Table 2.

Summary table of included studies

Author (year)	Research question	Participants	Telehealth initiative	Setting	Key findings	Overview of quality
Quantitative
Chatwin (2016) [22] Randomised crossover trial	Effect of home telemonitoring on interaction with acute services and quality of life and self-efficacy	68 patients with COPD or non-COPD respiratory failure	Philips Motiva home telemonitoring system with heart rate monitor, pulse oximeter, blood pressure monitor and weighing scales	Patient’s home	Admission rates and home visits increased in the telemonitoring arm Time to first exacerbation did not differ between groups. Self-efficacy fell in the telemonitored group.	Score = 18
Dey (2016) [25] Prospective interventional pilot study	Acceptability of technology to monitor symptoms in advanced peritoneal dialysis patients	22 adults with end stage renal failure on peritoneal dialysis	Specialised software on tablets for inputting symptom data and blood pressure measurement	Patient’s home	Claimed 36 admissions avoided, support to manage at home provided on 154 instances. 91% retention rate in study excluding medical reasons. No significant change in QOL scores. QUEST scores high indicating satisfaction with the technology.	Score = 12
Dierckx (2015) [26] Retrospective observational analysis	Does home telemonitoring reduce heart failure mortality?	333 patients with heart failure referred- 278 agreed to telemonitoring	Motiva home telemonitoring system for symptom data and clinical measurements. Can also transmit educational videos.	Patient’s home	Telemonitoring was associated with reduced all-cause mortality and overall improved survival. The number of admissions and time to first hospitalization was the same in each group. Patients who refused telemonitoring were generally older.	Score = 10
Hall (2013) [29] Service evaluation	An evaluation of the 7 day specialist palliative care service	N/A	Telephone advice service within an acute hospital	Hospital	99 calls with professionals and 37 with carers in a one-year period. Consultant contacted on average once per day at the weekend.	N/A
Hamad (2015) [31] Prospective observational	Description of the use of telehealth data in a COPD MDT	95 patients	Telehealth platform via smartphone or tablet to provide symptom status and oxygen saturations	Hospital	18 of 95 patients had no recommendations from the MDT. There were 141 recommendations generated for the remainder eg. referral to palliative care, smoking cessation.	N/A
Lewis (2010) [32] Randomised controlled trial	Does home telemonitoring reduce healthcare use in COPD?	40 patients with COPD	HealthHub system via Freephone line to monitor symptoms and pulse oximetry.	Patient’s home	Reduced contact with primary care in intervention group- not statistically significant but may be clinically important. No difference in ED attendance or hospital admissions. Patients uploaded median 97% data and no difficulties using technology.	Score = 17
Plummer (2011) [33] Service evaluation	Analysis of the specialist palliative care advice line	70 patients and carers	24/7 telephone advice line for patients, carers or professionals	Hospice	Most calls weekday after 5 pm and from patients or carers. Primary reason for call was symptom management. 65% callers remained at home following call.	Score = 8
Purdy (2015) [34] Retrospective observational study	Impact of the delivering choice programme on place of death and hospital usage	Analysis of 3594 patients	Electronic end of life register, out of hours advice line (plus two non-telehealth components)	Hospice and community	21–24% accessed some element of the programme. Patients using programme more likely to have cancer diagnosis. Care coordination centres most effective intervention. OOH advice line associated with reduced ED attendance in last week of life only. Patients using centres or entered on end of life register were less likely to die in hospital. Hospital admissions were lower in both counties for patients using the programme in 30 days prior to death.	Score = 18
Warren (2011) [35] Prospective observational study	Review of telephone support for patients with advanced breast cancer	229 calls related to patients with metastatic breast cancer	Telephone advice line	Hospital	Largest contact group was patients followed by professionals. Total time spent on calls was 63 h (30% of CNS working time). 1281 interventions generated from the calls.	Score = 12
