Page 10 Effect of telehealth on quality of life and psychological out comes over 12 months
P. 10
BMJ 2013;346:f653 doi: 10.1136/bmj.f653 (Published 26 February 2013) Page 10 of 20
RESEARCH
What is already known on this topic
For long term conditions, telehealth has been promoted to reduce healthcare costs while improving health related quality of life (HRQoL),
by facilitating self monitoring with remote surveillance by healthcare professionals
Evidence for the benefits of telehealth is ambivalent, with little empirical evidence on benefits on psychological outcomes
Methodologically rigorous trials of telehealth in relation to health related quality of life and psychological outcomes are required
What this study adds
Compared with usual care, second generation telehealth had no effect on HRQoL, anxiety, or depressive symptoms for patients with
chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months
The findings suggest that claims for potentially salutary or deleterious effects of telehealth are unfounded for most patients
Telehealth should not be introduced with the aim of improving quality of life or psychological outcomes
9 Sood S, Mbarika V, Jugoo S, Dookhy R, Doarn CR, Prakash N, et al. What is telemedicine? 36 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, et al. Structured
A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Telemed telephone support or telemonitoring programmes for patients with chronic heart failure.
J E Health 2007;13:573-90. Cochrane Database Syst Rev 2010:CD007228.
10 Ramaekers BLT, Janssen-Boyne JJ, Gorgels APM, Vrijhoef HJM. Adherence among 37 Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, et al. Home telemonitoring
telemonitored patients with heart failure to pharmacological and nonpharmacological for congestive heart failure: a systematic review and meta-analysis. J Telemed Telecare
recommendations. Telemed J E Health 2009;15:517-24. 2010;16:68-76.
11 Antonicelli R, Testarmata P, Spazzafumo L, Gagliardi C, Bilo G, Valentini M, et al. Impact 38 Schmidt S, Schuchert A, Krieg T, Oeff M. Home telemonitoring in patients with chronic
of telemonitoring at home on the management of elderly patients with congestive heart heart failure: a chance to improve patient care? Dtsch Arztebl Int 2010;107:131-8.
failure. J Telemed Telecare 2008;14:300-5. 39 Clarke M, Shah A, Sharma U. Systematic review of studies on telemonitoring of patients
12 Seibert PS, Whitmore TA, Patterson C, Parker PD, Otto C, Basom J, et al. Telemedicine with congestive heart failure: a meta-analysis. J Telemed Telecare 2011;17:7-14.
faciliatates CHF home health care for those with systolic dysfunction. Int J Telemed Appl 40 Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients
2008, doi:10.1155/2008/235031. with heart failure. Lancet 2011;378:731-9.
13 US Food and Drug Administration. Draft guidance for industry: patient-reported outcome 41 Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Bohm M, et al. Impact of remote
measures: use in medical product development to support labeling claims. 2009. www. telemedical management on mortality and hospitalizations in ambulatory patients with
fda.gov/downloads/Drugs/Guidances/UCM193282.pdf. chronic heart failure: the telemedical interventional monitoring in heart failure study.
14 European Medicines Agency. Reflection paper on the regulatory guidance for the use of Circulation 2011;123:1873-80.
health-related quality of life (HRQL) measures in the evaluation of medicinal products. 42 Bolton CE, Waters CS, Peirce S, Elwyn G. Insufficient evidence of benefit: a systematic
2005. www.emea.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/ review of home telemonitoring for COPD. J Eval Clin Pract 2011;17:1216-22.
WC500003637.pdf. 43 Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, et al. Home telehealth for
15 Department of Health. Guidance on the routine collection of patient reported outcome chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Telemed
measures (PROMs). 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/ Telecare 2010;16:120-7.
PublicationsPolicyAndGuidance/DH_092647. 44 Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K. Home telehealth for diabetes
16 Dawson J, Doll H, Fitzpatrick R, Jenkinson C, Carr AJ. The routine use of patient reported management: a systematic review and meta-analysis. Diabetes Obes Metab
outcome measures in healthcare settings. BMJ 2010;340:c186. 2009;11:913-30.
17 Greenhalgh J, Long AF, Flynn R. The use of patient reported outcome measures in routine 45 Maljanian R, Grey N, Staff I, Conroy L. Intensive telephone follow-up to a hospital-based
clinical practice: lack of impact or lack of theory? Soc Sci Med 2005;60:833-43. disease management model for patients with diabetes mellitus. Dis Manag 2005;8:15-25.
