| Chau et al [24] |
Hong Kong |
N=40
(Ia: 22, Cb: 18) |
Inclusion: aged 60 and older, with moderate or severe COPDc according to the classification of the Global Initiative of Obstructive Lung Disease, admitted to hospital at least once for exacerbation during the previous year. Exclusion: unable to communicate, had impaired cognitive function, illiterate, had hearing problems, or unable to operate the telecare device.
|
Home visits with education on self-care and symptom management techniques; a device kit (a specially designed mobile phone, a respiratory rate sensor, and a pulse oximeter), which is used for participants’ self-monitoring of oxygen saturation, pulse rate, and respiration rate |
Only home visits with education on self-care and symptom management techniques |
Community nurse |
8 weeks |
|
ORd 2.33 (95% CI 0.51 to 10.78) |
| Chow and Wong [25] |
Hong Kong |
N=281
(I: 96, C: 185) |
Inclusion: aged 65 and older; admitted with a medical diagnosis related to chronic respiratory, cardiac, type 2 diabetes mellitus, or renal diseases; able to speak Cantonese and to communicate; resident in the hospital service area; and able to be contacted by telephone after discharge. Exclusion: identified as having cognitive problems, Mini-Mental State Examination score of <20; discharged to institutional care; followed by a designated disease management program after discharge; unable to communicate; and terminally ill.
|
Telephone calls, comprehensive assessment based on the OMAHA system, analysis of self-care barriers, development of mutual self-care goals, evaluation of interventions |
Home visits, social calls |
Nurse case managers, senior year nursing students |
4 weeks |
|
SMDf 0.23 (95% CI –0.01 to 0.48) SMD 0.03 (95% CI –0.22 to 0.56) SMD 0.17 (95% CI –0.07 to 0.42)
|
| De San Miguel et al [26] |
Australia |
N=71
(I: 36, C: 35) |
Inclusion: Silver Chain clients with a diagnosis of COPD, receiving domiciliary oxygen, able to speak English, living in the metropolitan area. Exclusion: diagnosed with dementia, receiving palliative care, did not have a telephone landline, unable to use the telehealth equipment because of cognitive or physical impairment.
|
Telehealth equipment (HealthHUB), daily measurements, recording and monitoring of vital signs, assessment of general state of health, home visits, educational book about COPD, telehealth instruction manual, telephone calls, provision of support/advice/recommendations |
Home visits, education book about COPD |
Telehealth nurse |
24 weeks |
|
OR 0.28 (95% CI 0.10 to 0.76) |
| Finkelstein et al [27] |
United States |
N=84
(I: 40, C: 44) |
Inclusion: aged 60 and older, managing 1 or more chronic diseases, not receiving Medicare home health benefits but had functional limitations, able to manipulate a computer keyboard or a mouse, and had a broadband connection available in their area. Exclusion: not mentioned.
|
Home telehealth program using the VALUE workstation, videoconferences, electronic messages, ordering of health-related and home care services, access to health-related information, general access to the internet, physiological monitoring devices |
Usual care |
Telehealth nurse |
8.5 weeks |
|
OR 0.41 (95% CI 0.15 to 1.14) |
| Finlayson et al [28] |
Australia |
N=222
(I: 111, C: 111) |
Inclusion: aged 65 and older; admitted with a medical condition; had at least one risk factor for readmission (aged 75 or older, admitted to a hospital more than once in the previous 6 months, multiple comorbidities, living alone, poor social support, poor self-rating of health, functional impairment, or a history of depression). Exclusion: requires home oxygen, dependent on a wheelchair or unable to walk independently for 3 m, lives in a nursing home, presence of a cognitive deficit or progressive neurological disease.
|
Tailored exercise program, in-home visits, telephone follow-ups, reinforcement and further explanation of the exercise program, advice and support to the caregiver |
Usual care, exercise program without regular telephone follow-ups |
Advanced practiced nurse, exercise physiologist |
24 weeks |
|
OR 0.40 (95% CI 0.17 to 0.92) |
| Gellis et al [29] |
United States |
N=94
(I: 48, C: 46) |
Inclusion: aged 65 and older, diagnosed with heart failure or COPD, experienced frequent health care encounters (ie, hospitalized twice in the last 6 months or seen at least twice in the emergency room in the past 2 months), required 3 or more home visits per week, consented to participate in the program with random assignment, expressed a willingness to learn how to use the telehealth monitoring system. Exclusion: unable to learn to use the HomMED telehealth device due to physical disability, cognitively impaired based on a medical chart diagnosis and had no caregiver, exhibited behavioral/problems (eg, aggression, agitation, delirium, paranoia) that interfered with learning how to use the HomMED telehealth device and communicating with the telehealth nurse.
|
The Honeywell “HomMed” Health Monitoring System for daily monitoring of weight, noninvasive blood pressure, pulse, oxygen saturation, and temperature; further evaluation of abnormal readings by telehealth nurse, education and counseling on disease, self-care activities, and symptom management strategies |
Usual care, education |
Homecare telehealth nurse manager, registered homecare nurses |
12 weeks |
Mental component of QoL Depression
|
|
| Jolly et al [30] |
UK |
N=516
(I: 239, C: 277) |
Inclusion: has respiratory symptoms consistent with COPD, reported mild dyspnea at the baseline assessment, had a forced expiratory volume in 1 second/forced vital capacity score of <0.7 after postbronchodilator spirometry (consistent with current UK guidelines) at the baseline assessment. Exclusion: considered by doctors to be inappropriate for inclusion (eg, for having a terminal disease or a severe psychiatric disorder)
|
Telephone health coaching with supporting written documents, a pedometer, and a self-monitoring diary |
Usual care with a standard information leaflet about the self-management of COPD |
Nurse |
24 weeks |
QoL Self-efficacy Depression
|
SMD 0.18 (95% CI 0.00 to 0.36)g SMD 0.23 (95% CI 0.06 to 0.41)g SMD –0.15 (95% CI –0.33 to 0.03)
|
| Kazawa et al [31] |
Japan |
N=32
(I: 17, C: 15) |
Inclusion: had a proteinuria level of ≥2+ or a proteinuria level of 1+ and a hemoglobin A1c level of ≥7.0% (or a fasting blood sugar level of ≥130 mg/dL) at a health check conducted in 2013, and diagnosed with type 2 diabetes mellitus. Exclusion: has type 1 diabetes mellitus or gestational diabetes, had initiated dialysis, scheduled for renal transplantation in the near future, undergoing treatment for cancer, has a terminal illness, has cognitive impairment, or has a mental disorder.