Wye (2016) [36] Service evaluation	Analysis of electronic palliative care coordinating systems (EPaCCS)	101 health care professionals	Electronic palliative care record	Community	EPaCCS used in small proportion of patients (9–13%). Where EPaCCS used, seems to correlate with a home death.	Score = 17
Qualitative
Carlebach (2010) [21] Qualitative interviews	What are the experiences and opinions of users of telephone support service?	Palliative care diagnosis not specified. 6 patients, 8 carers, 13 health professionals	Hospice 24 h advice line	Hospice	Relatives and carers were group most likely to use service, followed by district nurses. The service was valued by users.	Score = 8
Duxbury (2015) [27] Qualitative interviews	What are the barriers and enablers to adoption of Coordinate My Care?	8 professionals	An online tool completed by health professionals for palliative patients	Community	Useful and relevant however process of completing ‘laborious’ and issues with connectivity- lack of remote access and some providers not connected.	N/A
Faull (2016) [28] Description of initiative	Description of online learning tool.	For professionals	e-ELCA online education tool for palliative care professionals	N/A	None- description only.	N/A
Hall (2012) [29] Qualitative interviews	The opinion of electronic palliative care summary record in Scotland	16 professionals, 6 patients/carers	Electronic palliative care system to allow recording of patient data and sharing with out of hours services	Community	Useful and feasible innovation. Felt to be more specific to cancer patients. Felt that not enough emergency providers know of its existence. Reassuring for patients and carers.	Score = 11
Hobson (2018) [37] Qualitative interviews	Identify how technology may improve the service for motor neurone disease	3 patients, six carers and 1 motor neurone disease specialist nurse	Tablet computer app which patients use to input health and wellbeing data	Hospice/ Community	Telehealth was acceptable to patients and carers. They wanted more information to help self-manage. The touch screen layout will be redesigned following observation of users.	Score = 15
Johnston (2011) [38] Qualitative interviews	Evaluating the use of telehealth in palliative care across Scotland	22 patients and carers, 8 healthcare professionals	Variety of telehealth interventions discussed	Hospice/ Community	Patients generally unaware of the term ‘telehealth’ but aware of the existence of technologies. Stakeholder telehealth activity consisted of videoconferencing for MDT, networking and education. Patients/carers aware of telephone advice lines, internet forums and personal safety alarms and found these useful. Felt to be used more in remote locations. Felt should supplement rather than replace existing support. Barriers to use were broadband coverage, funding and lack of awareness.	Score = 14
Leadbeater (2014) [39] Qualitative interviews	To review the organisation of community palliative care teams in rural England	6 specialist palliative care nurses	Variety of telehealth interventions discussed	Community	Two teams used videoconferencing for MDT meetings. 40–75% patient contact via telephone. 3 teams had laptops and 2 had remote access to patient records.	N/A
Middleton-green (2016) [40] Qualitative interviews	Evaluation of palliative care telephone advice line	8 patients and 6 carers	Telephone advice line or video call from iPad with hub staffed by nursing professionals	Hospice	5106 telephone calls received related to 1813 patients. Service found to be beneficial for emotional support and practical advice. Reports from patients of how advice prevented avoidable admission or expedited appropriate admission. Reported 98.5% of calls resulted in patients remaining in place of residence	Score = 10
Nwosu (2012) [41] Description	Describe smartphone applications for palliative medicine	N/A	Smartphone applications	N/A	Six applications identified- 2 ‘blog’ style, 2 with guidance to facilitate learning or practice and 2 apps to facilitate opioid prescribing.	N/A
Rafter (2016) [42] Description of service	Description of e-health in managing pressure ulcers in palliative care	2 case examples	e-Health system for staff to upload information/picture of ulcers.	Hospice	All patients received care pathways within 24 h of referral. Staff gave positive feedback- easy to use and increased job satisfaction.	N/A