18 Bower P, Cartwright M, Hirani S, Barlow J, Hendy J, Knapp M, et al. A comprehensive 46 Piette JD, Weinberger M, McPhee SJ. The effect of automated calls with telephone nurse
evaluation of the impact of telemonitoring in patients with long-term conditions and social follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial.
care needs: protocol for the Whole Systems Demonstrator cluster randomised trial. BMC Med Care 2000;38:218-30.
Health Serv Res 2011;11:184. 47 Whitlock WL, Brown A, Moore K, Pavliscsak H, Dingbaum A, Lacefield D, et al.
19 Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J, Chobanian L. Quality of life and associated Telemedicine improved diabetic management. Mil Med 2000;165:579-84.
characteristics in a large national sample of adults with diabetes. Diabetes Care 48 Jansa M, Vidal M, Viaplana J, Levy I, Conget I, Gomis R, et al. Telecare in a structured
1997;20:562-7. therapeutic education programme addressed to patients with type 1 diabetes and poor
20 Lloyd CE, Dyer PH, Barnett AH. Prevalence of symptoms of depression and anxiety in a metabolic control. Diabetes Res Clin Pract 2006;74:26-32.
diabetes clinic population. Diabetic Med 2000;17:198-202. 49 Chumbler NR, Neugaard B, Kobb R, Ryan P, Qin HJ, Joo YS. Evaluation of a care
21 Peyrot M, Rubin RR. Levels and risks of depression and anxiety symptomatology among coordination/home-telehealth program for veterans with diabetes: health services utilization
diabetic adults. Diabetes Care 1997;20:585-90. and health-related quality of life. Eval Health Prof 2005;28:464-78.
22 Ferrer M, Alonso J, Morera J, Marrades RM, Khalaf A, Aguar MC, et al. Chronic obstructive 50 Rogers A, Kirk S, Gately C, May CR, Finch T. Established users and the making of telecare
pulmonary disease stage and health-related quality of life. The Quality of Life of Chronic work in long term condition management: implications for health policy. Soc Sci Med
Obstructive Pulmonary Disease Study Group. Ann Intern Med 1997;127:1072-9. 2011;72:1077-84.
23 Mikkelsen RL, Middelboe T, Pisinger C, Stage KB. Anxiety and depression in patients 51 Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of
with chronic obstructive pulmonary disease (COPD). A review. Nord J Psychiatry reviews. Int J Med Inform 2010;79:736-71.
2004;58:65-70. 52 Barlow J, Singh D, Bayer S, Curry R. A systematic review of the benefits of home telecare
24 Putman-Casdorph H, McCrone S. Chronic obstructive pulmonary disease, anxiety, and for frail elderly people and those with long-term conditions. J Telemed Telecare
depression: state of the science. Heart Lung 2009;38:34-47. 2007;13:172-9.
25 Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure—a 53 Bensink M, Hailey D, Wootton R. A systematic review of successes and failures in home
meta-analytic review of prevalence, intervention effects, and associations with clinical telehealth. Part 2: final quality rating results. J Telemed Telecare 2007;13:10-4.
outcomes. J Am Coll Cardiol 2006;48:1527-37. 54 Chaudhry SI, Mattera JA, Krumholz HM. Telemonitoring in patients with heart failure:
26 Konstam V, Moser DK, De Jong MJ. Depression and anxiety in heart failure. J Card Fail authors’ reply. N Engl J Med 2011;364:1078-80.
2005;11:455-63. 55 Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin ZQ, et al. Telemonitoring
27 Heo S, Moser DK, Lennie TA, Zarnbroski CH, Chung ML. A comparison of health-related in patients with heart failure. N Engl J Med 2010;363:2301-9.
quality of life between older adults with heart failure and healthy older adults. Heart Lung 56 Bowling A, Farquhar M, Browne P. Life satisfaction and associations with social network
2007;36:16-24. and support variables in 3 samples of elderly people. Int J Geriatr Psychiatry
28 Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes—impact of depression 1991;6:549-66.
symptoms on adherence, function, costs. Arch Intern Med 2000;160:3278-85. 57 Klimidis S, Minas IH, Yamamoto K. Impact of illness scale: reliability, validity, and
29 Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic cross-cultural utility. Compr Psychiatry 2001;42:416-23.
diseases, and decrements in health: results from the World Health Surveys. Lancet 58 Ware JE Jr, Kosinski M, Turner-Bowker DM, Gandek B. User’s manual for the SF-12v2
2007;370:851-8. health survey with a supplement documenting SF-12 health survey. QualityMetric, 2002.
