JMIR Publications

ABSTRACT

Background:

Emergency telehealth has been used to improve rural and remote patients’ access to specialist care in the hope of mitigating the significant health disparities experienced by people living in these locations. Patient disposition decisions in rural and remote emergency departments (ED) can be complex and largely dependent on the expertise and experience available to local (receiving-end) hospitals. Whilst there has been some synthesis of evidence on the effectiveness of emergency telehealth on clinical practice in the rural and remote EDs for non-acute presentations, there has been limited evaluation of the influence of contextual factors such as clinical areas and acuity of presentations on these findings.

Objective:

This systematic review examined the outcome measures used in studying the effectiveness of rural and remote emergency telehealth and analyzed the clinical context in which these outcome measures were used and interpreted.

Methods:

The search strategy used medical subject headings (MeSH) and equivalent lists of subject descriptors to find articles covering four key domains: telehealth/telemedicine, emergency department(s), effectiveness, rural and remote. According to the Population, Intervention, Comparator, Outcome(s) of interest, and Study design (PICOS) framework, studies were selected. This search strategy was applied to MEDLINE (Ovid), Cochrane Library, Scopus, CINAHL, ProQuest, EconLit, and the CRD databases (e.g. NHS Economic Evaluation Database) for the search period of 1st January 1990 to 23rd May 2020. Qualitative synthesis was performed on the outcome measures used in the included studies, in particular regarding the clinical contexts within which they are interpreted.

Results:

Twenty-one full-text articles were included for qualitative analysis. Telehealth use in rural and remote EDs demonstrated effectiveness in achieving improved or equivalent clinical effectiveness, appropriate care processes, and depending on the context, improvement in speed of care, and favorable service utilization patterns. Different clinical effectiveness, including patient outcome measures, was used to affirm telehealth's safety and clinical effectiveness in rural and remote EDs. The definition of effectiveness varied across the clinical area and context of the studies. The acuity of patient presentation emerged as a dominant consideration in the interpretation of interlinking time-sensitive clinical effectiveness and patient disposition measures such as transfer and discharge rates, local hospital admission, length of stay, and ED length of stay.

Conclusions:

Ascertaining outcome measures in an evaluation of telehealth in rural and remote ED is a complex task. Emergency telehealth studies typically use multiple outcome measures to determine the effectiveness of the services. Analysis in this systematic review has found three criteria in outcome determination in this context: clinical area, acuity of presentation, and the level of definitive care relative to the hospital of origin. These criteria are useful when defining the favorable direction for each outcome measure of interest. The findings of this review have implications for emergency telehealth service design and policies. Clinical Trial: Systematic review registration number: PROSPERO CRD42019145903