A Meta-Analysis of the Clinical Impact of Telemedicine in Intensive Care Units Porto, June 2011...

A Meta-Analysis of the Clinical Impact of A Meta-Analysis of the Clinical Impact of Telemedicine in Intensive Care UnitsTelemedicine in Intensive Care Units

Porto, June 2011

Class 7, 1st yearIntrodução à Medicina II

Index

1. Background

1.1. Problem

1.2. Intervention

1.3. Outcomes

2. Research Question

3. Aim

4. Methodology

5. Results

6. Discussion

7. Conclusion

8. References

A Meta-analysis of the Clinical impact of telemedicine in intensive care units

Increasing volume of ICU patients [2] [4]Increasing volume of ICU patients [2] [4]

Shortage of intensivists[2][3] [5]Shortage of intensivists[2][3] [5]

Pressure to mantain and improve the quality of health care[1] [4] [5]

Pressure to mantain and improve the quality of health care[1] [4] [5]

Excessive work [1] [4] Excessive work [1] [4]

1. Background

1.1. Problem

TelemedicineTelemedicineTelemedicineTelemedicine

[1] Eklund M et al. Annual IEEE International Computer Software and Applications Conference. 2008.[2] Chu-Weininger M et al. Qual Saf Health Care. 2010.[3] Lucke J et al. JAMA. 2009[4] NEHI, Massachusetts Technology Collaborative, HTC. 2007.[5] Resche-Rigon M et al. Crit Care. 2006.

1. Background

Tele-ICU is the use of electronic information and communication technologies to provide and support health care when distance separates the participants

in Intensive Care Units.[4] [6]

Tele-ICU is the use of electronic information and communication technologies to provide and support health care when distance separates the participants

in Intensive Care Units.[4] [6]

[4] NEHI, Massachusetts Technology Collaborative, HTC. 2007.[6] Jarrah S et al. ACCP. 2010

1.2. Intervention


1.3. Outcomes

[3] Lucke J et al. JAMA. 2009. [7] McGregor C, Eklund J, Canada. 2009.[8] Young L et al. CHEST. 2010. [9] Yoo E, Dudley R, JAMA. 2009.

1. Background

Mortality Rate [3] [9]Mortality Rate [3] [9]

OutcomesOutcomesOutcomesOutcomesEffectiveness [9]Effectiveness [9]

Staff acceptance [8] [9]Staff acceptance [8] [9]

Costs for the hospital [7] [9]Costs for the hospital [7] [9]

Workload of human resources [7] [9] Workload of human resources [7] [9]

Length of Stay [3] [9]Length of Stay [3] [9]

What is the impact of Tele-ICU on

clinical and economic outcomes when

compared with monitoring in situ?

PopulationOutcomes

Intervention

Control



To gather evidence on the impact of Tele-ICU.

- Mortality rate; [3] [12]

- Length of stay; [9]

- Workload of human resources; [6]

- Acceptance of the health professionals; [8]

- Costs for the hospital; [10]

-Effectiveness of this technology. [11]

Specifically, evaluate the impact of this technology associated to the following outcomes:

[3] Lucke J et al. JAMA. 2009. [6] NEHI, Massachusetts Technology Collaborative, HTC. 2007.[8] Young L et al. CHEST. 2010.[9] Yoo E, Dudley R. JAMA. 2009.[10] Haught R. HHN Magazine. 2003.[11] Rosenfeld B et al. Crit Care Med. 2000.[12] McCambridge M et al.. AMA.

3. Aims

Index 1. Background


3. Aim

4. Methodology4.1. Selection criteria4.2. Query selection4.3. Articles’ selection4.4 Data extraction4.5. Data analysis4.6. Quality Assessment

5. Preliminary Results

6. Conclusion

7. References


Inclusion CriteriaInclusion Criteria Exclusion CriteriaExclusion Criteria

Articles containing original data and the following topics:

- The use of Telemedicine;- The use of ICU;- The measurement of at least one of the

outcomes that we defined.- Quality assessment – 20 or more

parameters using the STROBE

Type of study: Randomized control trials. If necessary, also search for

observational studies.

