Telehealth Interventions to Support Self-Management of Long-Term Conditions: A Systematic Metareview of Diabetes, Heart Failure, Asthma, Chronic Obstructive Pulmonary Disease, and Cancer

Abstract

Background: Self-management support is one mechanism by which telehealth interventions have been proposed to facilitate management of long-term conditions.

Objective: The objectives of this metareview were to (1) assess the impact of telehealth interventions to support self-management on disease control and health care utilization, and (2) identify components of telehealth support and their impact on disease control and the process of self-management. Our goal was to synthesise evidence for telehealth-supported self-management of diabetes (types 1 and 2), heart failure, asthma, chronic obstructive pulmonary disease (COPD) and cancer to identify components of effective self-management support.

Methods: We performed a metareview (a systematic review of systematic reviews) of randomized controlled trials (RCTs) of telehealth interventions to support self-management in 6 exemplar long-term conditions. We searched 7 databases for reviews published from January 2000 to May 2016 and screened identified studies against eligibility criteria. We weighted reviews by quality (revised A Measurement Tool to Assess Systematic Reviews), size, and relevance. We then combined our results in a narrative synthesis and using harvest plots.

Results: We included 53 systematic reviews, comprising 232 unique RCTs. Reviews concerned diabetes (type 1: n=6; type 2, n=11; mixed, n=19), heart failure (n=9), asthma (n=8), COPD (n=8), and cancer (n=3). Findings varied between and within disease areas. The highest-weighted reviews showed that blood glucose telemonitoring with feedback and some educational and lifestyle interventions improved glycemic control in type 2, but not type 1, diabetes, and that telemonitoring and telephone interventions reduced mortality and hospital admissions in heart failure, but these findings were not consistent in all reviews. Results for the other conditions were mixed, although no reviews showed evidence of harm. Analysis of the mediating role of self-management, and of components of successful interventions, was limited and inconclusive. More intensive and multifaceted interventions were associated with greater improvements in diabetes, heart failure, and asthma.

Conclusions: While telehealth-mediated self-management was not consistently superior to usual care, none of the reviews reported any negative effects, suggesting that telehealth is a safe option for delivery of self-management support, particularly in conditions such as heart failure and type 2 diabetes, where the evidence base is more developed. Larger-scale trials of telehealth-supported self-management, based on explicit self-management theory, are needed before the extent to which telehealth technologies may be harnessed to support self-management can be established.

Keywords: COPD; asthma; cancer; chronic disease; diabetes; heart failure; pulmonary disease, chronic obstructive; self-management; telehealth; telemonitoring.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) diagram of literature search. COPD: chronic obstructive pulmonary disease; RCT: randomized controlled trial.

Figure 2

Harvest plot of overall findings of reviews. Number below bar: review reference number. Number above bar: star weighting of review (based on size, revised A Measurement Tool to Assess Systematic Reviews score, and explicit self-management focus). Height of bar: number of randomized controlled trials (RCTs) concerning that self-management component. Block color: consistent effect. Hatched: inconsistent effect (see Table 3). Outcomes assessed were diabetes (hemoglobin A_1c), heart failure (mortality, hospital admission), asthma and chronic obstructive pulmonary disease (COPD) (validated symptom or quality of life, scores, physiological measurements), and cancer (validated symptom or quality of life).