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


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

In This Article


We conducted a systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.[38] See Appendix S1 for a checklist of each component.

Study Protocol

We reviewed all English-language studies published from the year of the Centers for Medicare and Medicaid Service's TMed coverage determination (January 2012) to July 2018.[36,39–44] Database searches were conducted in June 2017, and repeated in February and July 2018. The final search update covered the full date range, and records found in the previous searches were removed, based on the methods described by Bramer and Bain.[45] We present the aggregate results of all searches below.

With the assistance of two reference librarians (H.B.B., P.J.B.), the search included subject headings and key words to capture the concepts of TMed and older adults in English-language articles. The search strategy was adjusted for the syntax appropriate to each database. The following electronic databases were searched: Medline (PubMed); Cochrane Library (Wiley); Web of Science; CINAHL; EMBASE (Ovid); and PsycINFO (EBSCO). See Appendix S2 for our full search strategy. As our focus was on peer-reviewed publications, we deliberately omitted any gray literature, including websites, conference proceedings, abstract submissions, and clinical trial registries. Bibliographies of identified systematic reviews and all included articles were reviewed manually by the lead author (J.A.B.) for additional studies.

Selection Criteria

We used the Patients, Intervention, Controls, Outcomes framework to refine our criteria. Inclusion criteria consisted of: English-language studies; human studies; studies with a mean participant age of 65 years and corresponding 1 SD or range required to exceed 60 years, as conducted in our previous work;[46] and ambulatory TMed care delivered either in home or in an assisted living or long-term care setting on the receiving end of the intervention (not acute or hospital settings). For inclusiveness, participants were eligible if they had any comorbid physical and mental health conditions. Interventions were considered only if TMed was defined as live, real-time, synchronous, two-way videoconferencing on both the receiving and delivery end, as this is the most common type used within clinical settings and one that is most fully reimbursed.[47] This is in contrast to other modalities of telehealth, including remote monitoring, e-consultations, or store and forward, whose feasibility, acceptability, and preliminary effectiveness have been reviewed elsewhere.[48–50] Inclusion criteria also required a focus on patient care with a healthcare provider or trained staff (ie, physicians, associate providers [advanced practice registered nurses or physician's assistants], physical/occupational therapists, psychologists, social workers, or dietitians) on one end and a patient on the receiving end. We also included peer-to-peer therapy for medical conditions, as it ultimately resulted in delivering patient care. We excluded any TMed (videoconferencing) related to remote medical education. Studies involving social media (ie, Facebook or Twitter) were excluded. Initially, all study types (randomized controlled trials [RCTs] and observational or qualitative studies) were included as the study team was concerned that the number of high-quality RCTs would be limited. Following full-text review and identification of a sufficient amount of eligible RCTs (N = 17), our review protocol was modified to include only RCTs.

Data Extraction

Searches were combined using Endnote X8 (Thomson Reuters). Two sets of reviewers extracted data from the full-text articles identified in each search. Each set of reviewers conducted a test review for quality assurance purposes by manually conducting a title/abstract review of 200 citations, for which concordance was required to exceed 80%. Discrepancies between reviewers were adjudicated by the senior author (J.A.B.), an approach previously used.[46]

A total of 9185 citations were identified using our full search criteria (Figure 1). An additional 535 studies were identified from related systematic reviews during the search process. Pairs of reviewers manually reviewed citation titles and abstracts for inclusion criteria. Following initial title/abstract screening, discrepancies were reconciled before proceeding to full-text review. A second-level screening applied a hierarchical method of exclusion on the remaining full-text studies.

Figure 1.

Flow diagram of study selection process for the systematic review. We reviewed 36 systematic review bibliographies, which accounted for 535 additional records of studies for review (accounted for in the flow diagram as "additional records identified through other sources"). These articles were accounted for in the flow diagram. RCT indicates randomized controlled trial.

Quality Review

The Cochrane Collaboration's Risk-of-Bias Tool was used to evaluate bias for all included studies, as conducted in our group's previous work.[46] This tool focuses on the following: sequence generation; allocation concealment; blinding; incomplete outcome data; selective outcome reports; and other sources of bias. Two reviewers (L.M.S., P.R.D.) assessed each of the included studies, rating them as high, low, or unclear risk of bias for each criterion. The senior author (J.A.B.) adjudicated if any decisions differed.

Study-Level Outcomes

The primary outcomes were chosen a priori and intentionally left broad to ensure all potential effectiveness measures were captured. Our evaluation focused on effectiveness outcomes and acceptability of the intervention. All study data were extracted using a standardized data collection form, which included: publication year; country of origin; funding source; TMed modality (process, transmitting/receiving end, device used); study aim; number of study participants; mean age (and range); socioeconomic status (education, place of residence); function or frailty indicators; primary medical condition evaluated; sex distribution; study setting; and description of the intervention and control groups. We qualitatively evaluated the study's primary outcomes, video contact time, and the estimate of effect and presented study limitations. Significant methodological heterogeneity precluded meta-analysis.