Systematic reviews of telehealth interventions in UEC settings were identified by a search of seven databases. The search was conducted in February 2019 and limited to studies published in 2009 or later. Further details can be found in Chapter 2 (see Literature search and screening) and a sample search strategy is provided in Appendix 1. In selecting reviews for inclusion, we accepted reviews of telehealth as defined by the review authors and we did not exclude reviews on the basis of methodological quality. We have also followed authors’ practice regarding the use of ‘telehealth’, ‘telemedicine’ and similar terms.
Quantity and scope of included reviews
We included 12 systematic reviews published between 2010 and 2019. Seven of the reviews were published in 2017 or later. Four reviews dealt with ‘telestroke’, two dealt with trauma care and the remainder with a variety of other telehealth applications. Table 20 summarises the basic characteristics of the included reviews.
| First author and year of publication | Review objectives | Search date | Included studies | Headline findings |
|---|---|---|---|---|
| Telestroke reviews | ||||
| Baratloo 201848 | To assess the effect of telemedicine on treatment times and clinical outcomes of acute stroke care | May 2017 | 26 | Telemedicine significantly reduced onset to door and hospital stay durations without increasing mortality or symptomatic intracranial haemorrhage |
| Hubert 201449 | To analyse recent advances in the field of telemedicine for acute stroke, with a focus on pre-hospital management | May 2014 | 25 | Studies of pre-hospital management (n = 9) showed that stroke recognition can start at the dispatch emergency call, important clinical information can be electronically transmitted to hospitals before admission and acute treatment such as thrombolysis can be initiated if ambulances are suitably equipped |
| Johansson 201050 | To assess the feasibility, acceptability and treatment delivery reliability of telemedicine systems in acute stroke management | November 2008 | 18 | Telemedicine systems can be safe, feasible and acceptable and are associated with increased delivery of thrombolytic therapy |
| Rubin 201351 | To conduct a systematic review of the published literature on telemedical consultation for acute stroke evaluation and management | July 2012 | 145 | Telestroke technology is part of mainstream clinical practice in North America and internationally. More recent studies (n = 13) have evaluated telestroke in pre-hospital settings |
| Trauma reviews | ||||
| Eder 201852 | To provide a comprehensive overview of telemedicine applications in pre-hospital trauma care | March 2018 | 15 (including six simulation studies) | Evidence regarding effectiveness is still limited |
| Lewis 201253 | To offer a systematic review of the literature on telemedicine for the management of acute phase injuries | December 2010 | 31 | Potential benefits include lower travelling expenses, enhanced continuity of care and increased access to specialists in underserved and rural areas. Barriers to wider adoption remain |
| Other reviews | ||||
| Brunetti 201754 | To measure the effect of pre-hospital ECG triage by telemedicine on time to treatment in patients with STEMI | May 2016 | 11 | In a meta-analysis, relative reduction in time to treatment using telemedicine was around 40%. Absolute reduction was correlated with control group time to treatment, suggesting benefit was greatest in those travelling further for treatment |
| du Toit 201955 | To identify how telehealth has been used to assist in management of non-critical conditions in rural and remote EDs and summarise the outcomes | December 2017 | 15 | Telehealth was predominantly used for remote consultation by nurses with limited local medical support. Teleconsultation altered diagnosis or management in 18–66% of consultations. Transfers were increased but unnecessary transfers were reduced |
| Gattu 201656 | To review current literature relating to telemedicine in paediatric emergency medicine | Not reported | Unclear | Use of telemedicine in paediatric emergency medicine is limited by a lack of evidence, with most published studies coming from a few centres in the USA and Europe |
| Marsh-Feiley 201857 | To assess the literature regarding telesonography (ultrasound) in emergency medicine | February 2017 | 28 | Feasibility of telesonography was supported by multiple studies. There was evidence of clinical utility in remote and low resource settings. Diagnostic accuracy was slightly reduced by image transmission. There was a need for better study design and reporting |
| Rogers 201758 | To assess the efficacy and implementation challenges of telemedicine systems in ambulances | December 2016 | 23 | Telemedicine feasible and effective in reducing treatment times with high diagnostic accuracy. There was a lack of high-quality implementation research |
| Winburn 201859 | To systematically review published research on the use of telehealth in pre-hospital emergency care | April 2017 | 68 | The majority of included studies involved stroke or acute cardiovascular care. The use of telehealth in pre-hospital settings remains limited and there are opportunities for wider diffusion. Understanding of incentives and barriers to telehealth adoption a priority for research |
Summary of review findings
Stroke reviews
Three of the four included reviews of telehealth for stroke were essentially descriptive or mapping reviews with a narrative synthesis of included studies.49–51 The review by Hubert et al.49 was particularly relevant to our review because of its focus on pre-hospital applications. The authors concluded that use of telehealth technology to transmit information from the ambulance to hospital and to allow early initiation of treatment can help to mitigate the effects of distance from a hospital ED or stroke unit.
