remote monitoring) service/s?” The definition of Telehealth

that was used is: ‘the remote monitoring of patients in their own homes to anticipate exacerbations early and build their self-care

competencies.’ This therefore does not include telemedicine or telecare. Only published articles were included.

Reviews of economic evaluations of telemedicine have identified methodological problems as there are no set evaluation criteria to

systematically compare and contrast studies against. What the research does demonstrate is that each Telehealth service has

different components to it which will undoubtedly influence the outcomes which include the components of technology, economics,

education, clinical, organisational and users' perspective.

Source/Year Research methodology

Research title/web link Location/number in study

Aim/ Intervention Main findings

Positive evidence Journal of Medical Internet Research Jan 2017

19 systematic reviews

Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews.

Author(s): Bashi, Nazli; Karunanithi, Mohanraj; Fatehi, Farhad; Ding, Hang; Walters, Darren

Source: Journal of medical Internet research; Jan 2017; vol. 19 (no. 1); p. e18

The aim of this study was to investigate the effects of remote patient monitoring interventions on the health outcomes of patients with heart failure. Reviews consisted of diverse interventions such as telemonitoring, home telehealth, mobile phone-based monitoring, and videoconferencing. Quality of life, rehospitalisation, emergency department visits, and length of stay were reported as outcomes. Self-

Telemonitoring and home telehealth appear generally effective in reducing heart failure rehospitalisation and mortality. Other interventions, including the use of mobile phone-based monitoring and videoconferencing, require further investigation.

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care and knowledge were less commonly identified.

ClinicoEconomics and Outcomes Research July, 2017**

Cluster-randomised trial

Subgroup analysis of telehealthcare for patients with chronic obstructive pulmonary disease: The cluster-randomized danish telecare north trial

Author(s): Udsen F.W.; Ehlers L.H.; Lilholt P.H.; Hejlesen O.K.

Source: ClinicoEconomics and Outcomes Research; Jul 2017; vol. 9 ; p. 391-401

Denmark. 1,225 patients with chronic obstructive pulmonary disease (COPD).

Telehealthcare The study concludes that, across the COPD severities, patients with severe COPD are likely to be the most cost-effective group. This is primarily due to lower hospital-admission and primary-care costs. Telehealthcare for patients younger than 60 years is also more likely to be cost-effective than for older COPD patients. NB: The health system is not comparable and our local Telehealth service has a higher proportion of older people on it. The 2016 service review data showed the average age was 74.5% and only 17% were under 60 years of age. Our local service also does not have any referral criteria based on severity of condition.

NB: This is the same group of individuals that feature in 2 other papers indicated by ** in the journal title column

Diabetes June, 2017

Remote interventions improving specialty complex care (RIISCC) for patients with type 2

USA. Over 21 months 905 patients experienced the intervention

The aim was to evaluate the impact of implementing remote patient monitoring (Telehealth) services on type 2 diabetes

Conclusion: The probability of readmission for any condition was 34% lower in Telehealth.

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diabetes

Author(s): Eiland L.A.; Siahpush M.; Schwab R.J.; Su D.; Michaud T.L.; Tyson G.M.; Devany M.E.; Larsen J.L.

Source: Diabetes; Jun 2017; vol. 66

(T2DM) outcomes for patients transitioning from an academic hospital to home. The 90 day intervention included: 1) daily remote blood pressure, weight, pulse and glucose monitoring, 2) weekly coaching and education phone calls by an assigned nurse, and 3) 90 day remote interactive video visit for diabetes education.

Transitions of care for T2DM patients from the hospital to home can be difficult. These preliminary data suggest Telehealth hold particular promise for improving T2DM outcomes, readmission rates, and cost of care after hospital discharge. NB: Our local service also reports a high level of clinical coaching, but there are local opportunities to use DIASEND for people with brittle diabetes to send readings directly to the Diabetic Support Nurses for monitoring / support / medicine optimisation and positive findings from a community pharmacy project working with people with diabetes-using generic health coaching and Patient Activation Measures..

Journal of Human HypertensionJuly, 2017

Review of 46 randomised controlled trials including a total of 13,875 cases

Effectiveness of home blood pressure telemonitoring: A systematic review and meta-analysis of randomised controlled studies

Author(s): Duan Y.; Xie Z.; Dong F.; Wu Z.; Lin Z.; Sun N.; Xu J.

To summarise evidence about the effectiveness of home blood pressure telemonitoring

Compared with usual care, HBPT improved office systolic blood pressure (BP) and diastolic BP by 3.99 mm Hg (95% confidence interval (CI). NB: The clinical view is that this is unlikely to be cost effective.

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Source: Journal of Human Hypertension; Jul 2017; vol. 31 (no. 7); p. 427-437

Diabetes Technology and TherapeuticsAugust, 2017

Randomized Controlled Trial of Technology-Assisted Case Management in Low Income Adults with Type 2 Diabetes

Author(s): Egede L.E.; Williams J.S.; Voronca D.C.; Knapp R.G.; Fernandes J.K.

Source: Diabetes Technology and Therapeutics; Aug 2017; vol. 19 (no. 8); p. 476-482

113 people were randomized to either technology-assisted case management intervention or usual care.

Aim to assess the efficacy of technology-assisted case management with medication titration by nurses using guideline-based algorithms, under physician supervision in improving glycemic control in low-income rural adults with poorly controlled type 2 diabetes.

