Costs and benefits of personalized healthcare for patients with chronic heart failure in the care and education program "Telemedicine for the Heart"

Incorporating Technology Adoption in Medical Education: A Qualitative Study of Medical Students' Perspectives

Introduction

The integration of technology into medical education has witnessed significant growth in recent years, with tools such as virtual reality, artificial intelligence, and telemedicine gaining prominence. These tool in medical education, offering immersive, experiential learning experiences.

Methods

We approached medical students currently enrolled in medical education programs and who are familiar with and actively use AI in medical education. Initially, we invited 21 random students to participate in the study; however, only 13 agreed to interviews. Some students cited their busy exam schedules as the reason for not participating. The participants were informed of the objective of the study before the commencement of the recorded interviews. Semi-structured interviews were used to guide the record interviews. Audio recordings were transcribed and analyzed using Atlas.ti, a qualitative data analysis software.

Results

Participants exhibited a diverse range of perceptions and levels of awareness regarding VR, AI, and telemedicine technologies. Learning with virtual reality was considered to be fun, memorable, inclusive, and engaging by participants. The use of virtual reality technology is seen as complementing current teaching and learning approaches, helping to build learners' confidence, as well as providing medical students with a safe environment for problem-solving and trial-and-error learning. The students reported that AI was seen as a potential game-changer in the healthcare sector. Participants hoped that telemedicine would provide healthcare services to remote and underserved populations.

Conclusion

The study conducted focus group discussions with medical students and residents in Saudi Arabia to explore their views on integrating VR, AI, and telemedicine in medical education and practice. Their insights highlight the need for informed decision-making and strategic development to optimize the benefits and address challenges like initial investments, technical issues, ethics, and regulations. These considerations are crucial for fully realizing the potential benefits of technology in medical education globally.

Telehealth care and remote monitoring strategies in heart failure patients: A systematic review and meta-analysis

BACKGROUND

Heart failure (HF) is a cardiac clinical syndrome that involves complex pathological aetiologies. It represents a growing public health issue and affects a significant number of people worldwide.

OBJECTIVES

To synthesize evidence related to the impact of telemonitoring strategies on mortality and hospital readmissions of heart failure patients.

METHODS

A systematic literature review was conducted using PubMed, Scopus, CINAHL, IEEE Xplore Digital Library, Engineering Source, and INSPEC. To be included, studies had to be in English or Italian and involve heart failure patients of any NYHA class, receiving care through any telecare, remote monitoring, telemonitoring, or telehealth programmes. Articles had to contain data on both mortality and number of patients who underwent rehospitalizations during follow-ups. To explore the effectiveness of telemonitoring strategies in reducing both one-year all-cause mortality and one-year rehospitalizations, studies were synthesized through meta-analyses, while those excluded from meta-analyses were summarized narratively.

RESULTS

Sixty-one studies were included in the review. Narrative synthesis of data suggests a trend towards a reduction in deaths among monitored patients, but the number of rehospitalized patients was higher in this group. Meta-analysis of studies reporting one-year all-cause mortality outlined the protective power of care models based on telemonitoring in reducing one-year all-cause mortality. Meta-analysis of studies reporting the number of rehospitalized patients in one-year outlined that telemonitoring is effective in reducing the number of rehospitalized patients when compared with usual care strategies.

CONCLUSION

Evidence from this review confirms the benefits of telemonitoring in reducing mortality and rehospitalizations of HF patients. Further research is needed to reduce the heterogeneity of the studies.

Telemedicine for healthcare: Capabilities, features, barriers, and applications

Regular hospital visits can be expensive, particularly in rural areas, due to travel costs. In the era of the Covid-19 Pandemic, where physical interaction becomes risky, people prefer telemedicine. Fortunately, medical visits can be reduced when telemedicine services are used through video conferencing or other virtual technologies. Thus, telemedicine saves both the patient's and the health care provider time and the cost of the treatment. Furthermore, due to its fast and advantageous characteristics, it can streamline the workflow of hospitals and clinics. This disruptive technology would make it easier to monitor discharged patients and manage their recovery. As a result, it is sufficient to state that telemedicine can create a win-win situation. This paper aims to explore the significant capabilities, features with treatment workflow, and barriers to the adoption of telemedicine in Healthcare. The paper identifies seventeen significant applications of telemedicine in Healthcare. Telemedicine is described as a medical practitioner to diagnose and treat patients in a remote area. Using health apps for scheduled follow-up visits makes doctors and patients more effective and improves the probability of follow-up, reducing missing appointments and optimising patient outcomes. Patients should have an accurate medical history and show the doctor any prominent rashes, bruises, or other signs that need attention through the excellent quality audio-video system. Further, practitioners need file management and a payment gateway system. Telemedicine technologies allow patients and doctors both to review the treatment process. However, this technology supplements physical consultation and is in no way a substitute for a physical consultation. Today this technology is a safe choice for patients who cannot go to the doctor or sit at home, especially during a pandemic.

