1Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242

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AbstrActbackground The use of telehealth steadily increases as it has become a viable modality to patient care. Early adopters attempt to use telehealth to deliver high-quality care. Patient satisfaction is a key indicator of how well the telemedicine modality met patient expectations.Objective The objective of this systematic review and narrative analysis is to explore the association of telehealth and patient satisfaction in regards to effectiveness and efficiency.Methods Boolean expressions between keywords created a complex search string. Variations of this string were used in Cumulative Index of Nursing and Allied Health Literature and MEDLINE.results 2193 articles were filtered and assessed for suitability (n=44). Factors relating to effectiveness and efficiency were identified using consensus. The factors listed most often were improved outcomes (20%), preferred modality (10%), ease of use (9%), low cost 8%), improved communication (8%) and decreased travel time (7%), which in total accounted for 61% of occurrences.conclusion This review identified a variety of factors of association between telehealth and patient satisfaction. Knowledge of these factors could help implementers to match interventions as solutions to specific problems.

IntrOductIOnRationaleThe mental image of medical house calls is one of archaic practices in small towns and otherwise rural communities, or something associated with concierge medicine. However, telehealth brings the doctor back into the patient’s home. Healthcare has begun tran-sitioning to more technological-delivered services, making it possible to receive health-care services from the comfort of one’s home, without driving to the clinic, or frustratingly trying to find a parking spot before one’s appointment. This review examines tele-health and any association it might have with patient satisfaction.

This review uses the definition of telehealth from WHO:

The delivery of health care services, where distance is a critical factor, by all health care professionals using

information and communication technologies, for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, in all the interests of advancing the health of individuals and their communities.1

Following WHO’s example, we did not distin-guish between telehealth and telemedicine; instead we used the term telehealth to address both telehealth and telemedicine.1 This broad definition of telehealth encompasses several modes of delivery, such as videoconferencing, mobile applications and secure messaging. WHO recognises several branches of tele-medicine: teleradiology, teledermatology, telepathology and telepsychology.1 With the increased use of technology in healthcare, there has been a great emphasis on telehealth

Telehealth and patient satisfaction: a systematic review and narrative analysis

Clemens Scott Kruse, Nicole Krowski, Blanca Rodriguez, Lan Tran, Jackeline Vela, Matthew Brooks

To cite: Kruse CS, Krowski N, Rodriguez B, et al. Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242

► Prepublication history and additional material for this paper are available online. To view these files please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2017- 016242).

Received 2 February 2017Revised 23 June 2017Accepted 23 June 2017

Texas State University, San Marcos, Texas, USA

correspondence toDr Clemens Scott Kruse; scottkruse@ txstate. edu, scottkruse@ sbcglobal. net

Research

strengths and limitations of this study

► Inserting technology into a medical intervention should not be without deliberate design. This review serves as a voice of the patient to help guard against the implementation of technology merely for its convenience or shiny appeal.

► This study uses the Preferred Reporting Items for Systematic Reviews and Meta Analysis standard, which is an internationally recognised protocol for the conduct and reporting of systematic reviews that increases the validity of the results.

► A group  >30 selected from Medical Subject Headings key terms indexed through established research databases increases the reliability of the review.

► Published studies do not often clearly set out reasons for inserting technology into an intervention, and therefore, it is not clear whether the patient satisfaction observed was congruent with the change of intervention.

► Telehealth, in general, is a relatively new topic in medicine (since the 1990s) so inferences that result from studies are difficult to compare to older, more traditional interventions.

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because it can extend the services of providers to remote locations and capitalise on the availability of subject matter experts and overcome the barrier of proximity. Telehealth extends access, and it has the potential of making healthcare services more convenient for patients, especially those in rural areas, those with small children (child care) and those with mobility restrictions.2 3

Patient satisfaction is a growing concern in all aspects of healthcare, and as the voice of the customer, it is a measure of quality that is published in the USA through its Healthcare Effectiveness Data and Information Set, and it can be tied to reimbursements from the Center for Medi-care and Medicaid through results of Hospital Consumer Assessment of Healthcare Providers and Systems. As with traditional modalities of healthcare delivery, telehealth relies heavily on reports of patient satisfaction because the patients are the only source of information that can report how they were treated and if the treatment received met the patients’ expectations of care.4 5 If the patients are not happy with their healthcare services being provided remotely, the service becomes redundant and expen-sive. With the increase in prevalence of telehealth, it is important to maintain the key quality indicator of patient satisfaction regardless of modality of delivery. The voice of the customer needs to be continuously heard so that telehealth developers can exercise agility in the develop-ment process while the healthcare organisation continues to develop more technology-based care that meets the needs of patients and providers. The technology base inherent to telehealth dramatically changes the mode of delivery, but a strong patient-to-provider relationship must be maintained independent of the modality. A defi-nition of patient satisfaction, effectiveness and efficiency is provided at the end of the article.

ObjectiveWe had multiple research questions. R1: Is there an asso-ciation of telehealth with patient satisfaction? R2: Are there common facilitators of either efficiency or effec-tiveness mentioned in the literature that would provide a positive or negative association between telehealth and patient satisfaction?

MethOdsInformation sources, search and study selectionThe two sources of data were the Cumulative Index of Nursing and Allied Health Literature (CINAHL) via EBSCOhost and PubMed (MEDLINE). We used the Preferred Reporting Items for Systematic Reviews and Meta Analysis as our basis of organisation.6 We used a variety of key search terms, as listed in the Medical Subject Headings combined with Boolean operators. Search terms were adapted for use in the different databases. Details for each database are provided as onlinesupple-mentary file 1.

Inclusion criteria were 2010–2017, English only, full text available and human research. We also filtered for all

but academic publications (peer-reviewed in CINAHL) and in CINAHL we excluded MEDLINE to eliminate the duplicates already captured in PubMed. Instead of including reviews in the analysis, two reviews on a similar topic were earmarked for later comparison with our own results. Abstracts were reviewed for suitability based on our research concept that included both telehealth and some assessment of patient satisfaction.

data collection processA flow chart of our data collection process is located as online.supplementary material. Before reviewing abstracts for suitability to our objective, we agreed to look for articles that included telehealth and some measure of patient satisfaction. Articles were assessed according to the inclusion and exclusion criteria described above. Discussion sessions and consensus meetings were held to increase the inter-rater reliability of the group as they conducted the screening and analysis. During the consensus meetings, factors and themes were identified through observation and discussion; for example, as we discussed the articles, it became evident that patient satisfaction was often stated in terms of effectiveness and efficiency, so these became the themes.

Standard systematic review procedures were followed to control for selection bias and ensure our search was exhaustive.

Reviewers compiled their notes on patient satisfaction, effectiveness and efficiency in a literature matrix. Another consensus meeting was conducted to discuss findings and make inferences. During the consensus meeting, indi-vidual observations were discussed and combined into similar groupings throughout the sample to simplify our assessment of associations. This is a form of narrative analysis and sensemaking.7 Observations of effectiveness and efficiency were combined and sorted into an affinity matrix for final analysis.

data items and summary measuresOur litmus test was to include articles that included a combination of telehealth and patient satisfaction, and a measure or assessment of effectiveness or efficiency. We eliminated those that fell short of those goals.

risk of bias in individual studies and risk of bias across studiesBias was discussed during consensus meetings. The consensus meetings served as a control on our own selec-tion bias and selective reporting within studies.

summary measures and synthesis of resultsOur review examines articles that combine telehealth intervention with patient satisfaction and include some mention of effectiveness or efficiency. A physical count of these observations was made. After all observations were combined into an Excel file, and after all observations were condensed into themes of effectiveness or efficiency, all themes were displayed in an affinity matrix to identify the number of occurrences of each theme. These were sorted by frequency.

