By applying objective techniques for gathering and synthesizing information from primary studies, a systematic review can pool the vast literature concerning a specific issue, guide future research, and ensure a solid ground for medical decision-making and policy formulation. 19
Specifically, this review aims at assembling and critically evaluating the literature on home telemonitoring of chronic conditions and integrating the current body of knowledge in this area. Given the relative newness of this field, which dates back to the early 1990s, it is important to underscore the considerable research (65 studies) that has been already initiated and conducted in the area of home telemonitoring of chronic illnesses such as diabetes, hypertension, and pulmonary and cardiac diseases. Based on the studies found in the literature, researchers in the United States and several countries in Europe and other parts of the world have shown interest in exploring the benefits, use, and potential of home telemonitoring as a patient management approach. Significant evidence has been built that highlights major findings related to the effects of telemonitoring on patients, their medical conditions, and the whole process of care.
The studies examined in this review of home telemonitoring for the four categories of chronic illnesses have provided evidence confirming the accuracy and reliability of this technique. In general, very few errors and technical problems were faced in the projects considered, and reliable and accurate measures were consistently transmitted from patients’ homes. This is an important indicator of the success of home telemonitoring in ensuring the timely availability of quality data for clinical decision-making. With the continuous development in telecommunication technologies used for telemonitoring, 90
which support minimal patient intervention in the collection and transfer of data, and as such reduce bias and subjectivity, the data transferred by telemonitoring become as reliable as those collected through face-to-face patient examination. Consequently, an important question arises as to whether future studies need to continue investigating the quality of transferred data in telemonitoring settings. Given the technological progress and current coherent evidence on the effect of telemonitoring on the quality of data, we believe researchers should rather focus on examining other effects of telemonitoring that remain uncertain.
Furthermore, the studies examined in this review presented consistent findings related to the effects of home telemonitoring on patients’ attitudes and behaviors. This patient management approach appears to be very well received and accepted by patients themselves. It allows them to actively participate in the process of care, improves their awareness and feeling of security, and ultimately leads to their empowerment. Nevertheless, despite the current evidence on the attitudinal and behavioral effects of telemonitoring, little is known on the conditions that would support the development of patients’ empowerment and enhance their participation in the telemonitoring process, especially with the reported decrease in patients’ compliance with time that was noted in several studies. 38,41,64,71,89
In fact, the decrease in compliance with time is a critical issue that needs to be addressed and further investigated, especially in the case of chronic illnesses that require long-term follow-up and monitoring. Furthermore, future studies should examine the behavioral effects of telemonitoring with patients of different socioeconomic status, educational background, and age groups to determine whether the positive impacts previously observed hold or vary across these groups. These are essential questions that need to be addressed in order to be able to successfully manage telemonitoring in the practice of patient care at the population level.
Despite the scattered evidence on the positive impacts of home telemonitoring at the clinical level, the studies included in this review have emphasized the potential of this approach to improve patients’ medical conditions. As Utterback 91
discussed, the main goal of any successful patient management approach is to improve patients’ outcomes and enhance the quality of life. In this case, although evidence on the clinical effects of home telemonitoring has not been consistent and conclusive across the four chronic illnesses, especially in the case of pulmonary conditions and cardiac diseases, it is important to note that studies on two of these chronic conditions have demonstrated positive clinical effects. Hypertension and diabetes studies consistently reported a significant decrease in blood pressure and glucose level, respectively, and studies involving cardiac patients have indicated a significant improvement in patients’ quality of life, an area that has not been elaborated for the other three medical diseases. Given the importance of improving the medical condition of patients and their wellbeing in any care approach, future research should pursue the efforts to evaluate this category of clinical effects and systematically investigate the impacts of home telemonitoring on patients’ conditions and quality of life by examining larger samples of patients over longer periods of time. This will strengthen the body of knowledge in this area and further validate the use of home telemonitoring as a patient management approach.
Evidence on the effects of home telemonitoring on the utilization of services and its economic viability remains limited for all four chronic illnesses. Based on this review, there is a necessity for further development of research that investigates the impacts of telemonitoring on the utilization of health services (e.g., emergency room visits, clinic visits, hospitalizations, lengths of stay). With the continuous increase in health care costs and focus on quality, health care systems face the challenge of caring for a constantly growing number of patients at minimal cost. As a result, a shift of patient care away from health care organizations is necessary to reduce congestion in these settings (e.g., emergency rooms, hospital beds) and to diminish costs. Home telemonitoring is a promising approach for achieving these objectives. Yet, systematic evaluation of its structural effects has not been sufficient so far to support its diffusion. Similarly, very few detailed cost–benefit analyses of home telemonitoring programs have been observed in the literature, preventing practitioners and policymakers from confirming their economic viability.
Based on this review, researchers should learn from the current body of knowledge in the area of home telemonitoring and address some of the main issues that remain problematic. First, the majority of the studies found in the literature were nonrandomized trials without control groups. Future evaluation studies should consider stronger designs, such as randomized trials, with larger samples of patients and over longer periods of time in order to be able to draw firmer conclusions regarding the effects of home telemonitoring. Specifically, studies assessing the structural and economic impacts of home telemonitoring programs should extend over periods of more than six months. Second, throughout this review, we noticed variability in the approach for investigating and reporting the effects of telemonitoring. Yet, the utilization of validated instruments to measure these effects was limited. Therefore, researchers should consider in the future a more thorough and systematic approach for evaluating the impacts of telemonitoring and for presenting the details of the respective projects and results. Examples of detailed analyses found in the literature include those by Paré et al, 46
Benatar et al, 80
Goldberg et al, 81
and Rogers et al. 84
Third, it was not clear throughout the studies examined herein whether improvement in the clinical condition of patients was a result of the process of telemonitoring itself or of other mechanisms such as the intensified provider consultation. 57
Future studies should assess the impact of other potential mediating variables or conditions on the outcomes observed. Fourth, very few observations were made in relation to the effects of telemonitoring on health care providers, their acceptance of this approach, and their concerns about it, which are important issues to consider in future studies. Fifth, a comparison between the increase in work time spent by health care providers, as reported in several projects, 57–59
and the time spent by them otherwise caring for exacerbated cases and complications that could have been minimized by telemonitoring is worth examining to have a clearer idea of the actual effects of this approach on providers’ workloads. Last, it was noted in the literature that the benefits of telemonitoring may vary in relation to the geographic location (urban/rural settings), 57,60
stage of illness, 57
and the availability of health care specialists. 28
Assessing these contingencies might also help in drawing firm conclusions about the outcomes of telemonitoring programs.