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      Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review

      , 1 , 2 , 4 , 3

      BMC Health Services Research

      BioMed Central

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          A major benefit offered by telemedicine is the avoidance of travel, by patients, their carers and health care professionals. Unfortunately, there is very little published information about the extent of avoided travel. We propose to undertake a systematic review of literature which reports credible data on the reductions in travel associated with the use of telemedicine.


          The conventional approach to quantitative synthesis of the results from multiple studies is to conduct a meta analysis. However, too much heterogeneity exists between available studies to allow a meaningful meta analysis of the avoided travel when telemedicine is used across all possible settings. We propose instead to consider all credible evidence on avoided travel through telemedicine by fitting a linear model which takes into account the relevant factors in the circumstances of the studies performed. We propose the use of stepwise multiple regression to identify which factors are significant.


          Our proposed approach is illustrated by the example of teledermatology. In a preliminary review of the literature we found 20 studies in which the percentage of avoided travel through telemedicine could be inferred (a total of 5199 patients). The mean percentage avoided travel reported in the 12 store-and-forward studies was 43%. In the 7 real-time studies and in a single study with a hybrid technique, 70% of the patients avoided travel. A simplified model based on the modality of telemedicine employed (i.e. real-time or store and forward) explained 29% of the variance. The use of store and forward teledermatology alone was associated with 43% of avoided travel. The increase in the proportion of patients who avoided travel (25%) when real-time telemedicine was employed was significant ( P = 0.014). Service planners can use this information to weigh up the costs and benefits of the two approaches.

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          Most cited references 22

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          Of apples and oranges, file drawers and garbage: why validity issues in meta-analysis will not go away.

           Donald Sharpe (1997)
          This paper examines how threats to the validity of meta-analysis have been dealt with by clinical researchers employing this approach to literature review. Three validity threats were identified--mixing of dissimilar studies, publication bias, and inclusion of poor quality studies. Approaches to addressing these threats were evaluated for their effectiveness and popularity by surveying 32 published meta-analyses in clinical psychology. Distrust of meta-analysis, however, was found to transcend these validity threats. Other explanations for why this popular research strategy continues to receive widespread criticism were considered. Suggestions were made for how meta-analysis might better address these concerns.
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            Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis.

            Comparison of real time teledermatology with outpatient dermatology in terms of clinical outcomes, cost-benefits, and patient reattendance. Randomised controlled trial with a minimum follow up of three months. Four health centres (two urban, two rural) and two regional hospitals. 204 general practice patients requiring referral to dermatology services; 102 were randomised to teledermatology consultation and 102 to traditional outpatient consultation. Reported clinical outcome of initial consultation, primary care and outpatient reattendance data, and cost-benefit analysis of both methods of delivering care. No major differences were found in the reported clinical outcomes of teledermatology and conventional dermatology. Of patients randomised to teledermatology, 55 (54%) were managed within primary care and 47 (46%) required at least one hospital appointment. Of patients randomised to the conventional hospital outpatient consultation, 46 (45%) required at least one further hospital appointment, 15 (15%) required general practice review, and 40 (39%) no follow up visits. Clinical records showed that 42 (41%) patients seen by teledermatology attended subsequent hospital appointments compared with 41 (40%) patients seen conventionally. The net societal cost of the initial consultation was pound132.10 per patient for teledermatology and pound48.73 for conventional consultation. Sensitivity analysis revealed that if each health centre had allocated one morning session a week to teledermatology and the average round trip to hospital had been 78 km instead of 26 km, the costs of the two methods of care would have been equal. Real time teledermatology was clinically feasible but not cost effective compared with conventional dermatological outpatient care. However, if the equipment were purchased at current prices and the travelling distances greater, teledermatology would be a cost effective alternative to conventional care.
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              Study quality and evidence of benefit in recent assessments of telemedicine.

              We carried out a systematic review of recent telemedicine assessments to identify scientifically credible studies that included comparison with a non-telemedicine alternative and that reported administrative changes, patient outcomes or the results of an economic assessment. From 605 publications identified in the literature search, 44 papers met the selection criteria and were included in the review. Four other publications were identified through references cited in one of the retrieved papers and from a separate project to give a total of 48 papers for consideration, which referred to 42 telemedicine programmes and 46 studies. Some kind of economic analysis was included in 25 (52%) of the papers. In considering the studies, we used a quality appraisal approach that took account of both study design and study performance. For those studies that included an economic analysis, a further quality-scoring approach was applied to indicate how well the economic aspects had been addressed. Twenty-four of the studies were judged to be of high or good quality and 11 of fair to good quality but with some limitations. Seven studies were regarded as having limited validity and a further four as being unacceptable for decision makers. New evidence on the efficacy and effectiveness of telemedicine was given by studies on geriatric care, intensive care and some of those on home care. For a number of other applications, reports of clinical or economic benefits essentially confirmed previous findings. Although further useful clinical and economic outcomes data have been obtained for some telemedicine applications, good-quality studies are still scarce.

                Author and article information

                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central
                8 August 2011
                : 11
                : 185
                [1 ]Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, PO Box 6060, N-9038 Tromsø, Norway
                [2 ]Australian e-Health Research Centre, CSIRO, Leeuwin Centre, 65 Brockway Road, Floreat, WA 6014, Australia
                [3 ]School of Information Systems and Technology, University of Wollongong, Wollongong, NSW 2522, Australia
                [4 ]Research Centre for Modelling in Health, Kerman University of Medical Sciences, Kerman, Iran
                Copyright ©2011 Wootton et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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