Telemedicine Efficacy: the AHRQ Analysis

Telemedicine Efficacy: the AHRQ Analysis

At the request of Senators Bill Nelson (D, Florida) and John Thune (R, South Dakota) for a review of the literature on the value of telehealth and remote patient monitoring, AHRQ recently published an analysis of the state of the evidence of efficacy of telemedicine. Totten AM, Womack DM, Eden KB, McDonagh MS, Griffin JC, Grusing S, Hersh WR. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Technical Brief No. 26. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No.16-EHC034-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2016, at ii. [hereinafter “Evidence for Patient Outcomes.”]

https://www.effectivehealthcare.ahrq.gov/ehc/products/624/2254/telehealth-report-160630.pdf.

Briefly stated, the writers determined that the most consistent reports of benefit have been from telehealth used for communication and counseling, as in managing behavioral health problems, and in remote monitoring in chronic diseases such as cardiovascular and respiratory disease. In these areas, substantial evidence demonstrates improved mortality and quality of life, as well as reductions in hospital admissions. “Evidence for Patient Outcomes,” at vi; id. at 52.

Many commentators, both critics and supporters of telemedicine, have called for more studies to assess efficacy. Among the most notable features of the AHRQ report is a detailed, application-specific analysis of the state of the efficacy literature. The authors identified three categories of evidence. Category A referred to topics for which there is a sizable quantity of evidence and some consistency in the conclusions, sufficient to inform decisions on policy of interest to the lawmakers who requested the analysis. Category B covered topics that would benefit from new or additional systematic reviews. In Category B, there were enough primary studies to constitute a body of evidence, but not enough, in the collaborators’ view, to justify decision-making. Finally, Category C captured topics with few primary studies completed to date and less likely to constitute a body of evidence that the writers believed could support policy decisions.

Reproduced below is the authors’ “Table 8. Telehealth topics: Evidence categories.”

Category
/ Topic / Rationale
A / Remote patient monitoring for chronic conditions / Several systematic reviews available, consistent findings of benefit or potential benefit from most reviews
A / Communication and counseling for chronic conditions / Several systematic reviews available, consistent findings of benefit or potential benefit from most reviews.
A / Psychotherapy for behavioral health / Most systematic reviews report benefit or potential benefit; 1 review finds insufficient evidence for use in forensic and correctional psychiatry.
B / Consultation for various clinical reasons / Four reviews addressed telehealth for consultation; three of these did not come to a conclusion. The use of telehealth for consultation crosses clinical areas and may be a viable topic for future synthesis.
B / Applications of telehealth for acute/ICU care including remote patient monitoring and telementoring / The reviews identified for ICU/surgery and burn care combined with reviews in progress in critical care and postoperative care suggest a growing literature base on this important use of telehealth designed to expand access to high tech care in areas where access is limited.
B / Maternal and child health / Pregnancy and newborn routine health care monitoring is a frequent reason for health care visits and access can be limited in some areas. A preliminary search identified studies that cover multiple technologies and uses. A future systemative review may be able to organize the literature in a way that it would be useful for policy and decision-making.
C / Triage for urgent and primary care / While this has been proposed as a use for telehealth, most of the identified research was on telephone only interventions. It is unclear if telehealth is not used extensively for this purpose or if it has been used but has not been studied.
C / Applications in pediatrics (managing chronic serious conditions) / Healthcare for children with serious illnesses can be disruptive and impinge on normal life, activities and development. A small number of studies were identified across diverse conditions.
C / Applications relevant to the integration of mental and physical health / Although the integration of mental and physical health is an important goal in many health care reform efforts we did not identify overlap of these topics in telehealth research (e.g., telehealth to address depression in people with diabetes or to help patients struggling with addiction to obtain preventive care).
C / Impact of teledermatology on patient outcomes / While there is substantial evidence related to diagnostic concordance, we were unable to identify more than a few studies that included clinical outcomes. While diagnostic concordance is important, research focused on outcomes appears to be needed to inform decisions about this use of the telehealth.
C / Impact on cost and utilization / The evidence on costs is limited and does not correspond to the importance of this issue. Additionally, studies are needed that evaluate telehealth under new payment models.

“Evidence for Patient Outcomes,” at 47.

Assessment

One can further divide these conclusions into two groups: Surprising and unsurprising. In the latter, one could readily include the results respecting chronic conditions that require repeated assessments over long periods of time, among patients whose mobility may be limited, or among those with mental health problems, who have less need of physical examination than of regular communication with treaters. That pediatric applications have been studied to only a limited extent is not surprising; ethical and legal complexities tend to discourage research in children in most forms of health care, not just telehealth.

It may be a bit more surprising that, reportedly, there is a relative paucity of efficacy data for such widely available applications as consults, tele-ICU services, triage in urgent and primary care, and dermatology, all of which are well-established distance care practices. It ought to be relatively straightforward, then, to design and carry out studies to address questions currently unanswered, or answered to only a limited extent. Given the widespread recognition that reimbursement remains the single biggest obstacle to the advance of telemedicine, and given the importance of efficacy data to reimbursement decisions, the call for further research is hard to argue with.