|
Distance interviews via a tablet with a featured app (delivered to the participants by postal mail), a guidebook, a self-monitoring notebook, and foot care monofilament |
Direct face-to-face interviews and intermittent telephone calls |
Nurse trained in disease management |
24 weeks |
|
SMD 6.50 (95% CI –1.44 to 14.44) SMD 0.80 (95% CI –4.02 to 5.62) SMD 3.50 (95% CI 0.55 to 6.45)g SMD 0.68 (95% CI –0.15 to 1.51) SMD –0.42 (95% CI –1.23 to 0.39)
|
| Kleinpell et al [32] |
United States |
N=206
(I: 134, C: 72) |
Inclusion: aged ≥65 at high risk for postoperative complications; documented history of congestive heart failure; New York Heart Association functional classification of III or IV; ejection fraction of ≤40%; a history of atrial fibrillation; postdischarge complications of myocardial infarction, arrhythmias requiring treatment, reoperation, cardiac arrest, wound dehiscence, a positive wound culture; ICUh stay of >2 days, mechanical ventilation for >2 days; or failure to meet clinical pathway discharge goals by postoperative day 5. Exclusion: not mentioned.
|
Home telemonitoring twice daily of vital signs including heart rate, blood pressure, and pulse oximetry, and daily monitoring of weight, focused reinforcement of the discharge plan |
No intervention |
Advanced practice nurse |
4 weeks |
|
|
| Oksman et al [33] |
Finland |
N=1570
(I: 970, C: 470) |
Inclusion: has a glycated hemoglobin (hemoglobin A1c) level of >7, or a total cholesterol level of >4.5, or a low-density lipoprotein level of >2.3 for the previous 6 months, identified by a research nurse as being eligible for coaching. Exclusion: classified as ineligible by primary care physician, unable to co-operate or participate in health coaching, major elective surgery planned within 6 months, history of major surgery within the past 2 years, life expectancy <1 year, pregnancy.
|
Individual health coaching by telephone, in addition to routine social and health care, including 8 key recommendations developed by Pfizer Health Solutions: (1) know how and when to call for help, (2) learn about the condition and set goals, (3) take medicines correctly, (4) get recommended tests and services, (5) act to keep the condition well, (6) make lifestyle changes and reduce risk, (7) build on strengths and overcome obstacles, and (8) follow-up with specialists and appointments |
Routine social and health care |
Certified nurses and public health nurses |
48 weeks |
|
|
| Pecina et al [34] |
United States |
N=166
(I: 77, C: 89) |
Inclusion: aged 60 years and older with an ERAi score in the highest decile. The ERA score is a composite score of previous hospitalizations, age, race, and presence of chronic disease. A high ERA score indicates an increased risk of hospitalization and emergency department visits. Exclusion: unable or unwilling to use the monitoring equipment, or if there was a concern about undiagnosed dementia after a mental status test.
|
Telemonitoring of biometric data using an Intel Health Guide device, questionnaires on symptoms, videoconference visits |
Usual care |
Geriatric nurse practitioner |
48 weeks |
Depression |
SMD 0.11 (95% CI –0.20 to 0.41) SMD –0.35 (95% CI –0.65 to –0.04) SMD –0.02 (95% CI –0.33 to 0.28) SMD 0.00 (95% CI –0.31 to 0.31)
|
| Takahashi et al [35] |
United States |
N=205
(I: 102, C: 103) |
Inclusion: aged ≥60; enrolled in the Employee and Community Health program primary care panel and whose ERA score exceeded 15. The ERA is an electronic database used to assess patient risk for hospitalizations or emergency department visits based on administrative data on age, sex, previous hospitalizations, and comorbid conditions (stroke, dementia, heart disease, diabetes mellitus, and chronic obstructive pulmonary disease).
Exclusion: lives in a nursing home, has a clinical diagnosis of dementia or scored 29 or less in the short test of mental status, unable to use the telemonitoring system (ie, because of visual impairment or an inability to use the device).
|
Telemonitoring device (Intel Health Guide; Intel-GE) with real-time videoconferencing capability and peripheral measures (scales, blood pressure cuff, glucometer, pulse oximeter, and peak flow data) |
Usual care |
Registered nurse |
48 weeks |
|
|
| Wong et al [36] |
Hong Kong |
N=610
(I: 204, C: 406) |
Inclusion: admitted with a primary diagnosis related to a respiratory, diabetic, cardiac, or renal condition; Mini-Mental State Examination score of >20; able to speak Cantonese; lives within the service area; can be contacted by phone. Exclusion: discharged to an assisted care facility, being followed up by an immediate designated disease management program after discharge, unable to communicate, discharged for end-of-life care.
|
Telephone calls, comprehensive assessment based on the OMAHA system, develop mutual self-care goals, evaluate interventions |
Home visits, placebo calls (ie, social calls) |
Nurse case managers, trained nursing students |
4 weeks |
Self-efficacy Hospital admissions
|
|
