Guideline Development Tool

Author(s):

Question: Telemeditsiini compared to mitte for kõikidel südamepuudulikkusega patsientidel

Setting: Kas kõiki kroonilise südamepuudulikkusega patsiente tuleb parema ravitulemuse saamiseks jälgida telemeditsiini võimalusi kasutades või tavalisel viisil?

Bibliography:

Certainty assessment	№ of patients	Effect	Certainty	Importance
Üldsuremus^a
21^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,^11,^12,^13,^14,^15,^16,^17,^18,^19,^20,^21,^22,^b	randomised trials	very serious^c	not serious	not serious	not serious	none	723/5359 (13.5%)	782/5194 (15.1%)	RR 0.85 (0.76 to 0.94)	23 fewer per 1,000 (from 36 fewer to 9 fewer)	⨁⨁◯◯ Low
Kõigil põhjustel hospitaliseerimine^a
25^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,^12,^13,^14,^15,^16,^17,^18,^19,^20,^21,^23,^24,^25,^26,^27,^b	randomised trials	serious^c	serious^d	not serious	not serious	none			IRR 0.90 (0.81 to 0.99)^e,^f	-- per 1,000 (from -- to --)	⨁⨁◯◯ Low
Kõigil põhjustel hospitaliseerimine ravimituge (medication support) saanud patientide seas^g
15^1,^2,^4,^5,^7,^9,^13,^16,^17,^18,^19,^22,^23,^24,^26,^27,^b	randomised trials	serious^c	serious^h	seriousⁱ	not serious	none			IRR 0.83 (0.72 to 0.95)^f,^j	-- per 1,000 (from -- to --)	⨁◯◯◯ Very low
Kõigil põhjustel hospitaliseerimine ravimituge (medication support) mittesaanud patsientide seas^g
10^3,^6,^8,^10,^12,^14,^15,^20,^21,^25,^b	randomised trials	serious^c	not serious	serious^k	not serious^l	none			IRR 1.02 (0.93 to 1.12)^f,^m	-- per 1,000 (from -- to --)	⨁⨁◯◯ Low
Üldsuremus ravimituge saanud patsientide seas^g
12^1,^2,^4,^5,^7,^9,^11,^13,^16,^17,^18,^19,^22,^b	randomised trials	serious^c	not serious	not seriousⁿ	not serious	none			RR 0.77 (0.60 to 0.98)^o	1 fewer per 1,000 (from 1 fewer to 1 fewer)	⨁⨁⨁◯ Moderate
Üldsuremus ravimituge mittesaanud patsientide seas^g
9^3,^5,^6,^8,^10,^12,^14,^15,^20,^21,^b	randomised trials	serious^c	not serious	not serious^p	serious^q	none			RR 0.84 (0.70 to 1.01)^r	1 fewer per 1,000 (from 1 fewer to 1 fewer)	⨁⨁◯◯ Low
Kõigil põhjustel hospitaliseerimine telemonitooringu grupis^s
17^13,^18,^19,^20,^21,^24,^28,^29,^30,^31,^32,^33,^34,^35,^36,^37,^38,^39,^t	randomised trials	not serious	not serious	serious^u	not serious	none	1003/2784 (36.0%)	1110/2759 (40.2%)	OR 0.82 (0.73 to 0.91)	47 fewer per 1,000 (from 73 fewer to 22 fewer)	⨁⨁⨁◯ Moderate
Kõigil põhjustel hospitaliseerimine telefonitoe grupis^v
8^39,^40,^41,^42,^43,^44,^45,^46,^47,^t	randomised trials	not serious	not serious	not serious	not serious	none	1220/2873 (42.5%)	1322/2875 (46.0%)	OR 0.86 (0.78 to 0.96)	37 fewer per 1,000 (from 61 fewer to 10 fewer)	⨁⨁⨁⨁ High
Kardiaalsetel põhjustel hospitaliseerimine telemonitooringu grupis^s
13^13,^18,^21,^24,^29,^31,^32,^33,^36,^38,^39,^41,^45,^47,^t	randomised trials	not serious	serious^w	serious^u	not serious	none	534/2291 (23.3%)	616/2327 (26.5%)	OR 0.83 (0.72 to 0.95)	35 fewer per 1,000 (from 59 fewer to 10 fewer)	⨁⨁◯◯ Low
Kardiaalsetel põhjustel hospitaliseerimine telefonitoe grupis^v
6^39,^41,^42,^44,^45,^46,^47,^t	randomised trials	not serious	not serious	not serious	not serious	none	529/2124 (24.9%)	662/2160 (30.6%)	OR 0.74 (0.65 to 0.85)	60 fewer per 1,000 (from 83 fewer to 33 fewer)	⨁⨁⨁⨁ High
Üldsuremus telemonitooringu grupis^s
15^12,^14,^18,^19,^20,^21,^28,^30,^31,^32,^36,^37,^38,^39,^40,^48,^t	randomised trials	not serious	not serious	serious^u	not serious	none	214/2522 (8.5%)	273/2441 (11.2%)	OR 0.75 (0.62 to 0.90)	26 fewer per 1,000 (from 39 fewer to 10 fewer)	⨁⨁⨁◯ Moderate
Üldsuremus telefonitoe grupis^v
8^39,^40,^41,^42,^43,^45,^46,^47,^t	randomised trials	not serious	not serious	not serious	serious^l	none	548/2242 (24.4%)	567/2292 (24.7%)	OR 0.96 (0.83 to 1.11)	8 fewer per 1,000 (from 33 fewer to 20 more)	⨁⨁⨁◯ Moderate
Kardiaalne suremus telemonitooringu grupis^s
5^13,^20,^32,^33,^38,^39,^t	randomised trials	not serious	not serious	serious^u	serious^l	none	76/1009 (7.5%)	89/1007 (8.8%)	OR 0.84 (0.61 to 1.16)	13 fewer per 1,000 (from 33 fewer to 13 more)	⨁⨁◯◯ Low
Kardiaalne suremus telefonitoe grupis^v
3^39,^41,^45,^t	randomised trials	not serious	not serious	not serious	not serious	none	45/402 (11.2%)	67/406 (16.5%)	OR 0.54 (0.34 to 0.86)	69 fewer per 1,000 (from 102 fewer to 20 fewer)	⨁⨁⨁⨁ High