Wye (2014) [43] Realist evaluation	‘Real life’ evaluation of what facilitates home deaths and reduces hospital admissions for palliative patients	43 family carers and 105 professionals	Electronic end of life register, out of hours advice line (plus two non-telehealth components)	Hospice/ Community	Having skilled, experienced professionals with sufficient and dedicated time was important to the success of the project. Overall there was high carer satisfaction, low hospital utilization and more deaths in the community among project users. Patchy uptake of the service.	Score = 17
Protocols
Aiyegbusi (2017) [20] Study protocol	Does the use of patient-reported outcome measures promote care and safety in managing advanced CKD?	Stage 4 or 5 chronic kidney disease.	Electronic questionnaire on smartphone/ tablet/laptop/ computer of symptoms	Patient’s home	N/A	N/A
Choyce (2017) [23] Study protocol	Effect of home telemonitoring on clinical parameters and quality of life	Cystic Fibrosis patients with admission for IV antibiotics in last 24 months	Mobile phone for symptom reporting and Bluetooth spirometer	Patient’s home	N/A	N/A
Hudson (2016) [44] Study protocol	Feasibility of online cognitive behavioural therapy intervention	End stage renal failure on dialysis with depression or anxiety	Online cognitive behavioural therapy using an iPad accompanied by telephone support.	Patient’s home	N/A	N/A
Mixed
Cox (2011) [24] Intended mixed-methods. Qualitative interviews with clinicians	To assess the acceptability of technology to monitor symptoms following palliative radiotherapy for lung cancer	Patients with lung cancer receiving radiotherapy- none successfully recruited	CareHub device to monitor symptoms reported by patients	Patient’s home	21 patients identified, consent from clinician withheld for 20. 1 other patient declined to participate. 9 of 13 clinicians felt e-technology inappropriate in this group due to age. Themes of gatekeeping due to concern of burden of research on this population. Concerns their clinical judgement replaced by technology.	Score = 9
Hattink (2015) [45] Randomised controlled trial	Does an e-learning course increase empathy and understanding in dementia caregivers?	57 caregivers of people with advanced dementia	Web-based training portal on different aspects of dementia care	Carer’s home	30/57 UK participants did not complete the course. Modules rated useful and user-friendly. Empathy, perspective and coping with stress improved in the intervention group (though UK/Dutch results pooled).	Score = 16
Hudson (2017) [46] Randomised controlled trial	Feasibility of online cognitive behavioural therapy (CBT) intervention	25 patients- 18 intervention, 7 control	Online cognitive behavioural therapy using an iPad accompanied by telephone support.	Patient’s home	410 patients approached and 25 agreed to participate with 23 completing follow up. Adherence with online CBT higher in control arm. Numbers not large enough to show statistical difference for patient reported outcomes. Calculated QALY gain for supported arm £82,283 though wide confidence intervals.	Score = 17
Lisk (2012) [47] Mixed methods	Does geriatrician input for nursing home patients reduce emergency admissions?	Audit of 1954 nursing home residents with 3 nursing homes involved in pilot	Telephone advice line to speak to geriatrician and e-mail alert to geriatrician when patient admitted	Hospital and community	Reduction of bed days from 90 to 33 in initial pilot with calculated cost saving of £2630. In second phase of study calculated reduction of 250 bed days over 4 months with potential cost savings of £74,383. Service was well received by GPs.	N/A
Milton (2012) [48] Service evaluation	Describe the 7 day community specialist palliative care service	20 patients/carers 6 professionals	Proactive and reactive telephone support run by community specialist nurses	Community	36% of contact from the service was unplanned. There were 132 telephone contacts in a 6 month period. Viewed positively by all staff in the focus group and valued by patients.	Score = 9
White (2016) [49] Prospective longitudinal cohort study	Review of ‘ECHO’ education project for hospice nursing staff	34 community hospice nurses	Weekly educational session facilitated by videoconferencing	Hospice	28/34 completed pre and post intervention evaluation. Mean knowledge score improved by 11.3% (p = 0.0005) and all domains of self-efficacy improved. Project received positively by participants.	Score = 18

Studies with overview of quality scores highlighted in bold in the table met all of the nine quality criteria completely or to some extent