Comparative effectiveness of different forms of telemedicine for individuals with heart failure (HF): a systematic review and network meta-analysis

Abstract

Background: Previous studies on telemedicine have either focused on its role in the management of chronic diseases in general or examined its effectiveness in comparison to standard post-discharge care. Little has been done to determine the comparative impact of different telemedicine options for a specific population such as individuals with heart failure (HF).

Methods and findings: Systematic reviews (SR) of randomized controlled trials (RCTs) that examined telephone support, telemonitoring, video monitoring or electrocardiographic monitoring for HF patients were identified using a comprehensive search of the following databases: MEDLINE, EMBASE, CINAHL and The Cochrane Library. Studies were included if they reported the primary outcome of mortality or any of the following secondary outcomes: all-cause hospitalization and heart failure hospitalization. Thirty RCTs (N = 10,193 patients) were included. Compared to usual care, structured telephone support was found to reduce the odds of mortality(Odds Ratio 0.80; 95% Credible Intervals [0.66 to 0.96]) and hospitalizations due to heart failure (0.69; [0.56 to 0.85]). Telemonitoring was also found to reduce the odds of mortality(0.53; [0.36 to 0.80]) and reduce hospitalizations related to heart failure (0.64; [0.39 to 0.95]) compared to usual post-discharge care. Interventions that involved ECG monitoring also reduced the odds of hospitalization due to heart failure (0.71; [0.52 to 0.98]).

Limitations: Much of the evidence currently available has focused on the comparing either telephone support or telemonitoring with usual care. This has therefore limited our current understanding of how some of the less common forms of telemedicine compare to one another.

Conclusions: Compared to usual care, structured telephone support and telemonitoring significantly reduced the odds of deaths and hospitalization due to heart failure. Despite being the most widely studied forms of telemedicine, little has been done to directly compare these two interventions against one another. Further research into their comparative cost-effectiveness is also warranted.

Fig 1. Flow chart for the identification of studies used in the network meta-analysis of telemedicine interventions for heart failure patients

Fig 2. Evidence network for interventions included in the analysis of all-cause mortality.

Each node represents an intervention and the size of each node indicates how many patients received it of the total number of patients included in the network (N = 10,193). The solid lines connecting the nodes together indicate the existence of this comparison of interventions in the literature. The thickness of the lines represents how many studies of the total number of studies (30 studies) include a particular comparison.

Fig 3. The impact of different forms of telemedicine on the outcome of all-cause mortality.

Effect estimates from the network meta-analysis occupy the bottom left part of the diagram, the estimates from the pairwise meta-analyes occupy the top right part of the diagram and the diagonal corresponds to the comparison. The odds ratios and 95% Credible Intervals for the comparisons in this diagram should be read from left to right (e.g. Patients receiving structured telephone support had a 0.80 [0.66, 0.96] reduced odds of death compared to those receiving usual care). Significant results are underlined and in bold.