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Document: 1
Electronic communication with patients: evaluation of distance medicine
technology.
Balas E A, Jaffrey F, Kuperman G J, Austin Boren S, Brown G D, Pinciroli F,
Mitchell J A..
Electronic communication with patients: evaluation of distance medicine
technology.
Journal of the American Medical Association,
1997,
278(2),
pp.152-159
Record status
This record is a structured abstract written by CRD reviewers. The original
has met a set of quality criteria. Since September 1996 abstracts have been
sent to authors for comment. Additional factual information is incorporated
into the record. Noted as [A:....].
Author's objective
To evaluate the controlled evidence on the efficacy of distance medicine
technologies in clinical practice and health care outcome. Type of
intervention
Treatment; organisation\management.
Specific interventions included in the review
Computerised communication; telephone follow-up care; telephone reminders;
interactive telephone systems; telephone access; telephone screening.
Participants included in the review
Computerised communication: patients with diabetes; care givers of patients
with Alzheimer's Disease; college students; male patients with cardiac
disease.
Telephone follow-up care: emergency department patients; patients requiring
cardiac care; women due to undergo mammography; outpatients with
osteoarthritis; junior high school students
Telephone reminders: patients in a variety of situations receiving appointment
reminders; patients receiving reminders about immunisation; patients requiring
reminders about medication; diabetic patients; patients with osteoarthritis.
Interactive telephone systems: families of patients with Alzheimers Disease;
problem drinkers; households with young children; and elderly patients.
Telephone access: terminally\chronically ill patients; parents of newborns.
Telephone screening: broad geographic patient population
Outcomes assessed in the review
Computerised communication: outcomes included changes in haemoglobin levels;
decision confidence; ambulatory visits; oxygen consumption and dietetic
knowledge.
Telephone follow-up care: outcomes for emergency department patients included
numbers of patients scheduling and attending appointments; outcomes for
cardiac care patients included smoking cessation, emergency department visits,
general activity and knowledge; outcomes for mammography use were changes in
number of mammograms; outcomes for osteoarthritis were scores on the Arthritis
Impact Measurement Scales (AIMS); outcomes for tobacco use prevention were
changes in tobacco use.
Telephone reminders: outcomes included appointment keeping rates; immunisation
rates; medication compliance; diabetic foot problems and disability associated
with arthritis.
Interactive telephone systems: outcomes included medication adherence,
knowledge and immunisation visits, alcohol consumption and mental health.
Telephone access: outcomes included hospital use.
Telephone screening: information supplied.
Study designs of evaluations included in the review
Randomised controlled trials (RCTs) of electronic communication between
parties in separate locations assessing the effect of the intervention on the
process or outcomes of patient care.
What sources were searched to identify primary studies?
Initially the Columbia Registry of Information and Utilisation Management
Trials (1966 to 1996) was searched. In addition MEDLINE (1966 - 1996), HSTAR,
PsychLIT, CINAHL, Science Citation Index and COMPENDEX Ondisc were searched
retrieving any clinical trial in which "telephone", "computer" alone or in
combination were mentioned.
Criteria on which the validity (or quality) of studies was assessed
Methodological quality was evaluated using a validated clinical trial scoring
system (Bala et al, 1994) that awards a score of 1 to 100. Technical aspects
related to proper sampling are weighted heavily. The minimum required score
overall was set at 20 in this study.
How were the judgements of validity (or quality) made?
Not stated.
How were decisions on the relevence of primary studies made?
Titles, abstracts or both were read and judged as potentially eligible by 2
reviewers. The full article was then assessed for relevance (the 3 inclusion
criteria are given in the review) and the 2 reviewers discussed each to reach
a consensus.
How was the data extracted from primary studies?
Standardised abstraction forms were used. No other details provided.
Number of studies included
Eighty trials were included in the analysis. These were 7 RCTs involving
computerised communication; 37 RCTs involving telephone follow-up care (17 of
these were not significant and not presented in tables); 23 RCTs involving
telephone reminders; 6 RCTs involving interactive telephone systems; 4 RCTs
involving telephone access; 3 RCTs involving telephone screening and 17
assorted RCTs in various clinical areas for which minimal details re given.
How were the studies combined?
A narrative synthesis has been undertaken.
How were differences between studies investigated?
The interventions were grouped into the following categories: computerised
communication; telephone follow-up care; telephone reminders; interactive
telephone systems; telephone access and telephone screening. Within these
categories studies were clustered based on their clinical application areas.
Clinical areas with only 1 or 2 studies were described individually.
Results of the review
Computerised communication: 4 studies found beneficial effects in patients
with diabetes.
Telephone follow-up care: greater compliance with follow up instructions was
found among patients with urinary tract infections, pediatric emergencies and
various acute and chronic illnesses. Positive outcomes were also demonstrated
after cardiac surgery and acute myocardial infarction. Telephone follow up
among women significantly increased mammography and colposcopic examination
rates. Other areas where benefits were demonstrated included pain management
for osteoarthritis, therapy for panic disorder, antitubercolosis
chemoprophylaxis treatment, a dental screening programme and tobacco use
prevention. 17 studies in various clinical areas failed to show significant
and beneficial differences between intervention and control groups.
Telephone reminders: improved compliance with immunisation, with foot care
instructions, with medication compliance, appointment keeping rates and
improvement of outcomes among patients with osteoarthritis. However, in some
instances mailed reminders resulted in higher compliance rates than telephone
remainders.
Interactive telephone systems: 3 systems demonstrated beneficial effects for
elderly patients and improvements in the number of immunisation visits were
found in 2 trials.
Telephone access: 4 studies suggested that providing after hours telephone
access can reduce hospital use and is a cost effective approach to offering
primary care consultation services.
Telephone screening: 1 trial found a computer assisted telephone interview as
reliable as a printed questionnaire; 2 other trials failed to substantiate
this.
Was any cost information reported?
Yes. The authors discuss cost effectiveness and conclude "Available evidence
is insufficient to determine whether current telemedicine applications are
cost effective."
Author's conclusions
Based on controlled evidence from a variety of sources, the results of this
study indicate that distance medicine technologies have benefits in the areas
of preventive care, management of osteoarthritis, cardiac rehabilitation and
diabetes care.
Distance medicine technology enables greater continuity of care by improving
access and supporting the coordination of activities by a clinician. The
benefits of distance technologies in facilitating communication between
clinicians and patients indicate that application of telemedicine should not
be limited to physician to physician communication.
CRD commentary
This is a very comprehensive systematic review. Although two reviewers
assessed the relevance of the studies it is not clear if either the quality
scoring or the data-extraction was double checked. Not all the included
studies are displayed in the tables; 17 RCTs which failed to show "significant
or beneficial differences" are briefly mentioned only in the text. This gives
the tables a distinct positive bias.
Subject index terms
Subject indexing assigned by NLM: Medical-Informatics-Applications;
Outcome-and-Process-Assessment-Health-Care; Self-Care/st [standards];
Telecommunications/ut [utilization] Communication-;
Continuity-of-Patient-Care; Patient-Education; Patient-Participation;
Physician-Patient-Relations; Randomized-Controlled-Trials; Reminder-Systems;
Remote-Consultation; Telemedicine-; Telephone-utilization
Correspondence address
Dr E A Balas, School of Medicine, University of Missouri-Columbia, 324 Clark
Hall, Columbia, MO 65211, USA.
Copyright
University of York, 1998
Database no.: DARE-978227
