Telemedicina en trastorno alimentario: revisión sistemática / Telemedicine in eating disorders: systematic review

INTRODUCCIÓN Los trastornos de la conducta alimentaria son enfermedades graves definidos por hábitos alimentarios anormales asociados con importantes consecuencias médicas, psiquiátricas y psicosociales. Se considera telemedicina, a la prestación de servicios sanitarios a través de la utilización de tecnologías de la información y la comunicación, cuyo objetivo es proporcionar una mayor cobertura de servicios sanitarios con calidad a la población. Entre sus ventajas encontramos: mejor acceso a la población necesitada, eliminación de desplazamiento y mayor comodidad, en la literatura científica están descritos también los inconvenientes: problemas técnicos o de conexión, calidad de sonido y video, o falta de conocimientos y capacidad de manejo de la tecnología. Últimamente, la crisis mundial ha impulsado la necesidad de considerar los beneficios y las limitaciones de la telemedicina en la prestación y utilización de la atención sanitaria. Los pacientes con trastornos de la conducta alimentaria son uno de los colectivos más afectados, que podrían beneficiarse de esta forma de la prestación de la terapia. OBJETIVO El objetivo principal es evaluar la seguridad, efectividad, así como el análisis de costes de la telemedicina como medio complementario para favorecer la adherencia y para realizar el seguimiento de las terapias presenciales cognitivas en pacientes con trastorno alimentario. MÉTODO Se realizó una búsqueda sistemática de la literatura científica en las siguientes bases de datos referenciales hasta abril de 2022: MEDLINE (Ovid), EMBASE (Embase.com), Science Citation Index expanded (Web of Science ­ WOS), EconLit, EHealth, Cochrane Library, International HTA database (INAHTA), Cinahl (Ebsco) y PsycInfo (Ebsco). Por otro lado, se revisaron las webs de las principales agencias de evaluación de tecnologías sanitarias: CADTH, AHRQ, NICE, HIS, HIQA y las pertenecientes a la Red Española de Agencias de Evaluación de Tecnologías Sanitarias (RedETS). Se incluyeron las revisiones sistemáticas que analizan la seguridad, efectividad, el análisis de costes de la telemedicina como medio complementario de la terapia presencial en pacientes con trastornos alimentarios, y los estudios de evaluación económica. Se llevó a cabo la selección de los estudios y la extracción de los datos relevantes. Se evaluó la calidad de los estudios incluidos mediante la herramienta de evaluación critica de revisiones sistemáticas AMSTAR-2, y la FLC 3.0 de Osteba para la evaluación económica. RESULTADOS Se identificaron y analizaron 5 revisiones sistemáticas que aportan información sobre la efectividad y seguridad de la telemedicina y 3 estudios de evaluación económica. Se identificaron algunas debilidades en el análisis de calidad de los trabajos incluidos siendo en general moderada o baja. En relación a las intervenciones realizadas como tratamiento complementario de la terapia presencial, los estudios incluidos hacían referencia al uso de correo electrónico, aplicaciones para smartphones, vodcast y mensajes de texto SMS. En cuanto a los resultados de seguridad de esta tecnología, no se identificaron reacciones adversas directamente relacionadas con el uso de la telemedicina, salvo la preocupación por la falta de privacidad informática de los usuarios de la terapia mediante el uso de correo electrónico y aplicaciones para smartphone. En cuanto a los resultados de efectividad, en relación al tratamiento de anorexia nerviosa con el uso de vodcast se observó en los estudios revisados un aumento significativo en la cantidad de comida consumida, estado de ánimo, y reducciones significativas en la ansiedad, pensamientos negativos, la angustia y sesgo atencional en la comida. El tratamiento adicional con el correo electrónico de bulimia nerviosa presentó en los estudios revisados, una disminución significativa en el número de atracones y purgas, comidas nocturnas, síntomas de depresión y de disfunción eréctil. La aplicación para smartphone como tratamiento complementario para los pacientes con bulimia nerviosa o trastorno por atracón mejoró significadamente los síntomas de TCAs e incrementó el IMC. Por otro lado, se observaron reducciones significativas en los episodios de atracones y purga. El uso adicional de mensajes de texto (SMS) mejoró significadamente la abstinencia y la tasa de la remisión en los pacientes con bulimia nerviosa o EDNOS, reduciendo significadamente los síntomas de estos trastornos. En el caso de los pacientes con anorexia nerviosa o bulimia nerviosa se han observado reducciones significativas en la restricción dietética y aumento en la disposición al cambio. La evaluación económica está basada en la evidencia procedente de tres estudios que incluyen el mismo estudio de análisis de costes, dicho estudio sugiere que, la provisión de la terapia cognitiva a través de la telemedicina supone un coste menor que el tratamiento presencial. CONCLUSIONES Se ha realizado una revisión de la evidencia disponible sobre telemedicina como medio complementario a la terapia presencial en pacientes con TCAs. Respecto a su eficacia, se han identificado ventajas de la telemedicina como medio complementario de la terapia presencial de TCAs. En concreto, para anorexia nerviosa con el uso de vodcast y mensajes de texto SMS, para bulimia nerviosa con el uso de correo electrónico, para los pacientes con bulimia nerviosa o trastorno por atracón con el uso de la aplicación para smartphone; y para los pacientes con bulimia nerviosa o EDNOS con el uso de mensajes de texto. En lo que se refiere a los resultados de seguridad de la telemedicina, la falta de privacidad informática fue la principal preocupación, sin producir otros eventos adversos. La evaluación económica identificada, sugiere que, la provisión de la terapia cognitiva a través de la telemedicina supone un coste menor que el tratamiento presencial.

