Systematic Review of Cost Effectiveness Studies of Telemedicine Interventions

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Effectiveness and cost-effectiveness of telehealth in rural and remote emergency departments: a systematic review protocol

• Suzanne Robinson¹,
• James Boyd²,
• Andrew Jamieson^three,
• Robert Blakeman⁴,
• Kylie Bosich⁵,
• Justin Yeung⁵,
• Stephanie Waters^six &
• Delia Hendrie¹

Systematic Reviews volume 9, Commodity number:82 (2020) Cite this article

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Abstract

Background

Emergency telehealth has been used to improve accessibility of rural and remote patients to specialist care. Evidence to date has demonstrated effectiveness and toll-effectiveness of telehealth in rural and remote emergency departments within a diverseness of contexts. Still, systematic reviews to engagement take not focused on the rural and remote emergency departments. The purpose of this study is to review the consequence measures used in evaluations of emergency telehealth in rural and remote settings and assess evidence relating to their effectiveness and price-effectiveness.

Methods

Randomised controlled trials, not-randomised controlled trials, and full and partial economical evaluations (e.g. cost-effectiveness, cost-benefit, and price-utility analyses) of telehealth in rural and remote emergency departments will be included. Comprehensive literature searches will exist conducted in multiple electronic databases (from 1990 onwards): MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, EconLit, CRD databases (east.m. NHS Economic Evaluation database), and Tufts Toll-Effectiveness Registry. 2 authors will independently screen all citations, total-text manufactures, and abstract data. The methodological quality (or risk of bias) of individual studies will be appraised using an appropriate tool. A systematic narrative synthesis will be provided with information presented in the text and tables to summarise and explain the characteristics and findings of the studies. If feasible, we will conduct random effects meta-analysis.

Discussion

This review will place gaps in the current torso of evidence relating to the effectiveness and cost-effectiveness of rural and remote emergency telehealth services. By confining to articles written in the English linguistic communication, this assay may be subjected to publication bias and results need to exist interpreted accordingly. We believe the results of this review could be valuable for the design of future economical evaluations of emergency telehealth services implemented in the rural and remote context.

Systematic review registration

PROSPERO CRD42019145903

Peer Review reports

Background

Modest rural and remote hospitals demand to have admission to specialty intendance to ensure that patients receive the correct care in the right place at the right fourth dimension. However, small and rural hospitals confront particular challenges related to shortages of primary care and specialist providers. Emergency telehealth services accept been used to accost this result [1] and have been widely adopted in resource-poor emergency departments such equally those in rural and remote locations [1,ii,three,four]. Cost-effectiveness studies to date have reported evidence in rural and remote medical emergencies within a wide variety of contexts; yet, systematic reviews on effectiveness and cost-effectiveness of telehealth in the emergency departments to date have non focused on the rural and remote settings [5].

A literature review on the impact and effectiveness of emergency telehealth services provided an overview of the suitability, effectiveness, and available evidence on economic outcomes up to September 2013. From 38 manufactures reviewed, the authors provided an overview of major findings relating to technical quality, user perceptions, clinical processes and outcomes, disposition and throughput, and economic outcomes [6]. However, specific upshot measures to assess the effectiveness of emergency telehealth were not systematically reviewed. A minor number of studies reported economic analyses, and no formal cost-effectiveness evaluation was performed in any of the studies reviewed. The studies included in this review have not always used the term 'cost-effectiveness' strictly non within the meaning of formal economic evaluations [vii]. Since this review, the cost-effectiveness of telehealth in the rural and remote emergency settings have been reported in the context of pre-hospital patient intendance enabled past telehealth [8, nine], telemetry for chest pain patients presenting to the emergency departments [x], and acute ischemic stroke presentations to rural hospitals [11].

Reported benefits of emergency telehealth in rural and remote settings are not confined to acutely disquisitional presentations. A systematic review published in 2019 on non-critical emergency presentations in the rural and remote emergency departments establish that there was potential for telehealth programmes to assist in reducing unnecessary patient transfer and secondary over-triage [12]. These programmes may also increase the chapters of emergency section staff to diagnose and manage patients locally, translating to local hospital admission and reduced discharge rates post-obit teleconsultation [12]. It is unknown whether these findings are transferable to critical emergency presentations. Whether the effectiveness and cost-effectiveness on improving patient upshot is dependent on presenting atmospheric condition also remains unanswered.

