Скачать презентацию A Meta-Analysis of the Clinical Impact of Telemedicine Скачать презентацию A Meta-Analysis of the Clinical Impact of Telemedicine

975027d26717965809c8fdbe7a6e59ed.ppt

  • Количество слайдов: 29

A Meta-Analysis of the Clinical Impact of Telemedicine in Intensive Care Units Class 7, A Meta-Analysis of the Clinical Impact of Telemedicine in Intensive Care Units Class 7, 1 st year Introdução à Medicina II Porto, June 2011

Index 1. Background 1. 1. Problem 1. 2. Intervention 1. 3. Outcomes 2. Research 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

1. Background 1. 1. Problem Increasing volume of ICU patients [2] [4] Shortage of 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 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] 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] Mc. Gregor 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 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 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] Mc. Cambridge M et al. . AMA.

Index 1. Background 2. Research Question 3. Aim 4. Methodology 4. 1. Selection criteria 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 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 measurement of at least one of the outcomes that we defined. - Quality assessment – 20 parameters using the STROBE q Language: The use of ICU; - • Type of study: If necessary, also observational studies. more Randomized control trials. or search Other than Portuguese and English for Search in Pub. Med 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”[Me. SH Terms] OR “tele-medicine”[All 4. 2. Query Selection Pubmed INTERVENTION (((“telemedicine”[All Fields] OR “telemedicine”[Me. SH 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 P/I POPULATION (“ICU”[All Fields] OR “ICUs”[All Fields] OR “critical care facility”[All Fields] OR “intensive care OUTCOMES -health”[All Fields] OR “e. Health”[All Fields]) AND “length of stay”[Mesh Terms] OR “length of stay” [All Fields] OR “LOS” OR “patient status”[All unit”[Me. SH Terms] OR “intensive care units”[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 “e. ICU”[All Fields] OR “intensive care telemedicine”) AND Fields] OR “intensivist’s workload” OR ((“hospitals”[Me. SH 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 Isi. Webof. Knowledge Topic=(telemedicine* OR tele-medicine OUTCOMES P/I POPULATION INTERVENTION 4. 2. Query Selection Isi. Webof. Knowledge 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 e. Health) 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 e. ICU 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 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; abstract 5. If the 2 reviewers agree, the article is included/excluded. If not, a 3 rd 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 3 rd 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 End. Note 4. 3. Articles’ selection A Meta-analysis of the Clinical impact 4. Methodology End. Note 4. 3. Articles’ selection A Meta-analysis of the Clinical impact of telemedicine in intensive care units

4. Methodology Open. Office 4. 3. Articles’ selection A Meta-analysis of the Clinical impact 4. Methodology Open. Office 4. 3. Articles’ selection A Meta-analysis of the Clinical impact of telemedicine in intensive care units

4. Methodology 1864 Titles identified from literature search 389 from Pubmed 1475 from Isi 4. Methodology 1864 Titles identified from literature search 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 - 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 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 lity Morta tay fs ngth o Le

4. Methodology 4. 6. Quality Assessment § Use of the STROBE to evaluate the 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 Type of Study Intervention Control STROBE Franzini L, et 5. Results Type of Article Type of Study Intervention Control STROBE 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 Study STROBE Intervention Control Tang Z, et al [28] 5. Results Article Type of Study STROBE Intervention Control Tang Z, et al [28] Time-and-motion study Tele-ICU Monitoring in situ 26 Mc. Cambridge 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 Mortality Rate Graph 1 – Statistic results of the outcome mortality rate.

5. Results Lenght of stay Graph 2 – Statistic results of the outcome Length 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 ($) Article n=ncontrol+nintervention Control Intervention Breslow M, et al 5. Results Costs per day ($) 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 Expected Results Mortality Rate Results Won’t be affected Descreased RR=0, 77 Length 6. Discussion Expected Results Mortality Rate Results Won’t be affected Descreased RR=0, 77 Length of stay Will decrease 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 Decreased Mean Difference, CI 95% -0, 50 [-2, 23, -1, 19] 4 contraditory studies

7. Conclusion The implementation of telemedicine reduces, significantly, mortality rate and length of stay 7. Conclusion The implementation of telemedicine reduces, significantly, mortality rate and length of stay when compared with monitoring in situ. 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, Mc. Gregor C, Real-time Service-Oriented Architectures to Support 8. Bibliographic References [1] Eklund M, Mc. Gregor 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): R 5. [6] Jarrah S, Van der Kloot T, Tele-ICU: Remote Critical Care Telemedicine. American College of Chest – Physicians. 2010. [7] Mc. Gregor 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] Mc. Cambridge 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 [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 (Rev. Man) [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/quant. Desc. Central. 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/qual. What. 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 Health. System 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©, Harper. Collins 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. e 1 -329. e 6. [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 [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 The End