Effectiveness of telehealth versus standard care on health care utilization, health-related quality of life, and well-being in homebound populations: a systematic review protocol : JBI Evidence Synthesis

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Effectiveness of telehealth versus standard care on health care utilization, health-related quality of life, and well-being in homebound populations: a systematic review protocol

Pinero de Plaza, Maria Alejandra1,2,3; Beleigoli, Alline1; Brown, Shannon1; Bulto, Lemma N.1,3; Gebremichael, Lemlem G.1,3; Nesbitt, Katie1,3; Tieu, Matthew1; Pearson, Vincent1; Noonan, Sara1; McMillan, Penelope4; Clark, Robyn A.1,3; Hines, Sonia3; Kitson, Alison1,2; Champion, Stephanie1; Dafny, Hila1,3; Hendriks, Jeroen M.1,3,5

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doi: 10.11124/JBIES-21-00410
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Abstract

Introduction

Globally, an increasing number of people are diagnosed with health issues, including disabilities, mental health, injuries, and chronic conditions, that prevent them from leaving their homes.1,2 They are defined as homebound: people whose daily lives are physically limited to the boundary of their homes because of their ongoing health, energy levels, or functional impairments.1,2

An Australian program of research (co-led by homebound persons and their affiliated communities, eg, disability and chronic diseases groups and their carers) has self-classified their homebound groups as frail, homebound, and bedridden people (FHBP).3,4 Their FHBP definition unites distinct groups by their homebound experiences: feeling and/or “being trapped and unable to leave home.”4(p.2) Such a conceptualization excludes those affected by temporary incidents, COVID-19 lockdowns, or short-term illnesses.3,4

Worldwide, disease rates, symptom burden, functional limitations, and mortality are higher for homebound people than for the non-homebound population.5 They live with multiple chronic disorders and rare diseases that are not consistently recognized as disabilities or supported by health and social services.3,4,6 Further, investigating homebound people and ways to address their issues is imperative because they experience multidimensional psychosocial and health problems; for example, financial hardship, social isolation, depression, and higher suicide rates.7

The vulnerability experienced by homebound people is becoming more prevalent with COVID-19.8 The pandemic is increasing service demands and the prevalence of chronic health issues (eg, disability from long COVID, a type of post-infection syndrome that affects people's ability to resume everyday life and their capacity to work or study).9 It has also increased anxiety, depression, and isolation, and augmented the severe barriers that homebound groups face in accessing health care, worsening their health and well-being.9 However, digital technologies, such as mobile phones, tablets, and computers that enable remote health care delivery (ie, telehealth), could provide innovative solutions to the reported problems and excessive current pressures on health care providers and health systems.10

A recent randomized clinical trial (focusing on older homebound people and COVID-19) indicated that telehealth facilitated better medication adherence and quality of life when compared to the control group; the study called for an investigation into the further use of telehealth to tackle the pressing issues that homebound people face.11 In Australia, telehealth initiatives during the COVID-19 pandemic have been life-changing for many FHBP.3,4 The homebound population reported better and more equitable access to primary health care, stating that, for the first time, they could see their continuity of care supported by the telehealth relationship with their general practitioner (GP).3,4,10 However, from July 2020, decision-makers made telehealth only available to those who have attended a face-to-face GP appointment in the last 12 months, thus excluding homebound people. Approximately 600,000 Australians do not leave home as often as they would like due to their health conditions, and about 1.4 million have a severe or profound disability.3,4,10

A lack of evidence-based approaches to tackling the complexities of the health care system concerning the fundamental care needs of vulnerable populations makes it challenging to define which type of medical and/or therapeutic interventions have a significant effect on the homebound population.12,13 Around the world, homebound groups are affected by segregated and deteriorating support services.13 This cohort has expressed grave concerns about their marginalization and discrimination and refer to biases and inappropriate assumptions about their life experiences, current health diagnoses, and quality of life.12-15

The concerns that homebound people have reported are associated with undertreatment, as public health infrastructure and the health care delivery systems are ill-equipped to reach people's homes.12-14 Therefore, finding evidence to influence policymaking and prevent profound disparities concerning health care access and public services is necessary. This work must involve homebound people in decision-making, for example, concerning the Australian policy developments around telehealth access.3,4,10,12-18

