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Abstract
Background Despite the promise of telemedicine to improve care for ischaemic heart disease, there are significant obstacles to implementation. Demonstrating improvement in patient-centred outcomes is important to support development of these innovative strategies.
Objective To assess the impact of telemedicine interventions on mortality after acute myocardial infarction (AMI).
Methods Articles were searched in MEDLINE, Cochrane Central Register of Controlled Trials, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Base de Dados de Enfermagem (BDENF), Indice Bibliográfico Español en Ciencias de la Salud (IBECs), Web of Science, Scopus and Google Scholar, from January 2004 to January 2018. Study selection and data extraction were performed by two independent reviewers. In-hospital mortality (primary outcome), and door-to-balloon (DTB) time, 30-day mortality and long-term mortality (secondary outcomes) were assessed. Random effects models were applied to estimate pooled results.
Results Thirty non-randomised controlled and seven quasi-experimental studies were included (16 960 patients). They were classified as moderate or serious risk of bias by ROBINS-I (Risk Of Bias In Non-randomized Studies–of Interventions tool). In 31 studies, the intervention was prehospital ECG transmission. Telemedicine was associated with reduced in-hospital mortality compared with usual care (relative risk (RR) 0.63(95% confidence interval[CI] 0.55 to 0.72); I2 ⇓ <0.001%). DTB time was consistently reduced (mean difference −28 (95% CI −35 to –20) min), but showed large heterogeneity (I2=94%). Thirty-day mortality (RR 0.62;95% CI 0.43 to 0.85) and long-term mortality (RR 0.61(95% CI 0.40 to 0.92)) were also reduced, with moderate heterogeneity (I2=52%).
Conclusions There is moderate-quality evidence that telemedicine strategies, in particular ECG transmission, combined with the usual care for AMI are associated with reduced in-hospital mortality and very-low quality evidence that they reduce DTB time, 30-day mortality and long-term mortality.
- ehealth/telemedicine/mobile Health
- acute myocardial infarction
- meta-analysis
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Footnotes
Contributors MSM and ALR conceived and planned the study. MSM, BLDP and LMM performed the search for relevant studies. Data were screened, extracted and analysed by LMM, JAQO and MSM. LDR and MSM were in charge of the quality assessment. LMM and MSM performed data analysis. MSM wrote the first draft of the paper. All authors contributed to the interpretation of the findings and critically revised it for intellectual content.
Funding This study was partially supported by grants of the Brazilian Research agencies Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (CNPq), Fundação de Amparo a Pesquisa do Estado de Minas Gerais (FAPEMIG) and Coordenação de aperfeiçoamento de Pessoal de Nível Superior-Brasil (CAPES - Finance code 001). ALR and MSM are members of the National Institute of Science and Technology for Health Technology Assessment (IATS/CNPq). The authors are solely responsible for the design and data analyses, the drafting and editing of the manuscript, and its final contents. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Disclaimer There are no financial competing interests related to this study. MSM, JAQO, LDR, ALR work in a public telemedicine service in Brazil. MSM and ALR participated in two projects related to the implementation of myocardial infarction system of care which included ECG transmission, respectively, in Belo Horizonte and in the Northern Region of Minas Gerais, Brazil. The publications were included in this systematic review; however, as mentioned in methods session, sensitivity analysis was performed, excluding those publications.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent for publication Not required.