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Telemedicine (TM) is the use of telecommunication systems to deliver health care at a distance. It has the potential to improve patient health outcomes, access to health care and reduce healthcare costs. As TM applications continue to evolve it is important to understand the impact TM might have on patients, healthcare professionals and the organisation of care.

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We already developed a telemedicine system using a cellular phone and internet web site to monitor changes in blood pressure and pulse rate in patients at home (Nakamoto et al., Hypertension 42: 442â€"3, 2003). Using this system, we have conducted the blood pressure control crossover study with amlodipine vs. nifedipine CR. Methods: Patients who were not taking an anti‐hypertensive ca‐antagonist other than amlodipine (A) or nifedipine CR (N) were eligible to enter this study. The patients in the first group (n 11) started A 2.5 mg/day. Doses of A were increased to achieve home blood pressure less than 135 / 85 mmHg to the extent of 7.5 mg/day. If necessary, atenolol was added. After achieving the target blood pressure, home blood pressure was monitored for more than 6 weeks and then A was changed to N. Home blood pressure monitoring was continued for more than 6 weeks after changing medication. The patients in second group (n 9) took N firstly, and then changed to A. The alternative doses were as follows; A 2.5 mg/day N 20 mg/day, A 5.0 mg/day N 40mg/day, A 7.5 mg/day N 60 mg/day. Blood pressure was checked at least twice a day, in the morning within 1 hour after wake‐up and in the evening before going to bed. Data of blood pressure and pulse rate were measured by automatic sphygmomanometer and were directly collected by i‐converter. All data including the time of measurement were directly sent and accumulated in the main server constructed in NTT DoCoMo data center through cellular phone operated by i‐converter. We could download data to CSV file like Excel and analyze them easily. Results: The mean of morning blood pressure in each period of medicine was significantly decreased in N period ( 133.0 1.1 / 78.1 1.1 mmHg (A) vs. 130.0 0.9 / 77.9 1.0 mmHg (N), p 0.05 ). The mean of morning pulse rate significantly increased in N period ( 68.4 1.2 beats / min (A) vs. 70.5 1.3 beats / min (N), p 0.05 ).Conclusion: The blood pressure reduction effect of nifedipine CR is stronger than that of amlodipine. Also, nifedipine CR increases pulse rate at our alternative dose setting. In this study, we have collected more data of home blood pressure in the quality and quantity than the previous studies through our telemedicine system. We also reduced the effort of data analysis with this system. (59th Annual Fall Conference and Scientific Sessions of the Council for High Blood Pressure Research)

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People with inflammatory bowel disease (IBD) require intensive follow‐up with frequent consultations after diagnosis. IBD telehealth management includes consulting by phone, instant messenger, video, text message, or web‐based services. Telehealth can be beneficial for people with IBD, but may have its own set of challenges. It is important to systematically review the evidence on the types of remote or telehealth approaches that can be deployed in IBD. This is particularly relevant following the coronavirus disease 2019 (COVID‐19) pandemic, which led to increased self‐ and remote‐management.

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Twelve studies compared web‐based disease monitoring to usual care.

Three studies, all in adults, provided data on disease activity. Web‐based disease monitoring (n = 254) is probably equivalent to usual care (n = 174) in reducing disease activity in people with IBD (SMD 0.09, 95% CI −0.11 to 0.29). The certainty of the evidence is moderate.

Five studies on adults provided dichotomous data that we could use for a meta‐analysis on flare‐ups. Web‐based disease monitoring (n = 207/496) is probably equivalent to usual care (n = 150/372) for the occurrence of flare‐ups or relapses in adults with IBD (RR 1.09, 95% CI 0.93 to 1.27). The certainty of the evidence is moderate. One study provided continuous data. Web‐based disease monitoring (n = 465) is probably equivalent to usual care (n = 444) for the occurrence of flare‐ups or relapses in adults with CD (MD 0.00 events, 95% CI −0.06 to 0.06). The certainty of the evidence is moderate. One study provided dichotomous data on flare‐ups in a paediatric population. Web‐based disease monitoring (n = 28/84) may be equivalent to usual care (n = 29/86) for the occurrence of flare‐ups or relapses in children with IBD (RR 0.99, 95% CI 0.65 to 1.51). The certainty of the evidence is low.

