cer-216-telehealth-final-report.pdf - Comparative Effectiveness Review Number 216 R Telehealth for Acute and Chronic Care Consultations Comparative

cer-216-telehealth-final-report.pdf - Comparative...

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Unformatted text preview: Comparative Effectiveness Review Number 216 R Telehealth for Acute and Chronic Care Consultations Comparative Effectiveness Review Number 216 Telehealth for Acute and Chronic Care Consultations Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 Contract No. 290-2015-00009-I Prepared by: Pacific Northwest Evidence-based Practice Center Portland, OR Investigators: Annette M. Totten, Ph.D. Ryan N. Hansen, Pharm.D., Ph.D. Jesse Wagner, M.A. Lucy Stillman, B.S. Ilya Ivlev, M.D., Ph.D., M.B.I. Cynthia Davis-O’Reilly, B.S. Cara Towle, R.N., M.S.N., M.A. Jennifer M. Erickson, D.O. Deniz Erten-Lyons, M.D. Rongwei Fu, Ph.D. Jesse Fann, M.D., M.P.H. Joseph B. Babigumira, M.B.Ch.B., M.S., Ph.D. Katherine J. Palm-Cruz, M.D. Marc Avery, M.D. Marian S. McDonagh, Pharm.D. AHRQ Publication No. 19-EHC012-EF April 2019 Key Messages Purpose of Review To assess the effectiveness of telehealth consultations and explore supplemental decision analysis. Key Messages • Results vary by setting and condition, with telehealth consultations producing generally either better outcomes or no difference from comparators in settings and clinical indications studied. o Remote intensive care unit consultations likely reduce mortality. o Specialty telehealth consultations likely reduce patient time in the emergency department. o Telehealth consultations in emergency services likely reduce heart attack mortality. o Remote consultations for outpatient care likely improve access and clinical outcomes. • More detailed telehealth consultation costs and outcomes data would improve modeling assumptions. • Future research should employ rigorous methods and standardized outcomes for consistent measurement of telehealth consultation effectiveness. ii This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report. The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients. This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders. AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied. This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program website at . Search on the title of the report. Persons using assistive technology may not be able to fully access information in this report. For assistance contact [email protected] Suggested citation: Totten AM, Hansen RN, Wagner J, Stillman L, Ivlev I, Davis-O’Reilly C, Towle C, Erickson JM, Erten-Lyons D, Fu R, Fann J, Babigumira JB, Palm-Cruz KJ, Avery M, McDonagh MS. Telehealth for Acute and Chronic Care Consultations. Comparative Effectiveness Review No. 216. (Prepared by Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 19-EHC012-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2019. Posted final reports are located on the Effective Health Care Program search page. DOI: . iii The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Centers (EPCs), sponsors the development of systematic reviews to assist public- and private-sector organizations in their efforts to improve the quality of healthcare in the United States. These reviews provide comprehensive, science-based information on common, costly medical conditions, and new healthcare technologies and strategies. Systematic reviews are the building blocks underlying evidence-based practice; they focus attention on the strength and limits of evidence from research studies about the effectiveness and safety of a clinical intervention. In the context of developing recommendations for practice, systematic reviews can help clarify whether assertions about the value of the intervention are based on strong evidence from clinical studies. For more information about AHRQ EPC systematic reviews, see . AHRQ expects that these systematic reviews will be helpful to health plans, providers, purchasers, government programs, and the healthcare system as a whole. Transparency and stakeholder input are essential to the Effective Health Care Program. Please visit the website ( ) to see draft research questions and reports or to join an email list to learn about new program products and opportunities for input. If you have comments on this systematic review, they may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD 20857, or by email to [email protected] Gopal Khanna, M.B.A. Director Agency for Healthcare Research and Quality Arlene S. Bierman, M.D., M.S. Director Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality Stephanie Chang, M.D., M.P.H. Director Evidence-based Practice Center Program Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality Elise Berliner, Ph.D. Task Order Officer Center for Evidence and Practice Improvement Agency for Healthcare Research and Quality iv Investigator Affiliations Annette M. Totten, Ph.D. Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University Jennifer M. Erickson, D.O. Integrated Care Training Program/Psychiatry Consultation & Telepsychiatry Psychiatry and Behavioral Sciences University of Washington School of Medicine Ryan N. Hansen, Pharm.D., Ph.D. The CHOICE Institute, School of Pharmacy University of Washington Deniz Erten-Lyons, M.D. Department of Neurology Oregon Health & Science University Jesse Wagner, M.A. Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University Rongwei Fu, Ph.D. OHSU-PSU School of Public Health Department of Medical Informatics and Clinical Epidemiology, School of Medicine Oregon Health & Science University Lucy Stillman, B.S. Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University Jesse Fann, M.D., M.P.H. Division of Population Health, Department of Psychiatry & Behavioral Sciences Departments of Rehabilitation Medicine and Epidemiology University of Washington Psychiatry & Psychology, Seattle Cancer Care Alliance Clinical Research Division, Fred Hutchinson Cancer Research Center Ilya Ivlev, M.D., Ph.D., M.B.I. Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University (Dr. Ivlev was supported by National Library of Medicine Biomedical Informatics Training Grant #T15LM007088.) Cynthia Davis-O’Reilly, B.S. Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University Joseph B. Babigumira, M.B.Ch.B., M.S., Ph.D. Department of Global Health, School of Public Health University of Washington Cara Towle, R.N., M.S.N., M.A. Integrated Care Training Program/Psychiatry Consultation & Telepsychiatry Psychiatry and Behavioral Sciences University of Washington School of Medicine Katherine J. Palm-Cruz, M.D. University of Washington Marc Avery, M.D. Health Management Associates Marian S. McDonagh, Pharm.D. Department of Medical Informatics & Clinical Epidemiology Oregon Health & Science University v Acknowledgments The authors gratefully acknowledge the following individuals for their contributions to this project: Elaine Graham, M.L.S., for program guidance and collaborative support; Tracy Dana, M.L.S., for assistance with the literature search; Leah Williams, B.S., for editorial support; Sandra Assasnik, M.A., L.B. Miller, B.A., and Rachel Lockard, B.S., for administrative assistance; Brittany Lazur, M.P.H., for assistance with data abstraction; and our Task Order Officer, Elise Berliner, Ph.D., for support and guidance in developing this report. Technical Expert Panel In designing the study questions and methodology at the outset of this report, the EPC consulted several technical and content experts. Broad expertise and perspectives were sought. Divergent and conflicted opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, in the end, study questions, design, methodologic approaches, and/or conclusions do not necessarily represent the views of individual technical and content experts. Technical Experts must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified. The list of Technical Experts who provided input to this report follows: James Marcin, M.D., M.P.H. Vice Chair, Pediatric Clinical Research Director, UC Davis Center for Health and Technology Chief, Division of Pediatric Critical Care Medicine Professor, Department of Pediatrics UC Davis Children’s Hospital Davis, CA Margo Edmunds, Ph.D.* Vice President, Evidence Generation and Translation Academy Health Washington, DC Karen Kuntz, Sc.D. Professor, Division of Health Policy and Management School of Public Health, University of Minnesota Co-Leader Screening, Prevention, Etiology and Cancer Survivorship Program Masonic Cancer Center, University of Minnesota Minneapolis, MN C. Daniel Mullins, Ph.D.* Professor, Department of Pharmaceutical Health Services Research University of Maryland School of Pharmacy Baltimore, Maryland Karen Rheuban, M.D.* Director, UVA Karen S. Rheuban Center for Telehealth Professor of Pediatrics University of Virginia School of Medicine Charlottesville, VA vi Brian Wood, M.D. Medical Director, MW AETC ECHO Telehealth Project Associate Medical Director, Harborview Satellite HIV Clinic Associate Professor of Medicine, Division of Allergy and Infectious Diseases University of Washington School of Medicine Seattle, WA Sean Tunis, M.D., M.Sc. President and CEO, Center for Medical Technology Policy Baltimore, MD John D. Whited, M.D., M.H.S.* Durham Veterans Affairs Health Care System Associate Professor of Medicine Duke University School of Medicine Durham, NC *Provided input on Draft Report. Peer Reviewers Prior to publication of the final evidence report, EPCs sought input from independent Peer Reviewers without financial conflicts of interest. However, the conclusions and synthesis of the scientific literature presented in this report do not necessarily represent the views of individual reviewers. Peer Reviewers must disclose any financial conflicts of interest greater than $5,000 and any other relevant business or professional conflicts of interest. Because of their unique clinical or content expertise, individuals with potential nonfinancial conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential nonfinancial conflicts of interest identified. The list of Peer Reviewers follows: Lois Olinger, M.A. Vice President, Westat Rockville, MD Larry Davis, M.D. Professor of Neurology and Neuroscience University of New Mexico School of Medicine Chief, Neurology Service New Mexico VA Medical Center Albuquerque, NM Dan Malone, R.Ph., Ph.D., FAMCP Professor of Pharmacy Practice and Science Director, Comparative Effectiveness Research Group University of Arizona, College of Pharmacy Tucson, AZ vii Telehealth for Acute and Chronic Care Consultations Structured Abstract Objectives. To conduct a systematic review to identify and summarize the available evidence about the effectiveness of telehealth consultations and to explore using decision modeling techniques to supplement the review. Telehealth consultations are defined as the use of telehealth to facilitate collaboration between two or more providers, often involving a specialist, or among clinical team members, across time and/or distance. Consultations may focus on the prevention, assessment, diagnosis, and/or clinical management of acute or chronic conditions. Data sources. We searched Ovid MEDLINE®, the Cochrane Central Register of Controlled Trials (CCRCT), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL®) to identify studies published from 1996 to May 2018. We also reviewed reference lists of identified studies and systematic reviews, and we solicited published or unpublished studies through an announcement in the Federal Register. Data for the model came both from studies identified