SCOPING REVIEW

Telemedicine for diagnosis or treatment during Covid-19: systematic review

Jéssyca Maria França de Oliveira Melo1, Filipe Reis Garcia2, Daianny Seoni de Oliveira3, Taís Carpes Lanes4, Marcos Gabriel do Nascimento Junior5, Gustavo Magno Baldin Tiguman6, Mariane Albuquerque Lima Ribeiro7

1Universidade Federal de Pernambuco, Recife, PE, Brazil

2Universidade Luterana do Brasil, Canoas, RS, Brazil

3Universidade de São Paulo, Santos, SP, Brazil

4Universidade Federal de Santa Maria, Santa Maria, RS, Brazil

5Universidade Tiradentes, Aracaju, SE, Brazil

6Universidade de Campinas, Campinas, SP, Brazil

7Universidade Federal do Acre, Rio Branco, AC, Brazil

ABSTRACT

Objective: To describe the use of telemedicine by health professionals for diagnosis or treatment of patients during the Covid-19 pandemic. Method: This is a systematic literature review of observational studies. Five databases were used. The assessment of the studies methodological quality occurred individually among the revisors and the Joanna Briggs Institute (JBI) tool was used. Results: The reviewers selected 22 articles from 6,180 works. The services provided through telemedicine were consultation/screening, consultation/follow-up or monitoring, test reports, medication prescriptions and case discussions. The technological resources used were platforms using video and telephone (audio and video). The use of telemedicine made it possible to reduce their exposure to Covid-19, reduce social panic and anxiety, quickly medical specialties access and the possibility of access to diagnosis and treatment of patients with chronic and acute diseases. Conclusion: Telemedicine can be an important tool in healthcare, keeping patients and healthcare professionals safe during the Covid-19 pandemic.

Descriptors: Telemedicine; COVID-19; SARS-CoV-2.

INTRODUCTION

In December 2019, the first news of the new coronavirus SARS-CoV-2 appeared on the TV news. This disease appeared in China as a contagious and potentially lethal respiratory infection that resulted in the greatest health adversity, the coronavirus (Covid-19) pandemic. Countries have been working to contain the spread of the infection using social distancing and stay-at-home orders(1).

Even with vaccines and supporting therapies, social distancing, face masking and quarantine are also giving space to telemedicine health care. Telemedicine is defined as a telecommunication tool to disseminate information about health services(2,3). It is observed that the rise of this strategy has been growing in recent decades, and the evolution of mobile technology has made health professionals adhere to this tool and to be able to disseminate information about health(4-7).

Every pandemic and public health emergency leads to an increase in demand for medical care, which strains local capacities. To prevent increased demand for office visits and the spread of diseases, telemedicine offers a solution to quickly respond to changes in diagnostic and/or treatment options during a health emergency(4).

Telemedicine is carried out by video conference, webchat, email, via Zoom, phone calls or mixed. And these ways are capable of increasing access to care, continuing medical education and health professionals training(7). Thus, integrating the health system together with new technological possibilities aimed at bringing a perspective of improvement to clinical care, with the aim of reducing the distance between the health service and the community(5,6).

In this context, when health systems are collapsing and one needs to reduce costs and, at the same time, one  needs to ensure the quality, access, completeness and equity of the service,  thus, one  must use strategies that can help and improve this scenario(8).

This study aims, through a systematic literature review, to describe the use of telemedicine by health professionals for diagnosis or treatment in patients during the Covid-19 pandemic.

METHOD

This is a systematic literature review with a qualitative approach. The question used to outline the research is “What are the impacts of the use of telemedicine by health professionals for the diagnosis or treatment of patients during the Covid-19 pandemic?”. The recommendations were met from the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRSMA-P 2015 Guidelines)(9).

The instrument used to assess methodological quality for observational studies was The Joanna Briggs Institute (https://jbi.global/critical-appraisal-tools). All the steps were performed by three reviewers independently. A protocol for the review was registered through PROSPERO under registration number: CRD42020181435.

