TelemedTelecare.2012June18(4):211220. doi:10.1258/jtt.2012.

120219 PMCID:PMC3366107

Twentyyearsoftelemedicineinchronicdiseasemanagementanevidence synthesis
RichardWootton
AuthorinformationArticlenotesCopyrightandLicenseinformation

Abstract

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Aliteraturereviewwasconductedtoobtainahighlevelviewofthevalueoftelemedicineinthe managementoffivecommonchronicdiseases(asthma,COPD,diabetes,heartfailure,hypertension).A totalof141randomisedcontrolledtrials(RCTs)wasidentified,inwhich148telemedicineinterventions ofvariouskindshadbeentestedinatotalof37,695patients.Thevalueofeachinterventionwas categorisedintermsoftheoutcomesspecifiedbytheinvestigatorsinthattrial,i.e.noattemptwasmade toextractacommonoutcomefromallstudies,aswouldberequiredforaconventionalmetaanalysis. Summarizingthevalueoftheseinterventionsshows,first,thatmoststudieshavereportedpositiveeffects (n =108),andalmostnonehavereportednegativeeffects(n =2).Thissuggestspublicationbias. Second,therewerenosignificantdifferencesbetweenthechronicdiseases,i.e.telemedicineseems equallyeffective(orineffective)inthediseasesstudied.Third,moststudieshavebeenrelativelyshort term(medianduration6months).Itseemsunlikelythatinachronicdisease,anyinterventioncanhave mucheffectunlessappliedforalongperiod.Finally,therehavebeenveryfewstudiesofcost effectiveness.Thustheevidencebaseforthevalueoftelemedicineinmanagingchronicdiseasesison thewholeweakandcontradictory.