• Language:

Other than Portuguese and English

Search in PubMed and ISI Web of Knowledge

Type of Study

Systematic Review

4. Methodology

4.1. Selection criteria


“length of stay”[Mesh Terms] OR “length of stay” [All Fields] OR “LOS” OR “patient status”[All

Fields] OR “intensivist’s workload” OR ((“hospitals”[MeSH Terms] OR “hospitals”[All Fields] OR

“hospital”[All Fields]) AND costs) OR “quality control”[All Fields] OR “Staff Acceptance”[All Fields])

“teleintensivist”[All Fields] OR “tele-ICU”[All Fields] OR “virtual ICU”[All Fields] OR “tele-intensive

care” OR “RIC”[All Fields] OR “eICU”[All Fields] OR “intensive care telemedicine”) AND

(“ICU”[All Fields] OR “ICUs”[All Fields] OR “critical care facility”[All Fields] OR “intensive care

unit”[MeSH Terms] OR “intensive care units”[All Fields] OR “ICU patients”[All Fields] OR “ICU

patient”[All Fields] OR “intensive care patients” OR “critical care services”)) OR

(((“telemedicine”[All Fields] OR “telemedicine”[MeSH Terms] OR “tele-medicine”[All Fields] OR

“remote monitoring”[All Fields] OR “remote control”[All Fields] OR “remote consultation”[All

Fields] OR “telehealth”[All fields] OR “tele-health”[All Fields] OR “teleassistance”[All Fields] OR

“telecare”[All fields] OR “tele-care”[All fields] OR “mobile health”[All Fields] OR

“telemonitoring”[All Fields] OR “tele-monitoring”[All Fields] OR “remote analysis”[All Fields] OR

“e-health”[All Fields] OR “eHealth”[All Fields]) AND

INTE

RVEN

TIO

NPO

PULA

TIO

NO

UTC

OM

ESP/

I4.2. Query Selection

Pubmed


Topic=(telemedicine* OR tele-medicine OR remote monitoring control OR remote monitoring

OR remote control* OR remote consultation OR telehealth OR tele-health OR teleassistance OR

telecare OR tele-care OR mobile health OR telemonitoring OR tele-monitoring OR remote

analysis OR e-health OR eHealth) AND

Topic=(ICU* OR critical care facility OR intensive care unit* OR ICU patients* OR intensive care

patients OR critical care services OR ICU hospitals*) OR

Topic=(teleintensivist* OR tele-ICU OR virtual ICU OR tele-intensive care OR RIC* OR eICU OR

intensive care telemedicine) AND

Topic=(mortality OR length of stay OR LOS OR patient status OR intensivists workload OR costs*

OR quality control* OR Staff Acceptance*)

INTE

RVEN

TIO

NPO

PULA

TIO

NP/

IO

UTC

OM

ES4.2. Query SelectionIsiWebofKnowledge


1. Apply the query in Pubmed and ISI Web of Knowledge;

2. Mix and delete the repeated articles;

3. Randomly distribute them by 2 reviewers;

4. Use inclusion and exclusion criteria on the title and the abstracttitle and the abstract;

5. If the 2 reviewers agree, the article is included/excluded. If not, a 3rd one analyzes

it and decides;

6. Read the complete articles complete articles that were selected, using inclusion/exclusion criteria;

7. If the 2 reviewers agree, the article is included/excluded. If not, a 3rd one also

analyzes it and decides;

8. Use the STROBE to evaluate the quality of the articles.

4. Methodology4.3. Articles’ selection



EndNote


4. Methodology4.3. Articles’ selectionOpenOffice



1864 Titles identified from literature search

389 from Pubmed1475 from Isi web of knowledge

129 Duplicated were excluded

1735 Randomized and distributed to 2 reviewers for analysis by title and abstract

118 Included after analysis by title and abstract

1613 Excluded after analysis by title and abstract

1280 Don’t mention the use of telemedicine212 Mention telemedicine but not ICU36 Mention Tele-ICU but not the outcomes0 Mention Tele-ICU and outcomes but not original data5 Articles not written in English or Portuguese80 for criteria disagreement

12 Included for data extraction and analysis

106 Excluded after full text analysis

9 without PDF66 are not the defined type of study30 do not measure the required outcomes1 does not have 20 parameters in STROBE evaluation


Number of patients in ICU’s General characteristics: Age Gender Race/Ethnicity Health status

ParticipantsParticipants

Randomized intervention

- How is it controlled?

MethodsMethods

Clinical and economic outcomes:

- Mortality rate;

- Length of stay;

- Costs for the hospital;

- Staff acceptance;

- Effectiveness;

- Workload of human resources.