The review by Baratloo et al.48 used meta-analysis of 26 studies (6605 patients) to quantify the effect of telehealth care on time to treatment and other relevant outcomes. The authors found no statistical difference between telehealth care and standard care groups for in-hospital mortality, 90-day mortality, symptomatic intracranial haemorrhage or favourable clinical outcome (at discharge or 90 days later). Telehealth technology was associated with a reduction in onset to door time [mean difference (MD) –10.4 minutes, 95% CI –14.79 to –0.01 minutes) and duration of hospital stay. Onset to treatment time was significantly reduced in a fixed-effect model but not in a random-effects model, suggesting an influence of heterogeneity on the findings. Although based largely on observational studies, this meta-analysis provides some further support for telehealth care as a mitigation intervention.
Trauma reviews
Two narrative synthesis reviews looked at the role of telehealth in the management of trauma patients.52,53 The more recent review focused specifically on pre-hospital trauma care.52 The authors identified telemedical assistance by real-time telemetry and telemedical pre-hospital notification as complementary applications of the technology but concluded that evidence of effectiveness in this setting remains limited.
Pre-hospital reviews
Two reviews focused on pre-hospital applications of telehealth generally rather than specific conditions.58,59 One review dealt specifically with the use of the technology in ambulances.58 Overlap of included studies between the two reviews was low. Despite some promising findings, both studies identified barriers to uptake of telehealth in this setting and emphasised the need for high-quality research into understanding barriers to wider uptake and promoting effective implementation.
Specific telehealth technologies
Two reviews looked at telehealth-care-assisted ultrasound (telesonography)57 and pre-hospital triage by transmission of electrocardiographic data to support management of patients with STEMI.54 The telesonography review concluded that the intervention was feasible and potentially useful in remote settings, but the quality of research was generally poor.57
Brunetti et al.54 performed a meta-analysis of 11 non-randomised studies (7552 patients). Pre-hospital triage by telemedicine was associated with a significant reduction in time to treatment compared with control groups [relative reduction of 40% (95% CI 33% to 48%) in a random-effects model and 38% (95% CI 37% to 39%) in a fixed-effect model]. There was a strong correlation between absolute reduction in time to treatment and time to treatment in the control group (R2 = 0.83). This was based on an exploratory analysis (metaregression) but the correlation remained significant after correction for age, gender and sample size. This correlation suggests that people experiencing a longer time to treatment may benefit most from the use of telemedicine to aid triage, supporting the role of this technology to mitigate the impact of being at a distance from a suitable treatment facility.
Other reviews
Other included reviews provided evidence that telehealth care can be used in rural and remote locations with limited clinical support and reduce unnecessary transfers of patients with non-critical conditions;55 and that evidence for the technology in paediatric emergency care is relatively limited outside specialist centres.56
Summary
The included systematic reviews synthesise a large body of research on telehealth care for UEC conditions, particularly stroke. Most reviews have involved narrative synthesis, including identifying barriers to uptake of the technology and priorities for better research. Meta-analyses suggest that telehealth technologies can reduce time to treatment for people with stroke48 and STEMI54 by allowing initiation of treatment before arriving at the hospital and/or by transmitting clinical data to clinicians at the receiving hospital.