Effectiveness of telemedicine systems for adults with heart failure: a meta-analysis of randomized controlled trials

Abstract

Despite favorable effects from telemedicine (TM) on cardiovascular diseases, outcome and comparative impact of TM on heart failure (HF) adults remain controversial. A meta-analysis was conducted to summarize the evidence from existing randomized controlled trials (RCTs) which compared potential impact of TM on HF with conventional healthcare. TM mainly included structure telephone support (STS), involving interactive vocal response monitoring and telemonitoring. PubMed, MEDLINE, EMBASE, and the Cochrane Library were searched to identify RCTs to fit our analysis (1999 to 2018). Odds ratio (OR) with its 95% confidence interval (CI) was used. Sensitivity analysis, subgroup analysis, and tests for publication bias were conducted. Heterogeneities were also evaluated by I² tests. A total of 29 RCTs consisting of 10,981 HF adults were selected for meta-level synthesis, with follow-up range of 1-36 months. Telemonitoring is associated with the reduction in total number of all-cause hospitalization (OR 0.82, 95% CI 0.73-0.91, P = 0.0004) and cardiac hospitalization (OR 0.83, 95% CI 0.72-0.95, P = 0.007). Telemonitoring resulted in statistically significant risk reduction of all-cause mortality (OR 0.75, 95% CI 0.62-0.90, P = 0.003). However, the OR of HF-related mortality (OR 0.84, 95% CI 0.61-1.16, P = 0.28) is not significantly distinguishable from that of conventional healthcare. Receiving STS interventions is likely to reduce the hospitalization for all causes (OR 0.86, 95% CI 0.78-0.96, P = 0.006, I² = 6%) and the hospitalization due to HF (OR 0.74, 95% CI 0.65-0.85, P < 0.0001, I² = 0%), compared with interventions from conventional healthcare. OR of all-cause STS mortality (OR 0.96, 95% CI 0.83-1.11, P = 0.55) was identified in meta-analyses of eight cases. OR of STS cardiac mortality (OR 0.54, 95% CI 0.34-0.86, P = 0.009) was identified in meta-analyses of three cases. This work represents the comprehensive application of network meta-analysis to examine the comparative effectiveness of telemedicine interventions in improving HF patient outcomes. Compared with conventional healthcare, telemedicine systems with medical support prove to be more effective for HF adults, particularly in reducing all-cause hospitalization, cardiac hospitalization, all-cause mortality, cardiac mortality, and length of stay. While further research is required to confirm these observational findings and identify optimal telemedicine strategies and the duration of follow-up for which it confers benefits.

Keywords: Cardiovascular disease; Heart failure; Meta-analysis; Randomized controlled trials; Telemedicine.

Fig. 1

Selection process of the studies

Fig. 2

a Effect of telemonitoring versus usual care on all-cause hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. b Effect of telemonitoring versus usual care on cardiac hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. c Effect of telephone support interventions versus usual care on all-cause hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. .d Effect of telephone support interventions versus usual care on cardiac hospitalization in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. e Effect of telemonitoring versus usual care on all-cause mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. f Effect of telemonitoring versus usual care on cardiac mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. g Effect of telephone versus usual care on all cause of mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. h Effect of telephone versus usual care on cardiac mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. i Effect of interventions versus usual care on length of hospital stay in patients with chronic heart failure. M-H = Mantel–Haenszel risk ratio. Data are from full peer-reviewed publications only and reflect the most recent meta-analysis of telemedicine in heart failure

Fig. 2

a Effect of telemonitoring versus usual care on all-cause hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. b Effect of telemonitoring versus usual care on cardiac hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. c Effect of telephone support interventions versus usual care on all-cause hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. .d Effect of telephone support interventions versus usual care on cardiac hospitalization in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. e Effect of telemonitoring versus usual care on all-cause mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. f Effect of telemonitoring versus usual care on cardiac mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. g Effect of telephone versus usual care on all cause of mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. h Effect of telephone versus usual care on cardiac mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. i Effect of interventions versus usual care on length of hospital stay in patients with chronic heart failure. M-H = Mantel–Haenszel risk ratio. Data are from full peer-reviewed publications only and reflect the most recent meta-analysis of telemedicine in heart failure

Fig. 2

a Effect of telemonitoring versus usual care on all-cause hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. b Effect of telemonitoring versus usual care on cardiac hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. c Effect of telephone support interventions versus usual care on all-cause hospital admission in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. .d Effect of telephone support interventions versus usual care on cardiac hospitalization in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. e Effect of telemonitoring versus usual care on all-cause mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. f Effect of telemonitoring versus usual care on cardiac mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. g Effect of telephone versus usual care on all cause of mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. h Effect of telephone versus usual care on cardiac mortality in patients with chronic heart failure. CI, confidence interval; M-H, Mantel–Haenszel. i Effect of interventions versus usual care on length of hospital stay in patients with chronic heart failure. M-H = Mantel–Haenszel risk ratio. Data are from full peer-reviewed publications only and reflect the most recent meta-analysis of telemedicine in heart failure

Fig. 3

Evidence network for interventions included in the analysis of the outcomes of telemedicine versus usual care. Each node represents different outcomes and the size of each node indicates the total number of studies included in the network

Fig. 4

Funnel plot comparing interventions versus controls reporting all-cause mortality. Funnel plot assessing publication bias