Virtual models of chronic disease management: lessons from the experiences of virtual care during the COVID-19 response

Objective This study examined Gold Coast staff and patient experiences with the rapid expansion of a virtual model of chronic disease management during the COVID-19 pandemic. Methods The study undertook a survey of enrolled patients (n=24) and focus groups with clinical and administrative staff (n=44) delivering chronic disease programs at Gold Coast Health in Queensland. The study also examined routinely collected activity data for the chronic disease programs before COVID (January-February 2020) and for the first 3 months of the COVID-19 response (March-May 2020). Results Chronic disease programs continued to provide similar numbers of appointments over the COVID-19 response period, but there was a marked increase in the proportion of appointments that were delivered virtually, either by telephone or video conference. Most patients were satisfied with their virtual care experiences and felt that their health care needs were met. Conclusions The COVID-19 response provided an opportunity to learn and further develop models of virtual care. Staff and patients were generally supportive of continuing to include virtual appointments in the future. Ongoing concerns were predominantly around the support available to patients and staff to ensure they are trained and equipped to manage the technology and new mode of communicating. What is known about the topic? Emerging evidence suggests that virtual models of health care delivery, such as telephone and video consultations and remote patient monitoring, can be safe and cost-effective alternatives to traditional face-to-face chronic disease management programs. Virtual care is associated with equal or improved clinical outcomes, as well as efficiency improvements, such as reduced failure to attend rates. What does this paper add? The increasing burden of chronic disease across Australia, as well as the need to minimise the risk of vulnerable patient groups attending in-hospital appointments where it is safe and appropriate to do so, means that expanding the delivery of virtual chronic disease management will become increasingly necessary. The results of this study provide an opportunity to learn from a rapid rollout of virtual care for these staff and patient groups and will help inform advances in this area. What are the implications for practitioners? Existing evidence, demographic pressures and the COVID-19 pandemic response all point to virtual care as a viable and safe alternative to traditional models of chronic disease management. The lessons presented here provide more detailed guidance on the support that staff and patients require to ensure virtual care is a seamless and safe alternative or adjunct to traditional chronic disease management programs.

Telemedicine for Pre-Employment Medical Examinations and Follow-Up Visits on Board Ships: A Narrative Review on the Feasibility

BACKGROUND

Telemedicine has already been applied to various medical specialties for diagnosis, treatment, and follow-up visits for the general population. Telemedicine has also proven effective by providing advice, diagnosis, and treatment to seafarers during emergency medical events onboard ships. However, it has not yet been applied for pre-employment medical examinations and follow-up visits on board ships.

OBJECTIVE

This review aimed to assess the possibility of using telemedicine during periodic visits between one pre-employment medical examination and others on board ships, and to recommend necessary medical examination tests with screening intervals for seafarers.

METHODS

Various databases including PubMed, EMBASE, Scopus, CINAHL, and Cochrane Library were explored using different keywords, titles, and abstracts. Studies published between 1999 and 2019, in English, in peer-reviewed journal articles, and that are conference proceedings were considered. Finally, the studies included in this review were chosen on the basis of the eligibility criteria.

RESULTS

Out of a total of 168 studies, 85 studies were kept for further analysis after removing the duplicates. A further independent screening based on the inclusion and exclusion criteria resulted in the withdrawal of 51 studies that were not further considered for our analysis. Finally, 32 studies were left, which were critically reviewed. Out of 32 accepted studies, 10 studies demonstrated the effectiveness of the electrocardiogram (ECG) in monitoring and managing remote patients with heart failure, early diagnosis, and postoperative screening. In 15 studies, telespirometry was found to be effective in diagnosing and ruling out diseases, detecting lung abnormalities, and managing patients with chronic obstructive pulmonary disease (COPD) and asthma. Seven studies reported that telenephrology was effective, precise, accurate, and usable by non-medical personnel and that it reduced sample analysis times and procedures in laboratories.