Conclusions: Technology-assisted case management by a nurse with medication titration under physician supervision is efficacious in improving glycemic control in low-income rural adults with poorly controlled type 2 diabetes.© NB: There are local opportunities to use DIASEND for people with brittle diabetes to send readings directly to the Diabetic Support Nurses for monitoring / support / medicine optimisation

Journal of Cardiac Failure September, 2017

Review of randomised control trials and meta analysis.

Comparative Effectiveness of Telemonitoring Versus Usual Care for Heart Failure: a Systematic Review and Meta-Analysis.

Author(s): Yun, Ji Eun; Park, Jeong-Eun; Park, Hyun-Young; Lee, Hae-Young; Park, Dong Ah

Source: Journal of cardiac

failure; Sep 2017

Thirty-seven randomized controlled trials (9582 patients) of Telemonitoring met the inclusion criteria: 24 studies on all-cause mortality, 17 studies on all-cause hospitalisation, 12 studies on Heart Failure-related hospitalisation, and 5 studies on HF-

Aim to evaluate the effectiveness of telemonitoring (TM) in the management of patients with heart failure.

Telemonitoring showed a benefit when three or more biological data are transmitted or when transmission occurred daily. Telemonitoring intervention reduces the mortality risk in patients with heart failure, and intensive monitoring with more frequent transmissions of patient data increases its effectiveness. NB: We are unable to source detailed data from Telehealth to ascertain the number of biometric readings collated for

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related mortality. the cohort and know that not every individual is monitored daily.

The European Journal of General Practice December, 2017

One-year follow-up before and after exploratory study, without control group.

Telemonitoring in-home complex chronic patients from primary care in routine clinical practice: Impact on healthcare resources use.

Author(s): Martín-Lesende, Iñaki; Orruño, Estibalitz; Mateos, Maider; Recalde, Elizabete; Asua, José; Reviriego, Eva; Bayón, Juan Carlos

Source: The European journal of general practice; Dec 2017; vol. 23 (no. 1); p. 135-142

28 patients Aim to assess the impact of a primary care-based home telemonitoring intervention for highly unstable chronic patients on the use of healthcare resources. The intervention consisted of patient's self-measurements and responses to a health status questionnaire, sent daily from smartphones to a web-platform (aided by an alert system) reviewed by healthcare professionals. The primary outcome measure was the number of hospital admissions occurring 12 months before and after the intervention. Secondary outcomes were length of hospital stay and number of emergency department attendances. Primary care nurses were mainly in charge of the telemonitoring process and were assisted by the general practitioners when required.

In this small exploratory study, the primary care-based telemonitoring intervention seemed to have a positive impact decreasing the number of hospital admissions and emergency department attendances.

NB: Numbers are small and there was no statistical difference reported-our own local analysis reported in the 2016 service review report of a statistical difference of 47 saved admissions (looking at a cohort of 217 people) is more robust.

This model was based in primary care and therefore integrated and embedded rather than being a standalone service like our local service. There was also no control group.

Journal of Medical Internet

Impact of At-Home Telemonitoring on Health Services Expenditure and

Australia A total of 100 test patients and 137

Aim to evaluate the impact of introducing at-home telemonitoring to patients living

At-home telemonitoring of chronically ill patients showed a statistically robust positive

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Research Medical Informatics September, 2017

Hospital Admissions in Patients With Chronic Conditions: Before and After Control Intervention Analysis.

Author(s): Celler, Branko; Varnfield, Marlien; Nepal, Surya; Sparks, Ross; Li, Jane; Jayasena, Rajiv

Source: JMIR medical informatics; Sep 2017; vol. 5 (no. 3); p. e29

control patients were analysed.

with chronic conditions on health care expenditure, number of admissions to hospital, and length of stay. Each test patient was case matched with at least one control patient. Test patients were supplied with a telehealth vital signs monitor and were remotely managed by a trained clinical care coordinator, while control patients continued to receive usual care.

impact increasing over time on health care expenditure, number of admissions to hospital, and LOS as well as a reduction in mortality. NB: This model seems to match our local service. The analysis of the data is robust although there analysis demonstrated how they estimated changes in the rate of expenditure and savings over a year based on readings from only 30 days post start of Telehealth intervention projected across to one year rather than actual.

Expert Review of Medical Devices April, 2017

Review The management of patients with chronic heart failure: the growing role of e-Health.

Author(s): Piotrowicz, Ewa

Source: Expert review of medical devices; Apr 2017; vol. 14 (no. 4); p. 271-277

This paper's aims are to present different forms of e-Health including telecare, home monitoring of cardiovascular implantable electronic devices, remote monitoring of hemodynamic implantable devices and telerehabilitation in providing optimal long term management for heart failure patients. Areas covered: E-education and self-monitoring, structured telephone support and telemonitoring, remote monitoring of cardiovascular implantable electronics devices and hemodynamic implantable electronic devices

The data analysed in the paper suggests that remote monitoring is capable of identifying life-threatening deterioration and helps heart failure patients avoid seeking medical assistance in hospitals and that home-based telerehabilitation is well accepted, safe, effective and has high adherence among HF patients.

NB: This paper does not attribute the degree of positive outcome to a specific intervention-multiple methods are included.

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and telerehabilitation.

Journal of Medical Internet Research; September, 2017

Personalized Hypertension Management Using Patient-Generated Health Data Integrated With Electronic Health Records (EMPOWER-H): Six-Month Pre-Post Study.

Author(s): Lv, Nan; Xiao, Lan; Simmons, Martha L; Rosas, Lisa G; Chan, Albert; Entwistle, Martin

Source: Journal of medical Internet research; Sep 2017; vol. 19 (no. 9); p. e311

149 patients The model is designed to support timely patient-provider interaction by incorporating decision support technology to individualise care and provide personalised feedback for patients with chronic disease. Central to this process were patient-generated health data, including blood pressure (BP), weight, and lifestyle behaviours, which were uploaded using a smartphone. The aim of this study was to evaluate the programme among patients within primary care already under management for hypertension and with uncontrolled blood pressure.