OutcomesOutcomes

Remote monitoring control

InterventionIntervention

4. Methodology4.4. Data extraction


Descriptive analysisDescriptive analysis

Meta-analysisMeta-analysis

PopulationPopulation OutcomesOutcomesInterventionIntervention

4. Methodology4.5. Data Analysis

Mortality

Length of stay


Use of the STROBE to evaluate the quality of the articles

4. Methodology4.6. Quality Assessment


5. Results

Table 1.1 – Description of the type of intervention, control and type of study of each included article

Article Type of Study

Type of

STROBEIntervention Control

Franzini L, et al [25] Observational Tele-ICU Monitoring in situ 21

Rosenfeld B, et al [11] Observational Tele-ICU Monitoring in situ 27

Lucke J, et al [3] Observational Tele-ICU Monitoring in situ 25

Morrison J, et al [26] Observational Tele-ICU Monitoring in situ 24

Coletti C, et al [27] Cross-sectional

surveyTele-ICU Monitoring on-call 21

Chu-Weininger M, et al [2] Cross-sectional

surveyTele-ICU Monitoring in situ 25


5. Results

Table 1.2 – Description of the type of intervention, control and type of study of each included article (continuation)

Article Type of StudyType of

STROBE

Intervention Control

Tang Z, et al [28] Time-and-motion

studyTele-ICU Monitoring in situ 26

McCambridge M, et al [12] Before-and-after Tele-ICU Monitoring in situ 24

Breslow M, et al [29] Before-and-after Tele-ICU Monitoring in situ 26

Zawada E, et al [30] Before-and-after/

surveyTele-ICU Monitoring in situ 22

Westbrook J, et al [31] Before-and-after Tele-ICU Monitoring in situ 22

Vespa P, et al [32] Before-and-after Tele-ICU Monitoring in situ 23


5. ResultsMortality Rate

Graph 1 – Statistic results of the outcome mortality rate.

5. ResultsLenght of stay

Graph 2 – Statistic results of the outcome Length of Stay (LOS).


5. Results

Table 4 – Comparison of the costs before and after the intervention for each included article.

ArticleVespa P, et al [32]

Costs saving year($)

1.136.918

Table 5 – Costs saving per year

Article n=ncontrol+nintervention

Costs per day ($)

Control Intervention

Breslow M, et al [29] (ALL) n=1396+744 1648 1411

Breslow M, et al [29] (MICU) n=631+359 1303 1041

Breslow M, et al [29] (SICU) n=765+385 1933 1756

Franzini L, et al [25] n=1913+2057 2851 3653


6. Discussion

Expected ResultsExpected Results ResultsResults

Mortality RateMortality Rate Won’t be affected Descreased RR=0,77

Length of stayLength of stay Will decrease Decreased

Mean Difference, CI 95%-0,50 [-2,23, -1,19]

CostsCosts

There will be a major initial investment, but probably profitable in

long-term

4 contraditory studies


7. Conclusion


8. Bibliographic References[1] Eklund M, McGregor C, Real-time Service-Oriented Architectures to Support Remote Critical Care: Trends and Challenges. Annual IEEE International

Computer Software and Applications Conference. 2008; 1199-1204.

[2] Chu-Weininger M, Lucke J, Mazabob J, Thomas E, Weavind L, Wueste L, The impact of a tele-ICU on provider attitudes about teamwork and safety

climate. Qual Saf Health Care. 2010.

[3] Lucke J, Patel B, Thomas E, Weavind L, Wueste L, Association of Telemedicine for Remote Monitoring of Intensive Care Patients With Mortality,

Complications, and Length of Stay. JAMA. 2009; 302(24):2671-2678.

[4] Tele-ICU: Remote Management in Intensive Care Units. New England Healthcare Institute, Massachusetts Technology Collaborative,Health Technology

Center. 2007.

[5] Resche-Rigon M, Azoulay E, Chevret S. Evaluating mortality in intensive care units: contribution of competing risks analyses. Crit Care. 2006; 10(1): R5.

[6] Jarrah S, Van der Kloot T, Tele-ICU: Remote Critical Care Telemedicine. American College of Chest – Physicians. 2010.

[7] McGregor C, Eklund J, Next generation remote critical care through service-oriented architectures: challenges and opportunities, Canada. 2009.

[8] Young L, Chan P, Cram P, Staff Acceptance of Tele-Intensive Care Unit Coverage: A Systematic Review. CHEST. 2010; 101795.

[9] Yoo E, Dudley R, Evaluating Telemedicine in the ICU. JAMA. 2009; 302(24):2705-2706.

[10] Haught R, Pressures converge in the ICU.HHN Magazine. 2003.