A global review of telehealth for acute and chronic teleconsultations accept identified the impossibility of making generalisations nearly the clinical and economic effectiveness of telehealth consultations [five]. This review has sourced 29 studies on TeleStroke and 21 studies on emergency care telehealth specialist consultations. The review concluded that emergency care decreases time from presentation to decision, reduces ED time, and increases appropriate transfers and admissions [5]. Despite the recency and comprehensiveness of the review, the analysis on clinical effectiveness and cost-effectiveness across specialty or condition was insufficient, and the lack of rural and remote focus ways the context around the effectiveness and cost-effectiveness of the studies reviewed was absent-minded. Time is of the essence in emergency departments especially in rural and remote settings where longer transfer time is expected if inter-hospital movement is required. Treatment delays in transit due to altitude can potentially impact on clinical effectiveness in emergency departments peculiarly in remote locations, and the extent of telehealth effectiveness in bridging this gap beyond condition groups has besides not been reviewed.

The challenges in using bachelor effectiveness and cost-effectiveness evidence to inform resources resource allotment decisions is the variations in the clinical effectiveness and consequence measures. This is in turn influenced by the variations in the requirements of each clinical specialty (e.g. mental health, emergency medicine, neurology, ophthalmology, plastic surgery) or condition groups (eastward.1000. acute stroke, acute myocardial infarction, or burns). For example, the proportion of patients receiving the fourth dimension-critical thrombolysis infusion (tPA) and the modified Rankin Scale (mRS) has been used consistently across most TeleStroke studies as the clinical effectiveness measure out; however, tPA infusion is only applicable to ischaemic stroke patients. The effectiveness and cost-effectiveness findings are therefore non transferable to the haemorrhagic stroke and the transient ischaemic attack (TIA) presentations. The determination of stroke subtypes is heavily dependent on whether the site of presentation has computed tomography (CT) capability; therefore, the findings from the TeleStroke are as well hard to generalise to the patient cohorts presenting to hospitals with no CT imaging facility. The variations in telehealth utilisation depend on what conditions patients are presented with and the expected bear on of timely specialist consultation on clinical effectiveness. Some cost-effectiveness studies take used incremental price-effectiveness ratio (ICER) comparison the toll of improving one quality of life year (QALY) [thirteen]. A discussion is pending on the utility and pregnant of QALY for emergency telehealth in the rural and remote hospitals, especially variations in its meaning and utility across different clinical categories of presentations.

In social club to inform the pattern of hereafter economical evaluations of emergency telehealth in rural and remote setting, a systematic review is warranted to explore the clinical effectiveness measures used in past evaluations of emergency telehealth implemented in rural and remote settings, the utility of QALY every bit an effect mensurate in the toll-effectiveness studies in conjunction with the methodology, and findings from economical analysis of such services.

The purpose of this study is to review the outcome measures used in evaluations of emergency telehealth in rural and remote settings and to assess show relating to their effectiveness and cost-effectiveness.

Methods/design

This study protocol for a systematic review of the effectiveness and price-effectiveness of telehealth in rural and remote emergency departments is being reported in accord with the reporting guidance the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [14, xv] (run across PRISMA-P checklist in Additional file 1). This protocol was registered within the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42019145903; https://www.crd.york.ac.u.k./PROSPERO/display_record.php?RecordID=145903).

Eligibility criteria

Studies will be selected co-ordinate to criteria around the Population, Intervention, Comparator, Outcome(s) of involvement, and Written report design (PICOS framework) [16]. These are detailed as follows:

• Participants: We will include studies involving patients attended in rural or remote emergency departments. Rural and remote in this review volition be defined loosely as presentation locations not within a metropolitan city. Pick of study will not exist based on distance between 3rd centre and site of presentation.

• Interventions and comparators: Telehealth technology tin can range from telephone compared to face to face consults (that is treatment every bit usual) to video briefing consult compared to phone consults. Studies focusing on the effectiveness of a single mobile device, electronic health records volition too be excluded.

• Upshot(southward) of involvement: The primary issue volition be the incremental cost-effectiveness ratio in terms of costs per life years gained, quality-adjusted life years gained, or disability-adjusted life years avoided. The secondary outcomes will exist wellness outcomes, costs, or both as reported by investigators of included studies. Studies describing the effectiveness of telehealth without a well-defined effectiveness measure will not exist included.

• Written report design: Eligible studies will exist randomised controlled trials, non-randomised controlled trials, and full and partial health economic evaluations. Full economic evaluations will include toll-effectiveness analyses, toll-benefit analyses, toll-utility analyses, and cost minimization analyses. Partial economic evaluations will include toll comparisons, cost analysis, price-consequence description, cost descriptions, and cost of disease studies. We volition exclude reviews, editorials/commentaries, and methodological articles. No limitations volition exist imposed on publication status (articles, report reports, and unpublished studies will be eligible for inclusion).

The selection criteria have been summarised in Table 1, and just studies published in the English language from 1990 to the present will be considered.

