Rapid Response reports are organized so that the evidence for each research question is presented separately.
Quantity of Research Available
A total of 735 citations were identified in the literature search. Following screening of titles and abstracts, 712 citations were excluded and 23 potentially relevant reports from the electronic search were retrieved for full-text review. Three potentially relevant publications were retrieved from the grey literature search. Of these potentially relevant articles, twenty-four publications were excluded for various reasons, while two publications met the inclusion criteria and were included in this report. Appendix 1 describes the PRISMA flowchart of the study selection.
Additional references of potential interest are provided in Appendix 5.
Summary of Study Characteristics
Study characteristics are tabulated in Appendix 2.
Study Design
One 2010 HTA was retrieved,8 as well as a more recent Evidence in Context summary based on it.5 Since the HTA described the findings in greater detail, it was preferentially included. One 2014 RCT was found that compared teleconsultation in conjunction with remote echocardiograph for patients with suspected heart failure, with referral to the nearest specialty centre.9
No relevant economic evaluations or evidence-based guidelines were found.
Country of Origin
The HTA was conducted in Canada and included studies in adult cardiovascular diseases from Canada, Italy and Sweden.8 The RCT was conducted in Sweden.9
Patient Population
The HTA included adult and pediatric patients with any cardiovascular condition requiring consultation but without immediate access to a local cardiologist. Two clinical studies and four economic studies involved the pediatric population, and two clinical studies and one economic study involved the adult population, the subject of this review.8
The RCT included 38 patients with suspected congestive heart failure from a single centre. Their mean age was 69.6 years, and 61% were female.9
Interventions and Comparators
The HTA reviewed studies in which telecardiology consultation, with or without an associated diagnostic procedure, was compared with standard care.8
The RCT compared remote echocardiography followed by videoconsultation with a remote cardiologist with standard of care, which involved referral for echocardiography and cardiologist consultation.9
Outcomes
Clinical outcomes reported in the HTA included accuracy of interpretation of remote auscultation and appropriateness of prescribed treatment. Economic outcomes were cost savings to the healthcare system and society.8
The RCT measured time to diagnosis (i.e., time from initial patient visit to the time the specialist’s report was signed off) and patient satisfaction.9
Summary of Critical Appraisal
Details of critical appraisal are tabulated in Appendix 3.
The HTA8 was a rapid review, including a comprehensive search and the study selection limited to English-language studies of the previous 5 years. The quality of studies was appraised and found to be generally low. The studies were summarized narratively as they were heterogeneous in design, patient population, and intervention. Given the quality and quantity of studies, the interpretation of findings was appropriate.
The RCT9 had well-defined timepoints for determining the endpoint of time to diagnosis, thereby minimizing measurement bias. One patient declined to be randomized to the standard pathway of care, involving referral, and was excluded from the analysis, but the others were followed the endpoint of time of diagnosis. The randomization method and method of allocation concealment were not described. The blinding of patients and physicians to the assigned pathway of care was not possible, a potentially important source of bias through preferential treatment of one group or the other. The groups were not equivalent at baseline. For example, the teleconsultation group included more women and more patients with symptoms of fatigue (68% versus 5%) and edema (58% versus 16%). More severe symptomatology may have prompted expedited healthcare for these patients, biasing the difference in favour of teleconsultation. Conversely, teleconsultation only occurred on a biweekly schedule, which might have introduced an offsetting delay. The sample size was 38 patients, but the effect size was large (median 27 days versus 114 days).
Summary of Findings
Study findings are tabulated in Appendix 4.
1. What is the clinical effectiveness of telehealth for the assessment and follow-up of patients requiring cardiac care?
One non-blinded RCT (n=38)9 measured the effectiveness of remote echocardiography examination followed by cardiologist teleconsultation in time to diagnosis in patients with suspected heart failure, compared with referral to the nearest specialist centre site after the initial visit. Time to diagnosis was measured from the date of the initial patient visit to the date the specialist’s report was signed off.
For teleconsultation, the median was 27 days (minimum of 1 day, maximum of 169 days) compared with standard care (referral after initial visit) of 114 days (minimum 7 days, maximum 212 days; P<0.001). Most of this difference was due to the difference in times between randomization to echocardiography (median 12 days versus 86 days). Patient satisfaction was reported as good, but the method of measurement was not specified. The study did not report harms.9
The HTA identified two studies in adults.8 One (2008) was a feasibility study of the use of multidisciplinary teleconferencing in cardiovascular risk reduction for patients in rural Saskatchewan, involving nine patients in the telehealth intervention and 15 retrospective controls who had attended a cardiovascular risk reduction clinic outside the community. Both groups had a 2% reduction in the Framingham risk score, and the telehealth patients considered the videoconsultations a positive experience.8
The second study (2007) assessed the feasibility and accuracy of auscultation of heart and lung sounds by a remote cardiologist compared with in-person examination in 50 patients with heart failure. The findings for remote and in-person examinations agreed in 92% of patients, while remote lung sounds were incorrectly interpreted in 3 patients, with implications for treatment. The errors involved the first few patients examined, so accuracy seemed to improve with training and experience.8
2. What is the cost-effectiveness of telehealth for the assessment and follow-up of patients requiring cardiac care?
One economic study was included in the 2010 HTA,8 a cost-minimization modeling study within the Swedish healthcare context. The findings suggested an increased cost to the healthcare system from teleconsultation, associated with purchase and maintenance of equipment, but a cost-savings to patients and society.
3. What are the evidence-based guidelines regarding the use of telecardiology for the assessment and follow-up of patients requiring cardiac care?
No evidence-based guidelines were identified concerning the use of telecardiology for the assessment and follow-up of patients requiring cardiac care.
Limitations
The recent literature specifically addressing the use of videoconference consultation with a physician for cardiovascular disease in adults is limited to an unblinded RCT which reported considerable savings in time to diagnosis, and two older feasibility studies included in an HTA, which do not report clinical outcomes. The RCT is not blinded, therefore there was potential for significant bias by preferential tracking of patients in the interventional arm. The economic study identified in the HTA was based in Sweden, so may have limited applicability to the Canadian context. Our selection criteria excluded papers that did not sufficiently describe the intervention or identify indications, which has been identified as a deficit of literature in the related monitoring literature.10
