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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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
2. Research Question
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
2. Research Question
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
“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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology4.3. Articles’ selection
EndNote
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology4.3. Articles’ selectionOpenOffice
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology4.3. Articles’ selection
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
Descriptive analysisDescriptive analysis
Meta-analysisMeta-analysis
PopulationPopulation OutcomesOutcomesInterventionIntervention
4. Methodology4.5. Data Analysis
Mortality
Length of stay
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
Use of the STROBE to evaluate the quality of the articles
4. Methodology4.6. Quality Assessment
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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).
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
7. Conclusion
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
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
The End