Article type
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Abstract
Abstract: There is a growing demand for health care payors to cover telemedicine services, but evidence for their efficacy is unclear. We recently completed a systematic review assessing the diagnostic capabilities, access to care, health outcomes, patient and provider satisfaction, and cost-effectiveness of telemedicine services as well as built an inventory of active programs. The systematic review addressed three study areas of telemedicine: store-and-forward (pure asynchronous), self-monitoring/testing (based in homes or nursing facilities), and clinician-interactive. The review was limited to the population who would be eligible for Medicare in the United States (i.e., non-pregnant adults) and clinical situations that historically require face-to-face encounters (i.e., excluding teleradiology and telepathology). The objective of this report is to describe the coverage and quality of diagnostic and outcomes studies we assessed for the review.
Methods: To obtain studies, we performed a comprehensive literature search of four on-line databases, MEDLINE, CINAHL, EMBASE, and HEALTHSTAR. To build an inventory of telemedicine programs we also searched these databases as well as consulted compendia of telemedicine programs and Web sites. To measure the quality of studies, we applied criteria for diagnostic and outcomes studies used by our Agency for Healthcare Research (AHRQ) Evidence-Based Practice Center (EPC). Class designations and their characteristics for diagnostic studies were: I. Case series of consecutive patients from relevant population of individuals who would use telemedicine, using an objective gold standard with blinded interpretation of results, with inter-observer analysis II. Case series from relevant population who would use telemedicine, using an objective gold standard III. Case series not from relevant population or not using appropriate methodology for diagnostic test evaluation Class designations and their characteristics for outcomes studies were: I. Properly designed random controlled trials II. Random controlled trials that contain design flaws preventing specification of Class I; properly designed trials with control groups not randomized; multi-center or population-based longitudinal study; case control studies III. Descriptive studies (uncontrolled case series); clinical experience; expert opinion; case reports
Results: Overall we found severalfold more specialties using telemedicine than those having diagnosis and outcomes studies supporting its use. For the 29 studies of diagnostic efficacy, there were three Class I, 16 Class II, and 12 Class III studies. For the 17 studies of outcomes, there were nine randomized controlled trials, only three of which could be designated as Class I. There were 8 Class II and 6 Class III studies. Many of the Class II and III studies were evaluations that were reported along with descriptions of new technological approaches to telemedicine.
Conclusions: The use of telemedicine is widespread yet there are few high-quality studies assessing its diagnostic and outcomes capabilities. Further research should focus on well-designed studies of diagnostic efficacy and randomized controlled trials. Journal editors should separate reports of new technologies from evaluations, with the requirement that the latter adhere to standards of high-quality evidence.
Methods: To obtain studies, we performed a comprehensive literature search of four on-line databases, MEDLINE, CINAHL, EMBASE, and HEALTHSTAR. To build an inventory of telemedicine programs we also searched these databases as well as consulted compendia of telemedicine programs and Web sites. To measure the quality of studies, we applied criteria for diagnostic and outcomes studies used by our Agency for Healthcare Research (AHRQ) Evidence-Based Practice Center (EPC). Class designations and their characteristics for diagnostic studies were: I. Case series of consecutive patients from relevant population of individuals who would use telemedicine, using an objective gold standard with blinded interpretation of results, with inter-observer analysis II. Case series from relevant population who would use telemedicine, using an objective gold standard III. Case series not from relevant population or not using appropriate methodology for diagnostic test evaluation Class designations and their characteristics for outcomes studies were: I. Properly designed random controlled trials II. Random controlled trials that contain design flaws preventing specification of Class I; properly designed trials with control groups not randomized; multi-center or population-based longitudinal study; case control studies III. Descriptive studies (uncontrolled case series); clinical experience; expert opinion; case reports
Results: Overall we found severalfold more specialties using telemedicine than those having diagnosis and outcomes studies supporting its use. For the 29 studies of diagnostic efficacy, there were three Class I, 16 Class II, and 12 Class III studies. For the 17 studies of outcomes, there were nine randomized controlled trials, only three of which could be designated as Class I. There were 8 Class II and 6 Class III studies. Many of the Class II and III studies were evaluations that were reported along with descriptions of new technological approaches to telemedicine.
Conclusions: The use of telemedicine is widespread yet there are few high-quality studies assessing its diagnostic and outcomes capabilities. Further research should focus on well-designed studies of diagnostic efficacy and randomized controlled trials. Journal editors should separate reports of new technologies from evaluations, with the requirement that the latter adhere to standards of high-quality evidence.