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Open Access

Figure 1 Literature search process with inclusion and exclusion criteria. CINAHL, Cumulative Index of Nursing and Allied Health Literature.

resultsStudy selection, study characteristics and results of individual studiesOur search process is illustrated in figure 1.

After the initial search yielded 2193 results, 193 under-went abstract and then full-text review resulting in 44 papers being included in the study.

Table 1 lists a summary of our analysis and observa-tions from our team (n=44). For every article/study in the sample, we made observations for satisfied, which was a screening criteria, and effective and efficient. Studies are listed in order of publication with the most recent at the top. The reference numbers correspond to those in the references section.

synthesis of resultsWe analysed the way 44 articles reported patient satis-faction.8–51 In tota, 248 9 11 13 15–18 21–25 27–29 32 33 35 38 40 44

45 47 studies reported patient views on effectiveness, 610 12 14 30 41 51 studies reported patient satisfaction and

1419 20 26 31 34 36 37 39 42 43 46 48–50 studies reported both. The third column lists comments and details that could point to selection bias. Potential risk of bias among papers included no randomisation,12 small sample size,11 13 18 21 23

25 28 33 35 36 41 48 50 limited population,15 20 27 29 31 45–47 gender bias,19 20 23 38 47 technology bias,18 23 44 50 selection bias,24 32 38 geographically limited,8 9 12 14 16 17 34 37 43 age bias,20 29 30 38 44

51 education bias30 38 and racial bias.44 51

Additional analysisTable 2 outlines the frequency with which different factors were raised among the included paper. Through a narrative analysis we identified commonalities among the various studies (19 factors) and compiled them into an affinity matrix to show frequency of occurrence. The matrix is sorted by frequency of occurrence.

We acknowledge that frequency of occurrence does not equate to importance, but it has been used in other literature reviews as simply an issue of probability.52–54 Five factors were mentioned in the literature 65/119

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Open Access

Tab

le 1

C

omp

ilatio

n of

ob

serv

atio

ns fo

r ou

r sa

mp

le

Dat

eA

utho

rT

itle

Jour

nal

Sum

mar

y/re

leva

nce

Tech

nolo

gy

used

Po

tent

ial b

ias,

sam

ple

siz

e,

mis

cella

neo

us c

om

men

ts

Ap

ril 2

017

Sch

ulz-

Hei

k et

al8

Res

ults

from

a c

linic

al y

oga

pro

gram

 for

vete

rans

via

tel

ehea

lth

pro

vid

es c

omp

arab

le s

atis

fact

ion

and

hea

lth im

pro

vem

ents

to

in-

per

son

yoga

.

BM

C C

omp

lem

ent

Alte

rn M

edC

linic

al y

oga

with

US

Vet

eran

s A

ffairs

p

opul

atio

nV

ideo

conf

eren

cing

VA p

opul

atio

n in

Pal

o A

lto

only

(geo

grap

hica

lly li

mite

d),

acce

pta

ble

sam

ple

siz

e (n

=29

con

trol

, n=

30 in

terv

entio

n)

Janu

ary 

2016

Iqb

al e

t al

9C

ost

effe

ctiv

enes

s of

a n

ovel

at

tem

pt

to r

educ

e re

adm

issi

on

afte

r ile

osto

my

crea

tion

JSLS

Pat

ient

 sat

isfa

ctio

n: s

atis

fact

ion

scor

ed 4

.69

out

of 5

Effe

ctiv

e: h

osp

ital r

ead

mis

sion

rat

es

dec

reas

ed $

63 8

21 (7

1%) (

p=

0.00

2)

Tele

pho

ne c

all (

dai

ly)

for

3 w

eeks

 aft

er

dis

char

ge

Lim

ited

to

one

area

of t

he c

ount

ry

and

ben

efici

arie

s to

Uni

vers

ity

of F

lorid

a he

alth

sys

tem

(g

eogr

aphi

cally

lim

ited

), go

od

sam

ple

siz

e (n

=23

pre

inte

rven

tion,

n=

32 p

ostin

terv

entio

n)

May

 201

6M

ulle

r et

al10

Acc

epta

bili

ty, f

easi

bili

ty, a

nd c

ost

of t

elem

edic

ine

for

nona

cute

he

adac

hes:

a r

and

omiz

ed s

tud

y co

mp

arin

g vi

deo

and

tra

diti

onal

co

nsul

tatio

ns

J M

ed In

tern

et R

esU

sed

tel

ehea

lth t

o d

iagn

ose

and

tre

at n

on-

acut

e he

adac

hes

Sat

isfa

ctio

n: p

atie

nts

satis

fied

with

vid

eo a

nd

soun

d q

ualit

yE

ffici

ent:

med

ian

trav

el d

ista

nce

for

rura

l p

atie

nts

was

7.8

hou

rs, c

ost

€249

, los

t in

com

e €2

34 p

er v

isit

(sav

ed)

Effe

ctiv

e: in

terv

entio

n gr

oup

's c

onsu

ltatio

ns

wer

e sh

orte

r th

an c

ontr

ol g

roup

Vid

eoco

nfer

enci

ngN

on-a

cute

hea

dac

he

pat

ient

s fr

om N

orth

ern

Nor

way

, st

rong

sam

ple

siz

e (n

=20

0),

par

ticip

ants

ran

dom

ised

Ap

ril 2

016

Dia

s et

al11

Voic

e te

lere

hab

ilita

tion

in

Par

kins

on's

dis

ease

Cod

asS

atis

fact

ion:

rep

orte

d a

s hi

gh E

ffect

ive:

pre

fere

nce

for

tele

heal

th in

terv

entio

nV

ideo

conf

eren

ce a

nd

tele

pho

ne85

% m

ale

(gen

der

bia

s),

vid

eoco

nfer

enci

ng m

imic

ked

th

e fa

ce-t

o-fa

ce r

ehab

ilita

tion

for

Par

kins

on’s

pat

ient

s, s

mal

l sa

mp

le s

ize

(n=

20)

Nov

emb

er 2

016

Lang

abee

r et

al12

Tele

heal

th-e

nab

led

em

erge

ncy

med

ical

ser

vice

s p

rogr

am r

educ

es

amb

ulan

ce t

rans

por

t to

urb

an

emer

genc

y d

epar

tmen

ts

Wes

t J

Em

erg

Med

Sat

isfa

ctio

n: n

o d

ecre

ase

Effi

cien

t: 5

6% r

educ

tion

in a

mb

ulan

ce

tran

spor

ts a

nd 5

3% d

ecre

ase

in r

esp

onse

tim

e fo

r th

e in

terv

entio

n gr

oup

tha

n th

e co

ntro

l

Tele

pho

neLi

mite

d t

o p

atie

nts

regi

onal

to

Hou

ston

, Tex

as (g

eogr

aphi

cally

lim

ited

), no

ran

dom

isat

ion,

str

ong

sam

ple

siz

e (n

=55

70)

2016

Hoa

as e

t al

13A

dhe

renc

e an

d fa

ctor

s af

fect

ing

satis

fact

ion

in lo

ng-t

erm

te

lere

hab

ilita

tion

for

pat

ient

s w

ith

chro

nic

obst

ruct

ive

pul

mon

ary

dis

ease

: a m

ixed

met

hod

s st

udy

BM

C M

edic

al

Info

rmat

ics

and

D

ecis

ion

Mak

ing

Sat

isfa

ctio

n: g

ener

ally

hig

hly

satis

fied

Effe

ctiv

e: in

crea

sed

hea

lth b

enefi

ts, s

elf-

effic

acy,

ind

epen

den

ce, e

mot

iona

l saf

ety

and

m

aint

enan

ce o

f mot

ivat

ion

Web

pag

e fo

r d

aily

te

lem

onito

ring

and

sel

f-ca

re a

nd

wee

kly

follo

w-u

p

vid

eoco

nfer

ence

co

nsul

ts w

ith a

p

hysi

othe

rap

ist

Rem

ote

pop

ulat

ion

of n

orth

ern

Nor

way

, sm

all s

amp

le s

ize

(n=

10)

