Table 3.

Methods and outcome

Report title	Methods for data collection	Study duration	Analysis	Clinical outcomes	Other outcomes	Study limitations and critique
Koizumi et al [30]	Attending PCPs took the medical history. Patients measured the Blood Pressure, Electrocardiogram and heartrate and oxygen saturation which was recorded in the system and partial pressure of expiratory carbon dioxide was reported to the physician verbally.	One year for patient 1 and for patient 2 not mentioned. Weekly communication within all three parties	No analysis is presented in the paper	1. Depression; 2. Other health issues; 3. Respiratory symptoms were observed and discussed; however, the paper does not mention clear clinical outcomes neither the methods which were used for measuring these clinical outcomes	Effectiveness of system connecting multiterminal. The trial program resulted in the same information being exchanged remotely using the multi-station teleconsultation system that would be exchanged in a direct, face to-face encounter	The clinician’s observations are described in the results section. No specific method is mentioned to document the observations. The paper does not clearly mention the aims of the publication. The result describes that the system is effective yet the methods do not describe measuring the effectiveness although the study of two cases proves the feasibility of the intervention.
Raza et al [28]	Retrospective data analysis. The authors extracted data from computerized patient record system, paper chart, physician logbooks of teleconsultation visits, patients written comments after completion of teleconsultations.	January 1998 and December 2004 (7 y)	Descriptive statistics were undertaken for the study outcomes. Data analysis was done using Microsoft access, SPSS and ArcGIS. Analysis for patient satisfaction data are not described.	1. Reasons for referral and access to specialty care: Common reasons- abnormal thoracic radiography (38%), COPD (26%), and work-up of dyspnea (13%); 2. Medical process of care: Due to limited scope of physical examination, consultant, relied on the exam findings documented by the nurse or respiratory therapist present with the patient (vital signs documented in 99.7%, physical examination in 84% and respiratory examination in 92% patients); 3.Physician diagnosis: COPD (29%), benign pulmonary nodule (11%), bronchial asthma (6%), and lung cancer (6%). Final diagnosis by physicians after first consultation in 90% cases.	1. Medical decision making: clinically significant change in management for 41%) patients and follow-up required in 51% patients. 8% required face to face visit t the hub. 2. Study population and travel distances: Total travel distance and time saved for 684 visits is 473 340km or 294 120 miles and 748 work days considering only patient would have travelled to the hub and no one accompanied the patient. 3. patient satisfaction: Overall positive experience	The data analysed is extracted from the system included a range of sub-specialities however this paper describes data from pulmonary patients only. The analysis for the qualitative data are not described. Data from single teleconsultation spoke centre is described which cannot necessarily be representative of the complete system. There is an assumption that all encounters would have resulted in long distance referral, reducing the bar to consultation may have increased demand a historical comparator might have been useful
Averame et al [31]	The PCPs performed spirometry in their office after the training which was sent to specialist at the central office, the criteria used to accept a single telespirometric test were the presence of two at least acceptable and reproducible manoeuvres. Fixed diagnostic criteria was considered for interpretation of results. FEV1/FVC fixed ratio, and not FEV1/VC% predicted, was used to assess for the presence of airway obstruction. Patient characteristics were collected in case report form by the PCPs.	Not mentioned in the paper	Descriptive statistics, consisting of numbers and percentages for ordinal and categorical variables and means with standard deviations or medians with ranges for continuous variables and valid cases, are presented	Not mentioned	78% (7262) of the telespirometric tests were classified as acceptable of these 7262, 41% (3003) exhibited abnormal spirometric pattern. 23% of patients had a clinical diagnosis of COPD but normal telespirometry. Subgroup analysis was done for smoker, non-smokers, symptomatic, already detected COPD and Asthma.	Although the training provided to the PCPs is mentioned in the methods, the training assessment is not provided in the results. The distribution of 22% unacceptable spirometries are not described, if these were from a set of specific PCPs or dispersed amongst all 638 PCPs. The study participants were selected group of participants as selected by the PCPs and not a random representation of the population. The methods describe that the five pulmonology units provided trainings the number of specialists who supported the PCPs in assessing the spirometries is not mentioned.
