Systematic Reviews (5)

As the cases of diabetes type 2 increase, a systematic review by Dr Rashid Bashur from the E-Health Center, University of Michigan Health System, and his colleagues, published by Liebert, says telemedicine can help. Its findings are “The major contributions point to telemedicine’s potential for changing behaviors important to diabetes control and prevention, especially type 2 and gestational diabetes. Similarly, screening and monitoring for retinopathy can detect symptoms early that may be controlled or treated … Overall, there is strong and consistent evidence of improved glycemic control among persons with type 2 and gestational diabetes as well as effective screening and monitoring of diabetic retinopathy.”

The study reviewed 73 research articles on the outcomes of telehealth use for diabetes control. It analysed different patient populations, technologies, resources and research protocols. Other findings were:

  • Telemedicine for diabetes can be effective for rural patients
  • A 29% increase in adherence to prescribed glycemic tests by patients when nurses called patients to remind them
  • Decreases in A1c levels and cardiovascular risk factors with an electronic disease management system and a home care link to send messages for Type 1 or Type 2 diabetes.

The study provides evidence for African countries to use in assigning priorities to their telemedicine initiatives. It could overlap as good practices for some mHealth projects too.

mHealth is often promoted as a big part of the eHealth contribution for stronger healthcare in Africa. The potential is good, but not all mHealth is good mHealth. While this is obvious for all eHealth, the challenge is to know the difference before it’s implemented. A study in Medscape, Systematic Review on What Works, What Does Not Work and Why of Implementation of Mobile Health (mHealth) Projects in Africa, can help.

It uses SWOT analyses, the widely known strengths, weaknesses, opportunities, and threats, to review 44 peer-reviewed publications on mHealth over the ten years 2003 and 2013. It focused on sustainability, medium and long-term results, integration to health systems, management process, scale-up, replication, legal issues, regulations and standards.

It’s mHealth groups were:

  • 19 for patient follow-up and medication adherence
  • 10 for data collection and transfer and reporting
  • 4 for staff evaluation, monitoring and guidelines compliance
  • 4 for disease surveillance and intervention monitoring
  • 2 for staff training, support and motivation
  • 2 for drug supply-chain and stock management
  • 2 for overview of mHealth projects
  • 1 for patient education and awareness.

A common theme was that mHealth projects succeeded if they had accessibility, acceptance, low technology costs, effective adaptation to local contexts, strong stakeholder collaboration, and government involvement.

There were several significant threats. Funding dependency, unclear healthcare system responsibilities, unreliable infrastructure and lack of evidence on cost-effectiveness are challenges to successful implementation.

The main features of an effective mHealth project in Africa are seen as:

  • Good project design adapted to local contexts, promotion, education and awareness of the project
  • Technology and resources that use local resources, capacity building, availability and maintenance
  • Stakeholder involvement across public-private partnerships, multidisciplinary teams, ministries of health, political leaders and local champions
  • Government eHealth and mHealth departments engaged in programme monitoring, evaluation and research.

A conclusion is that mHealth projects are not a solution to the challenges that health systems face in many African countries. Evidence remains poor, and results are still specific and constrained to projects or setting. Questions regarding impact, scalability and increased coverage remain, such as transferability to different diseases, different settings and different target populations. Questions over cost-effectiveness and sustainability of projects in Africa still remain. While mobile phone technology continues to improve, more research on these areas is essential to understand mHealth’s potential and help to reach the hard isolated and marginalised communities.

The study provides a strong and constructive challenge to all mHealth decision takers in Africa. Responding to it isn’t too difficult.

The literature review Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use Functionalities is extremely valuable. It’s the antithesis of Earl Landgrebe’s daft remark at the Watergate hearings: “Don’t confuse me with the facts.” The review of 278 studies from 2011 up to 2013 was prepared for the USA’s Office of the National Coordinator for Health Information Technology (ONC) and completed by the Southern California Evidence-based Practice Center of the RAND Corporation. Whilst its focus was the USA meaningful use definition, the findings are widely applicable to eHealth in other countries.

The study reviewed three themes. They were the effect of eHealth on healthcare’s:

  • Efficiency
  • Quality
  • Safety.

Safety is an essential part of quality, but the review treats it separately.