Introduction

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Chronicillnesses,suchasasthma,COPD,diabetes,heartfailureandhypertensionrepresentasignificant burdenofdisease.BurdenofdiseaseismeasuredinDisabilityAdjustedLifeYears(DALYs),which reflectyearsoflifelostfromprematuredeathandyearsoflifelivedinlessthanfullhealth.Inhigh incomecountries,asthma,COPDanddiabetesrepresent11.1millionDALYsor7%ofthetotal DALYs.1 Aswellastheirsignificancefromtheperspectiveofthoseaffected,chronicdiseasesalso imposehugecostsonthehealthcaresystemsresponsibleformanagingthem.IntheUS,thedirecthealth carecostsforpatientswithasthma,diabetes,heartdiseaseandhypertensionwere$52.1billionin1996.2 Doestelemedicinehavearoleinthemanagementofchronicdiseases?Beforeconsideringthisquestion, itisworththinkingaboutwheretelemedicinewouldfitintothediseasemanagementprocess.Mostofus wouldimagine,apriori,thatcloserinvolvementofhealthcarestaffwithapatientwhohasoneormore chronicdiseaseswouldreducemorbidityandperhapsmortality.Thereissomeevidence,forexample, thatuseofnursecasemanagers(combinedwithapatienteducationprogramme)isefficacious.3 Useof casemanagersisoneaspectofprovidingintegratedcare,afashionabletermwitharatherelastic definition.Integratedcareiscommonlythoughtofasaprocessthatseekstoachieveseamlessand continuouscare,tailoredtotheindividualpatient'sneeds,andbasedonaholisticviewofthepatient. Thereareseveralsynonyms,suchasdiseasemanagement,caremanagement,managedcareand coordinatedcare.Integratedcareprogrammesseemtohavepositiveeffectsonthequalityofcare, althoughthewidelyvaryingdefinitionsandcomponentsmayleadtoinappropriateconclusionsbeing
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drawn.4 Howhastelemedicinebeenusedtosupportintegratedcareinchronicdiseasemanagement?Itsmain roleshavebeeninprovidingeducation(toimproveselfmanagement),inenablinginformationtransfer (e.g.telemonitoring),infacilitatingcontactwithhealthprofessionals(e.g.telephonesupportandfollow up)andinimprovingelectronicrecords.Thatis,telemedicinehasbeenusedinboththeprocessofcare andtheoutcomeofcare. Notethatthetermtelemedicinehasawidedefinitionmedicinepractisedatadistanceanda correspondinglywiderangeoftelemedicineapplicationshasbeentrialledinthemanagementofchronic diseases.Thetelemedicineinteractionshavebeenoftwotypes,eithertakingplaceinrealtime(e.g. videoconferencing)orasynchronously(e.g.storeandforwardtransmissionofdatafromahomeglucose meter).Monitoringapplicationshavebeenentirelyautomatic(e.g.passivemonitoringofactivityusing roomsensors)orhaverequiredthepatienttodosomething(e.g.transmitbodyweightvaluesusingthe buttonsonatelephone).Educationalapplicationshaveemployedspeciallydesignedhomedevices,or dependedonwebaccessfromPCsorsmartphones. Areviewconductedin2003concludedthattelemedicinelookedpromisingforchronicdisease management,butthatgoodqualitystudieswerescarceandthatthegeneralizabilityofmostfindingswas ratherlimited.5 Whathaschangedintheensuingnineyears?First,experimentationwithtelemedicinehas continuedapace.Therehasbeenacontinuedincreaseinthepublicationofpapersconcerning telemedicineandchronicdiseases(Figure1).Thenumbersofpapershasincreasedapproximatelyfive foldsince2003.Second,therehavebeensomesubstantialimplementations.Forexample,theVeterans AdministrationintheUShasreportedsome50,000patientsmanagedwithhometelecare.6 Despitethis enthusiasm,almostnothingisknownaboutthecosteffectivenessoftelemedicineinchronicdisease management. Figure1 Medlinepublicationsontelemedicineandfivechronicdiseases.There were1324publicationsbetween1990and2011. Costeffectivenessisacriticalmatterfortheadoptionofanynewtechniqueortechnologyintohealth care.Theconventionalapproachtoansweringquestionsaboutcosteffectivenessistosummarizethe resultsofrandomizedcontrolledtrials(RCTs)andproduceapooledestimateofeffect,byconductinga metaanalysis.Generally,theeffectofinterestistheQualityAdjustedLifeYear(QALY).Ifsuchan estimateforthecostofaQALYpassesanagreedthreshold(e.g.2535,000intheUKNHS),then widespreadimplementationoftheinterventionislikely.Ultimately,iftelemedicineisgoingtobeused onawidescaleinpublichealthcaresystems,itwillneedtopasstestssuchasthese.However,thereare significantdifficultiesintakingthisapproachinthepresentcontext.Crucially,therehavebeenveryfew studiesofcosteffectiveness,socalculatingapooledestimateisimpossible. Sinceestimatingthecosteffectivenessisunfeasiblebecauseofthelackofdata,somelesserassessment ofthevalueoftelemedicinemaybethebestthatcanbemanagedforthetimebeing.Again,the conventionalapproachisametaanalysis,examiningaquantitativeoutcomesuchasmortality, emergencydepartmentvisitsorlengthofstayinhospital.Suchanalyseshaveindeedbeenconductedfor specificoutcomesincertainchronicdiseases.Heretheproblemisthatthepublishedtrialshave employedawiderangeofoutcomemeasures,sothatapooledestimateofanyoneoutcomereducesthe

sizeofthedatasetveryconsiderably.Forexample,thereareatleast11RCTsoftelemedicineinCOPD, butthepublishedestimateoftheriskratioformortalitywasbasedononlythreestudies.7 Sinceconventionalmetaanalysiscannotyetprovidearobustsummaryofthisveryheterogeneousfield, adifferentproceduremustbeusedifthevalueoftelemedicineinchronicdiseasemanagementistobe estimated.Thepresentstudythereforetakesanewapproach,inordertoobtainahighlevelviewofthe valueoftelemedicineinchronicdiseasemanagement.

Methods

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TheanalysiswasconfinedtoRCTsinwhichoneormoretelemedicineinterventionshadbeencompared withacontrolgroup.Itwasrestrictedtopatientswithoneofthefollowingcommonchronicdiseases: asthma,COPD,diabetes,heartfailure,hypertension.Thetelemedicineinterventioncouldinclude telephonesupport,telemonitoring,videoconferencing,etc.Thevalueofthetrialresultwasdefinedin termsoftheoutcomesspecifiedbytheinvestigatorsineachstudyindividually.Asynthesiswascarried outbymetaregression.

Identificationofstudies

ThestudiesofinterestwereRCTsconcerningtheuseoftelemedicineinchronicdisease.Candidate studieswereidentifiedinathreestageprocess.First,systematicreviewsoftheuseoftelemedicineinthe chronicdiseasesofinterestwereidentified,andthereferencelistsofthesereviewsweresearchedby hand.Second,acomputerisedliteraturesearchwasconductedtoidentifyindividualRCTsdirectly. Finally,thereferencelistsofincludedstudiesweresearchedbyhand.