Technologically enabled blood pressure home-monitoring, with structured use of patient-generated health data and a personalised care-plan facilitating patient engagement, can support effective clinical management. The experience gained in this study provides support for the feasibility and value of using carefully managed patient-generated health data in the day-to-day clinical management of patients with chronic conditions. NB: The consultation process demonstrated that not everyone on Telehealth has/ or was aware that they had a personalised care plan. In addition individuals stated that they did not have access to something that stated what their health parameters were and what actions they should take if their readings were too high/low-this would be in a care/management plan.

Journal of Telemedicine and Telecare January, 2017

Maugeri Centre for Telehealth and Telecare: A real-life integrated experience in chronic patients.

Italy. 1635 patients recruited across five years.

Delivery of a telehealth programme tailored to a specific disease: chronic obstructive pulmonary disease (COPD)/chronic respiratory

Results show a reduction of the re-hospitalisation rate and costs, and increase in quality of life and patient satisfaction with the service. Conclusion:

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Author(s): Scalvini, Simonetta; Bernocchi, Palmira; Zanelli, Emanuela; Comini, Laura; Vitacca, Michele; Maugeri Centre for Telehealth and Telecare (MCTT)

Source: Journal of telemedicine and telecare; Jan 2017

insufficiency; amyotrophic lateral sclerosis/neuromuscular diseases; chronic heart failure (CHF); post-stroke; and post-cardiac surgery patients discharged from hospital after an acute event. Interventions (their nature was not described in detail) were performed by a nurse tutor with some specialist second pinion activities

multidisciplinary telehealth and telecare integrated approach can provide efficient management for the growing number of complex patients. NB: The paper describes a telehealth and telecare centre which is multi-disciplinary and does not make the distinction on attributing what evidence to one or the other. Our local service is Telehealth only and uni-disciplinary (nurse).

Health Services Research January, 2017

Matched control analysis

Telemedical Care and Monitoring for Patients with Chronic Heart Failure Has a Positive Effect on Survival.

Author(s): Herold, Robert; van den Berg, Neeltje; Dörr, Marcus; Hoffmann, Wolfgang

Source: Health services

research; Jan 2017

USA. 3,719 suitable controls were matched to 1,943 patients on telehealth.

Telemedical care and monitoring programs for patients with chronic heart failure

The probabilities to survive after 1 and 2 years were significantly increased in the intervention group who had telehealth. The findings indicate that patients with chronic heart failure may benefit from telemonitoring in routine care. NB: The support offered was trained nurse health coaching and counselling, information leaflets and remote monitoring-similar to our local service although this study had more planned health coaching interventions rather than the reactive responses of our service. The study is quite out-dated-from 2006.

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No evidence of positive impact British Medical Journal, 2017**

A cluster-randomised trial

Telehealthcare for patients suffering from chronic obstructive pulmonary disease: Effects on health-related quality of life: Results from the Danish TeleCare North' cluster-randomised trial

Author(s): Lilholt P.H.; Udsen F.W.; Ehlers L.; Hejlesen O.K.

Source: BMJ Open; May

2017; vol. 7 (no. 5)

Denmark 1,225 people (578 interventions, 647 controls)

Aim to assess the effect of telehealthcare compared with usual practice in patients with chronic obstructive pulmonary disease (COPD).

The overall sample and all subgroups demonstrated no statistically significant differences in Health Related Quality of Life between telehealthcare and usual practice. There was a suggestion that having the equipment may have provided a psychological benefit to individuals. NB: This is the same group of individuals that feature in 2 other papers indicated by ** in the journal title column. The method of intervention is similar to our local service although our local service had the additional facility for the patient to contact the service whereas in this model it was one way only from the service to the patient.

British Medical Journal, May 2017**

12-month cost-utility analysis conducted alongside a cluster-randomised trial.

Cost-effectiveness of telehealthcare to patients with chronic obstructive pulmonary disease: Results from the Danish TeleCare North' cluster-randomised trial

Author(s): Udsen F.W.; Ehlers L.; Lilholt P.H.; Hejlesen O.

Source: BMJ Open; May

Denmark 1225 patients with chronic obstructive pulmonary disease were enrolled, of which 578 patients were randomised to telehealthcare and 647 to usual care

Aim to investigate the cost-effectiveness of a telehealthcare solution in addition to usual care compared with usual care. The primary outcome measure for the cost-effectiveness analysis was the incremental cost-effectiveness ratio (ICER) expressed as the total cost per quality-adjusted

Telehealthcare is unlikely to be a cost-effective addition to usual care. COPD-specific hospital admissions costs are roughly the same in the telehealthcare and usual care group. NB: This is the same group of individuals that feature in 2 other papers indicated by ** in the journal title column

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2017; vol. 7 (no. 5) life-year (QALY) gained measured from baseline to follow-up at 12 months.

NB: The patients were monitored by ‘main stream teams’-primary healthcare nurses and assistants not a separate Telehealth service. The methods of intervention were similar to our local service, but it was 24/7 service. GPs were responsible for setting the health parameters. Methodology for collecting all health and social care costs was more robust than our service activity/impact data as their patient registration system allows for more linked data than in the UK.

Journal of Human HypertensionFebruary, 2017

Randomized, controlled, 3 months' trial.