In summary, responding to homebound people's calls requires evidence concerning improving their health conditions and life cycle to inform change. Using telehealth for such purposes demands measurable and replicable evidence-based knowledge about the burden of disease associated with health care access and its effects on health care utilization. Accessing this knowledge also requires data concerning the influence of telehealth on health-related quality of life and well-being of homebound populations. Therefore, Before developing further telehealth interventions to improve the lives of homebound people, it is necessary to synthesize the current knowledge around telehealth versus in-person care on health care utilization, health-related quality of life, and well-being.12-14,18,19 The proposed review will guide future research and action concerning the pressing and complex issues affecting homebound populations globally. Our extended network of collaborators (eg, clinicians, patients, and communities) requires further systematic and replicable evidence to implement change.12-14 A member of the homebound community (PM) is a co-author on this protocol and a co-leader of the FHBP research program. Including their voices and feedback will create appropriate recommendations to support or reject telehealth and identify gaps in knowledge to help future qualitative investigations dedicated to understanding why homebound people are under-served and under-researched.3,4,12-14

This review will aim to produce a reliable estimate of the effectiveness of telehealth by examining the available evidence on telehealth interventions for homebound populations and the outcomes concerning health care utilization, health-related quality of life, and well-being compared to in-person care. We conducted a preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis and found no current or in-progress systematic reviews addressing our review question.

Review question

What is the effectiveness of telehealth versus standard (in-person) care on health care utilization, health-related quality of life, and well-being in homebound populations?

Inclusion criteria

Participants

This review will consider studies that include homebound persons whose daily lives are physically limited to the boundary of their homes because of their ongoing health, energy, and psychosocial or socio-functional impairments. Participants must live in community settings (ie, their homes) and not be able to autonomously leave their homes due to their age or health conditions. In terms of severity, homebound persons are defined as people who never (completely homebound) or rarely (mostly homebound) left home in the last month. Those who only left home with assistance, had difficulty, or needed help leaving home are considered semi-homebound persons and are included in this review.19,20

Studies with participants at home due to temporary issues (eg, accident; illness; or physical, mental, and/or functional impairments that last less than six months) will be excluded from the review.19,20 This cohort receive regular care and leave their homes despite experiencing chronic conditions, movement, and other limitations (eg, short-term musculoskeletal injuries or infections, COVID-19 curfews, or lockdowns). Therefore, they can access primary care without telehealth services under regular circumstances.

Intervention

This review will consider telehealth, which is defined as interventions enabling remote health care and well-being services via technologies such as telephone services and digital technologies or platforms (eg, websites, apps, email, DVD-based interventions, mobile phones, tablets, and wearable devices that provide health advice or therapeutic services).

The scope captures telehealth usage, with or without assistance, delivered by health practitioners or other professionals (non-practitioners such as social workers, speech pathologists, dietitians, hypnotherapists, and therapeutic masseurs) addressing illness, injuries, or congenital conditions, physiological or psychological dysfunction, and other barriers associated with the outcomes described in this protocol. Adverse effects of any duration and type will also be considered and recorded.

Comparator

This review will consider standard in-person care as a comparator (ie, in-person health advice or health care delivery to homebound people via face-to-face/physical attendance). This comparator excludes services that are not considered standard practice for homebound people, such as using different technologies to enable remote health care and well-being services; for example, a combination of home care visits with remote monitoring via apps.

Outcomes

This review will consider studies that quantify the effectiveness of telehealth on health care utilization and health-related quality of life using validated quantitative instruments. The health and well-being factors are a comprehensive state of physical, mental, and social well-being and not merely the absence of disease or infirmity.21 The three mentioned outcomes overlap within the literature, and the clarification process is an ongoing methodological development.22 Therefore, we adopt the multidimensional definitions of the different instruments; for example, concerning health care utilization, we will extract outcomes that involve health-screening rates, attendance, or participation in behavioral change programs, such as attending cardiac rehabilitation or adherence to other health follow-up treatments. These outcomes include tools that measure health care utilization as the discretionary or nondiscretionary use of a health care service, procedure, device, or pharmaceutical drug to maintain the homebound person's health (preventing and/or treating health problems or obtaining information about their health status and prognosis).23