Four studies, all in adults, provided data on quality of life. Web‐based disease monitoring (n = 594) is probably equivalent to usual care (n = 505) for quality of life in adults with IBD (SMD 0.08, 95% CI −0.04 to 0.20). The certainty of the evidence is moderate.

Based on continuous data from one study in adults, we found that web‐based disease monitoring probably leads to slightly higher medication adherence compared to usual care (MD 0.24 points, 95% CI 0.01 to 0.47). The results are of moderate certainty. Based on continuous data from one paediatric study, we found no difference between web‐based disease monitoring and usual care in terms of their effect on medication adherence (MD 0.00, 95% CI −0.63 to 0.63), although the evidence is very uncertain. When we meta‐analysed dichotomous data from two studies on adults, we found no difference between web‐based disease monitoring and usual care in terms of their effect on medication adherence (RR 0.87, 95% CI 0.62 to 1.21), although the evidence is very uncertain.

We were unable to draw any conclusions on the effects of web‐based disease monitoring compared to usual care on healthcare access, participant engagement, attendance rate, interactions with healthcare professionals, and cost‐ or time‐effectiveness. The certainty of the evidence is very low.

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The evidence in this review suggests that web‐based disease monitoring is probably no different to standard care in adults when considering disease activity, occurrence of flare‐ups or relapse, and quality of life. There may be no difference in these outcomes in children, but the evidence is limited. Web‐based monitoring probably increases medication adherence slightly compared to usual care.

We are uncertain about the effects of web‐based monitoring versus usual care on our other secondary outcomes, and about the effects of the other telehealth interventions included in our review, because the evidence is limited.

Further studies comparing web‐based disease monitoring to standard care for the clinical outcomes reported in adults are unlikely to change our conclusions, unless they have longer follow‐up or investigate under‐reported outcomes or populations. Studies with a clearer definition of web‐based monitoring would enhance applicability, enable practical dissemination and replication, and enable alignment with areas identified as important by stakeholders and people affected by IBD.

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The included studies recruited patients with the following clinical conditions: cardiovascular disease (36), diabetes (21), respiratory conditions (9), mental health or substance abuse conditions (7), conditions requiring a specialist consultation (6), co morbidities (3), urogenital conditions (3), neurological injuries and conditions (2), gastrointestinal conditions (2), neonatal conditions requiring specialist care (2), solid organ transplantation (1), and cancer (1).

Telemedicine provided remote monitoring (55 studies), or real‐time video‐conferencing (38 studies), which was used either alone or in combination. The main TM function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice, (41); ii) provision of treatment or rehabilitation (12), for example the delivery of cognitive behavioural therapy, or incontinence training; iii) education and advice for self‐management (23), for example nurses delivering education to patients with diabetes or providing support to parents of very low birth weight infants or to patients with home parenteral nutrition; iv) specialist consultations for diagnosis and treatment decisions (8), v) real‐time assessment of clinical status, for example post‐operative assessment after minor operation or follow‐up after solid organ transplantation (8) vi), screening, for angina

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The type of data transmitted by the patient, the frequency of data transfer, (e.g. telephone, e‐mail, SMS) and frequency of interactions between patient and healthcare provider varied across studies, as did the type of healthcare provider/s and healthcare system involved in delivering the intervention.

We found no difference between groups for all‐cause mortality for patients with heart failure (16 studies; N = 5239; RR:0.89, 95% CI 0.76 to 1.03, P = 0.12; I² = 44%) (moderate to high certainty of evidence) at a median of six months follow‐up. Admissions to hospital (11 studies; N = 4529) ranged from a decrease of 64% to an increase of 60% at median eight months follow‐up (moderate certainty of evidence). We found some evidence of improved quality of life (five studies; N = 482; MD:‐4.39, 95% CI ‐7.94 to ‐0.83; P < 0.02; I² = 0%) (moderate certainty of evidence) for those allocated to TM as compared with usual care at a median three months follow‐up. In studies recruiting participants with diabetes (16 studies; N = 2768) we found lower glycated haemoglobin (HbA1c %) levels in those allocated to TM than in controls (MD ‐0.31, 95% CI ‐0.37 to ‐0.24; P < 0.00001; I²= 42%, P = 0.04) (high certainty of evidence) at a median of nine months follow‐up. We found some evidence for a decrease in LDL (four studies, N = 1692; MD ‐12.45, 95% CI ‐14.23 to ‐10.68; P < 0.00001; I2 = 0%) (moderate certainty of evidence), and blood pressure (four studies, N = 1770: MD: SBP:‐4.33, 95% CI ‐5.30 to ‐3.35, P < 0.00001; I² = 17%; DBP: ‐2.75 95% CI ‐3.28 to ‐2.22, P < 0.00001; I² = 45% (moderate certainty evidence), in TM as compared with usual care.