Certainty assessment

№ of patients

Effect

Certainty

Importance

№ of studies

Study design

Risk of bias

Inconsistency

Indirectness

Imprecision

Other considerations

telemeditsiini

mitte

Relative
(95% CI)

Absolute
(95% CI)

Üldsuremus^a

21^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,^11,^12,^13,^14,^15,^16,^17,^18,^19,^20,^21,^22,^b

randomised trials

very serious^c

not serious

none

723/5359 (13.5%)

782/5194 (15.1%)

RR 0.85
(0.76 to 0.94)

23 fewer per 1,000
(from 36 fewer to 9 fewer)

⨁⨁◯◯
Low

Kõigil põhjustel hospitaliseerimine^a

25^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,^12,^13,^14,^15,^16,^17,^18,^19,^20,^21,^23,^24,^25,^26,^27,^b

randomised trials

serious^c

serious^d

not serious

none

IRR 0.90
(0.81 to 0.99)^e,^f

-- per 1,000
(from -- to --)

⨁⨁◯◯
Low

Kõigil põhjustel hospitaliseerimine ravimituge (medication support) saanud patientide seas^g

15^1,^2,^4,^5,^7,^9,^13,^16,^17,^18,^19,^22,^23,^24,^26,^27,^b

randomised trials

serious^c

serious^h

seriousⁱ

not serious

none

IRR 0.83
(0.72 to 0.95)^f,^j

-- per 1,000
(from -- to --)