2016

Jaco

bs

et a

l14P

atie

ntsa

tisfa

ctio

n w

ith a

te

lera

dio

logy

ser

vice

in g

ener

al

pra

ctic

e

BM

C F

amily

Pra

ctic

eS

atis

fact

ion:

isla

nd r

esid

ents

, the

eld

erly

and

th

ose

with

no

hist

ory

of t

raum

a w

ere

mor

e sa

tisfie

d w

ith t

he t

echn

ical

and

inte

rper

sona

l as

pec

ts o

f the

tel

econ

sulta

tion

than

non

-re

sid

ents

, you

nger

pat

ient

s an

d t

hose

with

hi

stor

y of

tra

uma

Tele

rad

iolo

gyR

estr

icte

d t

o ru

ral h

ealth

and

N

ethe

rland

s (g

eogr

aphi

cally

lim

ited

), st

rong

sam

ple

(n=

381)

Feb

ruar

y 20

17B

rad

bur

y et

al15

Util

izin

g re

mot

e re

al-t

ime

vid

eoco

nfer

enci

ng t

o ex

pan

d

acce

ss t

o ca

ncer

gen

etic

ser

vice

s in

com

mun

ity p

ract

ices

: A

mul

ticen

ter

feas

ibili

ty s

tud

y

Jour

nal o

f Med

ical

In

tern

et R

esea

rch

Sat

isfa

ctio

n: a

ll p

atie

nts 

rep

orte

d s

atis

fact

ion

and

kno

wle

dge

incr

ease

d s

igni

fican

tlyE

ffect

ive:

gen

eral

anx

iety

and

dep

ress

ion

dec

reas

ed

Vid

eoco

nfer

enci

ngR

estr

icte

d t

o P

hila

del

phi

a,

Pen

nsyl

vani

a (g

eogr

aphi

cally

lim

ited

), go

od s

amp

le s

ize

(n=

41)

Con

tinue

d

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Open Access

Dat

eA

utho

rT

itle

Jour

nal

Sum

mar

y/re

leva

nce

Tech

nolo

gy

used

Po

tent

ial b

ias,

sam

ple

siz

e,

mis

cella

neo

us c

om

men

ts

Janu

ary 

2016

AlA

zab

and

K

had

er16

Tele

nep

hrol

ogy

app

licat

ion

in

rura

l and

rem

ote

area

s of

Jor

dan

: b

enefi

ts a

nd im

pac

t on

qua

lity

of li

fe

Rur

al a

nd R

emot

e H

ealth

Sat

isfa

ctio

n: p

atie

nt s

atis

fact

ion

mea

n=96

.8E

ffect

ive:

mea

n S

F8 s

core

incr

ease

d

sign

ifica

ntly

(phy

sica

l com

pon

ents

of q

ualit

y of

life

)

Ele

ctro

nic

mon

itorin

g an

d t

elep

hone

cal

lsR

ural

hea

lth (g

eogr

aphi

cally

lim

ited

), st

rong

sam

ple

siz

e (n

=64

)

Mar

ch 2

016

Fiel

ds

et a

l17R

emot

e am

bul

ator

y m

anag

emen

t of

vet

eran

s w

ith o

bst

ruct

ive

slee

p

apne

a

Sle

epS

atis

fact

ion:

no

diff

eren

ce in

func

tiona

l ou

tcom

es, p

atie

nt s

atis

fact

ion,

dro

pou

t ra

tes

or

obje

ctiv

ely

mea

sure

d P

AP

ad

here

nce

Effe

ctiv

e: t

elem

edic

ine

par

ticip

ants

sho

wed

gr

eate

r im

pro

vem

ent

in m

enta

l hea

lth s

core

s an

d t

heir

feed

bac

k w

as p

ositi

ve

Tele

mon

itorin

g an

d

tele

pho

ne fo

llow

-up

ca

lls

Res

tric

ted

to

vete

rans

in t

he

Phi

lad

elp

hia

area

(geo

grap

hica

lly

limite

d),

good

sam

ple

siz

e (n

=60

)

Janu

ary 

2016

Geo

rgss

on a

nd

Sta

gger

s18Q

uant

ifyin

g us

abili

ty: a

n ev

alua

tion

of a

dia

bet

es m

Hea

lth s

yste

m

on e

ffect

iven

ess,

effi

cien

cy,

and

sat

isfa

ctio

n m

etric

s w

ith

asso

ciat

ion

user

cha

ract

eris

tics

in

the

US

and

Sw

eden

Jour

nal o

f the

A

mer

ican

Med

ical

In

form

atic

s A

ssoc

iatio

n

Sat

isfa

ctio

n: g

ood

Effe

ctiv

e: g

ood

but

not

exc

elle

nt u

sab

ility

mH

ealth

ap

plic

atio

nYo

unge

r p

atie

nts 

with

mor

e ex

per

ienc

e w

ith in

form

atio

n te

chno

logy

sco

red

hig

her

than

ot

hers

(age

and

tec

hnol

ogy

bia

s),

smal

l sam

ple

siz

e (n

=10

)

Mar

ch 2

016

Pol

insk

i et

al19

Pat

ient

s' s

atis

fact

ion

with

and

p

refe

renc

e fo

r te

lehe

alth

vis

itsJo

urna

l of G

ener

al

Inte

rnal

Med

icin

eS

atis

fact

ion:

33%

 pre

ferr

ed t

eleh

ealth

vis

its t

o tr

aditi

onal

in-p

erso

n vi

sits

; wom

en p

refe

rred

te

lehe

alth

vis

itsE

ffici

ent:

tel

ehea

lth in

crea

sed

acc

ess

to c

are.

La

ck o

f ins

uran

ce in

crea

sed

od

ds

of p

refe

rrin

g te

lehe

alth

Effi

cien

t: o

ther

pos

itive

pre

dic

tors

wer

e q

ualit

y of

car

e re

ceiv

ed, t

eleh

ealth

con

veni

ence

an

d u

nder

stan

din

g of

tel

ehea

lth

Vid

eoco

nfer

enci

ng

at M

inut

e C

linic

s w

ith d

iagn

ostic

too

ls

oper

ated

by

a nu

rse

70%

 wom

en (g

end

er b

ias)

, tes

t w

as c

ond

ucte

d in

Cal

iforn

ia a

nd

Texa

s (c

onve

nien

ce s

amp

le),

stro

ng s

amp

le (n

=17

34)

2015

Levy

et

al20

Effe

cts

of p

hysi

cal t

hera

py

del

iver

y vi

a ho

me

vid

eo

tele

reha

bili

tatio

n on

func

tiona

l an

d h

ealth

-rel

ated

qua

lity

of li

fe

outc

omes

Jour

nal o

f R

ehab

ilita

tion

Res

earc

h an

d

Dev

elop

men

t

Sat

isfie

d: a

ll b

ut o

ne p

artic

ipan

t re

por

ted

sa

tisfie

d o

r hi

ghly

 sat

isfie

dE

ffect

ive:

par

ticip

ants

dem

onst

rate

d s

igni

fican

t im

pro

vem

ent

in m

ost

outc

omes

mea

sure

sE

ffici

ent:

par

ticip

ants

avo

ided

2,7

74.7

=/–

31

97.4

 tra

vel m

iles,

46.