CONCLUSION

using new technologies such as high-speed internet, video conferencing, and digital examination, personnel are able to make the necessary tests and perform virtual medical examination on board ships with necessary training.

A Remote Patient Monitoring Intervention for Patients With Chronic Obstructive Pulmonary Disease and Chronic Heart Failure: Pre-Post Economic Analysis of the Smart Program

Background

Exacerbation of chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) are associated with high health care costs owing to increased emergency room (ER) visits and hospitalizations. Remote patient monitoring (RPM) interventions aim to improve the monitoring of symptoms to detect early deterioration and provide self-management strategies. As a result, RPM aims to reduce health resource utilization. To date, studies have inconsistently reported the benefits of RPM in chronic illnesses. The Smart Program is an RPM intervention that aims to provide clinical benefit to patients and economic benefit to health care payers.

Objective

This study aims to economically evaluate the potential benefits of the Smart Program in terms of hospitalizations and ER visits and, thus, associated health care costs from the perspective of the public health care system.

Methods

Seventy-four patients diagnosed with COPD or CHF from one hospital site were included in this one-group, pre-post study. The study involved a secondary data analysis of deidentified data collected during the study period – from 3 months before program initiation (baseline), during the program, to 3 months after program completion (follow-up). Descriptive analysis was conducted for the study population characteristics at baseline, the clinical frailty score at baseline and 3-month follow-up, client satisfaction at 3-month follow-up, and number and costs of ER visits and hospitalizations throughout the study period. Furthermore, the cost of the Smart Program over a 3-month period was calculated from the perspective of the potential implementer.

Results

The baseline characteristics of the study population (N=74) showed that the majority of patients had COPD (50/74, 68%), were female (42/74, 57%), and had an average age of 72 (SD 12) years. Using the Wilcoxon signed-rank test, the number of ER visits and hospitalizations, including their associated costs, were significantly reduced between baseline and 3-month follow-up (P<.001). The intervention showed a potential 68% and 35% reduction in ER visits and hospitalizations, respectively, between the 3-month pre- and 3-month postintervention period. The average cost of ER visits reduced from Can $243 at baseline to Can $67 during the 3-month follow-up, and reduced from Can $3842 to Can $1399 for hospitalizations.

Conclusions

In this study, the number and cost of ER visits and hospitalizations appeared to be markedly reduced for patients with COPD or CHF when comparing data before and after the Smart Program implementation. Recognizing the limitations of the one-group, pre-post study design, RPM requires an upfront investment, but it has the potential to reduce health care costs to the system over time. This study represents another piece of evidence to support the potential value of RPM among patients with COPD or CHF.

Telemedicine: A systematic review of economic evaluations

Background: Telemedicine is an expanded term in health information technology that comprises procedures for transmitting medical information electronically to improve patients’ health status. The objective of this research is to evaluate the cost-effectiveness of telemedicine interventions in various specialty areas.

Methods: The Cochrane Library and Centre for Review and Dissemination were searched up to February 2013 using Mesh. Studies that compared any kind of telemedicine with any other routine care technique and used cost per health utility unit’s outcomes were included.

Results: Twenty-one articles were included. According to the included studies, it seems that using telemedicine in cardiology can be effective and cost-effective enough but pre-hospital telemedicine diagnostics program are likely to have little impact on acute myocardial infarction fatality. In pulmonary, telemedicine can be a cost-effective strategy for delivering outpatient pulmonary care to rural populations which have limited access to specialized services, but telemedicine is not cost- effective in asthma and airways cancer. In ophthalmology, especially in the diagnosis of diabetic retinopathy, the use of telemedicine is a cost-effective tool. In dermatology, telemedicine is not cost-effective enough in comparison of conventional cares. In other fields such as physical activity and diet, eating disorder, tele-ICU, psychotherapy for depression and telemedicine on ships, telemedicine can be used as a cost-effective tool for treatments or cares.

Conclusion: Most of the included studies confirmed that telemedicine is cost-effective for applying in major medical fields such as cardiology; but in dermatology, papers could not confirm the positive capability of telemedicine.

