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Meta-Analysis
. 2023 May 4;5(5):CD014821.
doi: 10.1002/14651858.CD014821.pub2.

Remote care through telehealth for people with inflammatory bowel disease

Morris Gordon  1 , Vassiliki Sinopoulou  1 , Svetlana Lakunina  1 , Teuta Gjuladin-Hellon  1   2 , Kelly Bracewell  3 , Anthony K Akobeng  4
Affiliations
Meta-Analysis

Remote care through telehealth for people with inflammatory bowel disease

Morris Gordon et al. Cochrane Database Syst Rev. .

Abstract

Background: People with inflammatory bowel disease (IBD) require intensive follow-up with frequent consultations after diagnosis. IBD telehealth management includes consulting by phone, instant messenger, video, text message, or web-based services. Telehealth can be beneficial for people with IBD, but may have its own set of challenges. It is important to systematically review the evidence on the types of remote or telehealth approaches that can be deployed in IBD. This is particularly relevant following the coronavirus disease 2019 (COVID-19) pandemic, which led to increased self- and remote-management.

Objectives: To identify the communication technologies used to achieve remote healthcare for people with inflammatory bowel disease and to assess their effectiveness.

Search methods: On 13 January 2022, we searched CENTRAL, Embase, MEDLINE, three other databases, and three trials registries with no limitations on language, date, document type, or publication status.

Selection criteria: All published, unpublished, and ongoing randomised controlled trials (RCTs) that evaluated telehealth interventions targeted at people with IBD versus any other type of intervention or no intervention. We did not include studies based on digital patient information resources or education resources, unless they formed part of a wider package including an element of telehealth. We excluded studies where remote monitoring of blood or faecal tests was the only form of monitoring.

Data collection and analysis: Two review authors independently extracted data from the included studies and assessed their risk of bias. We analysed studies on adult and paediatric populations separately. We expressed the effects of dichotomous outcomes as risk ratios (RRs) and the effects of continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs), each with their 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology.

Main results: We included 19 RCTs with a total of 3489 randomised participants, aged eight to 95 years. Three studies examined only people with ulcerative colitis (UC), two studies examined only people with Crohn's disease (CD), and the remaining studies examined a mix of IBD patients. Studies considered a range of disease activity states. The length of the interventions ranged from six months to two years. The telehealth interventions were web-based and telephone-based. Web-based monitoring versus usual care Twelve studies compared web-based disease monitoring to usual care. Three studies, all in adults, provided data on disease activity. Web-based disease monitoring (n = 254) is probably equivalent to usual care (n = 174) in reducing disease activity in people with IBD (SMD 0.09, 95% CI -0.11 to 0.29). The certainty of the evidence is moderate. Five studies on adults provided dichotomous data that we could use for a meta-analysis on flare-ups. Web-based disease monitoring (n = 207/496) is probably equivalent to usual care (n = 150/372) for the occurrence of flare-ups or relapses in adults with IBD (RR 1.09, 95% CI 0.93 to 1.27). The certainty of the evidence is moderate. One study provided continuous data. Web-based disease monitoring (n = 465) is probably equivalent to usual care (n = 444) for the occurrence of flare-ups or relapses in adults with CD (MD 0.00 events, 95% CI -0.06 to 0.06). The certainty of the evidence is moderate. One study provided dichotomous data on flare-ups in a paediatric population. Web-based disease monitoring (n = 28/84) may be equivalent to usual care (n = 29/86) for the occurrence of flare-ups or relapses in children with IBD (RR 0.99, 95% CI 0.65 to 1.51). The certainty of the evidence is low. Four studies, all in adults, provided data on quality of life. Web-based disease monitoring (n = 594) is probably equivalent to usual care (n = 505) for quality of life in adults with IBD (SMD 0.08, 95% CI -0.04 to 0.20). The certainty of the evidence is moderate. Based on continuous data from one study in adults, we found that web-based disease monitoring probably leads to slightly higher medication adherence compared to usual care (MD 0.24 points, 95% CI 0.01 to 0.47). The results are of moderate certainty. Based on continuous data from one paediatric study, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (MD 0.00, 95% CI -0.63 to 0.63), although the evidence is very uncertain. When we meta-analysed dichotomous data from two studies on adults, we found no difference between web-based disease monitoring and usual care in terms of their effect on medication adherence (RR 0.87, 95% CI 0.62 to 1.21), although the evidence is very uncertain. We were unable to draw any conclusions on the effects of web-based disease monitoring compared to usual care on healthcare access, participant engagement, attendance rate, interactions with healthcare professionals, and cost- or time-effectiveness. The certainty of the evidence is very low.