3±53

.3 h

ours

 or

driv

ing

time,

and

$11

51.5

0 ±

$13

26.9

0 in

tra

vel

reim

bur

sem

ent

Vid

eoco

nfer

enci

ngC

onve

nien

ce s

amp

le, 9

2% m

ale

(gen

der

bia

s), 6

9% >

64 y

ears

(age

b

ias)

, US

Vet

eran

s on

ly, s

mal

l sa

mp

le (n

=26

)

2014

Hol

mes

and

C

lark

21Te

chno

logy

-ena

ble

d c

are

serv

ices

: no

vel m

etho

d o

f man

agin

g liv

er

dis

ease

Gas

troi

ntes

tinal

N

ursi

ngS

atis

fied

: hig

h, p

atie

nts 

liked

the

sel

f-m

anag

e as

pec

tE

ffect

ive:

par

ticip

ants

lost

wei

ght,

out

com

es

imp

rove

d, r

ead

mis

sion

s d

ecre

ased

from

12

to 4

E

ffici

ent:

ave

rage

cos

t p

er p

atie

nt 6

8.86

Brit

ish

pou

nds

Rem

ote

mon

itorin

g an

d t

ext

mes

sagi

ngS

mal

l sam

ple

siz

e (n

=12

)

2015

Levy

et

al22

The

Mob

ile In

sulin

Titr

atio

n In

terv

entio

n (M

ITI)

for

insu

lin

glar

gine

titr

atio

n in

an

urb

an,

low

-inc

ome

pop

ulat

ion:

ra

ndom

ized

 con

trol

led

tria

l p

roto

col

JMIR

Res

earc

h P

roto

cols

Hig

hly

satis

fied

: pat

ient

sin

the

inte

rven

tion

grou

p r

epor

ted

hig

her

leve

ls o

f sat

isfa

ctio

nE

ffect

ive:

sig

nific

antly

mor

e in

the

inte

rven

tion

grou

p h

ad r

each

ed t

heir

optim

al in

sulin

leve

ls

Mob

ile In

sulin

Titr

atio

n In

terv

entio

nTr

ue e

xper

imen

t (r

and

omis

ed,

good

sam

plin

g te

chni

que

)

Tab

le 1

C

ontin

ued

Con

tinue

d

on 25 June 2018 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2017-016242 on 3 August 2017. D

ownloaded from

6 Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242

Open Access

Dat

eA

utho

rT

itle

Jour

nal

Sum

mar

y/re

leva

nce

Tech

nolo

gy

used

Po

tent

ial b

ias,

sam

ple

siz

e,

mis

cella

neo

us c

om

men

ts

2015

Moi

n et

al23

Wom

en v

eter

ans’

exp

erie

nce

with

a

web

-bas

ed d

iab

etes

pre

vent

ion

pro

gram

: a q

ualit

ativ

e st

udy

to

info

rm fu

ture

pra

ctic

e

Jour

nal o

f Med

ical

In

tern

et R

esea

rch

Effe

ctiv

e: im

pro

ved

beh

avio

ural

 out

com

es,

mor

e ap

pro

pria

te fo

r w

omen

Sat

isfie

d: p

artic

ipan

ts fe

lt em

pow

ered

and

ac

coun

tab

le, t

hey

felt

it w

as c

onve

nien

t an

d a

go

od fi

t w

ith t

heir

heal

th n

eed

s an

d li

fest

yle

Web

-bas

edW

omen

vet

eran

s, c

omp

uter

lit

erac

y w

as a

n is

sue

for

som

e (g

end

er b

ias)

, sm

all s

amp

le s

ize

(n=

17)

2015

Cot

rell

et a

l24P

atie

nt a

nd p

rofe

ssio

nal u

ser

exp

erie

nces

of s

imp

le t

eleh

ealth

fo

r hy

per

tens

ion,

med

icat

ion

rem

ind

ers

and

sm

okin

g ce

ssat

ion:

a

serv

ice

eval

uatio

n

BM

J O

pen

Sat

isfie

d: p

ositi

ve p

atie

nt s

atis

fact

ion

ind

icat

ors

Effe

ctiv

e: im

pro

vem

ents

wer

e m

ade

over

Fl

oren

ce, a

nd u

sers

too

k an

act

ive

app

roac

h to

ac

hiev

e th

eir

goal

s, p

atie

nts 

felt

emp

ower

ed

Tele

mon

itorin

g an

d

med

icat

ion

rem

ind

ers

Sat

isfa

ctio

n w

ith t

he s

ervi

ce

app

eare

d o

ptim

al w

hen

pat

ient

s w

ere

care

fully

sel

ecte

d

(sel

ectio

n b

ias)

, str

ong

sam

ple

(n

=17

07)

2014

Tab

ak e

t al

25A

tel

ehea

lth p

rogr

am fo

r se

lf-m

anag

emen

t of

CO

PD

ex

acer

bat

ions

and

pro

mot

ion

of a

n ac

tive

lifes

tyle

: a p

ilot

rand

omiz

ed c

ontr

olle

d t

rial

Inte

rnat

iona

l Jou

rnal

of

Chr

onic

Ob

stru

ctiv

e P

ulm

onar

y D

isea

se

Sat

isfie

d: s

atis

fact

ion

was

hig

her

with

the

co

ntro

l gro

up t

han

the

tele

heal

th g

roup

Effe

ctiv

e: b

ette

r cl

inic

al m

easu

res

in t

he

tele

heal

th g

roup

Web

-bas

ed a

nd

smar

tpho

ne

app

licat

ion

with

an

activ

ity c

oach

Str

ong

stud

y d

esig

n, s

mal

l sa

mp

le s

ize

(n=

19)

2014

Kim

et

al26

Cos

ts o

f mul

tidis

cip

linar

y p

aren

tera

l nut

ritio

n ca

re p

rovi

ded

at

a d

ista

nce

via

mob

ile t

able

ts

Jour

nal o

f Par

ente

ral

and

Ent

eral

Nut

ritio

nS

atis

fied

: eas

y to

use

, ver

y co

nven

ient

Effe

ctiv

e: o

utco

mes

sim

ilar

to in

-clin

ic v

isits

Effi

cien

t: c

ost

$916

.64

per

pat

ient

Tele

pho

ne w

ith

sem

istr

uctu

red

in

terv

iew

s

Goo

d s

amp

le s

ize

(n=

20 v

isits

 for

45 p

atie

nts)

2014

Can

cela

et

al27

Wea

rab

ility

ass

essm

ent

of a

w

eara

ble

sys

tem

for

Par

kins

on's

d

isea

se r

emot

e m

onito

ring

bas

ed

on a

bod

y ar

ea n

etw

orko

f sen

sors

Sen

sors

Sat

isfie

d: o

vera

ll sa

tisfa

ctio

n hi

gh, b

ut s

ome

conc

ern

over

pub

lic p

erce

ptio

ns a

bou

t th

e w

eara

ble

sen

sors

Effe

ctiv

e: fo

r re

mot

e m

onito

ring,

wea

rab

le

syst

ems

are

high

ly e

ffect

ive

Rem

ote

mon

itorin

g b

ased

on

a b

ody

area

ne

twor

kof s

enso

rs

An

exte

nsio

n of

the

Bod

y A

rea

Net

wor

k se

nsor

s (li

mite

d

pop

ulat

ion)

, goo

d s

amp

le s

ize

(n=

32)

2014

Cas

ey e

t al

28P

atie

nts'

exp

erie

nces

of u

sing

a

smar

tpho

ne a

pp

licat

ion

to

incr

ease

phy

sica

l act

ivity

: the

S

MA

RT

MO

VE

qua

litat

ive

stud

y in

p

rimar

y ca

re

Br

J G

en P

ract

Sat

isfie

d: g

ood

usa

bili

tyE

ffect

ive:

tra

nsfo

rmed

rel

atio

nshi

ps

with

ex

erci

se

Sm

artp

hone

ap

plic

atio

nS

mal

l sam

ple

siz

e (n

=12

)