30 Yohannes AM, Willgoss TG, Baldwin RC, Connolly MJ. Depression and anxiety in chronic 59 Mackintosh A, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome
heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical measures (PROMs) for heart failure. University of Oxford, 2009. http://phi.uhce.ox.ac.uk/
implications and management principles. Int J Geriatr Psychiatry 2010;25:1209-21. pdf/PROMs_Oxford_HeartFailure_17092010.pdf.
31 Maurer J, Rebbapragada V, Borson S, Goldstein R, Kunik ME, Yohannes AM, et al. 60 Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann
Anxiety and depression in COPD current understanding, unanswered questions, and Med 2001;33:337-43.
research needs. Chest 2008;134:43-56S. 61 Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome measures
32 Rodriguez-Artalejo F, Guallar-Castillon P, Pascual CR, Otero CM, Montes AO, Garcia (PROMs) for diabetes. University of Oxford, 2009. http://phi.uhce.ox.ac.uk/pdf/Diabetes_
AN, et al. Health-related quality of life as a predictor of hospital readmission and death 2009FINAL.pdf.
among patients with heart failure. Arch Intern Med 2005;165:1274-9. 62 Davies N, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome
33 Martinez A, Everss E, Luis Rojo-Alvarez J, Pascual Figal D, Garcia-Alberola A. A measures (PROMs) for chronic obstructive pulmonary disease (COPD). University of
systematic review of the literature on home monitoring for patients with heart failure. J Oxford, 2009. http://phi.uhce.ox.ac.uk/pdf/COPD2009_FINAL.pdf.
Telemed Telecare 2006;12:234-41. 63 Marteau TM, Bekker H. The development of a 6-item short-form of the state scale of the
34 Clark RA, Inglis SC, McAlister FA, Cleland JGF, Stewart S. Telemonitoring or structured Spielberger state trait anxiety inventory (STAI). Br J Clin Psychol 1992;31:301-6.
telephone support programmes for patients with chronic heart failure: systematic review 64 Perpina-Galvan J, Richart-Martinez M, Jose Cabanero-Martinez M. Reliability and validity
and meta-analysis. BMJ 2007;334:942-5. of a short version of the STAI anxiety measurement scale in respiratory patients. Arch
35 Maric B, Kaan A, Ignaszewski A, Lear SA. A systematic review of telemonitoring Bronconeumol 2011;47:184-9.
technologies in heart failure. Eur J Heart Fail 2009;11:506-17.
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
RESEARCH
What is already known on this topic
For long term conditions, telehealth has been promoted to reduce healthcare costs while improving health related quality of life (HRQoL),
by facilitating self monitoring with remote surveillance by healthcare professionals
Evidence for the benefits of telehealth is ambivalent, with little empirical evidence on benefits on psychological outcomes
Methodologically rigorous trials of telehealth in relation to health related quality of life and psychological outcomes are required
What this study adds
Compared with usual care, second generation telehealth had no effect on HRQoL, anxiety, or depressive symptoms for patients with
chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months
The findings suggest that claims for potentially salutary or deleterious effects of telehealth are unfounded for most patients
Telehealth should not be introduced with the aim of improving quality of life or psychological outcomes
9 Sood S, Mbarika V, Jugoo S, Dookhy R, Doarn CR, Prakash N, et al. What is telemedicine? 36 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, et al. Structured
A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Telemed telephone support or telemonitoring programmes for patients with chronic heart failure.
J E Health 2007;13:573-90. Cochrane Database Syst Rev 2010:CD007228.
10 Ramaekers BLT, Janssen-Boyne JJ, Gorgels APM, Vrijhoef HJM. Adherence among 37 Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, et al. Home telemonitoring
telemonitored patients with heart failure to pharmacological and nonpharmacological for congestive heart failure: a systematic review and meta-analysis. J Telemed Telecare
recommendations. Telemed J E Health 2009;15:517-24. 2010;16:68-76.
11 Antonicelli R, Testarmata P, Spazzafumo L, Gagliardi C, Bilo G, Valentini M, et al. Impact 38 Schmidt S, Schuchert A, Krieg T, Oeff M. Home telemonitoring in patients with chronic
of telemonitoring at home on the management of elderly patients with congestive heart heart failure: a chance to improve patient care? Dtsch Arztebl Int 2010;107:131-8.
failure. J Telemed Telecare 2008;14:300-5. 39 Clarke M, Shah A, Sharma U. Systematic review of studies on telemonitoring of patients
12 Seibert PS, Whitmore TA, Patterson C, Parker PD, Otto C, Basom J, et al. Telemedicine with congestive heart failure: a meta-analysis. J Telemed Telecare 2011;17:7-14.
faciliatates CHF home health care for those with systolic dysfunction. Int J Telemed Appl 40 Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients
2008, doi:10.1155/2008/235031. with heart failure. Lancet 2011;378:731-9.