Computerizedsearching

ComputerizedsearchesoftheMedlinedatabasewereconductedinJuly/August2011toidentify systematicreviews,andtoidentifyRCTs.Thesearchtermswere: 1. TelemedicineAND 2. Randomizedcontrolledtrial/systematicreviewAND 3. AsthmaORCOPDORdiabetesORheartfailureORhypertension. NonEnglishlanguagepaperswereincluded.

Selectionofstudies

Candidatestudieswereselectedforfurtherexaminationbasedontheabstractfullcopiesofthearticles werethenexaminedtoconfirmthattheymetthefollowinginclusioncriteria.Studieswereincludedif theyreported: 1. AnRCT 2. Atelemedicineintervention,suchastelemonitoringortelephonesupport 3. Patientswithasinglechronicdisease,orifmultiplediseasegroupshadbeenstudied,thenthe resultshadtobeseparatelyreportedforeachdiseasegroupofinterest.

Dataextraction

Thefollowinginformationwasextractedfromeachofthestudies: Noofsubjects

Typeofpatient,e.g.diseaseandseverity Natureoftheintervention.Inaddition,detailswererecordedaboutwhethertherewas Routinevoicecontactwithapersonsuchasacasemanager,nursespecialistorpharmacist Voicecontactwithaninteractivevoiceresponse(IVR)system Videocontactwithahealthprofessional,e.g.videoconferencing Messagingwithahealthprofessional,e.g.usingemail,webmessagingoronlinechat Telemonitoring,e.g.automatictransmissionofdatasuchassymptomsorvitalsigns Duration(months) Primaryandotheroutcomes Result Overallvalueofintervention. Theoverallvalueoftheinterventionwasratedintermsoftheoutcomesspecifiedforthestudyin question,withtheeffectcategorisedona5pointscale,seeTable1. Table1 Categorisationofthevalueoftheintervention
Synthesis

Therelationbetweenthevalueoftheinterventionstrialled(i.e.theestimatesofeffect)andvarious potentialexplanatoryvariableswasfirstexaminedgraphically.Possiblepredictorswerethenexamined collectivelyusingregressionmodelling.Sincethedependentvariablewascategorical,anorderedlogit regressionwasemployed,usingastandardpackage(Gretl.Seehttp://gretl.sourceforge.net/).

Results
Identificationandselectionofstudies

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Inthefirststageoftheidentificationprocess,atotalof22systematicreviewswasidentifiedrelatingto theuseoftelemedicineinthechronicdiseasesofinterest.728 Inthesecondstage,atotalof264reports ofRCTswasidentified.Afterscreeningthesepapersandexaminingthereferencelistsofthoseincluded, therewasafinaltotalof141RCTswhichmettheinclusioncriteria,seeTable2.Thesepapersreported trialsof148interventions,i.e.sometrialshadmultipleexperimentalarms. Table2 Identificationandselectionofstudies

RCTsandinterventionstrialled

Inasthma,trialsof20interventionswereidentified,seeTable3(seeonlineonlysupplementary data:http://jtt.rsmjournals.com/lookup/suppl/doi:10.1258/jtt.2012.120219//DC1).Thesetrialsinvolveda totalof10,406patients.Outcomemeasurescommonlyemployedwerehealthcareutilization,symptoms andqualityoflife. InCOPD,trialsof11interventionswereidentifiedtwoarticlescontainedthedetailsaboutonetrial,see Table4(seeonlineonlysupplementary data:http://jtt.rsmjournals.com/lookup/suppl/doi:10.1258/jtt.2012.120219//DC1).Thetrialsinvolveda

totalof1104patients.Outcomemeasurescommonlyemployedwerehospitaladmissionsandqualityof life. Indiabetes,trialsof39interventionswereidentifiedtherewerethreetrialsinwhichthedetailswere containedintworeportseach,seeTable5(seeonlineonlysupplementary data:http://jtt.rsmjournals.com/lookup/suppl/doi:10.1258/jtt.2012.120219//DC1).Thetrialsinvolveda totalof4970patients.OutcomemeasurescommonlyemployedwereHbA1c,qualityoflifeandself efficacy. Inheartfailure,trialsof61interventionswereidentifiedthereweresixtrialsinwhichthedetailswere containedintworeportseach,seeTable6(seeonlineonlysupplementary data:http://jtt.rsmjournals.com/lookup/suppl/doi:10.1258/jtt.2012.120219//DC1).Thetrialsinvolveda totalof16,388patients.Outcomemeasurescommonlyemployedweremortality,hospitaladmissions, qualityoflifeandhealthcarecosts. Inhypertension,trialsof17interventionswereidentifiedtherewere14RCTs,seeTable7(seeonline onlysupplementarydata:http://jtt.rsmjournals.com/lookup/suppl/doi:10.1258/jtt.2012.120219//DC1). Thesetrialsinvolvedatotalof4827patients.Outcomemeasurescommonlyemployedwereblood pressureandhealthcarecosts.
Sizeofthetrials