Janu

ary 

2014

Tsai

et

al29

Influ

ence

s of

sat

isfa

ctio

n w

ith

tele

care

and

fam

ily t

rust

in o

lder

Ta

iwan

ese

peo

ple

Inte

rnat

iona

l Jou

rnal

of

Env

ironm

enta

l R

esea

rch

and

Pub

lic

Hea

lth

Sat

isfie

d: u

ser

satis

fact

ion

very

hig

h E

ffect

ive:

use

r p

erce

ptio

n of

hig

h q

ualit

yTe

lem

onito

ring,

web

-b

ased

, tel

epho

neFo

cus

was

on

old

er u

sers

and

th

eir

fam

ilies

, con

veni

ence

sa

mp

le, g

ood

siz

e (n

=60

)

2014

Oliv

eira

et

al30

Tele

med

icin

e in

Ale

ntej

oTe

lem

edic

ine

and

e-

Hea

lthS

atis

fied

: pos

itive

imp

act

on p

atie

nt e

xper

ienc

eE

ffici

ent:

ave

rage

tim

e an

d c

ost

of a

tel

e-ap

poi

ntm

ent

is 9

3 m

in fo

r te

leco

nsul

tatio

n an

d

9.31

pou

nds

vers

us 1

90 m

in a

nd 2

5.32

pou

nds

for

a fa

ce-t

o-fa

ce

Tele

pho

neP

artic

ipan

ts a

re o

lder

and

less

ed

ucat

ed t

han

the

rest

of t

he

pop

ulat

ion

of P

ortu

gal (

age

and

ed

ucat

ion

bia

s)

2013

Min

atod

ani e

t al

31H

ome

tele

heal

th: f

acili

tato

rs,

bar

riers

, and

imp

act

of n

urse

su

pp

ort

amon

g hi

gh-r

isk

dia

lysi

s p

atie

nts

Tele

med

icin

e an

d

e-H

ealth

Sat

isfa

ctio

n: p

atie

nts 

rep

orte

d h

igh

leve

ls o

f sa

tisfa

ctio

n w

ith R

CN

sup

por

t b

ecau

se o

f th

e fe

edb

ack

on id

entifi

catio

n of

cha

nges

in

thei

r he

alth

sta

tus,

enh

ance

d a

ccou

ntab

ility

, se

lf-ef

ficac

y an

d m

otiv

atio

n to

mak

e he

alth

b

ehav

iour

chan

ges

Effe

ctiv

e: t

hrou

gh t

eleh

ealth

, gre

ater

sel

f-aw

aren

ess,

sel

f-ef

ficac

y an

d a

ccou

ntab

ility

E

ffici

ent:

feed

bac

k w

as m

ore

effic

ient

Tele

mon

itorin

g w

ith

nurs

e su

pp

ort

Lim

ited

pop

ulat

ion,

goo

d s

amp

le

size

(n=

33)

Tab

le 1

C

ontin

ued

Con

tinue

d

on 25 June 2018 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2017-016242 on 3 August 2017. D

ownloaded from

7Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242

Open Access

Dat

eA

utho

rT

itle

Jour

nal

Sum

mar

y/re

leva

nce

Tech

nolo

gy

used

Po

tent

ial b

ias,

sam

ple

siz

e,

mis

cella

neo

us c

om

men

ts

2013

Akt

er e

t al

32M

odel

ling

the

imp

act

of m

Hea

lth

serv

ice

qua

lity

on s

atis

fact

ion,

co

ntin

uanc

e an

d q

ualit

y of

life

Beh

avio

ur &

In

form

atio

n Te

chno

logy

Sat

isfie

d: s

atis

fact

ion

is r

elat

ed t

o se

rvic

e q

ualit

y, c

ontin

uanc

e in

tent

ions

and

qua

lity

of li

fe

Effe

ctiv

e: m

Hea

lth s

houl

d d

eliv

er h

ighe

r-or

der

, so

ciet

al o

utco

mes

Sm

artp

hone

ap

plic

atio

nS

elec

tion

bia

s

2014

Hun

g et

al33

Pat

ient

 sat

isfa

ctio

n w

ith n

utrit

ion

serv

ices

am

ongs

t ca

ncer

p

atie

nts 

trea

ted

with

aut

olog

ous

stem

cel

l tra

nsp

lant

atio

n:

a co

mp

aris

on o

f usu

al a

nd

exte

nded

car

e

Jour

nal o

f Hum

an

Nut

ritio

n an

d D

iete

tics

Sat

isfie

d: h

ighe

r us

e w

as in

dic

ativ

e of

hig

her

satis

fact

ion

Effe

ctiv

e: h

ighe

r us

e w

as c

linic

ally

imp

orta

nt t

o ou

tcom

es

Tele

pho

neS

mal

l sam

ple

siz

e (n

=18

)

Dec

emb

er 2

015

Bui

s et

al34

Use

of a

tex

t m

essa

ge

pro

gram

 to

rais

e ty

pe

2 d

iab

etes

ris

k aw

aren

ess

and

pro

mot

e he

alth

beh

avio

r ch

ange

(par

t II)

: ass

essm

ent

of p

artic

ipan

ts'

per

cep

tions

on

effic

acy

Jour

nal o

f Med

ical

In

tern

et R

esea

rch

Sat

isfie

d: 6

7.1%

 rep

orte

d v

ery

high

sat

isfa

ctio

nE

ffect

ive:

txt

4hea

lth m

essa

ges

wer

e cl

ear,

incr

ease

d d

isea

se li

tera

cy a

nd m

ore

cons

ciou

s of

die

t an

d e

xerc

ise

Effi

cien

t: lo

w p

artic

ipan

t co

sts

Text

mes

sagi

ngM

ichi

gan

and

Cin

cinn

ati o

nly

(geo

grap

hica

lly li

mite

d),

stro

ng

sam

ple

(n=

159)

2013

Hou

ser

et a

l35Te

lep

hone

follo

w-u

p in

prim

ary

care

: can

inte

ract

ive

voic

e re

spon

seca

lls w

ork

Stu

die

s in

Hea

lth

Tech

nolo

gy a

nd

Info

rmat

ics

Sat

isfie

d: s

tron

g sa

tisfa

ctio

n re

por

ted

for

the

inte

ract

ive

voic

e re

spon

se s

yste

m, I

VR

SE

ffect

ive:

pat

ient

s fe

lt in

form

ed

Tele

pho

neS

mal

l sam

ple

of t

hose

who

re

ceiv

ed t

he c

all I

VR

S, s

mal

l sa

mp

le s

ize

(n=

19)

2013

Kai

ry e

t al

36Th

e p

atie

nt's

per

spec

tive

of

in-h

ome

tele

reha

bili

tatio

n p

hysi

othe

rap

y se

rvic

es fo

llow

ing

tota

l kne

e ar

thro

pla

sty

Inte

rnat

iona

l Jou

rnal

of

Env

ironm

enta

l R

esea

rch

and

Pub

lic

Hea

lth

Sat

isfie

d: f

eelin

g an

ong

oing

sen

se o

f sup

por

t E

ffect

ive:

tai

lore

d c

halle

ngin

g p

rogr

amm

es

usin

g te

lere

hab

ilita

tion

Effi

cien

t: im

pro

ved

acc

ess

to s

ervi

ces

with

re

duc

ed n

eed

for

tran

spor

tatio

n, e

asy

to u

se

Vid

eoco

nfer

enci

ngC

onve

nien

ce s

amp

le, s

ingl

e ca

se,

smal

l sam

ple

siz

e (n

=6)

2013

Bis

hop

et

al37

Ele

ctro

nic

com

mun

icat

ion

imp

rove

s ac

cess

, but

bar

riers

to

its w

ides

pre

ad a

dop

tion

rem

ain

Hea

lth A

ffai

rsS

atis

fied

: eas

ier

acce

ss t

o an

d b

ette

r co

mm

unic

atio

n w

ith p

rovi

der

E

ffect

ive:

pat

ient

s w

ith r

epea

t is

sues

of a

co

nditi

on a

re a

ble

to

rese

t th

e tr

eatm

ent

for

the

mos

t re

cent

ep

isod

e E

ffici

ent:

it t

akes

ab

out

1 m

in p

er e

mai

l, an

d it

im

pro

ves

the

effic

ienc

y of

an

offic

e vi

sit

Em

ail a

nd

vid

eoco

nfer

enci

ngN

ew Y

ork

City

onl

y, s

tron

g re

sist

ance

to

chan

ge c

ited

(g

eogr

aphi

cally

lim

ited

), st

rong

sa

mp

le (n

=63

0)