The databases used were: Latin American and Caribbean Literature on Health Sciences (LILACS), EMBASE (Elsevier platform), Web of Science, MEDLINE (via PubMed) and Scopus. A combination of keywords, descriptors and MeSH was used as a search strategy, as follows:

"COVID-19"[Supplementary Concept] OR (2019 novel coronavirus disease) OR (covid 19) OR (COVID-19pandemic) OR (sars-cov-2 infection) OR (COVID-19virus disease) OR (2019 novel coronavirus infection) OR (2019-ncov infection) OR (coronavirus disease 2019) OR (coronavirus disease-19) OR (2019-ncov disease) OR (COVID-19virus infection); "Telemedicine"[Mesh] OR (Connected Health) OR (Digital Health) OR (Health 2.0) OR (Health Tele-Services) OR (Health Teleservices) OR (Health, Mobile) OR (Medicine 2.0) OR (Mobile Health) OR (Pervasive Computing) OR (Technologies for Healthcare) OR (Pervasive Health) OR Telecare OR Telecure OR Telehealth OR (Teleservices in the Health Sector) OR (Ubiquitous Health) OR eHealth OR mHealth OR (mHealth Alliance) OR u-Health”.

The Population, Intervention, Comparison, Outcome, and Study Design Criteria (PICOS) were used to determine the inclusion and exclusion of articles for this review.  The following articles were included: Use of telemedicine by healthcare professionals for diagnosis or treatment of patients during the Covid-19 pandemic; Patients of all age groups without restriction of pathologies treated by telemedicine during the Covid-19 pandemic period; Observational Studies (case report and series, cross-sectional, cohort and case-control) and all languages. Review studies and gray literature were excluded.

Search results were stored using Rayyan for records management by embedding all searches in a library. Duplicate records will be removed. A first screening of all articles will be done at the title and abstract search level based on scope. Inclusion criteria will be applied by three independent reviewers. The reviewers performed the analysis of each full-text article according to the inclusion and exclusion criteria. The selection of articles was carried out between December 2019 and May 2020 (Figura 1).

Source: Flowchart adapted from Peters et al., 2020.

Figure 1 – PRISMA flowchart of the study selection process for inclusion of studies for the systematic review. Santa Maria, RS, Brazil, 2020

Data extraction was performed by three authors using a Microsoft Excel spreadsheet. Articles were evaluated for publication date, year, country, target population/health professional, service provided (admission, consultation, meeting, remote patient monitoring, communication and counseling), technology used (asynchronous, synchronous, videoconferencing, mobile and mixed), sample size, study type, and category of findings (quality/technique, implementation, insights, clinical process/outcomes, cost-effectiveness).

The strategy for data synthesis was narrative and descriptive of the findings. The assessment of the methodological quality of the individual studies was performed by three researchers independently using Critical Appraisal Tools from Joanna Brigg’s Institute (JBI)(10).

The JBI is a tool used for methodological analysis of observational and experimental studies. In this aspect, the evaluation was used for observational studies, being a case report with 8 domains, a cohort study with 11 domains, a case series with 10 domains and a case-control study with 10 domains. The domains were answered with “yes”, “no”, “unclear” or “not applicable”. Data were recorded in a Microsoft Excel spreadsheet. This article did not require ethical approval because it is a literature review.

RESULTS

6,180 were found in the five databases and 769 articles were excluded due to duplicity. Of these 5,411 studies, 5,379 were excluded because they did not meet the inclusion criteria and at this stage, the selection was based on reading the title and abstract, totaling 32 studies. The 32 articles were read in full and the final selection was 22 works, according to the Figure 2. Figure 2 shows the following variables: Author, Country, Patient, Healthcare professional Service Provided, Technology Used and Study Design.

Figure 2 – Data extraction from the articles selected for the systematic literature review. Santa Maria, RS, Brazil, 2020

The 22 articles were carried out for methodological analysis according to the type of study being case report, case series, cross-sectional, cohort and case-control with the Critical Appraisal Tools tool (Figure 3, Figure 4 and Figure 5).

Figure 3 presents a methodological quality analysis of the type of case report study included.

Figure 3 - Methodological quality analysis of the type of case report study included. Santa Maria, RS, Brazil, 2020

Not applicable (NA)

Figure 4 presents a Methodological quality analysis of the type of case series and cohort study included.

Figure 4 - Methodological quality analysis of the type of case series and cohort study included. Santa Maria, RS, Brazil, 2020

Figure 5 presents a methodological quality of Cross-sectional studies and Case-Controls included.

