Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base

Objective

Home telemonitoring represents a patient management approach combining various information technologies for monitoring patients at distance. This study presents a systematic review of the nature and magnitude of outcomes associated with telemonitoring of four types of chronic illnesses: pulmonary conditions, diabetes, hypertension, and cardiovascular diseases.

Methods

A comprehensive literature search was conducted on Medline and the Cochrane Library to identify relevant articles published between 1990 and 2006. A total of 65 empirical studies were obtained (18 pulmonary conditions, 17 diabetes, 16 cardiac diseases, 14 hypertension) mostly conducted in the United States and Europe.

Results

The magnitude and significance of the telemonitoring effects on patients’ conditions (e.g., early detection of symptoms, decrease in blood pressure, adequate medication, reduced mortality) still remain inconclusive for all four chronic illnesses. However, the results of this study suggest that regardless of their nationality, socioeconomic status, or age, patients comply with telemonitoring programs and the use of technologies. Importantly, the telemonitoring effects on clinical effectiveness outcomes (e.g., decrease in the emergency visits, hospital admissions, average hospital length of stay) are more consistent in pulmonary and cardiac studies than diabetes and hypertension. Lastly, economic viability of telemonitoring was observed in very few studies and, in most cases, no in-depth cost-minimization analyses were performed.

Conclusion

Home telemonitoring of chronic diseases seems to be a promising patient management approach that produces accurate and reliable data, empowers patients, influences their attitudes and behaviors, and potentially improves their medical conditions. Future studies need to build evidence related to its clinical effects, cost effectiveness, impacts on services utilization, and acceptance by health care providers.Continued advances in science and technology and general improvements in environmental and social conditions have increased life expectancy around the world. ¹ As a result, the world’s population is aging. Over the last 50 years, the number of people age 60 years or over has tripled, and is expected to triple again to almost two billion by 2050. ² Population ageing is a global phenomenon affecting all regions. Globally, the proportion of older people was 8% in 1950 and 10% in 2000, and is projected to reach 21% in 2050. ³ China is the region where the increase is likely to be most spectacular, from 6.9% in 2000 to 22.7% in 2050. ³ Population ageing is profound, having major consequences and implications for all facets of human life, including health and health care. Indeed, as we age, the incidence and prevalence of chronic diseases, such as cardiovascular disease, chronic obstructive pulmonary disease (COPD), and diabetes, continue to increase. ^1,4 Chronic diseases have become major causes of death in almost all countries. By the end of 2005, it is estimated that 60% of all deaths will be due to chronic diseases. ⁵ Such prevalence of chronic diseases is one reason why expenditures on health care are skewed: in most health care delivery systems, 5% of patients are responsible for 50% of costs. ⁶ The economic burden of chronic diseases is profound, accounting for 46% of the global burden of disease. ⁷ The losses in national income for 2005 due to deaths from heart disease, stroke, and diabetes were estimated (in international dollars) to be $18 billion in China, $1.6 billion in the United Kingdom, and $1.2 billion in Canada. ⁵ In the United States, chronically ill patients account for 78% of all medical costs nationally. ⁸ The increasing burden of chronic disease on health care resources and costs provides a powerful incentive to find more compelling ways to care for these patients.The challenge is even more complex because of the supply-and-demand curve in health care. ⁴ Indeed, at the same time as we face dramatic increases in the numbers of chronically ill patients, there are global provider shortages. An acute nursing shortage exists in many developed countries, including the United States, United Kingdom, Australia, and Canada, and there is no realistic prospect that this situation will change in the near future. ^9–11 Furthermore, some countries have to cope with reductions in the number of persons entering the nursing profession. ^12–14 Several studies have also suggested a substantial physician shortage, which is expected to develop in the coming years in various countries. ^15–17 Dramatic increases in the numbers of chronically ill patients in the face of shrinking provider numbers and significant cost pressures mean that a fundamental change is required in the process of care. We need to identify patient management approaches that would ensure appropriate monitoring and treatment of patients while reducing the cost involved in the process. Provision of care directly to the patient home represents an alternative. It may be perceived as a substitute for acute hospitalization, an alternative to long-term institutionalization, a complementary means of maintaining individuals in their own community, and an alternative to conventional hospital outpatient or physician visits. ¹ Information technology can play a crucial role in providing care to the home, and telehealth technologies have been growing dramatically. More precisely, home telemonitoring is a way of responding to the new needs of home care in an ageing population. In this regard, Meystre ¹⁸ recently concluded that long-term disease monitoring of patients at home currently represents the most promising application of telemonitoring technology for delivering cost effective quality care. Yet, to be able to comprehensively assess and determine the benefits of home telemonitoring, it is essential to perform a systematic review that can critically synthesize the results of various studies in this area and provides a solid ground for clinical and policy decision making. ¹⁹ This article provides a systematic review of experimental and quasi-experimental studies involving home telemonitoring of chronic patients with pulmonary conditions, diabetes, hypertension, and cardiovascular diseases. Precisely, it reveals the nature and magnitude of the outcomes or impacts associated with telemonitoring programs across the world.