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

Results

We present our PRISMA flow diagram in Figure 1. In total, our search strategy identified 9720 total citations (Appendix S2), of which 6616 were reviewed after duplicates were removed. After initial title and abstract screening, 1173 citations required full-text review. Non-RCT and asynchronous communications were the most common reasons for exclusion. The final count of included articles consisted of 17 studies, all of which were based on unique study populations.

Risk-of-Bias Assessment

Table 1 indicates the bias assessment, according to the Cochrane Collaboration's Risk-of-Bias Tool,[51] of all included studies, according to the authors' judgment. Subjective methodological quality of all included studies was considered low to intermediate based on the proportion of studies found to have a "high" risk of bias, according to the Cochrane Tool. Methodological problems in the included studies consisted of nonblinded data collectors, outcome assessors, and treatment allocation. As expected, blinding of study participants and healthcare providers was not possible due to the nature of TMed interventions and, hence, we did not evaluate these components of the tool.

Study Characteristics

The majority of the included RCTs were based in the United States (n = 6), with Europe and South Korea consisting of five and four studies, respectively, (Table 2, Appendix S3). Only four studies focused in whole or in part on rural participants.[52–55] The majority of studies were funded by governmental or public agencies. Computers of all types (desktop, tablet, laptop) were used and included studies focused on effectiveness and participant perception of TMed usage. Study cohort number ranged from small pilot trials (n = 3) to a larger, multisite trial of 844 participants.

Participant Characteristics

Participants were older adults, ranging from a mean age of 65.1 years to 86.45 years, although the ranges (when reported) consisted of adults aged 60 to older than 90 years (Table 3). Socioeconomic status was indicated in nine studies, and patient frailty or functional status was inconsistently reported using different indexes. Most interventions focused on a spectrum of chronic disease entities, including neurological disorders, depression, chronic obstructive pulmonary disease, and diabetes, or high-risk older adults with different baseline characteristics. Studies varied in the sex distribution of participants. Most interventions occurred in the participant's home, with others delivered in nursing facilities or community centers.

Intervention and Outcomes

Table 4 outlines the intervention description and control group of all included studies. All intervention-based groups used synchronous videoconferencing modalities. Control groups varied by studies, predominantly consisting of standard, in-person, clinical care or usual health promotion care for the specific disease entity. Study duration varied from 2 weeks[55] to 5 years.[54] One study[56] did not report its study duration. Most primary outcome measures consisted of disease-specific outcome measures, including rehospitalizations, nonfatal events, or clinical complications. Video contact time ranged from monthly to three times per week. Only three studies commented on technical limitations of their video delivery,[57–59] of which one experienced considerable difficulty.[59]

The main outcomes also varied between studies (Table 4). A number of studies (n = 7) demonstrated similar outcomes compared to a corresponding control group; others demonstrated considerable acceptability, adherence, and self-reported function. A number of studies (n = 4) focused on fall, exercise, or strength-based measures and demonstrated improvements. Three studies suggested that TMed could lead to improved cognitive function. All but one study demonstrated feasibility in their older adult population. However, improvements in utilization parameters were only observed in one study, while five studies demonstrated no differences. Each study had a number of major limitations, the main ones which are listed in the accompanying table (Appendix S3).

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