Page 2 Effect of telehealth on quality of life and psychological out comes over 12 months
P. 2
BMJ 2013;346:f653 doi: 10.1136/bmj.f653 (Published 26 February 2013) Page 2 of 20
RESEARCH
Setting Provision of primary and secondary care via general practices, that are the focus of the Whole Systems Demonstrator (WSD)
18
specialist nurses, and hospital clinics in three diverse regions of England Evaluation. It is well established that health related QoL is
(Cornwall, Kent, and Newham), with established integrated health and reduced and anxiety and depression are elevated for patients
social care systems. with diabetes, 19-21 chronic obstructive pulmonary disease, 22-24
Participants Patients with chronic obstructive pulmonary disease and heart failure. 25-27 Health related QoL, anxiety, and depression
(COPD), diabetes, or heart failure recruited between May 2008 and have been linked with poorer outcomes on endpoints including
December 2009. self management, disease control, health service use, costs, and
28-32
Main outcome measures Generic, health related quality of life mortality.
(assessed by physical and mental health component scores of the SF-12, However, evidence for the effect of telehealth on these outcomes
and the EQ-5D), anxiety (assessed by the six item Brief State-Trait is unclear. At least seven systematic reviews have examined
33-39
Anxiety Inventory), and depressive symptoms (assessed by the 10 item this effect on health related QoL in heart failure, and while
Centre for Epidemiological Studies Depression Scale). most conclude that telehealth is beneficial, such inferences are
Results In the intention to treat analyses, differences between treatment not supported by the evidence they present. Typically, the
reviews are poorly reported (for example, they report how many
groups were small and non-significant for all outcomes in the complete studies found a significant association but not how many studies
case (0.480≤P≤0.904) or available case (0.181≤P≤0.905) cohorts. The looked for an association and failed to find one ), combine
35
magnitude of differences between trial arms did not reach the trial outcomes comprising measures that are conceptually distinct
defined, minimal clinically important difference (0.3 standardised mean (for example, health related QoL combined with patient
difference) for any outcome in either cohort at four or 12 months. Per satisfaction and treatment adherence ), and fail to balance the
37
protocol analyses replicated the primary analyses; the main effect of evidence appropriately. 39
trial arm (telehealth v usual care) was non-significant for any outcome 34
(complete case cohort 0.273≤P≤0.761; available case cohort In the two most transparent reviews, only one of three and
36
0.145≤P≤0.696). three of seven studies that evaluated the monitoring of
Conclusions Second generation, home based telehealth as implemented telehealth based vital signs reported any significant associations
between telehealth and improvements in health related QoL. In
in the Whole Systems Demonstrator Evaluation was not effective or a recent randomised controlled trial of third generation
efficacious compared with usual care only. Telehealth did not improve telehealth that is not included in the cited reviews, researchers
40
quality of life or psychological outcomes for patients with chronic found no effect of telehealth on depression scores over 24
obstructive pulmonary disease, diabetes, or heart failure over 12 months. months, but found an overall benefit on one of eight SF-36
The findings suggest that concerns about potentially deleterious effect subscales. Overall, claims that telehealth improves health
41
of telehealth are unfounded for most patients. related QoL for patients with heart failure are unsubstantiated. 38
Trial Registration ISRCTN43002091.