Table 1 Selection criteria

Full size table

Information sources

The primary source of literature volition exist a structured search of major electronic databases (from January 1990 onwards): MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, EconLit, CRD databases (e.yard. NHS Economic Evaluation database), and Tufts Cost-Effectiveness Registry. We volition perform hand-searching of the reference lists of included studies, relevant reviews, national clinical practice guidelines, or other relevant documents. Content experts and authors who are prolific in the field volition be contacted.

Search strategy

The search strategy was adult together with the Health Sciences librarian at the Curtin Academy to improve search quality. A search strategy using medical subject headings (MeSH) was designed to target four central domains: telehealth/telemedicine, emergency department/emergency department, effectiveness, or toll-effectiveness assay. A draft search strategy for MEDLINE is provided in Additional file 2. The final search strategies volition be reported in the complete review. Pilot searches were undertaken for each domain and combined concepts to ensure that the search strategy was effective.

Written report records

Data management

Identified records will be managed using the EndNote reference managing director, which will enable duplication of records to be identified and removed and records tracked through the screening and data collection process.

Selection process

Titles and abstracts will be screened past 1 reviewer (CT). Articles meeting the selection criteria will be retained for independent assessment against option criteria by the showtime reviewer and confirmed by two other reviewers (SR and DH). Any discrepancies volition exist reassessed by a fourth reviewer (JB) with the remaining discrepancies resolved by the full team. The concluding list of articles volition be downloaded in total text for detailed review. Additional records will be searched from reference lists of the manufactures retained.

A PRISMA flowchart will be used to demonstrate the process of identification and screening of articles to include in the systematic review, with reasons for exclusion noted.

Data extraction

Record extraction will be conducted by one reviewer (CT) and checked by a second reviewer (DH). Whatsoever disagreement volition be resolved through discussion or through an cess by a third reviewer (SR). Information volition be extracted using a standardised form. For all studies, items to be included in the data extraction sheet are the following: bibliographic data, aim and objectives, state, participant characteristics, intervention and comparator details, effect measure(southward) including clinical effectiveness, and service utilisation indicators. For the economic evaluation studies, additional data items will include perspectives of economical analysis, cost items included, conclusion-analytic models used, sensitivity analysis performed, and results (Additional file 2).

Reporting quality in individual studies

The reporting quality in full economic evaluations volition be evaluated using the Consolidated Wellness Economic science Evaluation Reporting Standards (CHEERS) argument. The chance of bias of individual studies will be evaluated using advisable tools. For randomised control trials, the Run a risk of Bias 2.0 tool will be used [17], for not-randomised control trials, the ROBINS-I tool [18], and for economical evaluations, the Joanna Briggs Constitute (JBI) suite of critical appraisal tools [nineteen].

Data synthesis

Review characteristics and result summaries

A narrative clarification of the PICO chemical element and findings of included studies will exist tabulated in 4 different tables summarising their bibliographic information, intervention, outcome measures, and conclusions at the study level. Additional file 4 lists the column headings of each of the summary tables. Articles volition besides be categorised and counted in a ii-way matrix co-ordinate to specialties and operational use of the intervention. An initial matrix is shown in Additional file 5 which will also be used for the collection of outcome measures to assess the effectiveness of emergency telehealth services.

A second-tier description of outcome measures will then be collated and categorised into clinical effectiveness or service utilisation measures, and whatsoever validity or data quality bug of the measures will be reviewed. The frequencies of each result mensurate will be counted, and whatever pattern around the context in which each of the measures has been used will be noted including any data collection issues. The frequency of each of the measures used past each written report perspectives (wellness system or societal perspectives) will be counted, rationales discussed by the authors in relation to the result measure out will exist noted, and appropriateness for economic evaluation will be discussed.

Economic evaluations volition be further summarised to include specialty, the type of economic evaluation conducted, effectiveness measure, toll items, and information collection methods including whether the costs are nerveless from routine authoritative data drove, survey samples, or from other sources. The incremental toll-effectiveness ratio (ICER) will be identified from cost-effectiveness studies.

Quantitative synthesis

The information from each newspaper summarised to a higher place volition be used to build prove tables of an overall description of included studies. If feasible and appropriate, data points from primary observational studies will be used to perform random effects meta-analyses. Since heterogeneity is expected a priori, we will guess summary estimates (e.thou. mean differences, standard mean differences) and its 95% confidence interval using the Hartung-Knapp-Sidik-Jonkman [20] random furnishings model. The random effects model assumes the report prevalence estimates to follow a normal distribution, considering both within-study and between-study variations. Forest plots volition be used to visualise the extent of heterogeneity among studies. We will quantify statistical heterogeneity by estimating the variance betwixt studies using I ^two statistics. I ^two is the proportion of variation in prevalence estimates that is due to genuine variation in prevalence rather than sampling (random) error. I ² ranges between 0 and 100% (with values of 0–25% and 75–100% taken to indicate low and considerable heterogeneity, respectively). We volition also report Tau2 and Cochran Q test with P value of < 0.005 considered statistically significant (heterogeneity).