Short-term telemedical home blood pressure monitoring does not improve blood pressure in uncomplicated hypertensive patients

Author(s): Hoffmann-Petersen N.; Bech J.N.; Pedersen E.B.; Lauritzen T.

Source: Journal of Human Hypertension; Feb 2017; vol. 31 (no. 2); p. 93-98

Denmark 375 people

The aim was to review telemonitoring of home blood pressure measurements as a supplement to diagnosis, control and treatment of hypertension.

Both the patients on the trial and those who were ‘controls’ achieved a significant blood pressure reduction in this 3-month trial. There was no difference in blood pressure reduction or number of patients reaching blood pressure goals. Further information and education of some general practitioners seem to be relevant regarding blood pressure management and control of hypertension

European Research in TelemedicineJuly, 2017

Review of studies

Les lecons apprises des principales etudes sur les objets connectes en telemedecine et sante

France Aim to review the impact of connected devices, selected mobile apps, SMS, emails, Telehealth.

The literature data are numerous, but the published results remain controversial, often due to poor methodological

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mobile

Lessons learned from key studies on connected devices in telemedicine and mobile health

Author(s): Simon P.

Source: European Research in Telemedicine; Jul 2017; vol. 6 (no. 2); p. 67-77

studies. The majority of the selected studies did not show a real ‘medical service’ to patients, both by systems of telemonitoring at home for patients with chronic diseases, and by different mobile digital technologies in the day-to-day practice of health professionals. The economic impact of the use of digital objects connected to medical purpose showed no reduction of costs. The few studies that have demonstrated clinical benefits remain anecdotal and their results require to be confirmed by further studies.

Frontiers in Pharmacology May 2017

Randomized controlled studies on the effectiveness of telemedicine in people with type 1 diabetes

Telemedicine for the management of glycaemic control and clinical outcomes of type 1 diabetes mellitus: A systematic review and meta-analysis of randomized controlled studies

Author(s): Lee S.W.H.; Ooi L.; Lai Y.K.

Source: Frontiers in Pharmacology; May 2017; vol. 8

38 studies Aim to synthesize evidence and quantify the effectiveness of telemedicine interventions for the management of glycaemic and clinical outcomes in type 1 diabetes patients, relative to comparator conditions.

Telemedicine interventions that involve individualised assessments, audit with feedback and skill building were also more effective in improving glycaemic control. However, no benefits were observed on blood pressure, lipids, weight, quality of life, and adverse events. Conclusions and Relevance: There is insufficient evidence to support telemedicine use for glycaemic control and other clinically relevant outcome among patients with

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type 1 diabetes.

Computers, Informatics, Nursing March, 2017

Qualitative interviews

Experience of Home Telehealth Technology in Older Patients With Diabetes.

Author(s): Chang, Chi-Ping; Lee, Ting-Ting; Mills, Mary Etta

Source: Computers, informatics, nursing : CIN; Mar 2017

18 individuals who used Telehealth

The aim was to consider people’s perceptions and suggestions regarding using such a service for diabetes management

Four main themes emerged: (1) initial trial encouragement from the doctors, nurses, and financial incentives; (2) enhanced self-management capability through continuous device use for better outcomes; (3) ambivalent feelings regarding dependence on others for problem solving; and (4) consideration for continual technology use for an uncertain future. These results serve as a reference for promoting, assessing, and verifying telehealth models for older patients with diabetes.

Journal of telemedicine and telecare January, 2017

Systematic review of clinical trial studies on telehealth self-management for older adults with chronic condition(s) published in peer reviewed journals.

The effectiveness of telehealth on self-management for older adults with a chronic condition: A comprehensive narrative review of the literature.

Author(s): Guo, Yuqi;

Albright, David

Source: Journal of telemedicine and telecare; Jan 2017 ; p. 1357633X17706285

31 articles Aim to examine the effectiveness of telehealth technologies on self-management among older adults.

According to the findings of the present study, telehealth technologies have shown effectiveness on improving self-care skills, improving self-monitoring behaviours and improving clinical outcomes among older adults with chronic condition(s) in different settings. Using telehealth technologies is an advisable intervention for promoting older patients' self-management. However, it is critical to consider racial diversity

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and culture-related health behaviour differences when using telehealth technologies.

Journal of Medical Internet Research; May 2017

A metareview (a systematic review of systematic reviews from January 2000 to May 2016) of randomized controlled trials of telehealth interventions to support self-management in 6 exemplar long-term conditions

Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer.

Author(s): Hanlon, Peter; Daines, Luke; Campbell, Christine; McKinstry, Brian; Weller, David; Pinnock, Hilary

Source: Journal of medical Internet research; May 2017; vol. 19 (no. 5); p. e172

53 systematic reviews, comprising 232 unique randomised control trials including diabetes, heart failure, asthma, COPD and cancer.

The objectives of this review were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilisation, and (2) identify components of telehealth support and their impact on disease control and the process of self-management.

While telehealth-mediated self-management it was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.

Mixed/inconclusive evidence

European Journal of Health Economics September, 2017

Comparison of two population groups-12 month intervention.

Health-economic evaluation of home telemonitoring for COPD in Germany: evidence from a large population-based cohort

Author(s): Achelrod D.; Schreyogg J.; Stargardt T.

Germany 651 telemonitoring participants and 7047 individuals in the standard care group.

Aim to analyse the effect of COPD telemonitoring pilot project on direct medical costs, health resource utilisation and mortality at 12 months.