Two systematic reviews have examined the effect of telehealth
Introduction on health related QoL for patients with chronic obstructive
pulmonary disease. They showed ambivalent evidence; half the
Over the coming decades, extended life expectancy and low studies suggested a significant positive effect on health related
fertility will result in a shift in the old age dependency ratio in QoL, and the other half showed no effect. 42 43
many countries including the United Kingdom, with a greater One systematic review has investigated the effect of telehealth
proportion of the population at retirement age than at working on health related QoL in diabetes. This review confounds two
44
1-3
age. Despite some positive changes in levels of old age patient reported outcomes with different meanings: health related
4
5
disability and years of self reported good health, greater QoL and patient satisfaction. Of only five studies that actually
numbers of older people living with long term conditions are measured health related QoL, three found no difference between
likely to present major challenges for health and social care telephone support and usual care, 45-47 one failed to report
systems in the years ahead. 2 3 6 7 differences between telehealth and usual care and one pre-post
48
One response to these pressures from health systems has been study of telehealth found significant improvements on only
the introduction of localised telehealth services. Telehealth three of eight SF-36 subscales (role-physical, bodily pain, and
enables the remote exchange of data between a patient and social functioning). 49
healthcare professionals to facilitate diagnosis, monitoring, and Despite their relevance, few studies have examined anxiety or
8 9
management of long term conditions. Some telehealth systems depression. This omission is important, given concerns about
incorporate an educational component aimed at improving the potential detrimental effects of telehealth on patients. Such
10
patient knowledge and self care (for example, treatment concerns include the greater burden of work on patients and
50
adherence). 11 12 Telehealth systems that send physiological or increased sense of isolation for vulnerable people by reducing
symptom data to a remote monitoring centre can alert healthcare face-to-face contact with healthcare professionals. 8
professionals when disease specific clinical parameters are
breached. Thus, telehealth affords the opportunity for earlier Notwithstanding steady growth in telehealth studies over the
intervention, which may reduce the frequency with which past 20 years, robust evidence to inform policy decisions is
51
expensive hospital based care is required. lacking. Systematic reviews show that although enthusiasts
Evaluations of service innovations such as telehealth need to have written much about the promise of telehealth, most studies
42 52 53
Furthermore,
do not meet orthodox quality standards.
assess the effect from the patient’s perspective, using self report evidence from a few small trials of variable methodological
measures such as quality of life (QoL), psychological outcomes, quality is difficult to interpret. 54
and acceptability of services. This approach is in line with the
developing agenda on patient reported outcomes, 13-17 and There is a danger of relying on even high quality systematic
complements more familiar outcomes such as service use, costs, reviews if they pool data from low quality studies. This risk
and mortality. was underscored in a large scale, multicentre evaluation of
Generic health related QoL, anxiety, and depression are automated telephone based monitoring for patients with heart 36
55
failure. By contrast with a recently updated Cochrane review,
outcomes relevant to patients with the three long term conditions this study found no evidence of benefit for interactive
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
RESEARCH
Setting Provision of primary and secondary care via general practices, that are the focus of the Whole Systems Demonstrator (WSD)
18
specialist nurses, and hospital clinics in three diverse regions of England Evaluation. It is well established that health related QoL is
(Cornwall, Kent, and Newham), with established integrated health and reduced and anxiety and depression are elevated for patients
social care systems. with diabetes, 19-21 chronic obstructive pulmonary disease, 22-24
Participants Patients with chronic obstructive pulmonary disease and heart failure. 25-27 Health related QoL, anxiety, and depression
(COPD), diabetes, or heart failure recruited between May 2008 and have been linked with poorer outcomes on endpoints including
December 2009. self management, disease control, health service use, costs, and
28-32
Main outcome measures Generic, health related quality of life mortality.
(assessed by physical and mental health component scores of the SF-12, However, evidence for the effect of telehealth on these outcomes
and the EQ-5D), anxiety (assessed by the six item Brief State-Trait is unclear. At least seven systematic reviews have examined
33-39
Anxiety Inventory), and depressive symptoms (assessed by the 10 item this effect on health related QoL in heart failure, and while
Centre for Epidemiological Studies Depression Scale). most conclude that telehealth is beneficial, such inferences are
Results In the intention to treat analyses, differences between treatment not supported by the evidence they present. Typically, the
reviews are poorly reported (for example, they report how many
groups were small and non-significant for all outcomes in the complete studies found a significant association but not how many studies
case (0.480≤P≤0.904) or available case (0.181≤P≤0.905) cohorts. The looked for an association and failed to find one ), combine
35
magnitude of differences between trial arms did not reach the trial outcomes comprising measures that are conceptually distinct
defined, minimal clinically important difference (0.3 standardised mean (for example, health related QoL combined with patient
difference) for any outcome in either cohort at four or 12 months. Per satisfaction and treatment adherence ), and fail to balance the
37
protocol analyses replicated the primary analyses; the main effect of evidence appropriately. 39
trial arm (telehealth v usual care) was non-significant for any outcome 34
(complete case cohort 0.273≤P≤0.761; available case cohort In the two most transparent reviews, only one of three and
36
0.145≤P≤0.696). three of seven studies that evaluated the monitoring of
Conclusions Second generation, home based telehealth as implemented telehealth based vital signs reported any significant associations
between telehealth and improvements in health related QoL. In
in the Whole Systems Demonstrator Evaluation was not effective or a recent randomised controlled trial of third generation
efficacious compared with usual care only. Telehealth did not improve telehealth that is not included in the cited reviews, researchers
40
quality of life or psychological outcomes for patients with chronic found no effect of telehealth on depression scores over 24
obstructive pulmonary disease, diabetes, or heart failure over 12 months. months, but found an overall benefit on one of eight SF-36
The findings suggest that concerns about potentially deleterious effect subscales. Overall, claims that telehealth improves health
41
of telehealth are unfounded for most patients. related QoL for patients with heart failure are unsubstantiated. 38
Trial Registration ISRCTN43002091.
