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

Discussion

We identified a number RCTs supporting TMed's feasibility, acceptability, and effectiveness across diverse health conditions, healthcare settings, and patient populations. Our data demonstrate that TMed can potentially be a useful modality of health service delivery. However, there were limitations with respect to the findings due to heterogeneity in study design, the plurality of underpowered studies in each arm, and other methodological limitations. This underscores the need for well-designed trials to minimize bias and provide definitive evidence of TMed use among ambulatory older adults.

Our review fills a gap as it focuses on trials conducted outside of the hospital setting. A number of included studies demonstrated equivalent outcomes, highlighting the potential for TMed to address geographic barriers while delivering comparable health outcomes. Hospitals aim to achieve improved efficiency, prompting smaller systems in more remote areas to use telestroke and teleintensive care programs that are successful and sustainable.[60–62] Yet, there is less emphasis on ambulatory or skilled nursing facility care. Our results suggest that policy makers should promote further ambulatory coverage by eliminating barriers for both providers and patients, alike.

There is a critical need for high-quality studies investigating the impact of TMed interventions in older adults. The Informatics for Diabetes Education and Telemedicine project (IDEATel) study[54,63] integrated early TMed and remote monitoring with web-based informatics using a home-installed, low-bandwidth, TMed device. Their cohort exceeded 800 Medicare beneficiaries. The authors found that TMed was acceptable,[64] usable in lower socioeconomic,[65] ethnic,[54] and older adult populations,[66] and improved diabetes self-management.[67] Their data suggested a need for implementation strategies for future dissemination. The other three methodologically high-quality studies demonstrated sample size concerns[68,69] and a sample consisting predominantly of males.[70] Additional, adequately powered studies focusing on diverse populations are needed.

Our findings demonstrate that TMed interventions are feasible and acceptable among older adults and that similar outcomes are achievable compared to usual, in-person care. Few studies, though, focused specifically on rural adults and the results were mixed. While TMed may provide a unique opportunity to reach isolated, low-resource populations with limited access to in-person medical services, well-designed, high-quality studies are needed. It is unclear whether the considerable bias and misperception related to older adults' use of technology[71] play a role. Providers are often hesitant in recommending technologies in older adults due to potential physical, sensory, cognitive, and visual-spatial abnormalities.[72–74] The population of older adults in the United States is rapidly growing,[75] with a workforce available to provide care for this demographic insufficient. TMed may help provide effective care, particularly in rural and underserved areas, and executing the Institute of Medicine's recommendation to advance TMed resources[76] is strongly supported by our observations.

Despite numerous limitations in study quality, our approach had a number of strengths supporting our conclusions. By using the PRISMA criteria, we reduced inherent bias and error that are present in conducting systematic reviews. Including research librarians increases the validity of our process. Our data substantiate that there are insufficient, well-designed RCTs in the use of TMed. The methodological inconsistencies in these trials provide an opportunity to focus on addressing these gaps in future work.

We acknowledge several limitations. First, many studies focused on specific diseases, and not multimorbid, frail older adults that often require a range of medical and social services,[77] impeding generalizability. The majority of studies did not highlight functional or socioeconomic status, suggesting a need for future studies to report on these parameters. Second, laptops and computers that may have larger screens rather than tablets or smartphone technologies were used, which are more affordable and widely available, but whose user interfaces may not necessarily be tailored to older adults—an important factor in usability.[78] Software and peripherals that may impact user experience and intervention effectiveness differ, which may increase the reach of future interventions. Data are needed to evaluate these devices, expanding on traditional healthcare delivery to nonhealthcare settings, beyond research or health centers. While our focus was not hospital based, only two RCTs were in nursing facilities.[53,79] Observational studies exist;[80,81] yet, the lack of rigorous studies in older adults has considerable implications as they are sicker and require increased medical assessment and acuity,[77] ultimately leading to increased utilization. Research to evaluate TMed interventions in such facilities is needed. Few studies described technological issues, particularly in areas with poor bandwidth, likely due to the urban-rural divide observed. Our findings are also prone to publication bias. Last, the heterogeneity of interventions and outcomes prevented us from conducting a formal meta-analysis, with some studies lacking formal statistical comparisons.

Our findings have a number of implications and provide a foundation for research priorities. The 2012 legislation covering TMed highlights an urgent need to develop novel, pragmatic interventions to evaluate TMed delivery, in both rural and nonrural populations. Currently, an Innovation Award is evaluating the impact of TMed on cost and reducible hospitalizations, irrespective of locality in long-term care settings.[82] Understanding barriers and facilitators of effective TMed implementation strategies in systems as well as payment models to improve efficiency for both older adults and provider systems is helpful. We have an opportunity to integrate technology in older adults who traditionally are excluded from trials. Usability needs differ,[78] and future trials should adapt delivery systems to different chronological and physiological groups. While a number of RCTs using TMed in nonhospital settings exist, well-designed, powered trials will provide guidance in using this technology in older adults, particularly in rural areas.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....