Telemedicine in chronic disease management: a Public Health perspective

Introduction In 2014, the School of Hygiene of the University of Padua carried out an evaluation of home telemonitoring (HTM) programs for the management of chronic diseases. Our aims were to verify their efficacy, and to identify a model of care that could be integrated into the current health system. Our analysis addressed both organizational and clinical matters. Methods Our evaluation involved 19 reviews and 53 randomized controlled trials (RCT). Main selection criteria were: papers published over the last 15 years, HTM performed through a sensor system, data sent remotely to physicians, health out-comes and monitored parameters clearly stated. Included diseases were: heart failure, hypertension, COPD, asthma and diabetes. Results Several critical issues were highlighted. Due to the general tendency in the scientific literature to report HTM efficacy, there is a lack of conclusive evidence whether telemedicine actually improves both clinical (e.g. decreased disease/all-cause mortality, drop in disease/all-cause hospitalization rates, improvement in biological parameters and quality of life) and organizational (decreased length of hospital stay, decreased emergency room/other service use, decreased costs) outcomes or not. Discussion From a Public Health perspective, discrepancies and weaknesses may affect published results, since the best method for organizing and delivering telemedicine programs has not yet been identified. There is still no consensus on the following topics: setting: which context expresses the potential of technology best? No studies were found comparing, e.g., rural with urban communities. Within urban scenarios, samples do not discriminate users by their capability to access the healthcare network (e.g. residents in peripheral areas with limited transportation resources, rather than users with reduced mobility); target: it is unclear which demographic or socioeconomic characteristics users should possess to gain most benefit from HTM; duration and frequency: there are significant differences in RCT (and HTM program) duration. It has not been established whether HTM is more effective when permanently implemented, or only in the early stages of disease (i.e. until stabilization). There is no agreement on the optimal HTM implementation frequency, nor whether the patients should also receive traditional interventions (e.g. nurse home visits);scope: it has not been determined whether measurements should be disclosed to patients as educational means to improve disease management. However, past literature does include some indications that the effectiveness of HTM programs may be attributable to care intensification (or to a perceived intensification by the patient, as per the “Hawthorne effect” described in sociology) or to the empowerment process. Conclusions HTM management of chronic diseases is a promising and remarkable strategy, still flawed by the lack of evidence. Reported efficacy, although modest, probably has a multifactorial origin. Our hypothesis is that it may not result from the technology itself, but from the impact of such process on multiple components of care, emphasizing patients' involvement and autonomy, and improving monitoring intensity. Further studies are needed to clarify the role played by the different HTM components (target, setting, etc.). The application of HTM as a tool for prevention, empowerment and reduction of healthcare access remains little explored.