The AHRQ Telehealth Evidence Map: An Analysis
By: Robert Longyear
Back in 2016, the Agency for Healthcare Research and Quality (AHRQ) commissioned a review of the clinical evidence for telehealth’s benefits. Remote patient monitoring was a significant part of the review as it has been studied extensively as a subset of telehealth. While reading the review (and, any health technology academic literature for that matter), I cannot help but think about how it reinforces the concept that we have a major definitional issue in the digital health arena. Telehealth is a broad term, while telemedicine is somewhat more specific yet both are often used interchangeably. The primary issue with considering RPM as a form of telehealth is that most people think of audio-visual physicians visits when they hear the term “telehealth.” This modality of virtual care is essentially like Zooming a physician or other healthcare provider wherein there is little superiority over traditional care models besides the provision of access to persons geographically distant from the healthcare provider. This access improvement is nice and certainly has tangible benefits, but the promise of RPM-based care models and other digital health tech-based care is that they can significantly improve the clinical performance of healthcare services over and above any access improvements.
The AHRQ review supports these conclusions and to the growth of remote patient monitoring into the standard of care for patients with a wide variety of conditions. Essentially, RPM has an excellent clinical evidence-base and excellent outcomes for patients. It has been primarily studied in patients with cardiometabolic conditions, however, there are applications across conditions both chronic and acute. In this article, I will summarize the findings of the AHRQ review and provide implications of it for various stakeholders across the healthcare industry.
What is AHRQ?
The Agency for Healthcare Research and Quality (AHRQ) is one of twelve agencies of the US Department of Health and Human Services. Its mission is as follows:
“AHRQ advances excellence in healthcare by producing evidence to make healthcare safer, higher quality, more accessible, equitable, and affordable.”
In the case of emerging healthcare technologies and care models, AHRQ funds the development of evidence reports and technology assessments to assist healthcare organizations both public and private in advancing healthcare services and population health in the US. It is important to note that the reports provide healthcare organizations with comprehensive, science-based information on innovations, technologies, and care models that can drive improvement in care for our most pressing healthcare needs. According to AHRQ,
“The goals of this Technical Brief are to provide an objective description of the state of the science in an evidence map of systematic reviews, that identifies key areas important for practice and policy decisionmaking in relation to the available evidence, creates a potential framework for assessing the applications and implications of telehealth interventions, generates a summary of ongoing research, and provides information on what future research is needed. In particular, through the Technical Brief, AHRQ hopes to gain insight on the appropriate conceptual framework and critical issues that will inform future research.”
The expectation from reports like this one, according to AHRQ, are to inform health plans, providers, and healthcare organizations by providing evidence-based conclusions.
Methods: How was this review performed?
The authors of the report utilized an evidence-map review which involves creating a comprehensive representation of the published studies to understand the breadth and depth of the conclusions from research on telehealth and its modalities.
The concept of the evidence map is similar to a systematic review wherein the goal is to describe rather than synthesize available research and to visually represent the conclusions whenever possible. The particular report focused on mapping the evidence from already published systematic reviews that synthesized the impact of telehealth interventions on clinical outcomes, utilization, or cost. The authors identified 1,494 citations about telehealth from which 58 systematic reviews met their inclusion criteria that was specified at the beginning of the project.
What does this tell us about telehealth and RPM?
The authors start their findings section with the statement:
“A large volume of research reported that telehealth interventions produce positive outcomes when used for remote patient monitoring, broadly defined, for several chronic conditions and for psychotherapy as part of behavioral health.”
With respect to RPM, after the review of the systematic reviews that covered remote patient monitoring, the authors concluded that models of care that utilize the technology produce positive health benefits for patients such as improved quality of life, condition management, condition improvement, and reductions in hospital admissions.
Given the quantity and quality of the evidence for RPM and other telehealth models, the authors recommend that future research should focus on implementation and how to incorporate telehealth models into clinical practice on a wide-scale.
Let us take a deeper dive into the findings of the report.
Telehealth Modalities Studied
Figure 1, below, shows the functions, or the modalities, of the telehealth models studied. It is important to note that these categories are not necessarily mutually exclusive or comprehensive, but they provide good insight into the breadth of the academic clinical studies on telehealth models of care. Remote patient monitoring is the largest category studied.
Figure 1: Telehealth Modalities Studied
Figure 2, below, shows the conditions of the target populations studied in the research that was reviewed by the systematic reviews included in the evidence-map–(confusing, I know.) This means that these are the conditions of the patients in which the conclusions for the efficacy of telehealth modalities can be drawn. Just like in pharmaceutical research studies that follow a phase 1, 2, and 3 pathway with the FDA, these populations can help healthcare leaders understand where to employ remote patient monitoring based on the evidence. That is not to say that there are other conditions and care settings wherein RPM models can be effective, but these are the areas in which we feel confident about the benefit to patients.
Figure 2: Distribution of Conditions Studied
If you follow the developments in the commercial RPM market (or the larger digital health market), these conditions line up well with the number of solutions marketed. Cardiometabolic conditions such as diabetes and hypertension are both highly prevalent, costly, and well-studied with respect to RPM. Thus, they are the focus of a great deal of commercial activity in the space.
Table 1 shows a summary of the first two pie charts. I include this table because it shows the number of patients included in the underlying studies included in the review. The total number for the entire review is 252,195 which lends itself to credibility of the conclusions drawn from this report. That is a significant sample size for these models. To compare, the majority of new drug clinical studies that make it to phase 3 include from 300 to 3000 study participants. Thus, it is important for healthcare providers and decision makers to understand that while the models and technologies vary widely between service providers, these types of clinical care models are well-understood despite no clear regulatory pathway. RPM, according to this review performed before 2016, has been studied in 48,321 patients. Thus, that is the equivalent of roughly 16 large-scale phase three drug trials.
Conclusions
The two dominant functions of telehealth covered by this report are communication & counseling (primarily in behavioral health) and remote patient monitoring. The evidence map below shows the function, the y-axis shows the number of patients in which the function was studied, the x-axis shows the weighted benefit for patients, while the shading/color of the bubble shows the strength of the evidence. RPM receives excellent marks on this chart for all of the factors analyzed.
Conclusions for Researchers
- Studies should be funded and executed in new conditions to learn more about the clinical outcomes in unstudied, but important conditions.
- As the authors of the AHRQ review suggest, future research should focus on implementation and adoption accelerators.
- Improving the definitions and descriptions of telehealth modalities will encourage better science, standardization, and positive patient outcomes at scale.
Conclusions for Healthcare Providers
- RPM is a viable and effective clinical model for you to implement in your clinics and facilities.
- Healthcare is moving into the home and as such technologies to collect data and connect the care team to the patient is going to become standard.
- RPM care models will become the dominant clinical model for patients with chronic disease in the next five years.
Conclusions for Investors
- RPM is a rapidly growing space with some estimates showing a global $110B market size by 2026 up from $22B in 2020.
- There are a number of approaches to RPM in the market, so it is important to ensure clinical effectiveness of the models employed by companies.
- All telehealth companies are not created the same as it is a catch-all term and thus product clinical capabilities, patient experience, and target market are important considerations.
Citation: Totten AM, Womack DM, Eden KB, McDonagh MS, Griffin JC, Grusing S, Hersh WR. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Technical Brief No. 26. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No.16-EHC034-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2016. www.effectivehealthcare.ahrq.gov/reports/final.cfm.