2013

Pie

tta

et a

l38S

pan

ish-

spea

king

pat

ient

s'

enga

gem

ent

in in

tera

ctiv

e vo

ice

resp

onse

 (IV

R) s

upp

ort

calls

for

chro

nic

dis

ease

sel

f-m

anag

emen

t:

dat

a fr

om t

hree

cou

ntrie

s

Jour

nal o

f Te

lem

edic

ine

and

Te

leca

re

Sat

isfie

d: 8

8% p

atie

nts

rep

orte

d ‘v

ery

satis

fied

’, 11

% ‘m

ostly

sat

isfie

d’

Effe

ctiv

e: 1

00%

pat

ient

s fe

lt th

e in

tera

ctiv

e vo

ice

resp

onse

: IV

R w

ere

help

ful,

77%

 rep

orte

d

imp

rove

d d

iet,

80%

 rep

orte

d im

pro

ved

sy

mp

tom

mon

itorin

g, 8

0% r

epor

ted

imp

rove

d

med

icat

ion

adhe

renc

e

Tele

pho

ne73

% w

omen

, ave

rage

6.1

yea

rs o

f ed

ucat

ion

(age

and

ed

ucat

ion

bia

s), s

tron

g sa

mp

le (n

=26

8)

2013

Gun

d e

t al

39A

ran

dom

ized

 con

trol

led

stu

dy

abou

t th

e us

e of

eH

ealth

in t

he

hom

e he

alth

car

e of

pre

mat

ure

infa

nts

BM

C M

edic

al

Info

rmat

ics

and

D

ecis

ion

Mak

ing

Sat

isfie

d: p

aren

ts fe

lt th

at t

he S

kyp

e ca

lls

wer

e b

ette

r th

an r

egul

ar fo

llow

-up

, and

it o

ften

re

pla

ced

an

in-h

ome

visi

tE

ffect

ive:

sam

e or

bet

ter

outc

omes

bec

ause

the

p

aren

ts d

id n

ot h

ave

to b

ring

infa

nts

inE

ffici

ent:

Nur

ses

took

<10

min

 of w

ork

time

dai

ly t

o an

swer

que

stio

ns

Vid

eoco

nfer

enci

ngR

and

omis

atio

n us

edS

emis

truc

ture

d in

terv

iew

s w

ere

only

use

d fo

r 16

fam

ilies

, sm

all

sam

ple

s (n

=13

, 12,

9)

Tab

le 1

C

ontin

ued

Con

tinue

d

on 25 June 2018 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2017-016242 on 3 August 2017. D

ownloaded from

8 Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242

Open Access

Dat

eA

utho

rT

itle

Jour

nal

Sum

mar

y/re

leva

nce

Tech

nolo

gy

used

Po

tent

ial b

ias,

sam

ple

siz

e,

mis

cella

neo

us c

om

men

ts

2013

ter

Huu

rne

et a

l40W

eb-b

ased

tre

atm

ent

pro

gram

 usi

ng in

tens

ive

ther

apeu

tic c

onta

ct fo

r p

atie

nts 

with

eat

ing

dis

ord

ers:

b

efor

e-af

ter

stud

y

Jour

nal o

f Med

ical

In

tern

et R

esea

rch

Sat

isfie

d: h

igh

satis

fact

ion

Effe

ctiv

e: s

igni

fican

t im

pro

vem

ents

in e

atin

g d

isor

der

psy

chop

atho

logy

, bod

y d

issa

tisfa

ctio

n,

qua

lity

of li

fe, a

nd p

hysi

cal a

nd m

enta

l hea

lth;

bod

y m

ass

ind

ex im

pro

ved

for

obes

ity g

roup

on

ly

Effi

cien

t: t

ask

com

ple

tion

rate

was

80%

 for

the 

youn

ger

grou

p a

nd 6

4.6%

 for

the 

old

er

grou

p

Web

-bas

edN

ot a

ll p

artic

ipan

ts r

epor

ted

the

sa

me

dia

gnos

es, s

tron

g p

re–p

ost

des

ign,

str

ong

sam

ple

(n=

89)

2012

Chu

n an

d

Pat

ters

on41

A u

sab

ility

gap

bet

wee

n ol

der

ad

ults

and

you

nger

ad

ults

on

inte

rfac

e d

esig

n of

an

Inte

rnet

-b

ased

tel

emed

icin

e sy

stem

Wor

kS

atis

fied

: on

a se

ven-

poi

nt s

cale

, sat

isfa

ctio

n sc

ores

wer

e 3.

41 y

oung

er a

nd 3

.54

old

er,

alth

ough

the

re w

as e

qua

l dis

satis

fact

ion

with

th

e d

esig

n of

the

sys

tem

Web

-bas

edS

mal

l sam

ple

siz

e (n

=16

)

2012

Lee

et a

l42Th

e V

ISY

TER

Tel

ereh

abili

tatio

n sy

stem

for

glob

aliz

ing 

phy

sica

l th

erap

y co

nsul

tatio

n: is

sues

an

d c

halle

nges

for

tele

heal

th

imp

lem

enta

tion

Jour

nal o

f Phy

sica

l Th

erap

y E

duc

atio

nS

atis

fied

: rep

orte

d a

s hi

gh a

nd v

ery

high

Effe

ctiv

e: in

crea

ses

acce

ss w

here

pro

xim

ity is

an

issu

eE

ffici

ent:

link

s m

ultip

le p

rovi

der

s to

geth

er fo

r te

leco

nsul

tatio

n

Vid

eoco

nfer

enci

ngLi

mite

d s

cop

e fo

r co

nclu

sion

s,

pat

ient

s in

Mex

ico,

pro

vid

ers

in t

he U

SA

(cul

tura

l bia

s), s

mal

l sa

mp

le (n

=3)

2012

Sai

fu e

t al

43E

valu

atio

n of

hum

an

imm

unod

efici

ency

viru

s an

d

hep

atiti

s C

tel

emed

icin

e cl

inic

s

The

Am

eric

an J

ourn

al

of M

anag

ed C

are

Sat

isfie

d: 9

5% r

epor

ted

hig

hest

leve

l of

satis

fact

ion

Effe

ctiv

e: 9

5% r

epor

ted

a p

refe

renc

e fo

r te

lem

edic

ine

vers

us in

-per

son

visi

t E

ffici

ent:

rep

orte

d a

sig

nific

ant

red

uctio

n in

hea

lth v

isit-

rela

ted

tim

e, m

ostly

due

to

dec

reas

ed t

rave

l

Vid

eoco

nfer

enci

ngVe

tera

ns in

Los

Ang

eles

, C

alifo

rnia

, onl

y, c

onve

nien

ce

sam

ple

(geo

grap

hica

lly li

mite

d),

stro

ng s

amp

le (n

=43

)

2012

Lua

and

 Nen

i44Fe

asib

ility

and

acc

epta

bili

ty o

f m

obile

ep

ilep

sy e

duc

atio

nal

syst

em (M

EE

S) f

or p

eop

le w

ith

epile

psy

in M

alay

sia

Tele

med

icin

e an

d

e-H

ealth

Sat

isfie

d: 7

4% r

epor

ted

ver

y or

qui

te u

sefu

l E

ffect

ive:

exc

elle

nt m

odal

ity fo

r ed

ucat

ion,

d

rug-

taki

ng r

emin

der

and

clin

ic a

pp

oint

men

t re

min

der

Text

mes

sagi

ngG

ood

mix

of g

end

ers,

hom

o-et

hnic

sam

ple

: 92.