Bonavia et al [32]	Telespirometry was conducted by the process as mentioned in the previous publication of the same study (Averame et al) [31]. Further a turbine spirometer (Spirotel) was use to perform these spirometries (not mentioned in the Averame et al). The data for comparison between Spirotel and conventional laboratory spirometry is not presented in these papers. Quality evaluation of the telespirometries was done by two authors based on ATS recommendation and office spirometry.	October 2002 and ended in October 2004	Descriptive analysis was performed (number of observations, means and standard deviations, and categorical data as absolute and percent frequencies.)		22.2 ± 25.2 tests per PCP during study period. 70% of the tests met the criteria for good or partial co-operation, allowing spirometric abnormalities to be detected. Normal telespirometry (38.9); Mild airway obstruction (4.5); Moderate airway obstruction (9.5); Severe airway obstruction (4.5);Very severe airway obstruction (0.7); Abnormal spirometry, but not clear airway obstruction (8.5); Suspected airway obstruction (3.3)	The number of PCPs sending at least one spirometry per month reduced to less than 100 by end of the study. This shows that there were problems in continuity of the telespirometry services especially in access to TCO and PCPs time for conducting telespirometry. Although these explanations are discussed in the discussion, the methods do not mention how these were confirmed. The aim of the study is to determine feasibility yet the methods do not mention measuring the hurdles or facilitators in conducting the telespirometry. Only telespirometry were assessed for acceptability and cooperation.
Bernocchi et al [33]	Assessment of TELEMACO network: By evaluating the organization of the integrated services across the Lombardy territories. Acceptance of TELEMACO Services by the Health Authority: By determining whether a system of reimbursement for the services provided could be implemented by the regional authorities after the project was completed	6 mo	Descriptive statistics	No consultation was used for pulmonology in the component 2 (component 2 is relevant to the objectives of the systematic review) of the system.	Assessment of TELEMACO network: Implementation of project had positive impact on innovations in working methods and procedures. Acceptance of TELEMACO Services by the Health Authority: health authority decided to implement new health networks for better home care	The study has three components, of which only second component which describes “Second opinion for PCPs in cardiology, Dermatology, Diabetology and pulmonology” is included in the description of the study for purpose of this systematic review. Moreover, the methods to assess the network and the acceptance are not described in details in the paper.
Thijssing et al [34]	1. Quality of Care: (using a questionnaire completed by PCPs after the TPCs) The % of Telepulmonology Consultation (TPC) requests, the %of patients physically referred by PCPs to pulmonologists, education effect experienced by PCP, % of TPCs in which the PCP was helped with the pulmonologist’s response and mean response time of pulmonologists; 2. Efficiency of Care: % of prevented physical referrals, % of physical referrals who otherwise would not have been referred to a pulmonologist.	April 2009 and November 2012. (3 y and 8 mo)	Descriptive statistics	Twenty-three percent of the patients were diagnosed with COPD by pulmonologist. The pulmonologist answered ‘Unsure’ to the question ’Diagnosis COPD?’ in 16% and with ‘No’ in 61% of the cases.	Quality of care: 1. percentage of TPCs sent by PCPs for which advice of a pulmonologist was requested: 69%; 2. 92% PCPs admitted to have learned from the pulmonologists; 3. in 96% cases, the PCPs or patients found the pulmonologists' advice helpful; 4. percentage of patients physically referred by the PCP to the pulmonologist, who would not have been referred without telepulmonology: 18% of the TPCs; 5. Pulmonologists answered the TPCs on average after 18.2 working hours. Efficiency of care: 1. the percentage of prevented physical referrals: 27%	Telepulmonology can contribute to more efficiency and a higher quality of care for COPD patients. The clinical follow up of the patients is not done, neither any data mentions if the patient visited the pulmonologists after the suggested referral. The pulmonologists are not asked about the services/ the data are not presented in the paper. The pulmonologists responded after 18 h average; however, the paper does not mention how the patients were informed about the diagnosis/ treatment suggested.