Examples of health care utilization instruments are the general self-rated health or mental health tools such as the Client Service Receipt Inventory, Treatment Inventory of Costs in Patients (TiC-P), the Los Angeles Epidemiologic Catchment Area Survey, the Intervista Costi Assistenza Psichiatrica, and the Client Socio-Demographic and Service Receipt Inventory.24 Health care utilization outcomes also consider direct costs associated with diagnosis, treatment, prevention, and management, as well as indirect costs, such as lost opportunities, resources related to health conditions, lost productivity, disability, and premature mortality23 (eg, disability-adjusted life years, health-adjusted life expectancy, and years lived with disability).25

Concerning health-related quality of life, we will consider outcomes from tools identified through generic measurable definitions of quality of life, which is a wide-ranging, multidimensional concept typically comprising subjective evaluations of both positive and negative aspects of life, or health-related quality of life, which incorporates those aspects of overall quality of life that affect either physical or mental health.26 Outcomes from these measures and tools will be included because they have been widely used and validated across different cultures, conditions, and ages (eg, 36-Item Short Form Survey [SF-36], EuroQol 5 Dimension tool [EQ-5D], WHO Quality of Life-BREF [WHOQOL-BREF] for adults, Kidscreen, Child Health Questionnaire [CHQ], and Pediatric Quality of Life Inventory [PedsQL] for children).26

Concerning well-being, our investigation will consider self-report instruments of ill health and unhappiness, together with measures of positive functioning and adaptation to unfavorable circumstances.27 We will consider measurements of well-being that can be associated or listed within the 99 measurements included in the thematic framework of well-being,27 which will assist us in considering all the dimensions of the construct: personal circumstances; activities and functioning; and social, physical, spiritual, and overall well-being (eg, the Positive Functioning Inventory, the Salutogenic Health Indicator Scale, the Flourishing Scale).27

Types of studies

This review will consider experimental and quasi-experimental study designs (eg, randomized controlled trials, non-randomized controlled trials, crossover trials, cluster-randomized trials, before-and-after studies, and interrupted time series). It will not include observational studies, gray literature, or qualitative investigations.

Methods

The proposed systematic review will be conducted in accordance with JBI methodology for systematic reviews of effectiveness.28,29 This protocol has been registered in PROSPERO (CRD42021289578).

Search strategy

An initial limited search of MEDLINE was conducted to identify articles on the topic and inform the search strategies. The text words in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy for MEDLINE (Ovid) and tested to ensure it retrieved and identified key articles (see Appendix I).

The search strategy will aim to locate peer-reviewed primary studies, including all identified keywords and index terms, adapted for the bibliographic databases Embase (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), Scopus, LILACS (BVS Portal), and Web of Science. Cochrane Central Register of Controlled Trials (CENTRAL), and JBI Evidence Synthesis (Ovid) are also included for an additional hand-search of references reflected within relevant systematic reviews. The reference lists of all studies selected for critical appraisal will be screened for additional studies. Peer-reviewed primary studies in any language will be included, with no date limit.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote v.20 (Clarivate Analytics, PA, USA), and duplicates removed. Following a pilot test, titles and abstracts will then be screened by 2 independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full. Their citation details will be imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).28

The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. The systematic review will record and report reasons for excluding full-text studies that do not meet the inclusion criteria. Any disagreements arising between the reviewers in the study selection process will be resolved through discussion or through a third reviewer. The study selection process will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.29

Our research team includes fluent native speakers of English, Dutch, Latin languages (eg, Spanish, Portuguese, Italian), Hebrew, Amharic, Oromo, and Mandarin. Their respective translations and contributions will be acknowledged in the final review paper. We will use Google Translate for any studies in a language the team cannot translate. Where two team members determine that the translated study may not meet the inclusion criteria (or this is not clear), the study will be excluded, and the exclusion noted in the final review. As we have no professional translation resources, relevant studies that cannot be translated will be excluded and listed in the final review.

Assessment of methodological quality

Two independent reviewers will critically appraise the selected studies. The methodological quality will be assessed for all studies included in the review. The standardized JBI critical appraisal checklist for RCTs and quasi-experimental studies will be used if non-randomized experimental studies require inclusion.30 Corresponding authors will be contacted twice to request missing or additional data for clarification, where required. Any disagreements between the reviewers will be resolved through discussion or with a third reviewer. The critical appraisal results will be reported in a table with accompanying narrative. All studies will undergo data extraction and synthesis (where possible), regardless of their methodological quality. Results of the critical appraisal will be summarized and incorporated into the review in table format.