13 US Food and Drug Administration. Draft guidance for industry: patient-reported outcome 41 Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Bohm M, et al. Impact of remote
measures: use in medical product development to support labeling claims. 2009. www. telemedical management on mortality and hospitalizations in ambulatory patients with
fda.gov/downloads/Drugs/Guidances/UCM193282.pdf. chronic heart failure: the telemedical interventional monitoring in heart failure study.
14 European Medicines Agency. Reflection paper on the regulatory guidance for the use of Circulation 2011;123:1873-80.
health-related quality of life (HRQL) measures in the evaluation of medicinal products. 42 Bolton CE, Waters CS, Peirce S, Elwyn G. Insufficient evidence of benefit: a systematic
2005. www.emea.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/ review of home telemonitoring for COPD. J Eval Clin Pract 2011;17:1216-22.
WC500003637.pdf. 43 Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, et al. Home telehealth for
15 Department of Health. Guidance on the routine collection of patient reported outcome chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Telemed
measures (PROMs). 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/ Telecare 2010;16:120-7.
PublicationsPolicyAndGuidance/DH_092647. 44 Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K. Home telehealth for diabetes
16 Dawson J, Doll H, Fitzpatrick R, Jenkinson C, Carr AJ. The routine use of patient reported management: a systematic review and meta-analysis. Diabetes Obes Metab
outcome measures in healthcare settings. BMJ 2010;340:c186. 2009;11:913-30.
17 Greenhalgh J, Long AF, Flynn R. The use of patient reported outcome measures in routine 45 Maljanian R, Grey N, Staff I, Conroy L. Intensive telephone follow-up to a hospital-based
clinical practice: lack of impact or lack of theory? Soc Sci Med 2005;60:833-43. disease management model for patients with diabetes mellitus. Dis Manag 2005;8:15-25.
18 Bower P, Cartwright M, Hirani S, Barlow J, Hendy J, Knapp M, et al. A comprehensive 46 Piette JD, Weinberger M, McPhee SJ. The effect of automated calls with telephone nurse
evaluation of the impact of telemonitoring in patients with long-term conditions and social follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial.
care needs: protocol for the Whole Systems Demonstrator cluster randomised trial. BMC Med Care 2000;38:218-30.
Health Serv Res 2011;11:184. 47 Whitlock WL, Brown A, Moore K, Pavliscsak H, Dingbaum A, Lacefield D, et al.
19 Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J, Chobanian L. Quality of life and associated Telemedicine improved diabetic management. Mil Med 2000;165:579-84.
characteristics in a large national sample of adults with diabetes. Diabetes Care 48 Jansa M, Vidal M, Viaplana J, Levy I, Conget I, Gomis R, et al. Telecare in a structured
1997;20:562-7. therapeutic education programme addressed to patients with type 1 diabetes and poor
20 Lloyd CE, Dyer PH, Barnett AH. Prevalence of symptoms of depression and anxiety in a metabolic control. Diabetes Res Clin Pract 2006;74:26-32.
diabetes clinic population. Diabetic Med 2000;17:198-202. 49 Chumbler NR, Neugaard B, Kobb R, Ryan P, Qin HJ, Joo YS. Evaluation of a care
21 Peyrot M, Rubin RR. Levels and risks of depression and anxiety symptomatology among coordination/home-telehealth program for veterans with diabetes: health services utilization
diabetic adults. Diabetes Care 1997;20:585-90. and health-related quality of life. Eval Health Prof 2005;28:464-78.
22 Ferrer M, Alonso J, Morera J, Marrades RM, Khalaf A, Aguar MC, et al. Chronic obstructive 50 Rogers A, Kirk S, Gately C, May CR, Finch T. Established users and the making of telecare
pulmonary disease stage and health-related quality of life. The Quality of Life of Chronic work in long term condition management: implications for health policy. Soc Sci Med
Obstructive Pulmonary Disease Study Group. Ann Intern Med 1997;127:1072-9. 2011;72:1077-84.
23 Mikkelsen RL, Middelboe T, Pisinger C, Stage KB. Anxiety and depression in patients 51 Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of
with chronic obstructive pulmonary disease (COPD). A review. Nord J Psychiatry reviews. Int J Med Inform 2010;79:736-71.