A most striking finding is that “Functionalities included in the Meaningful Use regulation, can improve healthcare quality and safety. The relationship between health IT and efficiency is complex and remains poorly documented or understood, particularly in terms of healthcare costs, which are highly dependent upon the care delivery and financial context in which the technology is implemented.”

It also points out the essential relationship between ICT and change for benefits realization. It says that of the ninety-two studies on the effect of eHealth on process quality, “The great majority of studies reported positive outcomes for process quality measures, not all studies did so, and most studies lacked sufficient detail to determine which factors may have led to the lack of benefit found in those studies. Our review found that single-site studies typically provided more specificity about the health IT interventions than did multi-site studies. Single-site studies also provided more detail about the context and complementary factors that may enhance the efficacy of the health IT or contribute to the success of the implementation. The small number of studies that seemed to account for contextual and complementary factors tended to show that health IT can have significant positive effects on process quality if the technology is implemented in combination with process changes that leverage the capabilities of the health IT.”  

Another finding that may help dispel an inappropriate view of eHealth as a means of reducing healthcare cost is that “Cost effects ranged from a 75 percent decrease to a 69 percent increase in the targeted costs; however, many of the studies clustered in the range of six percent to 12 percent increases in the targeted costs. These findings suggest that layering technology on the existing payment system may not result in lower costs.”

Assessing these aspects rigorously should be at the core of all decisions on eHealth initiatives.

iHealthBeat has a good summary of the study. The review showed:

  • 77% with positive or mixed-positive outcomes
  • 45% with had overwhelmingly positive outcomes
  • 20% had negative outcomes.

Specifically on patient safety:

  • 67% had positive results
  • 17% had negative results.

Armed with this study, no one can say they’re confused by the facts.

Research published in the Journal of Medical Internet Research claims that many telemonitoring appraisals do not comply with recognized guidelines and standards. Some methodological limitations identified in the study results affect the results and conclusions of some evaluations.

The research team concluded that, “Despite the availability of methodological guidelines that can be utilized to guide the proper conduct of systematic reviews and meta-analyses and eliminate potential risks of bias, this knowledge has not yet been fully integrated in the area of home telemonitoring.

The study found that the number of published reviews has increased substantially over the years, but the focus was mainly on home telemonitoring of patients with congestive heart failure. Other chronic diseases such as diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and asthma have less emphasis.

The study’s findings are that many reviews appear to lack optimal scientific rigor due to methodological issues and their overall quality does not appear to have improved. Evaluations did comply with several criteria satisfactorily, such as establishing an a priori design with inclusion and exclusion criteria, use of electronic searches on multiple databases, and reporting studies characteristics. But, other important areas need improvement, including duplicate data extraction, manual searches of highly relevant journals, inclusion of grey and non-English literature, assessment of the methodological quality of included studies and the quality of evidence.

It seems that progress on evaluations may be slow. Criticisms go back to Whitten’s review on telemedicine evaluations in 2002.

It’s not just that “riding a bicycle is about getting back to basics,” like Phil Keoghan, CBS’s Amazing Race presenter, suggests. Healthcare in Africa needs more important basics in place. Electricity is one of them. It’s now over a year since WHO’s report Limited electricity access in health facilities of sub-Saharan Africa: a systematic review of data on electricity access, sources, and reliability was completed. It was published in Global Health Science and Practice over six months ago. Its survey of eleven countries in sub-Saharan Africa (SSA) found that:

  • Only 34% of hospitals in SSA countries have reliable electricity supplies
  • Energy access varies considerably
  • In two countries, modest improvements in electricity access are underway
  • Ambitious plans to improve health service delivery need to address this critical issue
  • The United Nations Secretary-General’s Sustainable Energy for All (SE4All) initiative provides an opportunity to monitor energy access in healthcare facilities.

Electricity limitations are a “silent barrier” for healthcare. Dealing with it needs several initiatives.

A first step is establishing electricity access profiles of healthcare facilities. This can identify settings where lack of electricity may be a severe and underreported barrier to healthcare. Better data can inform innovations in the health and energy sectors and direct investments in areas with greatest need. This provides foundations for monitoring and managing progress inclosing energy gaps.

Whilst the survey excluded off-grid energy used by some facilities, the gap it identified is still an enormous challenge. Since the report, have health and energy ministries integrated strategies for health, healthcare and eHealth to make the most of expanded electricity supplies? Overcoming the barriers is complex set of tasks that will take several years to complete. Using a bicycle isn’t one of them.