The141RCTsinvolvedatotalof37,695patients,i.e.anaveragetrialsizeofabout270patients.There wasatendencyforthetrialsofpatientswithdiabetestobeslightlysmallerthanthenorm,andforthe trialsofpatientswithasthmatobeslightlylargerthanthenorm,seeFigure2.Therewasalinear relationship,thoughnotsignificant,betweenthenumbersofinterventionstrialledandthetotalnumber ofpatientsinthosetrials. Figure2 Sizeofthetrials.Thesolidlineshowsthelinearregression

Effectestimates

Moststudiesreportedfavourableeffects:eitherpositive(n =65)orweaklypositive(n =43)intermsof theoutcomesspecifiedbytheinvestigatorsintheirtrials.Therewere38studiesinwhichtheintervention wasnotsignificantlydifferentfromthecontrol,andonlytwo(oneweaklynegativeandonenegative)in whichtheinterventionwasworsethanthecontrol.Thatis,73%ofstudieswerefavourabletothe intervention,26%wereneutral,and1%wereunfavourable.

Heterogeneity

Intheabsenceofbiasandbetweenstudyheterogeneity,thescatterintheeffectestimateswillbedueto samplingvariationalone.Aplotoftheeffectestimatesfromindividualstudiesagainstsomemeasureof theprecisionofeachstudywillresembleasymmetricalinvertedfunnel.Usingthesquarerootofthe samplesizeasanestimateofprecisionshowedthattherewasconsiderableheterogeneityinthedataset, seeFigure3. Figure3

Funnelplot

Potentialexplanatoryvariables

TherelationbetweenthedurationoftheinterventionandtheeffectisshowninFigure4.Therewasno obvioustendencyforinterventionsappliedforlongerperiodstoproducemorepositiveresults.An orderedlogitregressionwasnotsignificant. Figure4 Durationofinterventions

Themedianeffectinallfivechronicdiseaseswasweaklypositive.Intheindividualdiseases,themedian effectwasweaklypositiveforasthma,diabetes,heartfailureandhypertension,andpositiveforCOPD. TheeffectindifferentdiseasetypesissummarisedinFigure5.Therewerenosignificantdifferences betweenthedifferentdiseasetypes(KruskalWallisP=0.96). Figure5 Diseasetype.Theboundariesoftheboxesindicatethe25thand75th percentiles,andalinewithintheboxmarksthemedian.Thewhiskers (errorbars)aboveandbelowtheboxesindicatethe90thand10th percentiles.Potentialoutliersareshownindividually... TheeffectintrialsusingtelemonitoringisshowninFigure6therewasnosignificantdifferenceineffect betweeninterventionswhichemployedtelemonitoringandthosewhichdidnot.Theeffectintrialsusing routinevoicecontactisshowninFigure7therewasnosignificantdifferenceineffectbetween interventionswhichemployedroutinevoicecontactandthosewhichdidnot.Theeffectintrialsusing videoconferencingisshowninFigure8therewasnosignificantdifferenceineffectbetween interventionswhichemployedvideoconferencingandthosewhichdidnot. Figure6 Telemonitoring.BoxplotattributesasforFigure5

Figure7 Routinevoicecontact.BoxplotattributesasforFigure5

Figure8 Videoconferencing.BoxplotattributesasforFigure5

TherelationbetweenthenumberofsubjectsandtheeffectisshowninFigure9.Therewasnoobvious tendencyfortrialsinwhichlargenumbersofsubjectshadbeenemployedtoproducemorepositive results.Anorderedlogitregressionwasnotsignificant. Figure9 Numberofsubjects

TherelationbetweentheyearofpublicationandtheeffectisshowninFigure10.Therewasatendency forstudieswhichhadbeenpublishedearliertoreportmorepositivefindings.Anorderedlogitregression wassignificantatP<0.05. Figure10 Yearofpublication

Synthesis

Inanorderedlogitregressionwithallpossiblepredictors,nonewassignificantexceptyearof publication(P=0.02).

