Remote care through telehealth for people with inflammatory bowel disease The Cochrane Database of Systematic Reviews
Abstract Background People with inflammatory bowel disease (IBD) require intensive follow‐up with frequent consultations after diagnosis. IBD telehealth management includes consulting by phone, instant messenger, video, text message, or web‐based services. Telehealth can be beneficial for people with IBD, but may have its own set of challenges. It is important to systematically review the evidence on the types of remote or telehealth approaches that can be deployed in IBD. This is particularly relevant following the coronavirus disease 2019 (COVID‐19) pandemic, which led to increased self‐ and remote‐management. Objectives To identify the communication technologies used to achieve remote healthcare for people with inflammatory bowel disease and to assess their effectiveness. Search methods On 13 January 2022, we searched CENTRAL, Embase, MEDLINE, three other databases, and three trials registries with no limitations on language, date, document type, or publication status. Selection criteria All published, unpublished, and ongoing randomised controlled trials (RCTs) that evaluated telehealth interventions targeted at people with IBD versus any other type of intervention or no intervention. We did not include studies based on digital patient information resources or education resources, unless they formed part of a wider package including an element of telehealth. We excluded studies where remote monitoring of blood or faecal tests was the only form of monitoring. Data collection and analysis Two review authors independently extracted data from the included studies and assessed their risk of bias. We analysed studies on adult and paediatric populations separately. We expressed the effects of dichotomous outcomes as risk ratios (RRs) and the effects of continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs), each with their 95% confidence intervals (CIs). We assessed the certainty of the evidence using GRADE methodology. Main results We included 19 RCTs with a total of 3489 randomised participants, aged eight to 95 years. Three studies examined only people with ulcerative colitis (UC), two studies examined only people with Crohn's disease (CD), and the remaining studies examined a mix of IBD patients. Studies considered a range of disease activity states. The length of the interventions ranged from six months to two years. The telehealth interventions were web‐based and telephone‐based. Web‐based monitoring versus usual care Twelve studies compared web‐based disease monitoring to usual care. Three studies, all in adults, provided data on disease activity. Web‐based disease monitoring (n = 254) is probably equivalent to usual care (n = 174) in reducing disease activity in people with IBD (SMD 0.09, 95% CI −0.11 to 0.29). The certainty of the evidence is moderate. Five studies on adults provided dichotomous data that we could use for a meta‐analysis on flare‐ups. Web‐based disease monitoring (n = 207/496) is probably equivalent to usual care (n = 150/372) for the occurrence of flare‐ups or relapses in adults with IBD (RR 1.09, 95% CI 0.93 to 1.27). The certainty of the evidence is moderate. One study provided continuous data. Web‐based disease monitoring (n = 465) is probably equivalent to usual care (n = 444) for the occurrence of flare‐ups or relapses in adults with CD (MD 0.00 events, 95% CI −0.06 to 0.06). The certainty of the evidence is moderate. One study provided dichotomous data on flare‐ups in a paediatric population. Web‐based disease monitoring (n = 28/84) may be equivalent to usual care (n = 29/86) for the occurrence of flare‐ups or relapses in children with IBD (RR 0.99, 95% CI 0.65 to 1.51). The certainty of the evidence is low. Four studies, all in adults, provided data on quality of life. Web‐based disease monitoring (n = 594) is probably equivalent to usual care (n = 505) for quality of life in adults with IBD (SMD 0.08, 95% CI −0.04 to 0.20). The certainty of the evidence is moderate. Based on continuous data from one study in adults, we found that web‐based disease monitoring probably leads to slightly higher medication adherence compared to usual care (MD 0.24 points, 95% CI 0.01 to 0.47). The results are of moderate certainty. Based on continuous data from one paediatric study, we found no difference between web‐based disease monitoring and usual care in terms of their effect on medication adherence (MD 0.00, 95% CI −0.63 to 0.63), although the evidence is very uncertain. When we meta‐analysed dichotomous data from two studies on adults, we found no difference between web‐based disease monitoring and usual care in terms of their effect on medication adherence (RR 0.87, 95% CI 0.62 to 1.21), although the evidence is very uncertain. We were unable to draw any conclusions on the effects of web‐based disease monitoring compared to usual care on healthcare access, participant engagement, attendance rate, interactions with healthcare professionals, and cost‐ or time‐effectiveness. The certainty of the evidence is very low. Authors' conclusions The evidence in this review suggests that web‐based disease monitoring is probably no different to standard care in adults when considering disease activity, occurrence of flare‐ups or relapse, and quality of life. There may be no difference in these outcomes in children, but the evidence is limited. Web‐based monitoring probably increases medication adherence slightly compared to usual care. We are uncertain about the effects of web‐based monitoring versus usual care on our other secondary outcomes, and about the effects of the other telehealth interventions included in our review, because the evidence is limited. Further studies comparing web‐based disease monitoring to standard care for the clinical outcomes reported in adults are unlikely to change our conclusions, unless they have longer follow‐up or investigate under‐reported outcomes or populations. Studies with a clearer definition of web‐based monitoring would enhance applicability, enable practical dissemination and replication, and enable alignment with areas identified as important by stakeholders and people affected by IBD.
SHOW FULL ABSTRACT Morris Gordon, Vassiliki Sinopoulou, Svetlana Lakunina, Teuta Gjuladin-Hellon, Kelly Bracewell, Anthony K Akobeng
School of MedicineUniversity of Central LancashirePrestonUK Centre for GuidelinesNational Institute for Health and Care Excellence (NICE)ManchesterUK University of Central LancashirePrestonUK Pediatric GastroenterologySidra MedicineDohaQatar 