[Current status and future of telemonitoring : Scenarios for telemedical care in 2025]

Telemonitoring is an already realized implementation of digital transformation in the healthcare system. It has the potential to support and secure a sustainable and comprehensive provision of healthcare for a rising number of chronically ill patients, e. g. patients with chronic heart failure. Remote regions in particular can profit from the benefits of telemonitoring; however, so far telemonitoring services have not become truly established in the German healthcare market. Together with experts from politics, science and practice, a scenario analysis "Health Care System 2025 - A Place for Telemonitoring?" was carried out with the aim to examine the future development of the healthcare market and to draw conclusions for providers of telemonitoring services or devices. The scenario analysis contained two workshops and an expert survey and was supported by a scenario software. The current drivers and barriers of the diffusion of telemonitoring were identified and the most relevant factors that influence the future development of the healthcare market were discussed. Based on those influencing factors, three different scenarios were determined: (1) administrating rather than shaping, (2) safely into the future and (3) interconnected and digital world. In the subsequent consequence analysis activities were defined, which describe the necessary infrastructure, software instruments, organizational structures and provision of services and discuss possible activities, which prepare telemonitoring solutions for the future.

Other side of the coin for personalised medicine and healthcare: content analysis of 'personalised' practices in the literature

OBJECTIVES

Various terms and definitions are used to describe personalised approaches to medicine and healthcare, but in ambiguous and inconsistent ways. They mostly have been defined in a top-down manner. However, actual practices might take different paths. Here, we aimed to provide a 'practice-based' perspective on the debate by analysing the content of 'personalised' practices published in the literature.

METHODS

The search in PubMed and EMBASE (April 2014) using the terms frequently used for personalised approaches resulted in 5333 records. 2 independent researchers used different strategies for screening, resulting in 157 articles describing 88 'personalised' practices that were implemented/presented on at least 1 individual/patient case. The content analysis was grounded on these data and did not have a priori analytical frameworks.

RESULTS

'Personalised medicine/healthcare' can be a commodity in the healthcare market, a way how health services are provided, or a keyword for emerging applications. It can help individuals/patients to gain control of their health, health professionals to provide better services, healthcare organisations to increase effectiveness and efficiency, or national health systems to increase performance. Country examples indicated that for integration of practices into health services, attitude towards innovations and health system and policy context is important. Categorisation based on the terms or the technologies used, if any, was not possible.

CONCLUSIONS

This study is the first to provide a comprehensive content analysis of the 'personalised' practices in the literature. Unlike the top-down definitions, our findings highlighted not the technologies but real-life issues faced by the practices. 'Personalised medicine' and 'personalised healthcare' can be differentiated by using the former for specific tools available and the latter for health services with a holistic approach, implemented in certain contexts. To realise integration of 'personalised medicine/healthcare' into real life, science, technology, health policy and practice, and society domains must work together.

Innovations in telemedicine for cardiovascular care

Cardiovascular disease is one of the main fields of application for telemedicine, with benefits in almost all areas in the continuum of cardiovascular disease. The greatest impact has been shown in the early diagnosis of cardiovascular disease, in second consultation, between non-cardiologist and cardiologist and between cardiologists, and in follow-up and secondary prevention of cardiovascular disease. At present, the main area of implementation for telemedicine in cardiovascular disease is represented by pre-hospital triage, with telemedicine electrocardiogram in acute myocardial infarction. Significant results have also been achieved in the second opinion consultation of pediatric subjects with congenital cardiovascular disease, home-monitoring and the management of patients affected by chronic heart failure or with an implanted device. However, there is significant room for further improvement in delivering telemedicine assistance even in 'very-remote' populations, such as detainees, patients in developing countries or in underdeveloped areas of developed countries.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Interactive telemedicine: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

OBJECTIVES

To assess the effectiveness, acceptability and costs of interactive TM as an alternative to, or in addition to, usual care (i.e. face-to-face care, or telephone consultation).

SEARCH METHODS

We searched the Effective Practice and Organisation of Care (EPOC) Group's specialised register, CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers to June 2013, together with reference checking, citation searching, handsearching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We considered randomised controlled trials of interactive TM that involved direct patient-provider interaction and was delivered in addition to, or substituting for, usual care compared with usual care alone, to participants with any clinical condition. We excluded telephone only interventions and wholly automatic self-management TM interventions.