Data extraction

Data will be extracted from studies and included in the review by 2 independent reviewers using the standardized JBI data extraction tool.30 The data extracted will include specific sociodemographics of homebound populations, study methods, measurement tools per intervention type, and outcomes of significance concerning health care utilization, health-related quality of life, and well-being. Any disagreements between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data.

Data synthesis

JBI SUMARI28 will be used for statistical meta-analysis of pooled studies (where possible). If there are sufficient studies for each type of intervention (eg, telehealth modalities addressing psychological conditions, illness, injuries, and/or congenital or physiological conditions), separate pooled analyses will be performed. Heterogeneity will be determined qualitatively by comparing study designs, outcome measures, risk of bias, and control groups. Effect sizes will be expressed as odds ratios (for dichotomous data) or weighted (or standardized) final post-intervention mean differences (for continuous data), and 95% CI will be calculated for analysis.

Heterogeneity will also be assessed statistically using the standard χ2 and I2 tests. Statistical analyses will be performed using a random effects model.31 When the intervention significantly improves any referred outcomes, subgroup analysis will be performed to explore the influence of the pertinent factors on the result (eg, based on gender, age, issue severity, telehealth intervention, and adverse effects, where sufficient and comparable data are available). This analysis will require at least two eligible studies in each category. Studies that blend group and individual interventions or remote and in-person interventions will not be eligible for inclusion in the subgroup analyses.

Sensitivity analyses will be conducted to determine whether the meta-analysis results are robust when there are changes in criteria during the review process; these analyses are not prespecified as further issues may be identified. If sensitivity analysis indicates that the overall findings are affected by decisions made during the review process, the corresponding authors of the included studies will be contacted twice (within 2 weeks) by email. In the instance of a missing standard deviation (SD), if the information is not received, it will be imputed from a similar study (in terms of intervention, comparator, sample size, and means). If there is more than one similar study (in terms of intervention, comparator, and sample size), the authors will evaluate whether the SD was approximately equal to the square root (mean). If only median and interquartile ranges were reported, the mean would be assumed to be equal to the median, and the SD will be calculated (=IQR/1.35).

Narrative syntheses will be conducted to describe and explain the studies, including tables and figures to aid in data presentation where appropriate. A funnel plot will be generated using STATA 17 (Stata Corp LLC, Texas, USA) to assess publication bias if 10 or more studies are included in a meta-analysis. Where appropriate, statistical tests for funnel plot asymmetry (Egger, Begg, and Harbord) will be performed.

Assessing certainty in the findings

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach for grading the certainty of evidence will be followed, and a Summary of Findings will be created using GRADEpro GDT (McMaster University, ON, Canada).32 The Summary of Findings will present the following information where appropriate: absolute risks for intervention (telehealth) versus standard care (in-person), estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The outcomes reported in the Summary of Findings will be health care utilization, health-related quality of life, and well-being in homebound populations. Any deviations from this proposed protocol will be justified and reported in the final systematic review.

Funding

RC and JH were supported by a Flinders University, Caring Futures Institute grant (Cardiac Focus Area Research Grant, 2021).

MAPP is supported by The Knowledge Translation team of the CFI and the National Health and Medical Research Council, Centre of Research Excellence in Frailty and Healthy Ageing.

Declarations

This protocol has been co-designed by a transdisciplinary group of experts, including a homebound consumer (PM), who has gathered feedback about FHBP from her extended networks.

Author contributions

All authors contributed to the search strategy, eligibility criteria, and analysis strategy. MAPP primarily developed the protocol; SB and MAPP performed the search strategy; and AB, JH, LG, LB, KN, SN, PM, RC, MT, SC, VP, HD, SH, AK revised and contributed to the conceptual drafting of the document. JH supervised the project.

Appendix I: Search strategy

Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review and Other Non-Indexed Citations, Daily and Versions(R)

Date searched: September 14, 2021

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Keywords:

bedridden; health care utilization; homebound; quality of life; telehealth

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