2% M

alay

(r

acia

l bia

s), m

edia

n ag

e 25

(age

an

d t

echn

olog

y b

ias—

you

nger

m

ay a

lread

y b

e m

ore

rece

ptiv

e to

tec

hnol

ogy)

, goo

d s

ize

sam

ple

(n

=51

)

2012

Fink

elst

ein

et a

l45D

evel

opm

ent

of a

rem

ote

mon

itorin

g sa

tisfa

ctio

n su

rvey

and

its

use

in a

clin

ical

tria

l with

lung

tr

ansp

lant

rec

ipie

nts

Jour

nal o

f Te

lem

edic

ine

and

Te

leca

re

Sat

isfie

d: 9

0% o

f the

sub

ject

s w

ere

satis

fied

w

ith t

he h

ome

heal

th t

eleh

ealth

ser

vice

Effe

ctiv

e: fr

eque

ncy

of c

omm

unic

atio

n in

crea

sed

Rem

ote

mon

itorin

gLi

mite

d p

opul

atio

n

2011

Gib

son

et a

l46C

onve

rsat

ions

on

tele

men

tal

heal

th: l

iste

ning

to

rem

ote

and

ru

ral F

irst

Nat

ions

com

mun

ities

Rur

al a

nd R

emot

e H

ealth

Sat

isfie

d: 4

7% p

ositi

ve r

esp

onse

, 21%

 neu

tral

, 32

% n

egat

ive

Effe

ctiv

e: in

crea

sed

com

fort

in t

he t

hera

peu

tic

situ

atio

n, in

crea

sed

use

fuln

ess

Effi

cien

t: in

crea

sed

acc

ess

to s

ervi

ces

Vid

eoco

nfer

enci

ngFi

rst-

natio

ns c

omm

uniti

es o

nly

(lim

ited

pop

ulat

ion)

, str

ong

sam

ple

(n=

59)

Tab

le 1

C

ontin

ued

Con

tinue

d

on 25 June 2018 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2017-016242 on 3 August 2017. D

ownloaded from

9Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242

Open Access

Dat

eA

utho

rT

itle

Jour

nal

Sum

mar

y/re

leva

nce

Tech

nolo

gy

used

Po

tent

ial b

ias,

sam

ple

siz

e,

mis

cella

neo

us c

om

men

ts

2010

Doo

renb

os e

t al

47S

atis

fact

ion

with

tel

ehea

lth fo

r ca

ncer

sup

por

t gr

oup

s in

rur

al

Am

eric

an In

dia

n an

d A

lask

a N

ativ

e co

mm

uniti

es

Clin

ical

Jou

rnal

of

Onc

olog

y N

ursi

ngS

atis

fied

: par

ticip

ants

rep

orte

d h

igh

leve

ls

of s

atis

fact

ion

with

sup

por

t gr

oup

s vi

a vi

deo

conf

eren

ceE

ffect

ive:

res

ults

of t

his

des

crip

tive

stud

y ar

e co

nsis

tent

with

oth

er r

esea

rch

that

sho

ws

the

need

for

sup

por

t gr

oup

s as

par

t of

ove

rall

ther

apy

for

canc

er s

urvi

vors

Voic

e te

leco

nfer

ence

fo

r gr

oup

mee

tings

All

par

ticip

ants

wer

e w

omen

(g

end

er b

ias)

, rur

al c

are

only

, p

artic

ipan

ts w

ere

mem

ber

s of

A

mer

ican

Ind

ian

or A

lask

an

Nat

ive

(lim

ited

pop

ulat

ion)

, str

ong

sam

ple

siz

e (n

=90

0)

2010

Bre

en e

t al

48Fo

rmat

ive

eval

uatio

n of

a

tele

med

icin

e m

odel

for

del

iver

ing

clin

ical

neu

rop

hysi

olog

y se

rvic

es

par

t II:

the

ref

errin

g cl

inic

ian

and

p

atie

nt p

ersp

ectiv

e

BM

C M

edic

al

Info

rmat

ics

and

D

ecis

ion

Mak

ing

Sat

isfie

d: t

elen

euro

phy

siol

ogy

imp

rove

d

satis

fact

ion

with

wai

ting

times

, ava

ilab

ility

of

resu

lts a

nd im

pac

t on

pat

ient

 man

agem

ent

Effe

ctiv

e: t

elep

hysi

olog

y an

d c

ontr

ol g

roup

s w

ere

equa

lly a

s an

xiou

s ab

out

thei

r p

roce

dur

e,

tele

phy

siol

ogy

can

imp

rove

acc

ess

to C

N

serv

ices

and

exp

ert

opin

ion

Effi

cien

t: r

educ

ed t

rave

l bur

den

and

nee

d fo

r ov

erni

ght

jour

neys

Tele

neur

ophy

siol

ogy

whi

ch in

clud

ed a

n E

EG

Rem

ote-

rura

l pop

ulat

ion

of

Nor

ther

n Ire

land

, sm

all s

amp

le o

f p

hysi

cian

s (n

=9

phy

sici

ans,

116

p

atie

nts)

2010

Eve

rett

and

  Ker

r49Te

lehe

alth

as

adju

nctiv

e th

erap

y in

insu

lin p

ump

tre

ated

pat

ient

s: a

p

ilot

stud

y

Pra

ctic

al D

iab

etes

In

tern

atio

nal

Sat

isfie

d: p

atie

nts 

rep

orte

d m

ore

und

erst

and

ing,

insi

ght

and

con

trol

by

view

ing

dat

a an

d e

asy

acce

ss t

o he

alth

pro

fess

iona

lE

ffect

ive:

inte

rven

tion

grou

p d

emon

stra

ted

im

pro

ved

dia

bet

es c

ontr

olE

ffici

ent:

hea

lth p

rofe

ssio

nal t

ime

was

<

10 m

in e

ach

day

to

revi

ew d

ata

and

was

in

corp

orat

ed in

to c

urre

nt w

orkl

oad

Tele

mon

itorin

g an

d

text

mes

sagi

ngE

ach

user

’s h

ome

was

vis

ited

to

set

up

and

dem

onst

rate

the

sy

stem

(goo

d c

ontr

ol fo

r va

lidity

), sm

all s

amp

le (n

=16

)

2010

Gar

dne

r-B

onne

au50

Rem

ote

pat

ient

 mon

itorin

g: a

hu

man

fact

ors

asse

ssm

ent

Hum

an F

acto

rs

Hor

izon

sS

atis

fied

: the

inte

rven

tion

dev

ice

was

intu

itive

to

use

Effe

ctiv

e: t

eleh

ealth

gro

up s

how

ed c

linic

al

imp

rove

men

tsE

ffici

ent:

eco

nom

ic a

naly

sis

show

ed s

avin

gs

in t

he C

OP

D t

elem

onito

ring

grou

p, s

oftw

are

issu

es c

ause

d m

any

inte

rven

tions

by

med

ical

st

aff w

hich

con

sum

ed t

ime

Rem

ote

mon

itorin

gM

edic

al li

tera

cy b

ecam

e an

issu

e w

hen

the

dev

ice

aske

d p

atie

nts 

if th

eir

read

ings

wer

e no

rmal

, sm

all s

amp

le s

ize

(n=

27 c

ontr

ol,

n=19

inte

rven

tion)

2010

She

in e

t al

51P

atie

nt s

atis

fact

ion

with

Te

lere

hab

ilita

tion

asse

ssm

ents

for

whe

eled

mob

ility

and

sea

ting

Ass

istiv

e Te

chno

logy

Sat

isfie

d: h

ighe

r sa

tisfa

ctio

n w

ith

tele

reha

bili

tatio

n E

ffici

ent:

gre

at t

ime

savi

ngs

in t

rave

l

Vid

eoco

nfer

enci

ng89

.6%

 Cau

casi

an, a

vera

ge a

ge

was

55,

(rac

ial a

nd a

ge b

ias)

, go

od s

amp

le (n

=32

)

CN

, Clin

ical

Neu

rop

hysi

olog

y; C

OP

D, C

hron

ic O

bst

ruct

ive

Pul

mon

ary

Dis

ease

; IV

RS

, Int

erac

tive

Voic

e R

esp

onse

Sys

tem

; PA

P, P

ositi

ve A

irway

s P

ress

ure;

 RC

N, R

emot

e C

are

Nur

se; V

A, V

eter

ans

Affa

irs.