Discussion

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Duringthelast20years,morethan1300Medlinepapershavebeenpublishedconcerningtheuseof telemedicineinthefivechronicdiseasesconsideredhere.Approximatelyoneintenofthesestudieshave beenformalrandomisedtrials.Awiderangeofoutcomeshasbeenreportedintheseexperiments,which makesaconventionalmetaanalysisoftheentiredatasetunfeasible.Thepresentworkwasundertakenin ordertoobtainahighleveloverviewofthevalueoftelemedicineinchronicdiseasemanagementina generalsense.Indoingso,datawereconsideredfromRCTsinwhichmorethanoneinterventionhad beentrialled.

Multiplicityadjustment

Inatrialwithmultipleexperimentalarms,thequestionariseswhetheramultiplicityadjustmentis requiredtoreducetheprobabilityofafalsepositiveresult,i.e.withtwotreatmentarms,each interventiongroupwillbecomparedseparatelywiththesamecontrolgroup.Onepossibility,for example,wouldbetouseaBonferroniadjustment.However,theconsensusofopinionisthata multiplicityadjustmentwouldnotbenecessaryiftheaimofthetrialwastoanswerquestionsaboutthe efficacyofeachinterventionseparately,i.e.theinterpretationoftheresultsofonecomparisonhadno directbearingontheinterpretationoftheresultsoftheothers.29 Inthepresentcontext,themultiarm studiesfoundinthereviewinvestigatedinterventionssuchastelephonesupportandtelemonitoring, whichcanbeconsideredindependent.Thusamultiplicityadjustmentwasnotrequiredforthepresent analysis.
Systematicreviews

DuringtheidentificationofRCTsforthepresentstudy,atotalof22systematicreviewswasidentified concerningtheuseoftelemedicineinthefivechronicdiseasesofinterest.Inapproximatelyhalfofthese

reviews,theauthorsprovidedaqualitativesummaryofthevalueoftelemedicine,usuallyintheformof anarrativereviewnoneoftheseconcludednegatively,i.e.thattelemedicinewasunhelpfulinchronic diseasemanagement,seeTable8. Table8 Systematicreviewsreportingpooledestimatesofquantitativeoutcomes (NSdifferenceindicatesnodifferencebetweeninterventionand controlgroupsatP0.05significantimprovementindicatesthat there... Theotherhalfofthereviewsprovidedpooledestimatesofvariousquantitativeoutcomes.Therewere fourquantitativeoutcomeswhichwerepotentiallyapplicableinallfivediseases: 1. Qualityoflife 2. Emergencydepartmentvisits 3. Hospitalization 4. Mortality. Inaddition,therewerethreequantitativeoutcomeswhichwerespecifictodiabetes: 1. HbA1c 2. Severehypoglycaemia 3. Diabeticketoacidosis. Betweenthem,the12systematicreviewsprovided23pooledestimatesofeffect,ofwhich approximatelyhalfshowedtelemedicinetoprovidesignificantlybetteroutcomesthanthecontrol condition.Conversely,theotherhalfofthepooledestimatesshowedtelemedicinetobenobetterthan thecontrolcondition.Thisemphasisestheratherweakandunsatisfactoryconclusionswhichcanbe drawnfromthesystematicreviewspresentlyavailable.
Heartfailure

Ofthe22systematicreviewsidentified,thelargestnumber(9)concernedtheuseoftelemedicineinheart failure.Thesereviews,whichwerepublishedoveranineyearperiod,provideeightpooledestimatesof effect,allexceptonebeingsignificantlypositiveinfavouroftelemedicine.Ofallthechronicdiseases consideredinthepresentstudy,therefore,theevidencewouldappearmostfavourableforheartfailure. Indeed,theappearanceofanauthoritativeCochranereviewthatfavouredtheuseoftelemedicine (telephonesupportortelemonitoring)inheartfailure17 wouldnormallysignalacceptanceofefficacyby thescientificcommunityandpotentiallypavethewayforwidespreadtrialsofeffectiveness. Unfortunately,therehavebeentwosubsequentreports30,31 fromlarge,wellpoweredRCTswhichare contradictory,andatthetimeofwriting,weexpecttheCochranereviewtoberevisedandreissuedto reflectthis.
Overview