Seven studies that recruited participants with different mental health and substance abuse problems, reported no differences in the effect of therapy delivered over video‐conferencing, as compared to face‐to‐face delivery. Findings from the other studies were inconsistent; there was some evidence that monitoring via TM improved blood pressure control in participants with hypertension, and a few studies reported improved symptom scores for those with a respiratory condition. Studies recruiting participants requiring mental health services and those requiring specialist consultation for a dermatological condition reported no differences between groups.

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The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients' adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial

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The effectiveness of daily SMS reminders in pharmaceutical care of older adults on improving patients' adherence to antihypertensive medication (SPPA): study protocol for a randomized controlled trial

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BACKGROUND: Despite a variety of efficient and cost‐effective antihypertensive medication, hypertension remains a serious health and economic burden. High consumption of cardiovascular drugs in the Slovak Republic does result neither in better hypertension control nor in significant decrease in cardiovascular mortality. At the same time, Slovakia has alarmingly low patients' adherence to medication intake. Studies have shown the efficiency of short messaging service (SMS) reminders to improve patients' adherence and health outcomes at low costs. Since SMS is popular among Slovaks, this approach may be feasible also in Slovakia. The primary objective is to assess if daily SMS reminders of antihypertensive medication intake provided by pharmacists in addition to the standard pharmaceutical care increase the proportion of adherent older hypertensive ambulatory patients.

METHODS: The SPPA trial is a pragmatic randomized parallel group (1:1) trial in 300 older hypertensive patients carried out in community pharmacies in Slovakia. Trial pharmacies will be selected from all main regions of Slovakia. Trial intervention comprises daily personalized SMS reminders of medication intake embedded into usual pharmaceutical practice. The primary outcome is a combined adherence endpoint consisting of subjective self‐reported medication adherence via the eight‐item Morisky Medication Adherence Scale (MMAS‐8) and objective pill count rate. Secondary outcomes include: change in the MMAS‐8; comparison of adherence rates using pill count; change in systolic blood pressure; and patient satisfaction. Also, direct treatment costs will be evaluated and a cost‐effectiveness analysis will be carried out.

DISCUSSION: The SPPA trial engages community pharmacists and mobile health (mHealth) technologies via evidence‐based pharmaceutical care to efficiently and cost‐effectively addresses current main healthcare challenges: high prevalence of hypertension; overconsumption of cardiovascular medicines; low adherence to medication treatment; and resulting uncontrolled blood pressure. The results may identify new possibilities and capacities in healthcare with low additional costs and high value to patients.

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The use of technology for remote care in inflammatory bowel disease

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The use of technology for remote care in inflammatory bowel disease

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What is inflammatory bowel disease?

Inflammatory bowel disease refers to two main conditions that cause inflammation of the gut. These are ulcerative colitis and Crohn's disease. Ulcerative colitis only affects the large intestine. Crohn's disease can affect any part of the digestive tract, from mouth to bottom.

Inflammatory bowel disease mainly causes stomach pain or discomfort, diarrhoea that can be bloody, weight loss, and tiredness.

What did we want to find out?

Providing care from a distance, also called telehealth, is becoming more common, especially since the coronavirus 2019 (COVID‐19) pandemic. Using technology to provide remote care could benefit people with inflammatory bowel disease. Telehealth can take place via telephone, instant messaging, video, text message, web‐based services, or other means.

We wanted to find which communication technologies are used for remote care in inflammatory bowel disease, how they are used, if they are accessible to everyone, and what are their benefits or drawbacks.

What did we do?

We searched for randomised controlled trials (RCTs; studies where participants are randomly assigned to one of two or more treatment groups) comparing telehealth with any other treatment for people with inflammatory bowel disease. RCTs give us the highest standard of evidence.

We applied no limitations for age or type of remote care in our search, but we excluded studies that did not focus on providing care, such as studies providing only patient information or education. We also excluded studies that provided remote blood or stool test monitoring with no other type of remote monitoring.