Tab

le 1

C

ontin

ued

on 25 June 2018 by guest. Protected by copyright.

http://bmjopen.bm

j.com/

BM

J Open: first published as 10.1136/bm

jopen-2017-016242 on 3 August 2017. D

ownloaded from

10 Kruse CS, et al. BMJ Open 2017;7:e016242. doi:10.1136/bmjopen-2017-016242

Open Access

Table 2 Affinity matrix

Factor Article reference number Frequency

Improved outcomes 8 9 11 13 15–18 20–26 31–33 38–41 47 50 24

Preferred modality 8 9 11 14 15 19 22 26 34 43 44 46 12

Ease of use 18 19 23 26 28 36–38 46 49 50 11

Low cost or cost savings 10 14 16 20 21 23 26 34 50 9

Improved communication 24 27 31 36 37 39 42 45 49 9

Travel time 10 12 20 30 36 43 48 51 8

Improved self-management 13 21 23 28 31 32 48 7

Quality 16 19 29 32 40 5

Increased access 19 42 46 48 4

Increased self-awareness 31 34 35 38 4

Decreased wait times 16 43 48 49 4

Fewer miles driven 10 14 20 51 4

Decreased in-person visits 12 39 43 3

Improved self-efficacy 13 23 31 3

Good modality for education 15 34 44 3

Low time to manage 37 39 49 3

Improved medication adherence 13 38 44 3

Decreased readmissions 9 21 2

Fewer missed appointments 44 1

119

occurrences (55%): improved outcomes,8 9 11 13 15–18 20–26 31–33

38–41 47 50preferred modality,8 9 11 14 15 19 22 26 34 43 44 46 ease of use,18

19 23 26 28 36–38 46 49 50low cost or cost savings,10 14 16 20 21 23 26 34 50 and improved communication.24 27 31 36 37 39 42 45 49

dIscussIOnSummary of evidenceTelehealth has the potential to extend the boundaries of providers’ practices by overcoming the barrier of prox-imity. Along with the introduction of a new modality of care comes change, and the literature mentioned various reactions to this change. One study identified heavy resis-tance to change,29 37 while others mentioned an embrace of the change.29 48 Older patients, in general, do not embrace change, but recent studies have identified a generational acceptance of technology and mHealth in general.55

Our findings from this systematic review and narrative analysis identify some issues that are salient in the liter-ature. To help overcome provider resistance to change to telehealth, it should be noted that over the last 7 years 20% of the factors of effectiveness in the litera-ture were improved outcomes. Providers and patients should embrace telehealth modalities because of its ease of use,18 19 23 26 28 36–38 46 49 50 its tendency to improve outcomes8 9 11 13 15–18 20–26 31–33 38–41 47 50 and communica-tion,24 27 31 36 37 39 42 45 49 and its low cost.10 14 16 20 21 23 26 34 50 It can decrease travel time10 12 20 30 36 43 48 51 and increase

communication with providers. Telehealth can provide a high-quality service, increase access to care,19 42 46 48 increase self-awareness31 34 35 38 and item powers patients to manage their chronic conditions.13 21 23 28 31 32 48 Health-care organisations should embrace telehealth because it decreases missed appointments,44 is a good modality for education,15 34 44 decreases wait times,16 43 48 49 decreases readmissions9 21 and improves medication adher-ence.13 38 44 But most importantly, policymakers need to help legislation catch up with the technology by enabling additional means of reimbursement for telehealth because the modality improves outcomes,8 9 11 13 15–18 20–26

31–33 38–41 47 50 which improves public health.

comparisonThe results of our review and narrative analysis are consis-tent with other reviews. Health outcomes have been identified as a factor of effectiveness in chronically ill patients in multiple studies.56 Improvements have been identified for both physical and behavioural conditions. The review by de Jong et al, did not identify a significant decrease in use.56 This review also focused on interven-tions that used asynchronous communication, like email and text messages, with an older population. Our study included both asynchronous and synchronous interven-tions with all ages.

We were able to locate a study from 2011 that also evaluated telehealth and patient satisfaction.57 The researchers used secondary data analysis as the basis

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for their study. Their study focused on patient satis-faction and home telehealth in US Veterans. Similar to the de Jong review, this study focused on an older population ranging from 55 to 87, while our analysis included younger age groups. Its focus on US Veterans while ours included this group as only part of our popu-lation. Our approach can equate to a greater external validity to our analysis. The Young et al review found that its participants were extremely satisfied with the care coordination/home telehealth programme. The US Veterans in this review embraced the new modality. The researchers found a decrease in use associated with the telehealth modality.limitationsWe identified several limitations in the conduct of our literature review and narrative analysis. Selection bias is possible within this study; however, our group consensus methods will have mitigated against this risk. Publi-cation bias is another risk, particularly as we did not extend our search to the grey literature. Limiting our search to only two databases could easily have omitted valid articles for our review. We controlled for inter-rater reliability through the initial focus study of the topic followed by several consensus meetings held along the iterative process. By continuing to review our findings, we follow the example of other reviews and narrative analyses.52–55

The final limitation that we identified was the young age of the telehealth modality of care. It has existed since the early 1990s, but compared with traditional medicine, it is quite young. Because it is technologically based, we chose to only look at the last five years, which could also limit our findings, but the rapid advancement of a tech-nologically based modality drives a more recent sample to make current observations and conclusions.

cOnclusIOnsOverall, it was found that patient satisfaction can be associated with the modality of telehealth, but factors of effectiveness and efficiency are mixed. We found that patients’ expectations were met when providers delivered healthcare via videoconference or any other telehealth method. Telehealth is a feasible option for providers who want to expand their practices to remote areas without having to relocate or expand their footprint of their prac-tice. As telehealth continues to be developed, special care should be given to incorporate features that enable acceptance and reimbursement of this modality.basic definitionsPatient satisfaction: The U.S. Center for Medicare and Medicaid Services defines this term as the patient’s perspective of care which can be objective and meaningful to create comparisons of hospitals and other healthcare organisations.58

Effective: Successful or achieving the results that you want.59 Usually associated with outcomes.

Efficient: Performing or functi8oning in the best possible manner with the least waste of time and effort; having and using requisite knowledge, skill and industry.60

Acknowledgements The authors acknowledge Texas State University for using their library database for their research.

contributors CK directed the initial research, served as lead author, mediated discussions about the merit of abstracts/articles, integrated the input from all team members and helped refine the figure and tables to provide continuity and flow. NK contributed the initial draft of the introduction and integrated her viewpoints into the methods, discussion and worked with JV on the in-text citations. BR contributed the initial draft of the abstract and integrated her viewpoints into the methods, discussion (benefits). LT created the initial draft of figure 1 (literature review process) and the initial draft of benefits and barriers charts. JV integrated her viewpoints into the methods, the initial draft of the discussion (barriers) section and worked with NK on the in-text citations. MB served as an expert in research in U.S. Veterans due to his research in this area, and he contributed meaningful contribution to the formation of analysis and conclusion.

competing interests None declared

Provenance and peer review Not commissioned; externally peer reviewed.

data sharing statement All data are freely available.

Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

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