Toavoidtheproblemofrequiringacommonoutcomefromalltrials,aswouldbeneededfora conventionalmetaanalysis,thepresentstudyadoptedadifferentapproachinwhichthevalueofeach interventionwascategorisedintermsoftheoutcomesspecifiedbytheinvestigatorsinthattrial.From this,itcanbeseenthatthemajorityoftrialsreportpositiveeffects,i.e.thereisastrongsuspicionof

publicationbias.Thisissupportedbytheobservationthatmorerecentpublicationstendtoreportweaker effects.Publicationbiaswasalsosuggestedbytheasymmetricfunnelplotforthedataset.Whilethisis certainlyaplausibleexplanationoftheoverwhelminglypositivefindingsreported,itisnottheonly one.32 Thereislikelytobetrueheterogeneitybecauseofdifferencesbetweentheinterventionsand differencesbetweenthediseases. Thepresentreviewsuggeststhattherearenomajordifferencesinthevalueofthetelemedicine interventionbetweenthediseasetypes.Furthermore,neithertelemonitoringnorvideoconferencing appeartobesuperiortotelephonesupport.Moststudieshavebeenrelativelyshorttermwhich,inthe caseofchronicdiseases,mayweakentheirpowertodemonstrateaneffect.TheworkofSheaet al.,33 whoreported5yearfollowupinpatientswithdiabetes,demonstratesthatlongtermtelemedicine interventionsarepossible. Awiderangeofoutcomeshasbeenemployedinthetrialsreviewed.However,therehavebeenfew studiesinwhichcosteffectivenesshasbeenmeasured.TheworkbyHebertetal.34 reportingQALY datafortelemedicineinheartfailure,thereforerepresentsanexemplar. Onthebasisoftheworkreviewed,itisnotpossibletostatethattelemedicineofaparticulartypewillbe costeffectiveinthemanagementofoneormorechronicdiseases.Afternearly20yearsofrandomised trialswork,thisseemsbothsurprisinganddisappointing.Nonetheless,themajorityofthestudies conductedhavereportedpositiveeffectsintermsoftheoutcomesspecifiedinthosetrials.Thisraisesthe possibilitythatthebeneficialeffectreportedisnotduetotelemedicineitself,somuchastotheincreased attentionduetotheexperimentalintervention,i.e.thataHawthorneeffectisatleastpartlyresponsible. Futureworkshouldbedesignedtoseparatethetrueeffectsoftelemedicinefromputativeplacebo effects.
Limitations

Thepresentstudyhadcertainlimitations.First,althoughthesearchforstudieswasconductedlargelyin accordancewiththeprocedureforasystematicreview,theremaybeotherRCTsthatcouldhavebeen found.Second,thevalueofeachstudywasassumedtobethesameinthemetaregression,i.e.no attemptwasmadetoweightthestudies.Third,otherchronicdiseasesmaybeofinterestinadditionto thefivecommonchronicdiseaseswhichwerestudied.Finally,synthesizingdisparateoutcomesdatain differentdiseaseshasnotbeenattemptedbeforeintelemedicinework,sofarasIamaware.Itisan acknowledgedlimitationofthisnewapproachthatthetheoreticalfoundationremainstobedeveloped. Inthemeantime,itcanatleastberegardedasaqualitativetechnique.

Futurework

Thepresentstudyraisesanumberofquestionsabouttheintrinsicvalueoftelemedicineinthe managementofchronicdisease.Itwouldthereforebeusefuliffuturestudiesweredesignedvery carefully,inordertoidentifythetruevalueofdistancesupport.Itwouldalsobevaluabletofuture reviewersifaminimumdatasetcouldbeagreedfortheoutcomemeasures.Quantitativeindices,from whichpooledestimatesofeffectcanbecalculated,andwhichareapplicableacrossalldiseasegroups include: 1. Qualityoflife(asmeasuredonthescaleappropriatetothediseaseinquestion) 2. Costtosociety 3. Emergencydepartmentvisits

4. Daysinhospital 5. Mortality. Thelastthreemaybefurthercategorisedasallcauseordiseasespecific. Finally,itseemsunlikelythatinachronicdisease,anyinterventioncanhavemucheffectunlessapplied foralongperiod.Futurestudiesmightconsiderinterventionslastingyearsratherthanmonths.

Conclusion

Theevidencebaseforthevalueoftelemedicineinmanagingchronicdiseasesisonthewholeweakand contradictory.

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