Study says telemedicine doesn't improve ICU outcomes
The use of telemedicine in intensive care units does not improve patients' risk of death or length of stay, according to a recent study.
The study, published in the December issue of the Journal of the American Medical Association, assessed the effect of a tele-ICU intervention on mortality, complications and length of stay in six ICUs of five hospitals in a large U.S. healthcare system. It was led by Eric J. Thomas, MD, of the University of Texas Health Science Center at Houston and colleagues, who measured outcomes before and after implementation of the tele-ICU system.
"Remote monitoring may be a partial solution for the intensivist shortage, but it is expensive, its use is increasing and there are few data in the peer-reviewed literature evaluating its effect on morbidity and mortality," said the authors.
The tele-ICU system included a remote office equipped with audiovisual monitoring and a computer workstation providing real-time vital signs with graphic trends; audiovisual connections to patients' rooms; early warning signals regarding abnormalities in a patient's status; and access to imaging studies and the medication administration record.
The study focused on 2,034 patients in the pre-intervention period (January 2003 to August 2005) and 2,108 patients in the post-intervention period (July 2004 to July 2006). Almost two-thirds of the patients in the post-intervention group had physicians who allowed tele-ICU intervention only for life-threatening situations. Physicians delegated full treatment authority to the tele-ICU for 655 patients.
Researchers found the observed hospital mortality rates were 12 percent in the pre-intervention period and 9.9 percent in the post-intervention period. After adjustment for severity of illness, there were no significant differences associated with the telemedicine intervention for hospital mortality. ICU mortality rates were 9.2 percent in the pre-intervention period and 7.8 percent in the post-intervention period, a difference also not significant after adjustment.
According to the study, the observed average hospital LOS among patients who survived to discharge was 9.8 days pre-intervention and 10.7 days post-intervention; the observed average ICU LOS for the patients who survived to transfer was 4.3 days for the pre-intervention period and 4.6 days for the post-intervention period, with neither difference significant.
"There was a significant interaction between the tele-ICU intervention and severity of illness, in which tele-ICU was associated with improved survival in sicker patients but with no improvement or worse outcomes in less sick patients," said researchers.
"Implementation of a tele-ICU was not associated with a reduction in overall hospital mortality for patients in these six ICUs," researchers said. "The lack of apparent benefit may be attributable to low decisional authority granted to the tele-ICU as well as to varied effects across different types of patients. Given the expense of tele-ICU technology, the conflicting evidence about its effectiveness, and the existence of other effective quality improvement interventions for ICUs, further use of this technology should proceed in the context of careful monitoring of patient outcomes and costs."
Evaluating the effectiveness of telemedicine is challenging, said Erika J. Yoo, MD, and R. Adams Dudley, MD, of the University of California, San Francisco, who wrote an accompanying editorial to the study.
"Given the heterogeneity of tele-ICU systems and the hospitals adopting them, it is unlikely that any single study can definitely address the benefits of telemedicine for the critically ill," they wrote. "Rather, literature syntheses will be the most important approach to improving the understanding of the effects of tele-ICU support."
"Tele-ICU is a potentially valuable change in ICU care, but its complexity means that 'tele-ICU improves care' is not a testable hypothesis." they added. "Therefore, performing and synthesizing tele-ICU research will be challenging. If future studies include more description of which components of ICU care were present before tele-ICU and which were added, it would be easier to interpret the results."