Understanding heart failure; explaining telehealth – a hermeneutic systematic review

Abstract

BackgroundEnthusiasts for telehealth extol its potential for supporting heart failure management. But randomised trials have been slow to recruit and produced conflicting findings; real-world roll-out has been slow. We sought to inform policy by making sense of a complex literature on heart failure and its remote management.MethodsThrough database searching and citation tracking, we identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta-analyses and 8 qualitative reviews); six mega-trials and over 60 additional relevant empirical studies and commentaries. We synthesised these using Boell’s hermeneutic methodology for systematic review, which emphasises the quest for understanding.ResultsHeart failure is a complex and serious condition with frequent co-morbidity and diverse manifestations including severe tiredness. Patients are often frightened, bewildered, socially isolated and variably able to self-manage. Remote monitoring technologies are many and varied; they create new forms of knowledge and new possibilities for care but require fundamental changes to clinical roles and service models and place substantial burdens on patients, carers and staff. The policy innovation of remote biomarker monitoring enabling timely adjustment of medication, mediated by “activated” patients, is based on a modernist vision of efficient, rational, technology-mediated and guideline-driven (“cold”) care. It contrasts with relationship-based (“warm”) care valued by some clinicians and by patients who are older, sicker and less technically savvy. Limited uptake of telehealth can be analysed in terms of key tensions: between tidy, “textbook” heart failure and the reality of multiple comorbidities; between basic and intensive telehealth; between activated, well-supported patients and vulnerable, unsupported ones; between “cold” and “warm” telehealth; and between fixed and agile care programmes.ConclusionThe limited adoption of telehealth for heart failure has complex clinical, professional and institutional causes, which are unlikely to be elucidated by adding more randomised trials of technology-on versus technology-off to an already-crowded literature. An alternative approach is proposed, based on naturalistic study designs, application of social and organisational theory, and co-design of new service models based on socio-technical principles. Conventional systematic reviews (whose goal is synthesising data) can be usefully supplemented by hermeneutic reviews (whose goal is deepening understanding).Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-017-0594-2) contains supplementary material, which is available to authorized users.

Time to challenge the spurious hierarchy of systematic over narrative reviews?

“…This principle was illustrated in a recent hermeneutic review of telehealth in heart failure by one of us 43. It identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta‐analyses) covering hundreds of primary studies, as well as six mega‐trials—almost all of which had concluded that more research (addressing the same narrow question with yet more randomised trials intended to establish an effect size for telehealth) was needed.…”

Value of Telemonitoring and Telemedicine in Heart Failure Management

“…Moreover, the complex literature on telehealth also seems marked by methodological issues, like publication bias and poor recruitment in clinical trials. 45 For example, in the TELE-HF study, 14 % of patients assigned to telemonitoring never used the system and by the final week of the study period, only 55 % of the patients were still using the system at least three times a week. 33 As an appropriate adherence to a given intervention can contribute to an adequate external validity of the studies, improvement of adherence represents a key element of the future research on telehealth.…”

“…patients under 65 years of age), whereas in other subgroups (patients with moderate or severe depression), involvement in self-management may be even associated with a reduced survival rate. 45 Again, careful stratification of patients enrolled in clinical studies seems to be a pivotal pre-requirement for a valuable application of telehealth to different healthcare contexts.…”

Factors for Supporting Primary Care Physician Engagement With Patient Apps for Type 2 Diabetes Self-Management That Link to Primary Care: Interview Study (Preprint)

“…For example, increased workload is a common factor for poor uptake of new health technologies [14,15,[18][19][20][21][22]. In this study, PCPs anticipated an increase in workload, particularly in the initial stages of implementation, and argued that their acceptance of this increase was contingent on the perceived benefit of the app for the patient.…”

“…Research suggests that their effectiveness is often limited by poor uptake and sustained use by health care providers [18,19]. Recent systematic reviews have suggested that key barriers for health care providers are increased workload, and disruption to existing clinical processes and staff roles as well as concerns about remuneration, data security and liability [18,[20][21][22].…”