Authors' conclusions: The evidence in this review suggests that web-based disease monitoring is probably no different to standard care in adults when considering disease activity, occurrence of flare-ups or relapse, and quality of life. There may be no difference in these outcomes in children, but the evidence is limited. Web-based monitoring probably increases medication adherence slightly compared to usual care. We are uncertain about the effects of web-based monitoring versus usual care on our other secondary outcomes, and about the effects of the other telehealth interventions included in our review, because the evidence is limited. Further studies comparing web-based disease monitoring to standard care for the clinical outcomes reported in adults are unlikely to change our conclusions, unless they have longer follow-up or investigate under-reported outcomes or populations. Studies with a clearer definition of web-based monitoring would enhance applicability, enable practical dissemination and replication, and enable alignment with areas identified as important by stakeholders and people affected by IBD.

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Conflict of interest statement

MG: has declared that they have no conflicts of interest. VS: has declared that they have no conflicts of interest. AA: was the principal investigator of a previously published randomised controlled trial that investigated the role of telephone consultation in paediatric inflammatory bowel disease. AA was not involved in screening for eligibility, data extraction, or risk of bias assessment for the trial he was involved in (Akobeng 2015). TGH: has declared that they have no conflicts of interest. SL: has declared that they have no conflicts of interest. KB: has declared that they have no conflicts of interest.

The authors MG, AA, and VS are members of Cochrane Gut but were not involved in the editorial process or decision‐making for this review.

Figures

1
1
Flow chart of study retrieval and selection.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 1: Disease activity (adults)
1.2
1.2. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 2: Disease activity (adults; fixed‐effect sensitivity analysis)
1.3
1.3. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 3: Flare‐ups/relapse (dichotomous; adults)
1.4
1.4. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 4: Flare‐ups/relapse (dichotomous; adults;  fixed‐effect sensitivity analysis)
1.5
1.5. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 5: Flare‐ups (continuous; adults)
1.6
1.6. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 6: Flare‐ups/relapse (dichotomous; children)
1.7
1.7. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 7: Quality of life (adults)
1.8
1.8. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 8: Quality of life (adults; fixed‐effect  sensitivity analysis)
1.9
1.9. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 9: Medication adherence (continuous; adults)
1.10
1.10. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 10: Medication adherence (continuous; children)
1.11
1.11. Analysis
Comparison 1: Web‐based disease monitoring versus usual care, Outcome 11: Medication adherence (dichotomous; adults)
2.1
2.1. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 1: Flare‐ups/relapse (dichotomous; adults)
2.2
2.2. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 2: Flare‐ups/relapse (dichotomous; children)
2.3
2.3. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 3: Quality of life (children)
2.4
2.4. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 4: Number of episodes accessing healthcare (one or more hospital admissions; children)
2.5
2.5. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 5: Medication adherence (adults)
2.6
2.6. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 6: Participant engagement (adults)
2.7
2.7. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 7: Rate of attendance/engagement with the intervention (scheduled consultations not cancelled; children)
2.8
2.8. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 8: Rate of attendance/engagement with the intervention (missed consultations; children)
2.9
2.9. Analysis
Comparison 2: Telephone‐based disease monitoring versus face‐to‐face monitoring, Outcome 9: Rate of attendance of interactions with health professionals (children)
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD014821

