Effectiveness of Ambulatory Telemedicine Care in Older Adults

A Systematic Review

John A. Batsis, MD, AGSF; Peter R. DiMilia, MPH; Lillian M. Seo, BS; Karen L. Fortuna, PhD; Meaghan A. Kennedy, MD, MPH; Heather B. Blunt; Pamela J. Bagley, PhD; Jessica Brooks, PhD; Emma Brooks, BS; Soo Yeon Kim, BS; Rebecca K. Masutani, MD; Martha L. Bruce, PhD; Stephen J. Bartels, MD, MS

Disclosures

J Am Geriatr Soc. 2019;67(8):1737-1749. 

In This Article

Abstract and Introduction

Abstract

Background: Disparities in healthcare access and delivery, caused by transportation and health workforce difficulties, negatively impact individuals living in rural areas. These challenges are especially prominent in older adults.

Design: We systematically evaluated the feasibility, acceptability, and effectiveness in providing telemedicine (TMed), searching the English-language literature for studies (January 2012 to July 2018) in the following databases: Medline (PubMed); Cochrane Library (Wiley); Web of Science; CINAHL; EMBASE (Ovid); and PsycINFO (EBSCO).

Participants: Older adults (mean age = 65 years or older, and none were younger than 60 years).

Interventions: Interventions consisted of live, synchronous, two-way videoconferencing communication in nonhospital settings. All medical interventions were included.

Measurements: Quality assessment, using the Cochrane Collaboration's Risk-of-Bias Tool, was applied on all included articles, including a qualitative summary of all articles.

Results: Of 6616 citations, we reviewed the full text of 1173 articles, excluding 1047 that did not meet criteria. Of the 17 randomized controlled trials, the United States was the country with the most trials (6 [35%]), with cohort sizes ranging from 3 to 844 (median = 35) participants. Risk of bias among included studies varied from low to high. Our qualitative analysis suggests that TMed can improve health outcomes in older adults and that it could be used in this population.

Conclusions: TMed is feasible and acceptable in delivering care to older adults. Research should focus on well-designed randomized trials to overcome the high degree of bias observed in our synthesis. Clinicians should consider using TMed in routine practice to overcome barriers of distance and access to care.

Introduction

Despite improvements in life expectancy and advances in medical therapies,[1] individuals residing in rural areas in the United States face increasing disparities in healthcare delivery.[2–4] Remote and distant communities demonstrate higher rates of the five leading causes of death in the United States,[5,6] attributed, in part, to the lack of resources[2,5] in the ambulatory setting,[7] limited access to specialists and specialized resources, fewer transportation options, and socioeconomic disparities.[8–12] Rural healthcare is especially problematic in vulnerable populations, including persons with disabilities,[13] children,[14] and older adults.[11]

Information and communication technologies provide an opportunity to improve rural healthcare delivery in older adults, the fastest growing user group of technology,[15] particularly in an era of burgeoning rural broadband and cellular connectivity.[16] While telemedicine (TMed) or telehealth encompasses many different modalities of using technology to deliver care, synchronous, two-way videoconferencing (referred and defined in this article as TMed) is a promising strategy in delivering rural healthcare[17–19] that may address the long-standing challenge of rural health service availability. As a result of the Telecommunications Act signed in 1996, infrastructure changes have helped support the feasibility and dissemination of TMed delivery, particularly for rural healthcare providers, patients, and communities[19] in the United States. With the expansion of high-speed broadband access to over 96% of the population,[20] there is now improved capability for TMed in surmounting the major barriers faced by rural residents and narrowing the rural-urban divide in healthcare utilization.[17] TMed has now become increasingly adopted, particularly in capitated and shared risk healthcare financing systems,[21–23] and emerging legislation[24,25] promises to further widespread dissemination.

While a number of observational studies and single-site pilot studies suggest that TMed may have long-term cost-effectiveness[26–30] may reduce hospital utilization[26,31–33] or emergency department visits,[34,35] data in ambulatory settings have been less commonly evaluated. Older adults have less experience with emerging technologies and have considerable sensory, memory, and other aging-related barriers to engaging in TMed.[36,37] Older adults' multiple comorbidities may also require in-person rather than remote-based care. The purpose of this review is to conduct a systematic evaluation of the evidence regarding TMed interventions conducted in older adults in nonhospital settings. Although the intent of our review is to consider implications for rural healthcare, we evaluated both rural and urban studies extending past the domestic United States to assess the feasibility, acceptability, and effectiveness of TMed in this population.

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