Additional analysis

A subgroup analysis of telehealth effectiveness is planned for each specialty to be reported, and a separate subgroup analysis volition exist performed for economic studies where the effect is incremental toll-effectiveness in toll/QALY gained. To assess the extent of publication bias, a funnel plot will be used with the effect size on the 10-axis and full sample size on the y-axis. An upside-down funnel-shaped distribution of studies indicates the absenteeism of a publication bias. Publication bias can be suspected if the studies showed an asymmetrical distribution [20]. If publication bias is detected, the trim-and-fill method can exist used to correct the bias [21].

Discussion

Although there is some evidence on the effectiveness of emergency telehealth services, bear witness on their effectiveness and cost-effectiveness in rural and remote settings is limited. A closer examination of outcomes used in rural and remote emergency telehealth is an important preparatory step in the design of a robust economical evaluation to capture the impact of distance and remoteness context. This review will provide insight into what outcome measures have been used to appraise the effectiveness of rural and remote telehealth services and how the selection of measures impact on the quality of and findings from economic evaluations.

Past assessing economic evidence extracted from this review, any critical gaps in the current body of evidence in this field will exist identified. Additionally, summarising the effectiveness and cost-effectiveness of emergency telehealth services in the rural and remote context volition provide useful data to inform both the design of future economic evaluations and decision-making surrounding the design and implementation of these services.

A systematic tendency of including and excluding sure toll items in the assay tin can be a source of potential limitation in economic studies where the findings are skewed towards a particular perspective, for example, the health systems perspective rather than the societal perspective. This will likewise impact on a counterbalanced assessment of toll-effectiveness of telehealth in rural and remote emergency departments. Due to the modest number of economic evaluations and the varied research methodology, the scope for quantitative meta-analysis may exist restricted. By circumscribed to articles written in the English language language, this analysis may be subjected to publication bias and results demand to be interpreted accordingly.

In the event of whatever deviation between the protocol and the complete review, these amendments volition be documented including the date of amendment, description of change, rationale, and consequences of these modifications.

Availability of information and materials

Data sharing is not applicative to this article as no dataset were generated or analysed during the current study.

Abbreviations

PROSPERO:

International Prospective Register of Systematic Reviews

PICO:

Participants, Intervention, Comparators and Outcomes

PCC:

Population, Concept, Context

AMED:

Allied Health and Complementary Medicine

CINAHL:

Cumulative Index to Nursing and Centrolineal Health Literature

MeSH:

Medical Subject Heading

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Thanks:

Consolidated Health Economics Evaluation Reporting Standards

ICER:

Incremental cost-effectiveness ratio

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Acknowledgements

The authors would similar to acknowledge the WA Country Health Service in supporting the industry-based enquiry to be conducted and the hosting Curtin Academy researcher on-site.

Funding

This study has been funded by the Health Research and Data Analytics Hub Ph.D. research stipend scholarship, Curtin University. The Hub also provides supervision to the Ph.D. research.

Writer information

Affiliations

1. Curtin Academy, Kent Street, Bentley, Perth, WA, 6102, Australia

   Christina Tsou, Suzanne Robinson & Delia Hendrie

2. La Trobe Academy, Plenty Rd & Kingsbury Dr, Bundoora, VIC, 3086, Australia

   James Boyd

3. WA Country Health Service, 189 Wellington Street, Perth, WA, 6000, Australia

   Andrew Jamieson

4. Consumer and Community Health Research Network, Level 6, 6 Verdun Street, Nedlands, WA, 6009, Commonwealth of australia

   Robert Blakeman

5. WA Country Health Service (Command Middle), Royal Perth Hospital, Level vi, Wellington Street, Perth, WA, 6000, Australia

   Kylie Bosich & Justin Yeung

6. WA Country Health Service, Royal Perth Infirmary, Level 6, Wellington Street, Perth, WA, 6000, Australia

   Stephanie Waters

Contributions

All authors have been involved in the conception and design of the systematic review protocol. The authors read and approved the final manuscript.

Corresponding writer

Correspondence to Christina Tsou.

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The authors declare that they accept no competing interests.

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Tsou, C., Robinson, S., Boyd, J. et al. Effectiveness and cost-effectiveness of telehealth in rural and remote emergency departments: a systematic review protocol. Syst Rev nine, 82 (2020). https://doi.org/10.1186/s13643-020-01349-y

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• Received: 25 September 2019

• Accepted: 03 Apr 2020

• Published: 17 April 2020

• DOI : https://doi.org/ten.1186/s13643-020-01349-y

Keywords

• Telehealth
• Telemedicine
• Clinical effectiveness
• Treatment consequence
• Toll-effectiveness
• Economic evaluation
• Rural population
• Rural health
• Remote

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