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We found 19 relevant RCTs, which enroled a combined total of 3489 people aged eight to 95 years. Remote care was delivered online (e.g. smartphone applications, websites) or by telephone.

Twelve studies compared web‐based care to usual care, three compared telephone‐based care to usual care, three compared web‐based care to "sham" care, one compared web‐based care to self‐care, and one compared psychological and telephone support to usual care.

Web‐based remote care is probably no different to usual care in adults for improving symptoms, avoiding relapses or flare‐ups, and enhancing quality of life.

We also found that people who receive web‐based care are probably less likely to skip their medicines compared to those that receive usual care. We are moderately certain about these results based on the current evidence.

The evidence on children is limited.

With the currently available information, we cannot make any judgements on other parameters such as access to care, whether people with inflammatory bowel disease approve of these programmes and are encouraged to attend appointments, to what degree clinical professionals are involved in them, and costs or time.

The evidence on other forms of remote care was also very limited.

What are the limitations of the evidence?

One limitation of the evidence was that the RCTs provided unclear descriptions of the remote care programmes, which means that any organisation wishing to copy and adopt these interventions would have difficulty doing so. The descriptions of usual care (the alternative treatment group in many studies) were also unclear. This means that standard care might be different from one study to another, which could make our findings less accurate.

Few studies looked at forms of remote care other than web‐based care.

Another limitation is that the different studies measured different results (outcomes) of treatment.

Finally, some studies used poor quality research methods.

What next?

No further studies comparing web‐based care to usual care in adults are necessary, unless they last for longer periods of time or give more details that would help clinicians adopt them anywhere in the world. This includes details on the type and number of staff needed, resources, equipment, costs, accessibility, and data security. More studies on children may be useful, as well as studies that examine differences based on sex and social or financial status. In any case, future studies should concentrate on measuring the results that matter most to people with inflammatory bowel disease and their care providers.

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Telemedicine uses telecommunication systems to deliver health care at a distance. This method of delivering health care may improve patient health outcomes, access to health care and reduce costs. It is important to understand the impact that care at a distance via telemedicine might have on patients, healthcare professionals and the organisation of care.

Review question

We assessed the effectiveness, acceptability, and costs of interactive telemedicine, delivered in addition to, or as an alternative to, usual care as compared to usual care alone.

Study characteristics

Researchers in The Cochrane Collaboration searched the literature up to June 2013 and found 93 eligible randomised controlled trials (N = 22,047 participants). The studies recruited participants with a number of clinical conditions: cardiovascular disease (36 studies), diabetes (21 studies), respiratory conditions (nine studies), mental health problems or substance abuse (seven studies), conditions requiring a specialist consultation (six studies), complex co morbidities (three studies), urogenital conditions (three studies), neurological injuries and conditions (two studies), gastrointestinal conditions (two studies), neonatal conditions requiring specialist care (two studies), patients recovering after solid organ transplantation (one study) and cancer (one study).

Telemedicine provided remote monitoring (55 studies), or real‐time video‐conferencing (38 studies), which was used either alone or in combination. The main telemedicine function varied depending on clinical condition, but fell typically into one of the following six categories, with some overlap: i) monitoring of a chronic condition to detect early signs of deterioration and prompt treatment and advice; ii) provision of treatment or rehabilitation, for example stroke rehabilitation; iii) education and advice for self‐management; iv) specialist consultations; v) real‐time assessment of clinical status, for example post‐operative assessment after minor operation vi); screening for depression or angina.

Key results

We found no difference in mortality between participants with heart failure receiving care through telemedicine, compared to those receiving health care without telemedicine. The results of the studies differed for admissions to hospital, from a relative decrease of 64% to an increase of 60%. Disease‐specific quality of life was slightly improved for heart failure participants receiving telemedicine as compared to those receiving usual care only.

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The evidence in this review demonstrates that web‐based disease monitoring is probably no different to standard care when considering disease activity, occurrence of flare‐ups or relapse, and quality of life in adults with inflammatory bowel disease (IBD), and it probably improves medication adherence slightly. Evidence in children is limited.

The effects of web‐based disease monitoring versus usual care on the remaining secondary outcomes are unclear, as are the effects of the other telehealth interventions included in our review, as there are insufficient high‐quality data.

Implications for research

For the comparison web‐based monitoring versus standard care, we consider that further studies are unlikely to change the findings of this review. Several outcomes demonstrate that the intervention is no more effective than standard care.