Telemonitoring enrolees used healthcare (all-cause and COPD-related) less intensely with shorter hospital stays, fewer inpatient stays and smaller proportions of people with emergency department visits and hospitalisations

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Source: European Journal of Health Economics; Sep 2017; vol. 18 (no. 7); p. 869-882

(with very severe COPD). Telemonitoring for COPD is a viable strategy to reduce mortality, healthcare costs and utilisation at 12 months. The evidence offers strong support for introducing telemonitoring as a component of case management. Whilst there was a decrease in healthcare utilisation in the telemonitoring group for inpatients, costs and increased in the outpatient sector.

NB: The 2nd

paper above linked cost effectiveness with COPD for those under 60 years. We also have local and national evidence that pulmonary rehab has strong support for self-management

1 (although

capacity is a current issue). This is the 2

nd study that links

effectiveness to severity of COPD-our service has no criteria based on severity and staff in the consultation stated no known link to condition type/severity and their perceived effectiveness of their service-it was person dependent. The

1 https://www.brit-thoracic.org.uk/document-library/clinical-information/pulmonary-rehabilitation/bts-guideline-for-pulmonary-rehabilitation/

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service in this study had additional planned and regular (2-3 wks) phone calls for specific healthy lifestyle/health coaching. Our local service only operates a reactive response to alerts.

British Journal of Urology March, 2017

A questionnaire comprising 39 questions of mixed construction, predominantly closed-ended Likert style statements.

Evaluating a regional and rural urological telehealth service: Patient perceptions

Author(s): Grills R.; Harrison

B.; Moore E.; Willder S.

Source: BJU International;

Mar 2017; vol. 119 ; p. 53

Australia 229 patients

This study investigated the perceptions of patients of accepting and using this Telehealth urology service.

Overall patients' perceptions indicate they are satisfied and accepting of the urological telehealth service provided; with cost (a fee was charged), distance from Hospital and disease complexity being the main determinants. 97 patients (63.5%) preferred telehealth consultations over face-to-face

Clinical Respiratory Journal July, 2017

Randomised Controlled Trial

A RCT of telehealth for COPD patient's quality of life: the whole system demonstrator evaluation

Author(s): Rixon L.; Hirani S.P.; Cartwright M.; Beynon M.; Newman S.P.; Doll H.; Steventon A.; Henderson C.

Source: Clinical Respiratory Journal; Jul 2017; vol. 11 (no. 4); p. 459-469

U.K. 447 participants with Chronic Obstructive Pulmonary Disease completed baseline and either a short (4 months) or long term (12 months) follow-up

Despite some concerns that the introduction of telehealth (TH) may lead to reductions in quality of life (QoL), lower mood and increased anxiety in response to using assistive technologies, this research focuses on the extent to which providing people with tools to monitor their condition can improve QoL.

There was a trend of improved QoL and mood in the TH group at longer-term follow-up, but not short term follow-up.

Primary Health Care; Aug 2017

Health technology and supported self-care in Liverpool.

Author(s): Hughes, Carol

Liverpool, UK 4,500

Telehealth (including educational videos) for people to actively manage long-term conditions such as chronic

Nil evidence presented-more of a discussion on how digital technology is used in Liverpool to support patients' self-care,

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Source: Primary Health Care; Aug 2017; vol. 27 (no. 7); p. 22-25

obstructive pulmonary disease (COPD), heart failure and diabetes, and to encourage behaviour change through supported care.

examining what role nurses play in service provision and outlining how the service has developed. NB: The Telehealth model is similar to our local service but has the additional intervention of patient educational videos, using fixed care plans and healthcare assistants. The healthcare assistants were linked into GPs and specialist nurses for support. Our local standalone service uses trained nurses and people do not have their own care plans.

Nursing Standard July, 2017

Literature review. The research question was: 'Do adults with hypertension being monitored with telehealth/telemonitoring have a higher quality of life and improved management compared with standard care?'

Using telehealth in the management of hypertension.

Author(s): Harrison,

Charlotte Elizabeth

Source: Nursing Standard; Jul 2017; vol. 31 (no. 48); p. 44-49

U.K. Aim To explore the usefulness of, and evidence for, telehealth in the management of hypertension in the primary care setting.

Ongoing challenges with the implementation of telehealth include suboptimal feedback, and reduced patient interest in and compliance with telehealth systems. It was also noted that patients involved in longer trials had a higher withdrawal rate than those enrolled on shorter intense studies. In addition, patient lifestyle choices, including outdoor working, and lack of Wi-Fi proved a challenge to self-monitoring. If not resolved, such challenges could adversely affect the widespread use of telehealth.

Applied Health Economics

A scoping review of

A Scoping Review of Economic Evaluations

Nine studies. The aim of this study was to examine economic evaluations

In six of the nine studies, home monitoring resulted in a

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and Health Policy September, 2017

economic evaluations based on randomised controlled trials

Alongside Randomised Controlled Trials of Home Monitoring in Chronic Disease Management

Author(s): Kidholm K.; Kristensen M.B.D.

Source: Applied Health Economics and Health Policy; Sep 2017 ; p. 1-10

alongside randomised controlled trials of home monitoring in chronic disease management and hereby to explore the resources included in the programme costs, the types of health-care utilisation that change as a result of home monitoring and discuss the value of economic evaluation alongside randomised controlled trials of home monitoring on the basis of the studies identified.

reduction in primary care or emergency contacts. However, in total, home monitoring resulted in increased average costs per patient in six studies and reduced costs in three of the nine studies. The review is limited by the small number of studies found and the restriction to randomised controlled trials. NB: The study stated that consideration should be paid for the use of the patient’s own devices.