⨁◯◯◯
Very low

Kõigil põhjustel hospitaliseerimine ravimituge (medication support) mittesaanud patsientide seas^g

10^3,^6,^8,^10,^12,^14,^15,^20,^21,^25,^b

randomised trials

serious^c

not serious

serious^k

not serious^l

none

IRR 1.02
(0.93 to 1.12)^f,^m

-- per 1,000
(from -- to --)

⨁⨁◯◯
Low

Üldsuremus ravimituge saanud patsientide seas^g

12^1,^2,^4,^5,^7,^9,^11,^13,^16,^17,^18,^19,^22,^b

randomised trials

serious^c

not serious

not seriousⁿ

not serious

none

RR 0.77
(0.60 to 0.98)^o

1 fewer per 1,000
(from 1 fewer to 1 fewer)

⨁⨁⨁◯
Moderate

Üldsuremus ravimituge mittesaanud patsientide seas^g

9^3,^5,^6,^8,^10,^12,^14,^15,^20,^21,^b

randomised trials

serious^c

not serious

not serious^p

serious^q

none

RR 0.84
(0.70 to 1.01)^r

1 fewer per 1,000
(from 1 fewer to 1 fewer)

⨁⨁◯◯
Low

Kõigil põhjustel hospitaliseerimine telemonitooringu grupis^s

17^13,^18,^19,^20,^21,^24,^28,^29,^30,^31,^32,^33,^34,^35,^36,^37,^38,^39,^t

randomised trials

not serious

serious^u

not serious

none

1003/2784 (36.0%)

1110/2759 (40.2%)

OR 0.82
(0.73 to 0.91)

47 fewer per 1,000
(from 73 fewer to 22 fewer)

⨁⨁⨁◯
Moderate

Kõigil põhjustel hospitaliseerimine telefonitoe grupis^v

8^39,^40,^41,^42,^43,^44,^45,^46,^47,^t

randomised trials

not serious

none

1220/2873 (42.5%)

1322/2875 (46.0%)

OR 0.86
(0.78 to 0.96)

37 fewer per 1,000
(from 61 fewer to 10 fewer)

⨁⨁⨁⨁
High

Kardiaalsetel põhjustel hospitaliseerimine telemonitooringu grupis^s

13^13,^18,^21,^24,^29,^31,^32,^33,^36,^38,^39,^41,^45,^47,^t

randomised trials

not serious

serious^w

serious^u

not serious

none

534/2291 (23.3%)

616/2327 (26.5%)

OR 0.83
(0.72 to 0.95)

35 fewer per 1,000
(from 59 fewer to 10 fewer)

⨁⨁◯◯
Low

Kardiaalsetel põhjustel hospitaliseerimine telefonitoe grupis^v

6^39,^41,^42,^44,^45,^46,^47,^t

randomised trials

not serious

none

529/2124 (24.9%)

662/2160 (30.6%)

OR 0.74
(0.65 to 0.85)

60 fewer per 1,000
(from 83 fewer to 33 fewer)

⨁⨁⨁⨁
High

Üldsuremus telemonitooringu grupis^s

15^12,^14,^18,^19,^20,^21,^28,^30,^31,^32,^36,^37,^38,^39,^40,^48,^t

randomised trials

not serious

serious^u

not serious

none

214/2522 (8.5%)

273/2441 (11.2%)

OR 0.75
(0.62 to 0.90)

26 fewer per 1,000
(from 39 fewer to 10 fewer)

⨁⨁⨁◯
Moderate

Üldsuremus telefonitoe grupis^v

8^39,^40,^41,^42,^43,^45,^46,^47,^t

randomised trials

not serious

serious^l

none

548/2242 (24.4%)

567/2292 (24.7%)

OR 0.96
(0.83 to 1.11)

8 fewer per 1,000
(from 33 fewer to 20 more)

⨁⨁⨁◯
Moderate

Kardiaalne suremus telemonitooringu grupis^s

5^13,^20,^32,^33,^38,^39,^t

randomised trials

not serious

serious^u

serious^l

none

76/1009 (7.5%)

