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Telehealth interventions to improve clinical nursing of elders |
Jones J F, Brennan P F |
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Authors' objectives To examine the impact of telehealth interventions on the clinical nursing of elders.
Searching MEDLINE (from 1966), CINAHL (from 1982), PsycINFO (from 1975), ERIC (from 1966) and ACM (from 1985) were searched to February 2001. Additional studies were sought by examining the work and bibliographies of known investigators, and by examining review articles. The searches were restricted to studies published in English.
Study selection Study designs of evaluations included in the reviewThe authors included only published reports that presented the findings of 'an exploratory or experimental study'; reviews were excluded.
Specific interventions included in the reviewTo be included, the studies had to focus on a nursing intervention using interactive computer or communications technology. Nursing interventions examined in the review included consultation, self-esteem enhancement or mood management, assessment of conditions, wound management and social support.
Participants included in the reviewTo be included, the studies had to target problems commonly observed in persons age 65 years and older. The actual studies included in the review examined elderly people with cardiac problems and depression, as well as wound care and cognitive functioning. The caregivers of patients with Alzheimer's disease were also examined.
Outcomes assessed in the reviewThe authors did not state any specific outcomes. The authors excluded 'research on telehealth applications addressing health care more broadly'. The actual outcomes examined in the review included 'feasibility and reliability' for assessing physical conditions, patient and nurse satisfaction, self-esteem and depression. Strain and decision-making skills were also examined for caregivers.
How were decisions on the relevance of primary studies made?Abstracts and articles were skimmed for relevance. Those that met the inclusion or exclusion criteria were then 'critically' read by three reviewers.
Assessment of study quality The authors described limitations of each study within tables and the text; however, no quality checklist was employed. Two reviewers read and summarised the articles.
Data extraction Two nursing team members read the articles and summarised key aspects into an Access database.
Methods of synthesis How were the studies combined?The authors presented the data as a descriptive synthesis.
How were differences between studies investigated?The authors stated that the studies varied by recruitment method, patient characteristics, study design, timeframe, setting, measurement of effects, and intervention focus. Consequently, the authors described the various studies, and/or projects, separately.
Results of the review Eighteen articles were included in the review. These described eight research projects, examining 362 patients, 102 caregivers and 1,745 clinical records. The study designs of these projects were described as 'retrospective reviews' (2), a 'randomised prospective trial' (1), a 'cross-over design' (1), a 'pair wise comparison' (1), a 'randomised field experience' (1) and interviews (2).
Most of the studies were reported to have methodological limitations. Of the eight projects, only six appeared to report on the effectiveness of an intervention using a health-related outcome. Two projects (retrospective reviews) described the nature of home care services that could be delivered using telehealth applications. In three projects, telehealth applications were compared with face-to-face assessments. One project ('cross-over design') examined patients with congestive heart failure and found few significant differences between the two modes of assessment. In another project ('pair wise comparison'), there were high percentages of agreement rates for describing wound characteristics using interactive video communication, compared with in-person consultation. In another project (structured interview), researchers found that the written parts of cognitive functioning of the elderly could be assessed reliably using fax and videoconferencing.
One project ('randomised field experience') examined the effectiveness of a computer network on the caregivers' (of Alzheimer's patients) perceptions of social support. It also examined the impact of telehealth on their decision-making skills. In this project it was reported that access to computer networks increased decision-making confidence, but not decision-making skills.
Another project (randomised prospective trial) examined the effects of computer networks on self-esteem and depression in the elderly. The interactive computer was associated with a change in self-esteem, but there was no effect on depression.
One project (using a semi-structured phone interview) examined the patients' perceptions, uses and benefits of telehealth, and reported positive outcomes.
Cost information The results of a cost analysis study of telehealth wound management were reported. The average cost of a telehealth wound consultation ($136.16) was less than that of a face-to-face consultation ($246.28).
Authors' conclusions Telehealth interventions have the potential to improve the clinical nursing care of elders because they provide alternative, equivalent approaches to assess key indicators of the physical and psychological state of elders. In addition, they are acceptable to nurses, elders and family caregivers, and may prove less costly than face-to-face interventions.
CRD commentary The inclusion and exclusion criteria were broad, such that all types of studies were included in the review. The intervention was meant to target problems commonly observed in persons aged 65 years or older, but the review also examined caregivers of persons with Alzheimer's disease; this is a different area of research than suggested by the title of the review, or as stated in the objectives. Two studies included in the review do not really evaluate the effectiveness of telehealth applications. While useful, they should only be described within a background section, and not in the tables. There was some effort to search for relevant research literature. However, only published studies and English language studies were included, thus introducing retrieval bias. The authors presented a critical evaluation of the studies, although it would have been beneficial to have used a standard quality checklist (where applicable) to identify other important methodological problems (e.g. was the randomised study really randomised). In some cases the authors criticised some of the studies for being homogeneous. This, however, can be an advantage rather than a limitation, as the intervention can be confidently applied to a certain group of patients.
While there are lengthy tables in the review, more detail (e.g. participants' age, number of individuals in treatment groups) and a clearer description of the results of each study are needed. In addition, the type of study designs have not been clearly defined. Overall, the reader cannot evaluate the data from the original studies and cross-check it with what has been interpreted in the review. The studies were summarised appropriately as a descriptive synthesis, but the data were not always presented clearly. Given the limitations of some of the study designs for adequately assessing the effectiveness of an intervention, and that many were of poor quality (as the authors stated), the conclusions (particularly as summarised in the abstract) should have been much more cautious.
Implications of the review for practice and research Practice: The authors stated that the use of telehealth approaches for clinical assessment, while not ready for wide-scale clinical deployment, shows great promise in assisting nurses.
Research: The authors stated that more studies are needed where the telehealth innovation is examined as a component part of a nursing intervention. Human-factor considerations of device design, interface layout and navigation strategies have not been addressed in any of the studies to date. Research instruments measuring the unique components of telehealth applications are needed.
Funding National Institute of Nursing Research, grant number T32 3223.
Bibliographic details Jones J F, Brennan P F. Telehealth interventions to improve clinical nursing of elders. In: Archbold P G, Stewart B J, Lyons K S (eds). Annual Review of Nursing Research 20. New York, NY, USA: Springer. 2002 Indexing Status Subject indexing assigned by NLM MeSH Aged; Clinical Nursing Research; Databases, Bibliographic; Geriatric Nursing /standards; Humans; MEDLINE; Quality Assurance, Health Care; Telemedicine AccessionNumber 12002004109 Date bibliographic record published 31/03/2004 Date abstract record published 31/03/2004 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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