Journal of Chronic Obstructive Pulmonary Disease March, 2017

A meta-analysis- a statistical analysis that combines the results of multiple scientific studies.

Continuity of Care to Prevent Readmissions for Patients with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Author(s): Yang F.; Xiong Z.-F.; Li L.; Qiao G.; Wang Y.; Zheng T.; He H.; Hu H.; Yang C.

Source: COPD: Journal of Chronic Obstructive Pulmonary Disease; Mar 2017; vol. 14 (no. 2); p. 251-261

This meta-analysis was aimed to assess the efficacy of continuity of care as interventions, which reduced readmission and mortality rates. Interventions were health education, Telehealth and nursing support.

The results showed that health education reduced all-cause readmission at 3 months. In addition, health education, comprehensive nursing intervention and telemonitoring reduced all-cause readmissions over 6-12 months. Home visits also reduced COPD-specific readmissions, but it did not reduce the risk for all-cause readmissions. There was no statistically significant difference in reducing mortality and quality of life (QOL). In conclusion, nursing interventions, telemonitoring, health education and home visits should receive more consideration than other interventions when working with

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people with COPD. NB: The study design means it’s difficult to attribute outcomes to interventions. Our local service does not offer home visits.

European Journal of Heart Failure May, 2017

A cohort study, prospective, randomised, controlled trial

Home telemonitoring in patients with heart failure: The experience of a region of northern Italy in the EU funded project smartcare

Author(s): Radini D.; Apuzzo G.M.; Stellato K.; Sola G.; Delli Quadri N.; Fragiacomo E.; Di Lenarda A.

Source: European Journal of Heart Failure; May 2017; vol. 19 ; p. 173

Italy 201 people

The aim was to improve integrated social and health care through the implementation of home telemonitoring, empowerment, self-care and self-management of heart failure patients.

"Long term" (6-12 months) telemonitoring was not proven effective. "Short-term" (3-6 months) post-discharge telemonitoring demonstrated a significant reduction in hospital stay due to a reduction of the length of stay (10.2 vs 19.2 days; p=0.01), associated with a significant increase in unplanned contacts, but this required ‘a significant but modest increase in nursing resources.’ NB: Our service retains a large number of people on the service for a long time. In the 2016 review, 82% of individuals were on the service for longer than 6 months, 25% for over 6 years although the service does review everyone each 6 months to view if they are stable and suitable for discharge.

European Journal of Heart Failure May, 2017

A literature search was undertaken between June

Effective interventions to improve self-care in patients with heart failure

Author(s): Klompstra L.;

14 studies were included that had a total of 7 interventions. The

The aim was to systematically summarize outcomes of studies that measured self-care. There were 7

Inconclusive evidence: There are several interventions that have shown to be effective to increase self-care in patients with HF,

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2003 and November 2015

Jaarsma T.; Sedlar N.; Stromberg A.; Martensson J.; Lainscak M.; Farkas J.

Source: European Journal of Heart Failure; May 2017; vol. 19 ; p. 308

average number of patients included in the studies was 225 (range 82-602) and the follow-up period ranged between 3 and 12 months.

interventions cited and Telehealth was one of these.

such as telemonitoring, nurse-led or multidisciplinary-led educational programs. However, at the same time there is a considerable amount of interventions, including the same components as the effective interventions, which did not work to increase self-care. NB: The study methodology is weak, mixing interventions so no clear causal impact is possible. Our local service is nurse led and not integrated within multi-disciplinary teams..

Chronic Respiratory Disease August, 2017

Review of previous papers. Systematic review and meta-analysis quality and the risk of bias of underlying primary studies were assessed

Clinical-effectiveness of self-management interventions in chronic obstructive pulmonary disease: An overview of reviews

Author(s): Murphy L.A.; Harrington P.; Teljeur C.; Ryan M.; Taylor S.J.C.; Smith S.M.; Pinnock H.

Source: Chronic Respiratory Disease; Aug 2017; vol. 14 (no. 3); p. 276-288

16 reviews of a large body of clinical effectiveness literature including multiple systematic reviews evaluating a range of self management interventions in chronic diseases-from 1977-2015. NB: The reviews for Telehealth alone were only four - of 38 Randomised Control Trials (30 unique RCTs). Three out of this four had a similar model to our local Telehealth

The aim was to review the optimal format and the short- and long-term benefits of chronic obstructive pulmonary disease (COPD) self-management interventions in adults. Across the 16 reviews the interventions were broadly classified as education or action plans, complex interventions with an SM focus, pulmonary rehabilitation (PR), telehealth and outreach nursing.

Strong evidence was found that pulmonary rehabilitation is associated with significant improvements in health-related quality of life (HRQoL). Limited evidence for education, action plans, telehealth interventions and outreach nursing for HRQoL was found. There was strong evidence that education is associated with a significant reduction in COPD-related hospital admissions, moderate to strong evidence that telehealth interventions are associated with reduced health care utilisation. No evidence that mortality reduced with Telehealth. The

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service. It included all age ranges.

strongest evidence was for education.

Journal of Medical Internet Research Medical Informatics; Mar 2017

Pilot randomized controlled trial

Does Telehealth Identify Exacerbations of Chronic Obstructive Pulmonary Disease and Reduce Hospitalisations? An Analysis of System Data.

Author(s): Kargiannakis, Melissa; Fitzsimmons, Deborah A; Bentley, Claire L; Mountain, Gail A

Source: JMIR medical informatics; Mar 2017; vol. 5 (no. 1); p. e8

23 participants Aim to report on data captured during a pilot randomised controlled trial of telehealth-supported care within a community-based service for patients discharged from hospital following an exacerbation of their COPD. This is to determine whether telehealth monitoring can identify an exacerbation of COPD, providing clinicians with an opportunity to intervene with timely treatment and prevent hospital readmission.