DATA COLLECTION AND ANALYSIS

For each condition, we pooled outcome data that were sufficiently homogenous using fixed effect meta-analysis. We reported risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and mean differences (MD) for continuous outcomes.

MAIN RESULTS

We included 93 eligible trials (N = 22,047 participants), which evaluated the effectiveness of interactive TM delivered in addition to (32% of studies), as an alternative to (57% of studies), or partly substituted for usual care (11%) as compared to usual care alone.The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).Telemedicine provided remote monitoring (55 studies), or real-time video-conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self-management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real-time assessment of clinical status, for example post-operative assessment after minor operation or follow-up after solid organ transplantation (8) vi), screening, for angina (1).The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e-mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.We found no difference between groups for all-cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I(2) = 44%) (moderate to high certainty of evidence) at a median of six months follow-up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow-up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:-4.39, 95% CI -7.94 to -0.83; P < 0.02; I(2) = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow-up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD -0.31, 95% CI -0.37 to -0.24; P < 0.00001; I(2)= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow-up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD -12.45, 95% CI -14.23 to -10.68; P < 0.00001; I(2 =) 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:-4.33, 95% CI -5.30 to -3.35, P < 0.00001; I(2) = 17%; DBP: -2.75 95% CI -3.28 to -2.22, P < 0.00001; I(2) = 45% (moderate certainty evidence), in TM as compared with usual care.Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video-conferencing, as compared to face-to-face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

AUTHORS' CONCLUSIONS

The findings in our review indicate that the use of TM in the management of heart failure appears to lead to similar health outcomes as face-to-face or telephone delivery of care; there is evidence that TM can improve the control of blood glucose in those with diabetes. The cost to a health service, and acceptability by patients and healthcare professionals, is not clear due to limited data reported for these outcomes. The effectiveness of TM may depend on a number of different factors, including those related to the study population e.g. the severity of the condition and the disease trajectory of the participants, the function of the intervention e.g., if it is used for monitoring a chronic condition, or to provide access to diagnostic services, as well as the healthcare provider and healthcare system involved in delivering the intervention.

Telemedicine for cardiovascular disease continuum: A position paper from the Italian Society of Cardiology Working Group on Telecardiology and Informatics

Telemedicine is the provision of health care services, through the use of information and communication technology, in situations where the health care professional and the patient, or 2 health care professionals, are not in the same location. It involves the secure transmission of medical data and information, through text, sound, images, or other forms needed for the prevention, diagnosis, treatment, and follow-up of a patient. First data on implementation of telemedicine for the diagnosis and treatment of acute myocardial infarction date from more than 10 years ago. Telemedicine has a potential broad application to the cardiovascular disease continuum and in many branches of cardiology, at least including heart failure, ischemic heart disease and arrhythmias. Telemedicine might have an important role as part of a strategy for the delivery of effective health care for patients with cardiovascular disease. In this document the Working Group on Telecardiology and Informatics of the Italian Society of Cardiology intends to remark some key-points regarding potential benefit achievable with the implementation of telemedicine support in the continuum of cardiovascular disease.

The empirical foundations of telemedicine interventions for chronic disease management

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

Policy expectations and reality of telemedicine - a critical analysis of health care outcomes, costs and acceptance for congestive heart failure

A critical review of evidence was carried out to discover whether the actual performance of telemedicine fulfils the expectations of German policy-makers. The analysis was conducted using the example of telemedicine for congestive heart failure (CHF). It was based on both German and international evidence. The PubMed, MEDLINE, Google Scholar and Cochrane Library databases were searched, as well as public sources from the German Federal Ministry of Health. Forty-five studies reporting patient outcomes, costs or acceptance of telemedicine for CHF were included in the review, of which 28 were interventional. The policy expectations of telemedicine generally are: high technology acceptance and improved patient outcomes at lower costs. However, in the field of CHF, policy-makers underestimate the complexity of telemedicine and the technology has not yet lived up to its expectations. Although some studies show improvements in all-cause mortality and CHF-related hospitalisations, there is excessive study heterogeneity and vagueness in the areas of costs and acceptance. Methodological insufficiencies as well as the scarcity of evidence in the German context do not allow definite conclusions to be drawn. Policy-makers and other stakeholders should increase their efforts to consolidate isolated telemedicine projects, establish guidelines for clinical treatment procedures and economic evaluations, and define industry/technical device standards to enhance the comparability of interventions. Imposing the use of telemedicine on patients and physicians is not likely to be fruitful. A successful adaptation requires an analysis of needs and continuous education on both sides.