Longer‐term studies with outcome measures after some years could provide more relevant findings for a chronic disease such as IBD. Additionally, future studies should provide more detailed reports of the interventions to allow practical dissemination and replication. This includes details on the type and number of staff needed, resources, equipment, costs, accessibility, and data security. Further studies on children could be useful, as well as studies that examine differences in efficacy between subgroups (e.g. sex or socio‐economic status).

There is also a need to investigate the impact of other forms of remote telehealth, including those reported in this review in small numbers. Nine ongoing studies are currently examining other remote care strategies.

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There were significant issues related to risk of bias in the studies included in this review. Despite our requests to authors of included studies, we received few data to change our judgements in these key areas.

Most studies did not blind participants, personnel, or outcome assessors, but this can be considered acceptable given the context of the review. As we explained in a previous review (Gordon 2022), research has demonstrated that even in double‐blind trials, participant expectancies can limit the validity of the design; assessing participants' beliefs about their treatment could help to overcome this issue (Colagiuri 2010). Nevertheless, blinding remains a concern and a potential limitation of the included studies in this review, and we have downgraded the certainty of the evidence for all our outcomes accordingly.

Reporting of the interventions themselves is another source of potential bias, as it is difficult to determine what specific interventions each study delivered. As discussed in Overall completeness and applicability of evidence, unclear reporting is a recognised problem within non‐pharmacological intervention studies (Hoffman 2013), and within health education systematic reviews (Gordon 2016), although the GRADE approach does not explicitly identify this issue (Gordon 2020). Lack of detail in the reporting of interventions constitutes the most serious problem with the evidence base, limiting the utility of our outcomes, because these interventions cannot be replicated or disseminated.

The outcome of paediatric flare‐ups or relapses for web‐based disease monitoring compared to usual care was downgraded twice for imprecision (low participant numbers) and risk of bias concerns (blinding and attrition).

All reported primary outcomes for telephone‐based disease monitoring compared to face‐to‐face monitoring were downgraded three times for serous imprecision (very low participant numbers) and risk of bias concerns.

The only secondary outcome we were able to meta‐analyse was medication adherence for web‐based disease monitoring compared to usual care. We considered the evidence for this outcome based on continuous data in adults to be of moderate certainty, downgrading once for risk of bias; and we considered the evidence based on continuous data in children and the evidence based on dichotomous data in adults to be of very low certainty, downgrading for very serious imprecision and risk of bias concerns.

Potential biases in the review process

Clinical heterogeneity is a major concern in this review. Most studies included people with both CD and UC at different disease states. Had we excluded studies that did not differentiate between CD and UC (most studies), we would have lost a key source of evidence in this area. Nevertheless, this clearly introduces a source of bias.

Although some studies analysed IBD populations as one cohort while others analysed UC and CD populations separately, and despite the mix of disease states in the included studies, we do not consider indirectness to be an issue. The constituents of the interventions were homogenous in their scope for web‐based monitoring, and varied only in the type of telehealth method adopted. There is no clinical evidence to suggest indirectness between subgroups of IBD and disease state. However, we recognise the variation in the methods used by the included studies may be a limitation of this review. Our outcomes are direct measures for efficacy and safety in IBD treatment.

We decided to only include studies where the remote component was the primary focus and not part of a larger package, and we may have missed studies with relevant evidence as a result.

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1)https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002098.pub2/full?highlightAbstract=telemedicine%7Ctelemedicin

2)https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014821.pub2/full?highlightAbstract=the%7Ctelemedicine%7Cdevelopment%7Ctelemedicin%7Cworld%7Cin%7Cof%7Cdevelop

3)https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007718.pub2/full?highlightAbstract=telemedicine%7Ctelemedicin

4)https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013408.pub2/full?highlightAbstract=telemedicine%7Ctelemedicin

5)https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012489.pub2/full?highlightAbstract=telemedicine%7Ctelemedicin

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1) What is telemedicine

2) Telemedicine system

3) Telehealth

4) Web‐based monitoring versus usual care

5) Disease monitoring

6) Video‐conferencing

7) Patients

8) The effectiveness of daily SMS reminders

9) The use of technology for remote care in inflammatory bowel disease

10) 19 relevant RCTs

11) Telecommunication systems

12) Implications for practice

13) Quality of the evidence

14) Literature