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GEMS

Barriers in delivering health care to older adults? Telemedicine can help

Patel, Milan DO

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doi: 10.1097/EBP.0000000000000965
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Effectiveness of ambulatory telemedicine care in older adults: A systematic review

Batsis JA, DiMilia PR, Seo LM, et al. Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review. J Am Geriatr Soc. 2019. doi:10.1111/jgs.15959.

KEY TAKEAWAY: Telemedicine (TMed) should be considered when access to health care is limited; however, more studies with less bias need to be conducted.

LEVEL OF EVIDENCE: STEP 2, downgraded because of the high level of bias in the included trials.

BRIEF BACKGROUND INFORMATION: Older adults’ access to health care can be limited by transportation and low accessibility to healthcare providers because of living in a rural area. Telemedicine has provided an effective avenue to make healthcare delivery accessible.

PATIENTS: Patients with a mean age of 65 years.

INTERVENTION: Live, synchronous, two-way videoconferencing communication in non–hospital (ambulatory or nursing home) settings.

CONTROL: Standard, in-person clinical care.

OUTCOME: Primary outcome: Telemedicine effectiveness and patient acceptability of the intervention.

STUDY DESIGN: Systematic Review

METHODS BRIEF DESCRIPTION:

  • PRISMA (Preferred Reporting Items for Systematic Review) guidelines were used.
  • The authors reviewed Medline (PubMed), Cochrane Library (Wiley), Web of science, CINAHL, EMBASE (Ovid), and PsycINFO (EBSCO) to gather the articles.
  • Inclusion criteria:
    • ◦ English-language studies from January 2012 (year of Centers for Medicare and Medicaid Service's TMed coverage determination) to July 2018.
    • ◦ TMed delivered in ambulatory setting or long-term care facility.
    • ◦ Only RCTs that used TMed with real-time, synchronous, two-way videoconferencing on both ends.
    • ◦ People providing healthcare intervention had to be healthcare providers (physicians, APNs, PT, OT, social workers, dieticians, and psychologists).

Cochrane Collaboration Risk of Bias tool was used to the evaluate risk of bias.

Data unable to be pooled.

INTERVENTION (# IN THE GROUP): 17 RCTs; 1,946.

COMPARISON (# IN THE GROUP): 17 RCTs; 1,609.

FOLLOW-UP PERIOD: Duration and follow-up of studies varied from 2 weeks to 5 years.

RESULTS:

Many of the individual RCTs showed improved health outcomes when compared with the control group.

  • There was a decrease in the number and the duration of contact events when delivering speech pathology care by TMed versus in person.
  • Decrease in nonfatal heart failure events and lower admission rates among telehealth groups versus in person.
  • Improvement in ESWT (endurance exercise capacity) for telerehabilitation program versus in person.
  • Diabetic care adherence improved in TMed coaching (in Spanish if needed) versus in person.
  • Tele-exercise program with one-on-one remote instruction improved lower-limb muscle mass versus in person.
  • Incidence of metabolic and GI complications were lower among groups with undergoing home enteral nutrition care using TMed versus standard home visits.

Some trials found TMed made no difference compared with in-person care:

  • Hospital readmission after discharge.
  • Kidney disease follow-ups.
  • No difference in cognitive scores with the use of neurocognitive tests.

LIMITATIONS:

  • A variety of qualitative measures were used to measure primary outcomes.
  • Only specific diseases were target in the RCTs used instead of studying older adults with many comorbid conditions.
  • Functional or socioeconomic status was not indicated in many of the studies.
  • New technologies adopted without assessing usability by older adults.
  • Heterogeneity of the intervention and outcomes prevented meta-analysis.

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