[11] Rosenfeld B, Dorman T, Breslow M, Pronovost P, Jenckes M, Zhang N, Anderson G, Rubin H. A Intensive care unit telemedicine: alternate paradigm for

providing continuous intensivist care. Crit Care Med. 2000; 28 (2):3925-31.

[12] McCambridge M, Jones, K, Paxton, H, Baker K, Sussman E, Etchason J, Association of Health Information Technology and Teleintensivist Coverage With

Decreased Mortality and Ventilator Use in Critically Ill Patients. American Medical Association.648-653.

[13] Cook D, Sackett D, Spitzer W. Methodologic guidelines for systematic reviews of randomized controlled trials in health care from the Potsdam

consultation on meta-analysis. J Clin Epidemiol. 1995; 48:167-71.

[14] Green S. Systematic reviews and meta-analysis. Singapore Med J. 2005; 46(6): 270.

[15] Jarrah S, Van der Kloot T, Tele-ICU: Remote Critical Care Telemedicine. American College of Chest – Physicians. 2010.

[16] Elaine S, Rosenthal D. Electronic Intensive Care: A Technical Solution To The Intensivist Shortage. Proceedings of the Academy of Health Care

Management. 2004; 1(1).

[17] Review Manager (RevMan) [Computer program]. Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008.

[18] Statistical Package for the Social Sciences (SPSS) [Computer program]. Version 18. IBM Corporation, 2010.

[19] Measures of Central Tendency [Internet] 2007 [updated 2006 Jul 13; cited 2010 Dec 10]. Available from:

http://hsc.uwe.ac.uk/dataanalysis/quantDescCentral.asp

[20] Qualitative Analysis - What It Is [Internet] 2007 [updated 2006 Jul 13; cited 2010 Dec 10]. Available from:

http://hsc.uwe.ac.uk/dataanalysis/qualWhat.asp[

[21]Grigsby J, Marilyn J, Telemedicine and Remote Patient Monitoring. JAMA. 2002; 288(4):423-425.

[22]Cummings J, Krsek C, Vermoch K, Matuszewski K, Intensive Care Unit Telemedicine: Review and Consensus Recommendations. University HealthSystem

Consortium. 2007.

[23]Goran S, A Second Set of Eyes: An Introduction to Tele-ICU. Critical Care Nurse. 2010; 30(4): 46-55.

[24]Collins English Dictionary – Complete and Unabridged©,HarperCollins Publishers. 2003.

[25] Franzini L, Thomas E, Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large health care system.

Journal of Critical Care. 2011; 26(3): 329.e1-329.e6.

[26] Morrison J, Cai Q, Davis N, Yan Y, Berbaum M, Ries M, Solomon G, Clinical and economic outcomes of the electronic intensive care unit: results from two

community hospitals. Crit Care Med. 2010.;38(1): 2-8.

[27] Coletti C, Elliott D, Zubrow M, Resident Perceptions of a Tele-Intensive Care Unit Implementation. Telemedicine Journal and E-Health. 2010; 16(8): 894-

897.

[28] Tang Z, Weavind L, Mazabob J, Thomas E, Chu-Weininger M, Johnson T, Workflow in intensive care unit remote monitoring: A time-and-motion study.

Critical Care Medicine,.2007; 35(9): 2057-2063.

[29] Breslow M, Rosenfeld B, Doerfler M, Burke G, Yates G, Stone D, Tomaszewicz P, Hochman R, Plocher D, Effect of a multiple-site intensive care unit

telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med. 2004; 32(1): 31-8.

[30] Zawada E, Herr P, Larson D, Fromm R, Kapaska D, Erickson D, Impact of an intensive care unit telemedicine program on a rural health care system.

Postgrad Med. 2009; 121(3): 160-70.

[31] Westbrook J, Coiera E, Brear M, Stapleton S, Rob M, Murphy M, Cregan P, Impact of an ultrabroadband emergency department telemedicine

system on the care of acutely ill patients and clinicians' work. Medical Journal of Australia. 2008; 188(12): 704-708.

[32] Vespa P, Miller C, Hu X, Nenov V, Buxey F, Martin N, Intensive care unit robotic telepresence facilitates rapid physician response to unstable

patients and decreased cost in neurointensive care. Surg Neurol. 2007; 67(4): 331-7.

Impacts of remote monitoring control on clinical and economic outcomes in intensive care units: a systematic review

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A Meta-Analysis of the Clinical Impact of Telemedicine in Intensive Care Units Porto, June 2011...

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