89/1007 (8.8%)

OR 0.84
(0.61 to 1.16)

13 fewer per 1,000
(from 33 fewer to 13 more)

⨁⨁◯◯
Low

Kardiaalne suremus telefonitoe grupis^v

3^39,^41,^45,^t

randomised trials

not serious

none

45/402 (11.2%)

67/406 (16.5%)

OR 0.54
(0.34 to 0.86)

69 fewer per 1,000
(from 102 fewer to 20 fewer)

⨁⨁⨁⨁
High

a. Some strategies were commonly used, such as telemonitoring weight scales (26/26, 100% RCTs), call-center support (24/26, 92%), and daily weight monitoring (25/26, 96%). Strategies that were not commonly used included nurse support (2/26, 8%), intervention for depression and anxiety (3/26, 12%), and exercise (3/26, 12%). The telemonitoring programs in the RCTs generally contained multiple strategies, with a mean of 8.7 strategies per care program.

b. Ding H, Chen SH, Edwards I, et al. Effects of Different Telemonitoring Strategies on Chronic Heart Failure Care: Systematic Review and Subgroup Meta-Analysis. J Med Internet Res. 2020;22(11):e20032. Published 2020 Nov 13. doi:10.2196/20032

c. Metaanalüüsi kaasatud uuringutest 11 RCT-d ei kasutanud osalejate ja uuringu läbiviijate pimendamist, 9 uuringut ei raporteerinud pimendamist ning vaid kuues RCT-s kasutati pimendamist. Neljateistkümnes uuringus (54%) raporteeriti ebaselget kallutatuse ohtu "unclear risk of bias".

d. Tõenduse ebakõla suur - I2=73,2%

e. Uuritavate arv N=9912

f. IRR - incidence rate ratio

g. Medication support - support to optimally adjust medication therapy or support participants to adhere to the medication recommendations for CHF

h. I2=70.7%

i. 15st uuringus viies kasutati mHealth interventsiooni (tarkvararakenduste komplekt mobiilseadmetele nagu nt nutitelefonid, nutitahvlid jt), ühes PC rakendust ja ühes mõlemat.

j. Uuritavate koguarv N=4563

k. 10st uuringus viies kasutati mHealth interventsiooni (tarkvararakenduste komplekt mobiilseadmetele nagu nt nutitelefonid, nutitahvlid jt).

l. Usaldusvahemik läbib ühte, mis viitab sekkumise ebaefektiivsusele

m. Uuritavate arv N=5349

n. 12st uuringust 5 kasutas mHealth interventsiooni, üks uuring PC rakendust ning üks uuring kasutas mõlemat.

o. Uuritavate arv N=5475

p. 9st uuringust 4 kasutas mHealth interventsiooni.

q. Usaldusvahemik lai, sekkumisega kaasnev mõju ulatub surmade arvu vähenemisest 30% võrra kuni efekti puudumiseni.

r. Uuritavate arv N=5088

s. Telemonitoorimise sekkumiste alla kuulus nt kaalu ja vererõhu monitoorimine; mHealth tarkvaralahenduste ja PC rakenduste kasutamine; arsti tugi; ravimitugi; kõnekeskuse tugi.

t. Zhu Y, Gu X, Xu C. Effectiveness of telemedicine systems for adults with heart failure: a meta-analysis of randomized controlled trials. Heart Fail Rev. 2020 Mar;25(2):231-243. doi: 10.1007/s10741-019-09801-5. PMID: 31197564; PMCID: PMC7046570

u. Mõnedes kaasatud uuringutes kasutati invasiivset monitooringut

v. Telefonitoe sekkumise rühmas kasutati tavapäraselt õe poolt telefoni teel läbi viidud patsiendi monitoorimist, harimist ja nõustamist.

w. Tõenduse ebakõla suur - I2=59%

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Explanations

References