Implementing guideline based heart failure care in the Northern Territory: challenges and solutions

The Northern Territory of Australia is a vast area serviced by two major tertiary hospitals. It has both a unique demography and geography, which pose challenges for delivering optimal heart failure services. The prevalence of congestive heart failure continues to increase, imposing a significant burden on health infrastructure and health care costs. Specific patient groups suffer disproportionately from increased disease severity or service related issues often represented as a "health care gap". The syndrome itself is characterised by ongoing symptoms interspersed with acute decompensation requiring lifelong therapy and is rarely reversible. For the individual client the overwhelming attention to heart failure care and the impact of health care gaps can be devastating. This gap may also contribute to widening socio-economic differentials for families and communities as they seek to take on some of the care responsibilities. This review explores the challenges of heart failure best practice in the Northern Territory and the opportunities to improve on service delivery. The discussions highlighted could have implications for health service delivery throughout regional centres in Australia and health systems in other countries.

Measuring the effect of telecare on medical expenditures without bias using the propensity score matching method

OBJECTIVE

This article examines the effect of telecare on medical expenditures for chronic diseases using survey data from Nishi-aizu Town, Fukushima Prefecture, Japan. The study uses the propensity score matching (PSM) method, a rigorous analytical method that overcomes sample selection bias, a common problem when using survey data.

SUBJECTS AND METHODS

One hundred ninety-nine users (treatment) of telecare and 209 nonusers (control) were selected from residents, and their medical expenditures were obtained from the National Health Insurance scheme for comparison. Individual characteristics of the two groups, including age, sex, income, and health conditions, were compared, and variables that contained biases were specified by a t test. After calculation of their propensity scores and elimination of biases, the effect of telecare on medical expenditures was estimated. To obtain robust results, four different matching methods were applied: caliper matching, single nearest-neighbor matching, Epanechnikov kernel matching, and biweight kernel matching.

RESULTS

No independent variable showed significant differences between the two groups after matching, indicating that selection biases were successfully eliminated using PSM. Using PSM, we saw a decrease in medical expenditures in Japanese yen of 25,538-39,936 (USD 319.23-499.20) per year per user and a decrease in the number of treatment days of 2.6-4.0 days. In comparison, our previous analyses using the same data underestimated the effects of telecare. PSM provides greater effects by reducing bias.

CONCLUSIONS

Using PSM to compare subjects in two groups with similar characteristics except for their use or nonuse of telecare, we demonstrated that the treatment group has lower medical expenditures for chronic diseases than the control group. Proper matching is important in evaluating the impact of telecare interventions. Limitations of PSM include its requirement for a large number of samples and the limited ability to explain why and how telemedicine produces these effects. Other empirical methods are required to identify the mechanism of how telemedicine works.

Effectiveness of telemedicine and distance learning applications for patients with chronic heart failure. A protocol for prospective parallel group non-randomised open label study

INTRODUCTION

Chronic heart failure in Baltic Sea Region is responsible for more hospitalisations than all forms of cancer combined and is one of the leading causes of hospitalisations in elderly patients. Frequent hospitalisations, along with other direct and indirect costs, place financial burden on healthcare systems. We aim to test the hypothesis that telemedicine and distance learning applications is superior to the current standard of home care.

METHODS AND ANALYSIS

Prospective parallel group non-randomised open label study in patients with New York Heart Association (NYHA) II-III chronic heart failure will be carried out in six Baltic Sea Region countries. The study is organised into two 6-month follow-up periods. The first 6-month period is based on active implementation of tele-education and/or telemedicine for patients in two groups (active run period) and one standard care group (passive run period). The second 6-month period of observation will be based on standard care model (passive run period) to all three groups. Our proposed practice change is based on translational research with empirically supported interventions brought to practice and aims to find the home care model that is most effective to patient needs.

ETHICS AND DISSEMINATION

This study has been approved by National Bioethics Committee (2011-03-07; Registration No: BE-2-11).

TRIAL REGISTRATION

This study has been registered in Australian New Zealand Clinical Trials Registry (ANZCTR) with registration number ACTRN12611000834954.