This review sought to gather and synthesize the evidence on home telehealth for management of post-stroke patients. We looked at 3 areas:
- Patients: How is home telehealth used in treating post-stroke patients? Do patients like it? How clinically effective is it?
- Providers: What is the impact of home telehealth on health human resources? What are the roles of nurses, general practitioners, and specialists in its delivery? How do providers characterize their experiences with home telehealth?
- System: How is home telehealth incorporated into the care continuum? What is the economic impact of incorporating home telehealth into post-stroke care? What policies need to be in place for home telehealth to be successful?
In order to answer these questions, we conducted a systematic search for literature published from 2005 to 2010. This search retrieved 8 studies that met our inclusion criteria. The quality of the evidence was generally strong. A final search for publications from 2011 to 2012 found 1 additional study. Though findings from this study were incorporated into the review, be aware that material from the 2011-2012 period was screened and analyzed in a slightly different way than the studies retrieved in our original search.
Number and Location
A search of literature published from 2005-2010 located 8 studies of home telehealth for stroke treatment. Of these, 3 examined telehealth for physiological rehabilitation following stroke (Holden et al., 2007; Piron et al., 2006, 2009); 3 explored the use of telehealth in supporting oral anticoagulation therapy (O’Shea et al., 2008; Ryan et al., 2009; Salvador et al., 2008); and the remaining 2 studies focused on telehealth interventions intended to facilitate health education, peer support, and remote consultation for stroke patients and their caregivers (Lutz et al., 2009; Pierce et al., 2009; Steiner et al., 2008). Steiner et al. (2008) and Pierce et al. (2009) comprise a multi-part study: they present different outcomes, but describe the same intervention.
Four studies were conducted in the United States (Holden et al., 2007; Lutz et al., 2009; O’Shea et al., 2008; Pierce et al., 2009; Steiner et al., 2008) and 4 in Western European countries, including Italy (Piron et al., 2006, 2009), Ireland (Ryan et al., 2009) and Spain (Salvador et al., 2008). No Canadian studies were identified. Only 1 article specified whether the study population resided in an urban or a rural area (Steiner et al. 2008).
A scan of material from 2011-2012, a time period not covered by our initial searches, found 1additional study that met our inclusion criteria and filled gaps left by the first rounds of searching (Kuo et al., 2012). This study was analyzed in a slightly different way than the studies retrieved in our original search, and its findings were incorporated into this review in a limited fashion. For more details, please see Methods.
The Oxford 2011 Levels of Evidence were used to assess the strength of the evidence base. Studies were placed on a scale running from Level 1, considered the highest level of evidence, through to Level 5. Levels are based primarily on study design. Studies were also assigned scores for quality of execution and reporting. Low execution/reporting scores resulted in downgrading.
The Oxford 2011 Levels of Evidence are intended to provide guidance rather than absolute judgments, and do not obviate the need for careful appraisal of local needs and context. The quality of studies within a given level can vary, as can their applicability to select populations. Furthermore, this system is not suitable for all forms of assessment. In the text that follows, the Oxford 2011 Levels of Evidence are used only when discussing clinical outcomes.
The evidence base for home telehealth in stroke management was generally strong. Of the 8 studies retrieved, 5 received a Level 2 rating (Pierce et al., 2009; Piron et al., 2006, 2009; Ryan et al., 2009; Salvador et al., 2008; Steiner et al., 2008). These studies used concurrent comparison groups, prospective measurement of exposure and outcomes, and randomization. The crossover study by Ryan et al. (2009) was particularly strongly designed and executed, as was Pierce et al. (2009). Of the remaining studies, 2 qualified as Level 4 evidence (Holden et al., 2007; O’Shea et al, 2008); and 1 as Level 5 (Lutz et al., 2009). All 3 were case series studies with relatively small samples (n=12-60); however, Lutz et al. (2009) was downgraded a level for its low execution/reporting score.
Length of intervention period varied from 0.5 to 12 months. The studies on stroke rehabilitation tended to have shorter intervention periods of 1 to 1.5 months (Holden et al., 2007; Piron et al., 2006., 2009), while those on oral anticoagulation therapy examined 6- to 12-month periods (O’Shea et al., 2008; Ryan et al., 2009; Salvador et al., 2008). The 2 studies on education and post-stroke support bracketed the range of durations: 1 was just 0.5 months, while the other was 12 months (Lutz et al., 2009; Pierce et al., 2009; Steiner et al., 2008).
|And on the qualitative side . . .In addition to the publications described above, 1 qualitative study was retrieved (Damianakis et al., 2008). The study, based in Ontario, evaluated social workers’ perspectives on the effectiveness of web-conferencing in providing therapeutic support to caregivers of patients recovering from stroke. The intervention involved the provision of group therapy through web-conferencing. Nine therapists facilitated weekly 1-hour sessions for 10 weeks. Researchers surveyed therapists about their experiences in making the shift from face-to-face group therapy to online videoconferencing group therapy. Open-ended survey questions covered the following topic areas: “(1) working online as compared to face-face, (2) transitioning from facilitating face-to-face groups to video Internet groups, (3) assessing the quality of relationships amongst group members and client outcomes, (4) advantages and disadvantages of working through web-conferencing, and (5) recommendations for other clinicians beginning to work online” (p. 8).|
Population Characteristics: Demographics
The average ages of study participants were between 54 and 72 years. Most studies had a relatively equal proportion of male and female participants.
Of the 8 studies, 5 do not mention race or ethnicity. In those that do mention ethnicity, most were conducted primarily with Caucasian individuals (Lutz et al., 2009; O’Shea et al., 2008; Pierce et al., 2009; Steiner et al., 2008). Eligibility criteria in 1 study included the ability to communicate in English (Pierce et al., 2009; Steiner et al., 2008).
In only 2 cases was socioeconomic status reported. These studies focused on interventions with an educational component (Lutz et al., 2009; Pierce et al., 2009; Steiner et al., 2008). Socioeconomic status was indicated by mean years of schooling (Steiner et al., 2008; Pierce et al., 2009); employment status (Steiner et al., 2008; Pierce et al., 2009); and high school completion (Lutz et al., 2009).
Population Characteristics: Clinical Characteristics
In the 3 studies that examined telehealth for stroke rehabilitation, there was significant variation in the length of time that patients had lived with a stroke diagnosis or time since the stroke occurred. The mean time post-stroke was approximately 1 year in 2 studies conducted among patients who had experienced a single ischemic attack and were afflicted with mild to intermediate arm motor impairment (Piron et al., 2006; Piron et al., 2009). Inclusion criteria for patients in the remaining study were more stringent, requiring unilateral cerebral or brain stem lesion of vascular etiology with resultant hemiparesis and a certain degree of motor and sensory recovery in the upper extremity involved in the stroke (Holden et al., 2007). Average time post-stroke in this study was 3.8 years.
Several studies excluded patients with severe sensory impairment or clinical evidence of cognitive impairment, such as apraxia (Lutz et al., 2009; Piron et al., 2006; Piron et al., 2009; Holden et al., 2007).
 For a comprehensive overview of this system, please refer to Jeremy Howick, Iain Chalmers, Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, and Hazel Thornton. “Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document)”.
Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653
 Systematic reviews of randomized trials; n-of-1 trials.
 Mechanism-based reasoning.
 Subjects in Salvador et al. (2008) were not recruited through random sampling, but were randomized to group assignment.