Two systematic reviews have examined the effect of telehealth
Introduction on health related QoL for patients with chronic obstructive
pulmonary disease. They showed ambivalent evidence; half the
Over the coming decades, extended life expectancy and low studies suggested a significant positive effect on health related
fertility will result in a shift in the old age dependency ratio in QoL, and the other half showed no effect. 42 43
many countries including the United Kingdom, with a greater One systematic review has investigated the effect of telehealth
proportion of the population at retirement age than at working on health related QoL in diabetes. This review confounds two
44
1-3
age. Despite some positive changes in levels of old age patient reported outcomes with different meanings: health related
4
5
disability and years of self reported good health, greater QoL and patient satisfaction. Of only five studies that actually
numbers of older people living with long term conditions are measured health related QoL, three found no difference between
likely to present major challenges for health and social care telephone support and usual care, 45-47 one failed to report
systems in the years ahead. 2 3 6 7 differences between telehealth and usual care and one pre-post
48
One response to these pressures from health systems has been study of telehealth found significant improvements on only
the introduction of localised telehealth services. Telehealth three of eight SF-36 subscales (role-physical, bodily pain, and
enables the remote exchange of data between a patient and social functioning). 49
healthcare professionals to facilitate diagnosis, monitoring, and Despite their relevance, few studies have examined anxiety or
8 9
management of long term conditions. Some telehealth systems depression. This omission is important, given concerns about
incorporate an educational component aimed at improving the potential detrimental effects of telehealth on patients. Such
10
patient knowledge and self care (for example, treatment concerns include the greater burden of work on patients and
50
adherence). 11 12 Telehealth systems that send physiological or increased sense of isolation for vulnerable people by reducing
symptom data to a remote monitoring centre can alert healthcare face-to-face contact with healthcare professionals. 8
professionals when disease specific clinical parameters are
breached. Thus, telehealth affords the opportunity for earlier Notwithstanding steady growth in telehealth studies over the
intervention, which may reduce the frequency with which past 20 years, robust evidence to inform policy decisions is
51
expensive hospital based care is required. lacking. Systematic reviews show that although enthusiasts
Evaluations of service innovations such as telehealth need to have written much about the promise of telehealth, most studies
42 52 53
Furthermore,
do not meet orthodox quality standards.
assess the effect from the patient’s perspective, using self report evidence from a few small trials of variable methodological
measures such as quality of life (QoL), psychological outcomes, quality is difficult to interpret. 54
and acceptability of services. This approach is in line with the
developing agenda on patient reported outcomes, 13-17 and There is a danger of relying on even high quality systematic
complements more familiar outcomes such as service use, costs, reviews if they pool data from low quality studies. This risk
and mortality. was underscored in a large scale, multicentre evaluation of
Generic health related QoL, anxiety, and depression are automated telephone based monitoring for patients with heart 36
55
failure. By contrast with a recently updated Cochrane review,
outcomes relevant to patients with the three long term conditions this study found no evidence of benefit for interactive
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