via the systematic review and from other sources. Methods. We included comparative studies that provided data on clinical, cost, or intermediate outcomes associated with the use of any technology to facilitate consultations for inpatient, emergency, or outpatient care. We rated studies for risk of bias and extracted information about the study design, the telehealth interventions, and results. We assessed the strength of evidence and applicability, and then synthesized the findings using quantitative and qualitative methods. An exploratory decision model was developed to assess the potential economic impact of telehealth consultations for traumatic brain injuries in adults. Results. The search yielded 9,366 potentially relevant citations. Upon review, 8,356 were excluded and the full text of 1,010 articles was pulled for review. Of these, 233 articles met our criteria and were included—54 articles evaluated inpatient consultations; 73, emergency care; and 106, outpatient care. The overall results varied by setting and clinical topic, but generally the findings are that telehealth improved outcomes or that there was no difference between telehealth and the comparators across the settings and for the clinical indications studied. Remote intensive care unit (ICU) consultations likely reduce ICU and total hospital mortality with no significant difference in ICU or hospital length of stay; specialty telehealth consultations likely reduce the time patients spend in the emergency department; telehealth for emergency medical services likely reduces mortality for patients with heart attacks; and remote consultations for outpatient care likely improve access and a range of clinical outcomes (moderate strength of evidence in favor of telehealth). Findings with lower confidence are that inpatient telehealth consultations may reduce length of stay and costs; telehealth consultations in emergency care may improve outcomes and reduce costs due to fewer transfers, and also may reduce outpatient visits and costs due to less travel (low strength of evidence in favor of telehealth). Current evidence shows no difference in clinical outcomes with inpatient telehealth specialty consultations, no difference in mortality but also no difference in harms with telestroke consultations, and no difference in satisfaction with outpatient telehealth consultations (low strength of evidence of no difference). Too few studies reported information on potential harms from outpatient telehealth consultations for conclusions to be drawn (insufficient evidence). viii An exploratory cost model underscores the importance of perspective and assumptions in using modeling to extend evidence, and the need for more detailed data on costs and outcomes when telehealth is used for consultations. For example, a model comparing telehealth to transfers and in-person neurosurgical consultations for acute traumatic brain injury identified that the impact of telehealth on costs may depend on multiple factors, including how alternatives are organized (e.g., if the telehealth and in-person options are part of the same healthcare system) and whether the cost of a telehealth versus an in-person consultation differ. Conclusions. In general, the evidence indicates that telehealth consultations are effective in improving outcomes or providing services, with no difference in outcomes; however, the evidence is stronger for some applications, and less strong or insufficient for others. However, as specific details about the implementation of telehealth consultations and the environment were rarely reported, it is difficult to assess generalizability. Exploring the use of a cost model underscored that the economic impact of telehealth consultations depends on the perspective used in the analysis. The increase in both interest and investment in telehealth suggests the need to develop a research agenda that emphasizes rigor and focuses on standardized outcome comparisons that can inform policy and practice decisions. ix Contents Evidence Summary ....................................................................................................................... 1 Introduction ................................................................................................................................... 1 Background ..................................................................................................................................1 Definitions of Telehealth and Telehealth Consultation for This Project .....................................2 Scope and Questions ....................................................................................................................2 Key Questions for the Systematic Review.............................................................................. 3 PICOTS ................................................................................................................................... 4 Analytic Framework ............................................................................................................... 5 Methods .......................................................................................................................................... 7 Systematic Review Methods ........................................................................................................7 Literature Search Strategy....................................................................................................... 7 Criteria for Inclusion/Exclusion of Studies in the Review ..................................................... 8 Data Abstraction and Data Management ................................................................................ 8 Assessment of Methodologic...
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