Metting et al [35]	1. Feasibility: the proportion of PCPs in the target area who used the AC service, the proportion of patients with asthma or COPD who were assessed by the service, the quality of the spirometry and the number of patients that could be diagnosed, and the variation in diagnostic pattern between the different pulmonologists by using χ2. 2. Follow-up visits. Patients for whom medication change was advised by the pulmonologist were automatically scheduled for an additional follow- up assessment after 3 mo	2007 to 2012 (5 y)	Nonparametric paired tests were used to compare baseline data with follow-up data. Paired t tests were used for the longitudinal evaluation of FEV1(in litres). Follow-up data of baseline GOLD stages are presented to show the distribution of these patients to other GOLD stages	1. Usable quality for diagnosis- spirometry as per pulmonologist: 93.6%; 2. diagnosed patients: 79.4%; 3. Baseline diagnosis matching with follow-up: 91.2%; 4. Inhalation technique improved significantly: from 35.1% to 52.5% in three months; 5. Significant improvement in Asthma and COPD status during follow-up: Well controlled asthma patients from 23.9% to 49.5% and well controlled COPD patients from 27.4% to 48.9% in three months	79.3% of the PCPs in the target area referred patients to the service. 60% of adults’ asthma and COPD patients were referred at least once.	If PCP followed the referral recommendation of the pulmonologist is not documented
Fadaizadeh et al [36]	(1) Compare the pace of tele-consultation and regular (bedside) consultation: Patient records assessed and the mean time between requesting consultation and visit by the off-site physicians was evaluated and compared; (2) Physicians’ satisfaction from tele-Consultation: A questionnaire comprising of three choices was used (fully satisfied, partly satisfied, and not satisfied)	October 13 to December 2015 (26 mo)	Comparison of mean time using Mann- Whitney non- parametric test.	The highest rate of consultation was in neurology (27 cases) and thereafter, in neurosurgery (11 cases). Other consultations were in endocrinology (3 cases), gastroenterology (2 cases), thoracic surgery (2 cases), vascular surgery (2 cases), ophthalmology (1 case), haematology (1 case) and dermatology (1 case)	1. Teleconsultations were answered 2.5 times faster than face to face consultation; 2. Satisfaction survey results showed that the physicians were fully satisfied with teleconsultations in 82.75% of cases. They were partly satisfied in 12.06% and not satisfied in 5.17% of consultations	The paper describes the tele-ICU for thoracic surgery patients however, the consultation provided was mostly for other problems and only two consultations of thoracic surgery are mentioned in the results. Moreover, the number of consulting physician/s is not mentioned in the paper
Weikert et al [37]	Authors evaluated basic patient characteristics (age and sex) as well as the geographic distribution of referring hospitals. Furthermore, authors analysed technical aspects like slice thickness, tube current (mAs) and peak kilovoltage, determined whether the slice thickness of transmitted CTs complied with the recommendations defined by the Fleischner Society and in the ATS/ERS/JRS/ALAT-guideline. A questionnaire based online survey was conducted to assess satisfaction with and impact of the program and the structured reports that were generated within the context of the teleradiology program.	Jan 2014 to May 2019 (5 y)	Descriptive statistical analysis	Satisfaction with the centralized IPF expert teleradiology program was 8.4 (out of 10). Their impact on the clinical management of the patients was rated 9.0/10. The utility of the teleradiology program regarding the gaining of own expertise in IPF was assessed as 9.3/10.	All referring physicians (100%) stated that they would recommend the centralized IPF teleradiology program to their colleagues	The HRCT referral although was intended from 12 countries, half of those did not contribute to even 10% of the total number of scans. The survey was taken only by one third of the total participating physicians hence the satisfaction results couldn’t be generalized.
Wrenn et al [29]	Authors categorized the question asked during teleconsultation as “diagnosis,” “treatment,” and/or “monitoring.” They further reviewed the medical record to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the teleconsultation emergency department visit, or hospital admission during the follow-up	August 2012 and January 2013 (6 mo)	Descriptive statistics	No clinical outcomes	1. PCPs asked questions related to diagnosis in 71% of cases, treatment in 46% of cases, and monitoring in 21% of cases; 2. CPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the teleconsultation, 14% of patients had a specialist visit within the UCSF system in the same specialty as the teleconsultation	The patient visit to specialists were recorded if the patient visited the same hospital, however, there is a possibility that the patients could access another health care facility. The results are analysed from the data collected from one centre hence the results may not be generalizable.