References

References to studies included in this review

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Ankersen 2019 {published data only}
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    1. Ankersen DV, Weimers P, Marker D, Bennedsen M, Saboori S, Paridaens K, et al. Individualized home-monitoring of disease activity in adult patients with inflammatory bowel disease can be recommended in clinical practice: a randomized-clinical trial. World Journal of Gastroenterology 2019;25(40):6158-71. - PMC - PubMed
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    1. Carlsen K, Jakobsen C, Hansen LF, Paerregaard A, Kallemose T, Houen G, et al. Self-administered telemedicine empowers paediatric and adolescent patients with inflammatory bowel disease. Journal of Pediatric gastroenterology and Nutrition 2016;62 Suppl 1:131.
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Cross 2012 {published data only}
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Cross 2019 {published data only}
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de Jong 2017 {published data only}
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Del Hoyo 2018 {published data only}
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Elkjaer 2010a {published data only}
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Heida 2018 {published data only}
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Hughes 2017 {published data only}
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Ley 2020 {published data only}
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Malickova 2020 {published data only}
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McCombie 2020 {published data only}
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Reich 2019 {published data only}
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Siegel 2018 {published data only}
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Stunkel 2012 {published data only}
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References to studies excluded from this review

Ankersen 2017 {published data only}
    1. Ankersen DV, Marker D, Weimers P, Burisch J, Munkholm P. Home monitoring of disease activity and fecal calprotectin in adult patients with inflammatory bowel disease-interim analysis of 68 patients. United European Gastroenterology Journal 2017;5(5):A287.
Camba 2013 {published data only}
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Carlsen 2017b {published data only}
    1. Carlsen K, Houen G, Jakobsen C, Kallemose T, Paerregaard A, Riis LB, et al. Individualized infliximab treatment guided by patient-managed eHealth in children and adolescents with inflammatory bowel disease. Inflammatory Bowel Diseases 2017;23(9):1473-82. - PubMed
    1. Carlsen K, Houen G, Jakobsen C, Kallemose T, Paerregaard A, Riis LB, et al. Individualized infliximab treatment guided by patient-managed eHealth in children and adolescents with inflammatory bowel disease. Inflammatory Bowel Diseases 2017;23(9):1473-82. - PubMed
    1. Carlsen K, Jakobsen C, Hansen LF, Paerregaard A, Kallemose T, Houen G, et al. Self-administered telemedicine empowers paediatric and adolescent patients with inflammatory bowel disease. Journal of Crohn's and Colitis 2016;10:S53-4.
    1. Carlsen K, Jakobsen C, Hansen LF, Paerregaard A, Kallemose T, Riis LB, et al. Quality of life in paediatric inflammatory bowel disease patients in a self-administered telemedicine randomised clinical study. Journal of Crohn's and Colitis 2016;10:S421-2.
    1. Carlsen K, Jakobsen C, Hansen LF, Paerregaard A, Riis LB, Munkholm PS, Wewer V. Self-administered telemedicine reduces number of outpatient visits and days of absence from school in paediatric and adolescent patients with inflammatory bowel disease. Journal of Crohn's and Colitis 2016;10:S53.
Creed 2019 {published data only}
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Del Hoyo 2021 {published data only}
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Gray 2020 {published data only}
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    1. Greenley RN, Gumidyala AP, Nguyen E, Plevinsky JM, Poulopoulos N, Thomason MM, et al. Can you teach a teen new tricks? Problem solving skills training improves oral medication adherence in pediatric patients with inflammatory bowel disease participating in a randomized trial. Inflammatory Bowel Diseases 2015;21(11):2649-57. - PubMed
Jambaulikar 2015 {published data only}