It seems that the clinical Telehealth team can identify exacerbations based on an increase in Telehealth alerts although the number of alerts reduced over time (and no reason was suggested). There was some indication that telehealth monitoring potentially delayed hospitalisations until after patients had been discharged from the service. It was suggested that telehealth-supported care can fulfil an important role in enabling patients with COPD to better manage their condition and remain out of hospital, but adequate resourcing and timely response to alerts is a critical factor in supporting patients to remain at home. NB: The study only looked at 8 week intervention period and 6 months follow up time and we have no local service data on timeliness of response or access to primary care..

British Medical Journal August, 2017

Systematic review and narrative

Telehealth and patient satisfaction: a systematic review and narrative

44 articles Aim to explore the association of telehealth and patient satisfaction in regards to

Conclusion: Overall, it was found that patient satisfaction can be associated with the

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analysis analysis.

Author(s): Kruse, Clemens Scott; Krowski, Nicole; Rodriguez, Blanca; Tran, Lan; Vela, Jackeline; Brooks, Matthew

Source: BMJ open; Aug 2017; vol. 7 (no. 8); p. e016242

effectiveness and efficiency. modality of telehealth, but factors of effectiveness and efficiency are mixed .In 61% of occurrences positive outcomes that were listed most often were improved outcomes (20%), preferred modality of intervention (10%), ease of use (9%), low cost 8%), improved communication (8%) and decreased travel time (7%).

NB: Some of the articles were out of date (2011) and US and not UK based, the editors themselves identified selection and publication bias and this study including videoconferencing as well as Telehealth..

Telemedicine Journal July, 2017

Evaluation of the National Health Service (NHS) Direct Pilot Telehealth Program: Cost-Effectiveness Analysis.

Author(s): Clarke, Malcolm; Fursse, Joanna; Connolly, Nancy; Sharma, Urvashi; Jones, Russell

Source: Telemedicine journal and e-health : the official journal of the American Telemedicine Association; Jul 2017

Two Primary Care Trusts (PCTs) enrolled 321 patients diagnosed with COPD into the telehealth program. 227 patients having a complete baseline record of at least 88 days of continuous remote monitoring and meeting all inclusion criteria were included in the statistical analysis

Aim to evaluate the cost-effectiveness of a pilot telehealth program applied to a wide population of patients with chronic obstructive pulmonary disease (COPD).

Cost-effectiveness had high variance both between the PCTs ranging from a saving of £140,800 to an increase of £9,600. The average saving was £1,023 per patient per year. The largest impact was on length of stay with a fall in the average length of inpatient care in PCT1 from 11.5 days in the period 12 months before monitoring to 6.5 days during monitoring, and similarly in PCT2 from 7.5 to 5.2 days.There was a wide

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discrepancy in the results from the two PCTs. This places doubt on outcomes and may indicate also why the literature on cost-effectiveness remains inconclusive. The wide variance on savings and the uncertainty of monitoring cost do not allow a definitive conclusion on the cost-effectiveness as an outcome of this study. It might well be that the average saving was £1,023 per patient per year, but the variance is too great to allow this to be statistically significant.

Home healthcare now; Apr 2017

Review of published articles

Home Telehealth Interventions for Older Adults With Diabetes.

Author(s): Walker, Cassondra L; Kopp, Mary; Binford, Roxanne M; Bowers, Cynthia J

Source: Home healthcare now; Apr 2017; vol. 35 (no. 4); p. 202-210

6 articles Aim to explore home telemedicine interventions for the treatment of older adults with diabetes.

The articles reviewed suggest that case management, education, closed-loop feedback and communication, home telemonitoring devices or units, and motivational interviewing or coaching can effectively decrease admissions, costs per person per year, mortality, and cognitive decline in older adults with diabetes. The scarcity of high-quality studies is consistent with findings from previous systematic reviews, and highlights the need for additional investigation before applying the results in practice NB: Too many variables to draw

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firm conclusions..

Journal of Telemedicine and Telecare August, 2017

Randomised controlled 12-month trial

A small-scale randomised controlled trial of home telemonitoring in patients with severe chronic obstructive pulmonary disease.

Author(s): Shany, Tal; Hession, Michael; Pryce, David; Roberts, Mary; Basilakis, Jim; Redmond, Stephen; Lovell, Nigel; Schreier, Guenter

Source: Journal of telemedicine and telecare; Aug 2017; vol. 23 (no. 7); p. 650-656

42 patients This was a pilot study to examine the effects of home telemonitoring of patients with severe chronic obstructive pulmonary disease (COPD). Home telemonitoring of oximetry, temperature, pulse, electrocardiogram, blood pressure, spirometry, and weight with telephone support and home visits was tested against a control group receiving only identical telephone support and home visits.

The results suggest that telemonitoring had a reduction in COPD-related admissions, emergency department presentations, and hospital bed days. Telemonitoring also seemed to increase the interval between COPD-related exacerbations requiring a hospital visit and prolonged the time to the first admission. The interval between hospital visits was significantly different, while the other findings did not reach significance and only suggest a trend. There was a reduction in hospital admission costs. Telemonitoring did not seem to change patients' psychological well-being. The ability to draw firm conclusions is limited due to the small sample size.

Managed Care (Langhorne, Pa.) April 2017

Some Thumbs Up, Some Down, on Telehealth Quality of Care.

