ABSTRACT
As both the largest integrated health system and largest provider of telehealth in the country, the Veterans Health Administration (VHA) has a particular interest in understanding how best to implement and utilize virtual care. VHA has long embraced virtual care as part of its mission to "serve all who have served” regardless of their socioeconomic and geographic circumstances. Having begun conducting "virtual care” in the 1960s when doctors first communicated with patient's via TV screens,1 VHA has since provided over 2.6 million episodes of care to more than 900,000 Veterans in 20192 and has distributed over 50,000 data- and video-enabled iPads for Veterans throughout the country.3 Virtual care within VHA includes services such as MyHealtheVet secure messaging, the Home Telehealth program that combines case management principles with remote monitoring to improve access and coordinate care, and the VA Video Connect (VVC) video platform for synchronous visits within both specialty and primary care.4 Increasing Veteran access to care via virtual care has been an integral part of VHA's strategy for improving chronic disease management for a population that is on average older and sicker than their civilian counterparts.5,6 Given the importance that virtual care has for Veteran care even beyond the COVID-19 pandemic, understanding the strengths and limitations associated with synchronous virtual care will be critical in shaping how VHA utilizes virtual care going forward.
ABSTRACT
BACKGROUND: Extensive literature support telehealth as a supplement or adjunct to in-person care for the management of chronic conditions such as congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM). Evidence is needed to support the use of telehealth as an equivalent and equitable replacement for in-person care and to assess potential adverse effects. OBJECTIVE: We conducted a systematic review to address the following question: among adults, what is the effect of synchronous telehealth (real-time response among individuals via phone or phone and video) compared with in-person care (or compared with phone, if synchronous video care) for chronic management of CHF, chronic obstructive pulmonary disease, and T2DM on key disease-specific clinical outcomes and health care use? METHODS: We followed systematic review methodologies and searched two databases (MEDLINE and Embase). We included randomized or quasi-experimental studies that evaluated the effect of synchronously delivered telehealth for relevant chronic conditions that occurred over ≥2 encounters and in which some or all in-person care was supplanted by care delivered via phone or video. We assessed the bias using the Cochrane Effective Practice and Organization of Care risk of bias (ROB) tool and the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We described the findings narratively and did not conduct meta-analysis owing to the small number of studies and the conceptual heterogeneity of the identified interventions. RESULTS: We identified 8662 studies, and 129 (1.49%) were reviewed at the full-text stage. In total, 3.9% (5/129) of the articles were retained for data extraction, all of which (5/5, 100%) were randomized controlled trials. The CHF study (1/5, 20%) was found to have high ROB and randomized patients (n=210) to receive quarterly automated asynchronous web-based review and follow-up of telemetry data versus synchronous personal follow-up (in-person vs phone-based) for 1 year. A 3-way comparison across study arms found no significant differences in clinical outcomes. Overall, 80% (4/5) of the studies (n=466) evaluated synchronous care for patients with T2DM (ROB was judged to be low for 2, 50% of studies and high for 2, 50% of studies). In total, 20% (1/5) of the studies were adequately powered to assess the difference in glycosylated hemoglobin level between groups; however, no significant difference was found. Intervention design varied greatly from remote monitoring of blood glucose combined with video versus in-person visits to an endocrinology clinic to a brief, 3-week remote intervention to stabilize uncontrolled diabetes. No articles were identified for chronic obstructive pulmonary disease. CONCLUSIONS: This review found few studies with a variety of designs and interventions that used telehealth as a replacement for in-person care. Future research should consider including observational studies and studies on additional highly prevalent chronic diseases.