From September 2008 to September 2011, The King’s Fund supported the work of the Whole System Demonstrator Programme by compiling an evidence database of studies that were able to demonstrate the impact (positive or negative) telehealth could have on the management of people with long-term conditions.
The purpose of the database, initially supported through research funding from the Department of Health, was to provide a simple portal through which academics, policy-makers, commissioners and providers could access the research evidence
To compile the evidence, we used a range of databases (CINAHL; MedLine; HMIC; PsychINFO; ASSIA; and NHS Evidence), plus evidence from unpublished local evaluations submitted to the research team directly. By examining abstracts of the results of these searches, with further review of full articles where necessary, studies were filtered and added to the database using specific criteria.
430 studies were included in the database, ranging in date from 1988 to 2011, and covering 20 long-term conditions/client groups. Of these, 197 represented ‘high level evidence’ studies (typically randomised controlled trials) with 233 studies from the ‘wider evidence base’.
This review focused on seven key areas: diabetes; heart failure/stroke; COPD; depression; older people; multiple long-term conditions; and hypertension. Three of these – diabetes, heart failure/stroke and COPD – were chosen because they were conditions specifically examined in the Whole System Demonstrator Pilot Evaluation and provided a basis for comparison. The remaining four were chosen based on the Fund’s specific interest in how care to older people and those with multiple long-term conditions can be better supported.The seven chosen conditions made up 72 per cent of the database entries (310 studies).
To be included in our review, the studies needed to meet one or more of the following impact criteria:
- Service utilisation – did the study report changes in the utilisation of service (for example, of hospital bed use, long-term residential home stays, use of domiciliary services)?
- Clinical effectiveness – did the study report impact on clinical outcomes (for example, in the ability to manage vital signs such as blood glucose levels for people with diabetes)?
- Cost and cost-effectiveness – did the study report on the economic consequences of introducing the technology?
- Social care outcomes – did the study report on whether participants were more able to enjoy a better quality of life (for example, greater independence or mobility, ability to return to work, reduced carer burden)?
- Participant-reported outcomes – did the study measure the self-reported impact on outcomes as perceived by users?
- User/carer experiences – did the study measure the experience of people in using the technology itself?
64 of 310 studies met one or more of the criteria and were selected for the review. The breakdown of studies was unevenly distributed by condition as follows: heart failure/stroke (22 studies), diabetes (22), multiple LTCs (7), depression (4), hypertension (4), COPD (3) and older people (2).
The results of our review show that the evidence for the positive impact of telehealth is promising, but mixed. Only a few studies showed any negative impact, yet about one-third reported that telehealth had made no positive difference over usual care. Of the two-thirds of studies which did demonstrate positive benefits or trends, few could claim that their results were statistically significant.
The nature of the evidence itself presents problems in making conclusions about the benefits of telehealth. The majority of studies describing impact have been limited to specific conditions (specifically diabetes and heart failure) and few examine how telehealth can be used for people with other conditions or multiple long-term needs.
The variety of interventions described in studies also makes comparison and generalisation problematic. The studies have great differences, for example in:
- the type of telehealth intervention (eg. from simple telephone-based support to the more sophisticated use of mobile or remote monitoring devices)
- the client being supported (eg. older people, adolescents, ethnic minorities)
- the context of the intervention (eg. rural/urban location, level of deprivation)
- the design of the research study (eg. nature of control group; variation in type of impact measures).
Most studies also do not adequately discuss the differences between those being provided with a telehealth intervention and those receiving ‘usual’ care. Therefore it is difficult to determine the impact of using new technology to support people with long-term conditions from the wider model of care management that is often introduced at the same time.
Our work on telehealth shows that its successful deployment is far more than just a question of technology. Telehealth is a new approach to care that implies the need for fundamental redesign of services, strong collaboration across health and social care, the reshaping of professional roles and staff training, and a specific focus on supporting patients, users and carers to get the best out of technology when managing their care.
This research was carried out by Nick Goodwin and Susan Royer.