INTRODUCTION Eating disorders are serious disorders defined by abnormal eating habits associated with significant medical, psychiatric and psychosocial consequences. Telemedicine is considered as the provision of health services through the use of information and communication technologies, which aims to provide increased coverage of quality health services to the population. Telemedicine is considered to be the provision of health services through the use of information and communication technologies, the aim of which is to provide better coverage of quality health services to the population. Among its advantages are: better access to the population in need, elimination of travel and greater comfort. The scientific literature also describes the disadvantages: technical or connection problems, sound and video quality, or lack of knowledge and ability to use the technology. Recently, the global crisis has prompted the need to consider the benefits and limitations of telemedicine in health care delivery and utilisation. Patients with eating disorders are one of the most affected groups who could benefit from this form of therapy delivery. OBJECTIVE The main objective is to evaluate the safety, effectiveness and cost analysis of telemedicine as a complementary medium to promote adherence and to follow up cognitive face-to-face therapies in patients with an eating disorder undergoing treatment. METHODS A systematic search of scientific literature was carried out in the following reference databases until April 2022: MEDLINE (Ovid), EMBASE (Embase.com), Science Citation Index expanded (Web of Science - WOS), EconLit, EHealth, Cochrane Library, International HTA database (INAHTA), Cinahl (Ebsco) and PsycInfo (Ebsco). In addition, the websites of the main health technology assessment agencies were reviewed: CADTH, AHRQ, NICE, HIS, HIQA and those belonging to the Spanish Network of Health Technology Assessment Agencies (RedETS). Systematic reviews analysing the safety, effectiveness and cost analysis of telemedicine as an adjunct medium to face-to-face therapy in patients with eating disorders were included, as well as economic evaluation studies. Studies were selected, and relevant data were extracted. The quality of the included studies was assessed using the AMSTAR-2 critical appraisal tool for systematic reviews and Osteba's FLC 3.0 for economic evaluation. RESULTS Five systematic reviews providing information on the effectiveness and safety of telemedicine and three economic evaluation studies were identified and analyzed. Some weaknesses were identified in the quality analysis of the included studies and the overall quality was moderate or low. In relation to interventions delivered as a complementary treatment to face-to-face therapy, the included studies referred to the use of email, smartphone apps, vodcast and SMS text messaging. In terms of the safety outcomes of this technology, no direct adverse reactions related to the use of telemedicine were identified, except for concerns about the lack of computer privacy of therapy users through the use of email and smartphone apps. Regarding the results of effectiveness, in relation to the treatment of anorexia nervosa with the use of vodcast, significant increases in the amount of food consumed, mood, and significant reductions in anxiety, negative thoughts, distress and attentional bias to food were observed in the studies reviewed. Additional treatment of bulimia nervosa with email showed significant decreases in binge eating and purging, night eating, symptoms of depression and erectile dysfunction in the studies reviewed. The smartphone app as an adjunct treatment for patients with bulimia nervosa or binge eating disorder significantly improved symptoms of ED and increased BMI. Furthermore, significant reductions in binge eating and purging episodes were observed. Additional use of SMS text messaging significantly improved abstinence and remission rate in patients with bulimia nervosa or EDNOS, significantly reducing symptoms of these disorders. For patients with anorexia nervosa or bulimia nervosa, significant reductions in dietary restraint and increased readiness to change have been observed. The economic evaluation is based on evidence from three studies including the same cost analysis study. In summary, this study suggests that the provision of cognitive therapy via telemedicine is less costly than face-to-face treatment. CONCLUSIONS A review of the available evidence on telemedicine as an adjunct to face to-face therapy in patients with ED. Regarding its efficacy, advantages of telemedicine as a complementary medium to face-to-face therapy for EDCs have been identified. Specifically, for anorexia nervosa with the use of vodcast and SMS text messaging, for bulimia nervosa with the use of email, for patients with bulimia nervosa or binge eating disorder with the use of the smartphone app; and for patients with bulimia nervosa or EDNOS with the use of text messaging. In terms of telemedicine safety outcomes, lack of computer privacy was the main concern, with no other adverse events. The economic evaluation identified suggests that the provision of cognitive therapy via telemedicine is less costly than face-to-face treatment.

Cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme compared with usual care using a CBT manual alone for patients with heart failure: secondary analysis of data from the SEMAPHFOR trial.

OBJECTIVE: To assess the cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme for patients with heart failure compared with usual care including the un-facilitated access to the same manual, from the perspective of the NHS. DESIGN: Data were obtained from a pragmatic, multi-centre, randomized controlled 'open' trial conducted in seven centres in the UK between 2006 and 2008. Effectiveness was estimated as Quality-Adjusted Life Years. Resource use was measured prospectively on all patients using information provided by patients in postal questionnaires, case-note review, electronic record review and interviews with patients. Unit costs were obtained from the literature and applied to the relevant resource use to estimate total costs. Multiple imputation was used to handle missing data. RESULTS: There were no substantial differences in the utility scores between treatment groups in all follow-up assessments, in the use of medication or outpatient visits and both groups report a similar frequency of contact with health care professionals. After controlling for baseline utility and using imputed dataset, treatment was associated with a reduction in QALY of 0.004 and a additional cost of £69.49. The probability that the intervention is cost-effective for thresholds between £20,000 and £30,000 is around 45%. CONCLUSIONS: There is little evidence that the addition of the intervention had any effect on costs or outcomes. The uncertainty around both estimates of cost and effectiveness mean that it is not reasonable to make recommendations based on cost-effectiveness alone.