    1. Jambaulikar GD, Lee J, Aholoukpe M, Regueiro M, Schwartz DA, Ghazi LJ, et al. Internal locus of control and increased self-efficacy are associated with higher quality of life in patients with inflammatory bowel disease. Gastroenterology 2015;148(4):S841.
Krier 2011 {published data only}
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    1. NCT01296841. Telemedicine to provide inflammatory bowel disease outpatient care. clinicaltrials.gov/ct2/show/study/NCT01296841 (first received 16 February 2011).
Mastronardi 2020 {published data only}
    1. Mastronardi M, Curlo M, Polignano M, Vena N, Rossi D, Giannelli G. Remote monitoring empowerment of patients with IBDs during the SARS-CoV-2 pandemic. Healthcare 2020;8(4):337. - PMC - PubMed
Miloh 2017 {published data only}
    1. Miloh T, Shub M, Montes R, Ingebo K, Silber G, Pasternak B. Text messaging effect on adherence in children with inflammatory bowel disease. Journal of Pediatric Gastroenterology and Nutrition 2017;64(6):939-42. - PubMed
Moss 2010 {published data only}
    1. Chaudhary N, Junior J, Tukey M, Falchuk KR, Cheifetz A, Moss AC. S1053 Impact of a patient support program on mesalamine adherence in patients with ulcerative colitis. Gastroenterology 2009;136(5):A178. - PubMed
    1. Moss AC, Chaudhary N, Tukey M, Junior J, Cury D, Falchuk KR, et al. Impact of a patient-support program on mesalamine adherence in patients with ulcerative colitis—a prospective study. Journal of Crohn's and Colitis 2010;4(2):171-5. - PubMed
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NCT01852097 {published data only}
    1. NCT01852097. An online intervention to address barriers to IBD medication adherence [A pilot randomised controlled trial to determine the feasibility, acceptability and effectiveness of a CBT based online intervention to address practical and perceptual barriers to medication adherence in inflammatory bowel disease]. clinicaltrials.gov/ct2/show/NCT01852097 (first received 13 May 2013).
NCT02265588 {published data only}
    1. NCT02265588. Healthy approach to physical and psychological problems in youngsters with IBD (HAPPY-IBD). clinicaltrials.gov/ct2/show/NCT02265588 (first received 16 October 2014).
NCT02707068 {published data only}
    1. NCT02707068. Quality Of LIfe Tool for IBD [Quality Of LIfe Tool for IBD (QOLITI): pilot testing of a self-administered intervention to target psychological distress in inflammatory bowel disease]. clinicaltrials.gov/ct2/show/NCT02707068 (first received 14 March 2016).
NCT03486158 {published data only}
    1. NCT03486158. The CalproSmartNOR Study – a new clinical tool for monitoring patients with inflammatory bowel disease. clinicaltrials.gov/ct2/show/study/NCT03486158 (first received 3 April 2018).
NCT03695783 {published data only}
    1. NCT03695783. The IBD&me randomized controlled trial [Impact of a web-based decision aid on shared decision-making in patients with inflammatory bowel disease: the ibd&me randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT03695783 (first received 3 April 2018).
NCT04151420 {published data only}
    1. NCT04151420. Real life remote monitoring of mild, moderate and severe infectious complications in ibd by patient reported assessment. clinicaltrials.gov/ct2/show/NCT04151420 (first received 5 November 2019).
NCT04165265 {published data only}
    1. NCT04165265. The use of web-app constant-care in patients with acute severe ulcerative colitis treated with rescue therapy. clinicaltrials.gov/ct2/show/NCT04165265 (first received 15 November 2019).
Oser 2018 {published data only}
    1. Oser M, Szigethy E, Wallace ML, Weaver EK, Culp A, Kogan J, Regueiro MD. Randomized adaptive trial of digital behavioral program for anxiety and depression in ibd patient centered medical home. Gastroenterology 2018;154(6):S-153.
RBR‐79dn4k {published data only}
    1. RBR-79dn4k. Effect of a program on drug use in patients with Ulcerative Colitis [Impact of an intervention program on nonadherence to drugs in ulcerative colitis patients: randomized clinical trial]. ensaiosclinicos.gov.br/rg/RBR-79dn4k (first received 1 February 2020).
Snoei 2009 {published data only}
    1. Snoei L, Bodegraven A, Oldenburg B, Stijnen T, Kaptein AA. Prototype evaluation of a self-management Internet diary for patients with ulcerative colitis. Patient Preference and Adherence 2009;3(101475748):179-87. - PMC - PubMed
Sutton 2019 {published data only}
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Tripp 2017 {published data only}
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Zhang 2020 {published data only}
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References to studies awaiting assessment