Author(s): Kirkner, Richard

Mark

Source: Managed care (Langhorne, Pa.); Apr 2017; vol. 26 (no. 4); p. 23-25

Publication Date: Apr 2017

9 studies The report states that evaluating the quality of telemedicine care is about as easy as evaluating the quality of health care, and researchers are still ironing out the methodological kinks. That may be one reason research results are all over the place. This article involved reviewing nine such studies, and the findings are a mixed bag.

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Circulation February, 2017

Review of papers.

Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care.

Author(s): Schwamm, Lee H.; Chumbler, Chair Neale; Brown, Ed; Fonarow, Gregg C.; Berube, David; Nystrom, Karin; Suter, Robert; Zavala, Mirian; Polsky, Daniel; Radhakrishnan, Kavita; Lacktman, Nathaniel; Horton, Katherine; Malcarney, Mary-Beth; Halamka, John; Tiner, A. Colby

Source: Circulation; Feb

2017; vol. 135 (no. 7)

USA The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions.

Telemonitoring in ambulatory patients with heart failure has improved mortality and reduced hospitalisation in some studies, although the 3 largest trials have shown outcomes comparable to usual care. Effective programs need timely data, appropriate staff, and a feedback loop to patients with sufficient empowerment to understand and implement instructions.

Trials of implanted cardiac devices with remote monitoring have demonstrated a reduction in time to diagnosis and clinical decision, as well as improved clinical outcomes.

Although many telehealth studies have shown high rates of patient satisfaction, convincing evidence of clinical benefit is limited to specific applications.

NB: If telehealth is to achieve its full potential, it should be

integrated into the traditional ambulatory and hospital base delivery models. Our local service is standalone.

Journal of the American

Remote telemonitoring in chronic heart failure does

621 patients assigned either to

Aim to view if home telemonitoring for patients with

Total mortality and days alive and not in hospital were not

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College of Cardiology March, 2017

not reduce healthcare cost but improves quality of life: End points of the cardioBBEAT trail.

Author(s): Voeller, Heinz; Bindl, Dominik; Nagels, Klaus; Hofmann, Reiner; Vettorazzi, Eik; Wegscheider, Karl; Fleck, Eckart; Nagel, Eckhard

Source: Journal of the American College of Cardiology (JACC); Mar 2017; vol. 69 ; p. 672-672

remote health monitoring or usual care.

chronic heart failure offers a clinical benefit or a health economic advantage over usual care. The CardioBBEAT trial was designed to prospectively assess simultaneously the benefit and the health economic impact of a dedicated home monitoring system for patients with CHF based on actual costs directly obtained from patients’ health care providers.

significantly different between those receiving health monitoring and those receiving usual care. There was no evidenced cost effectiveness for remote health monitoring, but there was an improved quality of life compared to usual care without remote health monitoring.

Journal of Telemedicine and Telecare February, 2017

A nine-month randomised, controlled trial compared standard care to standard care supplemented with mobile telehealth (self-monitoring, -phone data transmissions, graphical and nurse-initiated feedback, and educational calls).

A randomised, controlled trial of the effects of a mobile telehealth intervention on clinical and patient-reported outcomes in people with poorly controlled diabetes

Author(s): Baron J.S.; Hirani

S.; Newman S.P.

Source: Journal of telemedicine and telecare; Feb 2017; vol. 23 (no. 2); p. 207-216

81 patients The aim is to determine the effects of mobile telehealth (MTH) on glycosylated haemoglobin (HbA1c) and other clinical and patient-reported outcomes in insulin-requiring people with diabetes

Findings from this study must be interpreted with caution given the small sample size, but they do not support the widespread adoption of mobile telehealth technology to achieve clinically significant changes in HbA1c. Mobile telehealth technology may, however, have positive effects on blood pressure and protective effects on some aspects of mental health.

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Heart Lung and Circulation April, 2017

Review The Use of Telehealth to Reduce Inequalities in Cardiovascular Outcomes in Australia and New Zealand: A Critical Review

Author(s): Wade V.; Stocks

N.

Source: Heart Lung and Circulation; Apr 2017; vol. 26 (no. 4); p. 331-337

Australia, New Zealand

A critical review exploring evidence of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services.

This critical review argues that there is sufficient evidence to move to larger-scale implementation of telehealth for acute cardiac, acute stroke, and cardiac rehabilitation services. For cardiovascular chronic disease and risk factor management, telehealth-based services can deliver value but the evidence is less compelling, as the outcomes of these programs are variable and depend upon the context of their implementation.

NB: The study included looking at videoconferencing/transmitting of results for diagnosis/consultations, texting and telecare equipment such as fixed sensor monitoring and wearable devices-none of which is included in our local Telehealth service as these are separate interventions. It also stated Telehealth should be ‘part f the system’ and not separate.

Nursing Standard; 2017

Personal experience by a Telehealth Lead Nurse

'Telehealth is patient empowerment in action'.

Author(s): Trueland,

Jennifer

Source: Nursing Standard; 2017; vol. 31 (no. 36); p. 24-

1 nurse’s views-Lead Telehealth Nurse in Liverpool. Supporting 3,500 people over 5 years.

Paper describes benefits and mind shift from writer who feels you can support patients remotely-no evidence provided.

NB: The model is slightly different to our local one where

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26 community matrons visit people to assess eligibility and the service is integrated.

People buy their own equipment at the end of their 4 or 6 months monitoring as they can see the value self-monitoring brings.

Documents

Appendix X: Telehealth research/evidence base · Appendix X: Telehealth research/evidence base A search of the recent literature and research was conducted by the Cornwall Health