Figure 5 - Methodological quality of Cross-sectional studies and Case-Controls included. Santa Maria, RS, Brazil, 2020

DISCUSSION

Telemedicine has provided health professionals with a reduction in their exposure to COVID-19, reduction of social panic and anxiety, access to medical specialties quickly and the possibility of access to diagnosis and treatment of patients.  There was adherence by patients to the use of telemedicine in ophthalmology, and among the benefits for patients were: reduction of waiting and travel time, but they claim concern about the diagnosis and loss of contact. For physicians, it was a possibility to minimize the transmission of COVID-19 and to use it to check symptoms, screening, ensure adherence to treatment and follow up pre and postoperative patients(1).

Payra Middleton et al.(4), telehealth needs legislation that ensures this form of care and the possibility of providing health services to people with difficulty accessing health. The telemedicine strategy is favorable for implementing multidisciplinary care as long as it uses appropriate technology and clinically stable patients(5).

For the adhesion of vulnerable populations, there are some recommended strategies: reduce digital technology disparities; virtual approaches to address social needs and language barriers; Internet privacy and security; and among the challenges are refunds to users and other forms of follow-up. An important intervention for adherence to telemedicine, for example, may have been influenced by the presence of family members at home during the pandemic in the treatment proposed to children(12).

Among the advantages discussed in the studies belonging to this review, there was the possibility of precision in the diagnosis, quick access to specialists for the population with difficulty to travel, cost reduction and reduction in the number of patients and overcrowding in outpatient centers(2,11,15) and reduce concern among patients with chronic diseases(2).

In the area of ​​urology, the use of the telemedicine service provided follow-up, consultations, guidance and prescription. More than 50% of urology patients were eligible for telehealth care and are in agreement with this type of care, as well as an efficient screening measure and protecting doctors and patients in the face of the COVID-19 pandemic and the disadvantages loss of clinical information and inaccuracies in telephone assistance(23-24).

The use of telemedicine in communicable diseases has become useful(27) to provide usual care(28). With the Covid-19 pandemic being a highly contagious disease, social distancing was recommended, and this led to an increase in the use of telemedicine(28). During this period of the pandemic, there was a 50-300-fold increase in the number of patients consulted via telemedicine(29). Another data on the use of telemedicine, 50% of physicians adhered to telemedicine and report that virtual consultation was not part of their practice(29-30).

The adhesion of telehealth technology in this scenario is evident that it is an effective and safe tool which there is a need to promote new incentives, policies and remove old barriers to telemedicine acceptance. It is clear that it is essential to follow guidelines and scientific evidence for the implementation of this system so that it can play a role in standardizing the provision of this service.

Among the benefits of telemedicine, it can reduce patient travel to the office/hospital, also causing a significant reduction in the emission of carbon dioxide and other atmospheric pollutants. There was no such description regarding pollutant reduction in this systematic review(31-33).

Regarding the use of telemedicine during the pandemic, 34.2% of the physicians claimed that telemedicine is valid in these circumstances and 42.5% stated that online consultation should be integrated into clinical practice, but 23% of the physicians reported that telemedicine was not important for their professional activity(33).

About the implementation of telemedicine, there are some negative aspects, namely: secrecy and privacy; reimbursement or payment of service bills using remote communication; and the technical or logistical difficulties involved in implementing telemedicine. Among other situations that concerned health professionals about the use of telemedicine, the issue of the patient's education level and their adherence to this practice and the legalization of prescriptions and virtual medical certificates were also mentioned(34).

Regarding the methodological evaluation of the articles, it can be mentioned that the case reports and case series studies present in this work meet the evaluation criteria, only one case report question obtained eight negative responses out of a total of 13 studies related to whether the condition post-intervention clinic was clearly described.

As for the cohort, there was a work of eleven questions and six negative answers. And of the four studies evaluated, the question “were confounding factors identified” all the evaluators' answers were negative. The three cross-sectional studies provided information to obtain a good assessment of methodological quality, but the cohort study had 80% of the criteria evaluated with negative responses by the evaluators.

The limitation was the lack of studies of randomized trials on the topic of telemedicine, and thus, the studies used for the systematic review were classified with a low level of evidence.

CONCLUSION

Telemedicine can be an important tool in health services in terms of prevention, screening, diagnosis, treatment and follow-up, keeping patients and health professionals safe during the COVID-19 pandemic even though the studies present in this review are observational.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 05/06/2023

Approved: 08/07/2023