Bonnaud 2021 {published data only}
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Hommel 2015 {published data only}
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NCT02694042 {published data only}
    1. NCT02694042. Mission is remission®: how can a disease self-management website change care? clinicaltrials.gov/ct2/show/NCT02694042 (first received 29 February 2016).
NCT03059186 {published data only}
    1. NCT03059186. A gratitude intervention in improving well-being and coping in people living with inflammatory bowel disease. clinicaltrials.gov/ct2/show/NCT03059186 (first received 23 February 2017).
NCT03186872 {published data only}
    1. NCT03186872. Improving quality of care with a digital behavioral program in ibd patient centered medical home. clinicaltrials.gov/ct2/show/NCT03186872 (first received 14 June 2017).
NCT04754620 {published data only}
    1. NCT04754620. Distant management of Crohn's disease by smartphones is feasible and effective additionally it reduces the costs. clinicaltrials.gov/ct2/show/NCT04754620 (first received 15 February 2021).
NTR2892 {published data only}
    1. NTR2892. Adherence as a lifetime effort [Promoting recall of information and treatment adherence]. www.trialregister.nl/trial/2753 (first received 11 May 2011).
NTR4648 {published data only}
    1. NTR4648. Improving adherence in ulcerative colitis patients on 5-ASA. https://www.trialregister.nl/trial/4406 (first received 17 June 2014).

References to ongoing studies

ACTRN12617000389303 {published data only}
    1. ACTRN12617000389303. Teleconsulting versus normal consulting in the care of inflammatory bowel disease in rural Southern District Health Board patients. [Establishing the role of Teleconsulting in the care of chronic conditions in rural areas of the Southern District Health Board (SDHB): A randomised controlled trial (RCT) in patients with inflammatory bowel disease]. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372543&isRe... (first received 16 March 2017).
IRCT2020061304775 {published data only}
    1. IRCT20200613047757N1. Designing a mobile-based inflammatory bowel disease management system by using gamification techniques and determining its effectiveness on disease activity index, mental health and quality of life [Evaluation of the effectiveness of mobile-based inflammatory bowel disease management system by using gamification techniques on disease activity index, mental health and quality of life]. www.irct.ir/trial/59842 (first received 16 November 2021).
NCT03985800 {published data only}
    1. NCT03985800. Specialty medical homes to improve outcomes for patients with IBD and behavioral health conditions. clinicaltrials.gov/ct2/show/NCT03985800 (first received 14 June 2019).
NCT04207008 {published data only}
    1. NCT04207008. Trial of a decision support intervention for adolescents and young adults with ulcerative colitis (iBDecide). clinicaltrials.gov/ct2/show/NCT04207008 (first received 20 December 2019).
NCT04388865 {published data only}
    1. NCT04388865. Patient Automated Text Hovering for IBD (PATH-IBD). clinicaltrials.gov/ct2/show/NCT04388865 (first received 14 May 2020).
NCT04653259 {published data only}
    1. NCT04653259. Digital nutrition therapy for patients with IBD (LYFEMD). clinicaltrials.gov/ct2/show/NCT04653259 (first received 4 December 2020).
NCT04861597 {published data only}
    1. NCT04861597. Digital behavioral interventions in inflammatory bowel disease. clinicaltrials.gov/ct2/show/NCT04861597 (first received 27 April 2021).
Norton 2021 {published data only}
    1. ISRCTN71618461. A supported online self-management for symptoms of fatigue, pain and urgency/incontinence in people with inflammatory bowel disease: the IBD-BOOST trial [A randomised controlled trial of supported online self-management for symptoms of fatigue, pain and urgency/incontinence in people with inflammatory bowel disease: the IBD-BOOST trial]. www.isrctn.com/ISRCTN71618461 (first received 2 September 2019).
    1. Norton C, Syred J, Kerry S, Artom M, Sweeney L, Hart A, et al. Supported online self-management versus care as usual for symptoms of fatigue, pain and urgency/incontinence in adults with inflammatory bowel disease (IBD-BOOST): study protocol for a randomised controlled trial. Trials 2021;22(1):1-18. - PMC - PubMed
RBR‐7t8fv7 {published data only}
    1. RBR-7t8fv7. Clinical trial of the effectiveness of telephone nursing care to individuals with inflammatory bowel disease. ensaiosclinicos.gov.br/rg/RBR-7t8fv7 (first received 25 July 2016).

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References to other published versions of this review

Gordon 2021b
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