Original Title: État des connaissances - Soins virtuels en médecine interne

Authors' objectives: The aging of the population and the increasing prevalence of chronic diseases will, undoubtedly, lead to a significant increase in the demand for continuous home and institutional care, in the current context of limited professional resources in Québec. Furthermore, the COVID-19 pandemic has led to a major advance in the use of virtual care tools to ensure access to care and services and to promote the continuity of care. In addition to information technologies that are now frequently used, the integration of virtual care modalities into care pathways is of growing interest for the evaluation, treatment, and follow-up of patients in specialty medicine. These modalities have the potential to improve access to health care for most patients, but also to foster their engagement in the management of their illness. In the context of a national project on virtual care, the Ministère de la Santé et des Services sociaux (MSSS) has mandated the Institut national d'excellence en santé et en services sociaux (INESSS) to provide a state-of-knowledge report to guide the use of virtual care in specialty medicine. This work will help maintain or optimize care pathways and support clinical practices and the provision of care and services to patient. The objective of this work is to inform public decision-makers, medical associations, and health and social services professionals about virtual care practices in specialty medicine. The project involves the following seven reports: 1) Pediatrics, 2) Psychiatry, 3) Neurology, 4) Hematology/Oncology, 5) Respirology, 6) General Surgery, and 7) Internal Medicine (this report).

Authors' results and conclusions: RESULTS: (#1 FINDINGS CONCERNING VIRTUAL CARE IN INTERNAL MEDICINE): The results concerning the virtual care interventions that were identified in care pathways often involve multiple modalities, e.g., telemonitoring, teleconsultation, tele-education, telerehabilitation and teleassistance; • Only a few reviews of the care pathways being in the field of practice of internal medicine in Québec were found, specifically, the preoperative medical assessment, the management of peripheral vascular disease and the management of multimorbidity; • Some authors of the selected studies conclude that further studies of good quality will be necessary. (#2.1 VIRTUAL CARE PATHWAYS REPORTED AS BEING CLINICALLY EFFECTIVE): • Disease management, support and monitoring via telemonitoring for patients with heart failure; • Education, advice on disease management and symptom monitoring via telemonitoring combined with tele-education for patients with heart failure. (#2.2 VIRTUAL CARE PATHWAYS REPORTED AS HAVING POTENTIAL CLINICAL EFFICACY, WHICH IS TO BE CONFIRMED BY FUTURE EVIDENCE): Medical evaluation via teleassistance or teleconsultation for patients scheduled for surgery; • Home rehabilitation support for intermittent claudication via telemonitoring using portable monitors to improve walking; • Multimorbidity management via the telemonitoring of biological and clinical parameters for individuals with multiple chronic diseases. (#3.1 VIRTUAL CARE MODALITIES FOR WHICH A POSITIVE IMPACT HAS BEEN REPORTED, SUCH AS: ): Telemonitoring used alone or in combination with other virtual care modalities for patients with heart failure patients to reduce the mortality rate and the symptoms associated with the disease and to improve disease management and quality of life; • Telerehabilitation for patients with heart failure to reduce the symptoms associated with the disease and to improve treatment adherence and quality of life; • Tele-education for patients with heart failure to reduce the mortality rate and improve treatment adherence and quality of life. (#3.2 ASPECTS THAT NEED TO BE CLARIFIED BY FURTHER STUDIES: ): Telemonitoring or telemonitoring combined with tele-education for clinical efficacy according to the length of the intervention, the frequency of the interventions, the professionals involved and the technological tools used in patients with heart failure; • Telemonitoring combined with tele-education for clinical efficacy according to the patient’s sociodemographic characteristics and type of heart failure, and for long-term efficacy in patients with heart failure; • Teleconsultation and teleassistance for the preoperative medical assessment; • Telemonitoring using portable monitors to improve walking in individuals with intermittent claudication. (3.3 VIRTUAL CARE MODALITIES REPORTED AS HAVING A POSITIVE IMPACT ON ORGANIZATIONAL EFFICIENCY, SUCH AS): Telemonitoring alone or in combination with other virtual care modalities for patients with heart failure patients to reduce the use of services; • Tele-education for patients with heart failure to reduce the use of services; • Teleconsultation and teleassistance for the medical assessment of patients scheduled for surgery, to check their eligibility for surgery and prepare them properly for it. (#3.4 FEW RESULTS CONCERNING PATIENT SAFETY): No adverse events or complications reported for telemonitoring combined with telerehabilitation in patients with heart failure. (#3.5 REPORTED SATISFACTION EQUIVALENT TO THAT WITH STANDARD CARE, ACCORDING TO THE REVIEWS CONSULTED): • Patients with heart failure state that they are generally satisfied with the use of telemonitoring, telerehabilitation, and telemonitoring alone or combined with tele-education; • Patients and virtual care providers have a high level of satisfaction with teleconsultation and teleassistance, which is comparable to the level of satisfaction with in-person services in the context of the preoperative medical assessment. LIMITATIONS: This report is limited by the following methodological constraints: the type of documents selected, the literature review period of 5 years, the fact that independent study selection was used for only 10% of the studies, the absence of a formal evidence assessment, and the descriptive data synthesis with no meta-analysis. Most of the selected systematic reviews aggregate or select, without distinction, data from primary studies conducted in various care settings with a variety of comparators, clinical situations, and technologies. When meta-analyses are included, the heterogeneity of the studies and interventions, the small number of studies compared or the small number of participants, and the poor quality of the studies are often listed in the limitations. In addition, cultural sensitivity or cultural adaptation and collaborative care, which are topics that should not be overlooked for equity in virtual care, were very rarely discussed. Lastly, selection, confounding and measurement biases in the studies also need to be taken into consideration. The practice of internal medicine in Québec differs not only from the practice in the other Canadian provinces but also from the practice in comparable countries around the world. For this reason, the literature search strategy had to be adjusted according to the main medical conditions managed by Québec internists. Therefore, following consultations with key collaborators, the search strategy for the present report focused on the following contexts: the preoperative medical assessment, the management of peripheral vascular disease, the management of multimorbidity and heart failure. CONCLUSION: In terms of internal medicine practice in Québec, the care pathway most studied in the literature for the use of virtual care is heart failure. Telemonitoring is the modality most frequently used in the care pathways studied. Virtual care in internal medicine generally seem promising for some care pathways. In any event, the modalities are used alone or in combination with other modalities, and virtual care can be used in place of or in addition to standard care.

Authors' methods: A scoping review was conducted to portray the care pathways that might be supported or optimized with the use of virtual care. A review of the scientific and grey literature was carried out, the time period being the past 5 years. The existing national and international guidelines, guidance and discussion papers, and health technology assessment (HTA) reports published on the topic were also consulted to identify additional care pathways or to confirm those mentioned in the systematic reviews. Documents were selected according to predefined inclusion and exclusion criteria. These steps were carried out by one reviewer, and 10% of the titles and abstracts evaluated were independently reevaluated by a second reviewer. The literature selection process led to evidence extraction by a reviewer. The extracted data were analyzed and presented in the form of a narrative synthesis and tables for each care pathway identified. Because of the rapid nature of the work and the type of review conducted, the methodological quality of the selected documents was not assessed. In addition, the consistency of the study results, the number of studies and their perceived quality, the biases noted, and the statistical analyses of the meta-analyses were taken into account when drawing up the findings concerning care pathways and virtual care modalities that support or optimize clinical practices in specialty medicine.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Med_Interne_EC.pdf

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Rapports/OrganisationsSoins/INESSS_Soins_virtuels_Med_Interne_EC.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)