A Meta-Analysis of the Clinical Impact of
Telemedicine in Intensive Care Units
Class 7, 1st year
Introdução à Medicina II
Porto, June 2011
Index
1. Background
1.1. Problem
1.2. Intervention
1.3. Outcomes
3. Aim
4. Methodology
5. Results
6. Discussion
7. Conclusion
2. Research Question
8. References
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
1. Background
1.1. Problem
Increasing volume of ICU patients [2] [4]
Shortage of intensivists[2][3] [5]
Telemedicine
Excessive work [1] [4]
Pressure to mantain and improve the
quality of health care[1] [4] [5]
[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
1.2. Intervention
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
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
1. Background
1.3. Outcomes
Mortality Rate [3] [9]
Length of Stay [3] [9]
Effectiveness
[9]
Outcomes
Workload of human resources [7] [9]
Costs for the hospital [7] [9]
Staff acceptance [8] [9]
[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.
2. Research Question
Outcomes
Intervention
Population
What is the impact of Tele-ICU on
clinical and economic outcomes when
compared with monitoring in situ?
Control
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
3. Aims
To gather evidence on the impact of Tele-ICU.
Specifically, evaluate the impact of this technology associated to the following outcomes:
- 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]
[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.
Index
1. Background
2. Research Question
3. Aim
4. Methodology
4.1. Selection criteria
4.2. Query selection
4.3. Articles’ selection
4.4 Data extraction
4.5. Data analysis
4.6. Quality Assessment
5. Preliminary Results
6. Conclusion
7. References
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology
4.1. Selection criteria
Type of Study
Systematic Review
Inclusion Criteria
Exclusion 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
parameters using the STROBE

Type of study:

Randomized control trials.

If
necessary,
also
observational studies.
Language:

or
search
Other than Portuguese and English
more
for
Search in
PubMed and ISI Web of Knowledge
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4.2. Query Selection
Pubmed
INTERVENTION
(((“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
OUTCOMES
P/I
POPULATION
“e-health”[All Fields] OR “eHealth”[All Fields]) 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
“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
“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])
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
OUTCOMES
P/I
POPULATION
INTERVENTION
4.2. Query Selection
IsiWebofKnowledge
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*)
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology
4.3. Articles’ selection
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 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 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.
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology
EndNote
4.3. Articles’ selection
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology
OpenOffice
4.3. Articles’ selection
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
1864 Titles identified from literature search
4. Methodology
389 from Pubmed
1475 from Isi web of knowledge
4.3. Articles’ selection
129 Duplicated were excluded
1735 Randomized and distributed to 2 reviewers
for analysis by title and abstract
1613 Excluded after analysis by title and abstract
1280 Don’t mention the use of telemedicine
212 Mention telemedicine but not ICU
36 Mention Tele-ICU but not the outcomes
0 Mention Tele-ICU and outcomes but not original data
5 Articles not written in English or Portuguese
80 for criteria disagreement
118 Included after analysis by title and abstract
12 Included for data extraction and analysis
106 Excluded after full text analysis
9 without PDF
66 are not the defined type of study
30 do not measure the required outcomes
1 does not have 20 parameters in STROBE evaluation
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology
4.4. Data extraction
Methods

Randomized intervention
Intervention

Remote monitoring control
- How is it controlled?
Participants
Outcomes
Clinical and economic outcomes:

Number of patients in ICU’s

General characteristics:
- Mortality rate;

Age
- Length of stay;

Gender
- Costs for the hospital;

Race/Ethnicity
- Staff acceptance;

Health status
- Effectiveness;

- Workload of human resources.
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4. Methodology
4.5. Data Analysis
Meta-analysis
Population
Intervention
Descriptive analysis
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
Outcomes
4. Methodology
4.6. Quality Assessment
 Use of the STROBE to evaluate the quality of the articles
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
5. Results
Type of
Article
STROBE
Type of Study
Intervention
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
survey
Tele-ICU
Monitoring on-call
21
Chu-Weininger M, et al [2]
Cross-sectional
survey
Tele-ICU
Monitoring in situ
25
Table 1.1 – Description of the type of intervention, control and type of study of each included article
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
5. Results
Article
Type of
Type of Study
STROBE
Intervention
Control
Tang Z, et al [28]
Time-and-motion
study
Tele-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-andafter/survey
Tele-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
Table 1.2 – Description of the type of intervention, control and type of study of each included article (continuation)
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
5. Results
Mortality Rate
Graph 1 – Statistic results of the outcome mortality rate.
5. Results
Lenght 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
Costs per day ($)
Article
n=ncontrol+nintervention
Control
Intervention
Breslow M, et al [29] (ALL)
n=1396+744
1648
1411
Breslow M, et al [29] (MICU)
n=631+359
1303
1041
Breslow M, et al [29] (SICU)
n=765+385
1933
1756
n=1913+2057
2851
3653
Franzini L, et al [25]
Table 4 – Comparison of the costs before and after the intervention for each included article.
Article
Vespa P, et al [32]
Costs saving
year($)
1.136.918
Table 5 – Costs saving per year
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
6. Discussion
Mortality Rate
Expected Results
Results
Won’t be affected
Descreased
RR=0,77
Decreased
Length of stay
Will decrease
Mean Difference, CI 95%
-0,50 [-2,23, -1,19]
Costs
There will be a major
initial investment, but
probably profitable in
long-term
A Meta-analysis of the Clinical impact of telemedicine in intensive care units
4 contraditory studies
7. Conclusion
The implementation of
significantly,
and
compared with
reduces,
when
.
So, we believe that the implementation of
Telemedicine have a good impact in intensive care
units.
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 timeand-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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