2004;58:65-70. 52 Barlow J, Singh D, Bayer S, Curry R. A systematic review of the benefits of home telecare
24 Putman-Casdorph H, McCrone S. Chronic obstructive pulmonary disease, anxiety, and for frail elderly people and those with long-term conditions. J Telemed Telecare
depression: state of the science. Heart Lung 2009;38:34-47. 2007;13:172-9.
25 Rutledge T, Reis VA, Linke SE, Greenberg BH, Mills PJ. Depression in heart failure—a 53 Bensink M, Hailey D, Wootton R. A systematic review of successes and failures in home
meta-analytic review of prevalence, intervention effects, and associations with clinical telehealth. Part 2: final quality rating results. J Telemed Telecare 2007;13:10-4.
outcomes. J Am Coll Cardiol 2006;48:1527-37. 54 Chaudhry SI, Mattera JA, Krumholz HM. Telemonitoring in patients with heart failure:
26 Konstam V, Moser DK, De Jong MJ. Depression and anxiety in heart failure. J Card Fail authors’ reply. N Engl J Med 2011;364:1078-80.
2005;11:455-63. 55 Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin ZQ, et al. Telemonitoring
27 Heo S, Moser DK, Lennie TA, Zarnbroski CH, Chung ML. A comparison of health-related in patients with heart failure. N Engl J Med 2010;363:2301-9.
quality of life between older adults with heart failure and healthy older adults. Heart Lung 56 Bowling A, Farquhar M, Browne P. Life satisfaction and associations with social network
2007;36:16-24. and support variables in 3 samples of elderly people. Int J Geriatr Psychiatry
28 Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes—impact of depression 1991;6:549-66.
symptoms on adherence, function, costs. Arch Intern Med 2000;160:3278-85. 57 Klimidis S, Minas IH, Yamamoto K. Impact of illness scale: reliability, validity, and
29 Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic cross-cultural utility. Compr Psychiatry 2001;42:416-23.
diseases, and decrements in health: results from the World Health Surveys. Lancet 58 Ware JE Jr, Kosinski M, Turner-Bowker DM, Gandek B. User’s manual for the SF-12v2
2007;370:851-8. health survey with a supplement documenting SF-12 health survey. QualityMetric, 2002.
30 Yohannes AM, Willgoss TG, Baldwin RC, Connolly MJ. Depression and anxiety in chronic 59 Mackintosh A, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome
heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical measures (PROMs) for heart failure. University of Oxford, 2009. http://phi.uhce.ox.ac.uk/
implications and management principles. Int J Geriatr Psychiatry 2010;25:1209-21. pdf/PROMs_Oxford_HeartFailure_17092010.pdf.
31 Maurer J, Rebbapragada V, Borson S, Goldstein R, Kunik ME, Yohannes AM, et al. 60 Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann
Anxiety and depression in COPD current understanding, unanswered questions, and Med 2001;33:337-43.
research needs. Chest 2008;134:43-56S. 61 Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome measures
32 Rodriguez-Artalejo F, Guallar-Castillon P, Pascual CR, Otero CM, Montes AO, Garcia (PROMs) for diabetes. University of Oxford, 2009. http://phi.uhce.ox.ac.uk/pdf/Diabetes_
AN, et al. Health-related quality of life as a predictor of hospital readmission and death 2009FINAL.pdf.
among patients with heart failure. Arch Intern Med 2005;165:1274-9. 62 Davies N, Gibbons E, Fitzpatrick R. A structured review of patient-reported outcome
33 Martinez A, Everss E, Luis Rojo-Alvarez J, Pascual Figal D, Garcia-Alberola A. A measures (PROMs) for chronic obstructive pulmonary disease (COPD). University of
systematic review of the literature on home monitoring for patients with heart failure. J Oxford, 2009. http://phi.uhce.ox.ac.uk/pdf/COPD2009_FINAL.pdf.
Telemed Telecare 2006;12:234-41. 63 Marteau TM, Bekker H. The development of a 6-item short-form of the state scale of the
34 Clark RA, Inglis SC, McAlister FA, Cleland JGF, Stewart S. Telemonitoring or structured Spielberger state trait anxiety inventory (STAI). Br J Clin Psychol 1992;31:301-6.
telephone support programmes for patients with chronic heart failure: systematic review 64 Perpina-Galvan J, Richart-Martinez M, Jose Cabanero-Martinez M. Reliability and validity
and meta-analysis. BMJ 2007;334:942-5. of a short version of the STAI anxiety measurement scale in respiratory patients. Arch
35 Maric B, Kaan A, Ignaszewski A, Lear SA. A systematic review of telemonitoring Bronconeumol 2011;47:184-9.
technologies in heart failure. Eur J Heart Fail 2009;11:506-17.
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
