Effect of telemedicine on the quality of life of people with heart disease: a systematic reviewObjective: to synthesize the scientific evidence on the effectiveness of telemedicine-based interventions in improving health-related quality of life and self-management of patients with heart disease.
Method: systematic review of effectiveness, following the recommendations of the Joanna Briggs Institute and the reporting guideline Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist. The search was conducted in six databases: Cochrane Library, Virtual Health Library, PubMed, CINAHL, Web of Science Core Collection and Scopus, without period restriction, in English, Portuguese or Spanish. The methodological quality and risk of bias of the studies were assessed using the JBI critical appraisal tool and the certainty of the evidence was classified using the GRADE tool.
Results: of the 44 randomized clinical trials included, the main interventions analyzed were telemonitoring, telephone contact and telerehabilitation. Out of the studies evaluated, 88.63% demonstrated an improvement in health-related quality of life, with 45.45% of these showing a statistically significant difference.
Conclusion: telemedicine shows promise as a valuable tool for the care and self-management of individuals with cardiac conditions. However, further studies are needed to confirm its effectiveness and impact on health outcomes.
Descriptors:
Telemedicine; Heart Diseases; Self-Management; Quality of Life; Telerehabilitation; Self Care
Highlights:
(1) The main resources observed were: telemonitoring, tele-connection and telerehabilitation. (2) Telemedicine can be an effective tool in the care of cardiac conditions. (3) The real impact on quality of life in cardiac diseases is still uncertain. (4) Studies related to aspects of quality of life are still needed.
Objetivo: sintetizar as evidências científicas sobre a efetividade das intervenções baseadas em telemedicina na melhoria da qualidade de vida relacionada à saúde e ao autogerenciamento de pacientes com doenças cardíacas.
Método: revisão sistemática de efetividade, seguindo as recomendações do Joanna Briggs Institute e do guia de relato PreferredReportingItems for Systematic Reviews and Meta-Analyses Checklist. A busca foi conduzida em seis bases de dados: Cochrane Library, Biblioteca Virtual em Saúde, PubMed, CINAHL, Web of Science Core Collection e Scopus, sem restrição de período, nos idiomas inglês, português ou espanhol. A qualidade metodológica e o risco de viés dos estudos foram avaliados utilizando a ferramenta de avaliação crítica da JBI e a certeza da evidência foi classificada por meio da ferramenta GRADE.
Resultados: dos 44 ensaios clínicos randomizados incluídos, as principais intervenções analisadas foram telemonitoramento, contato telefônico e telerreabilitação. Dos estudos avaliados, 88,63% demonstraram melhora na qualidade de vida relacionada à saúde, com 45,45% destes apresentando diferença estatisticamente significativa.
Conclusão: a telemedicina mostra-se promissora como ferramenta valiosa para o cuidado e o autogerenciamento de indivíduos com condições cardíacas. No entanto, são necessários mais estudos para confirmar sua efetividade e seu impacto nos desfechos de saúde.
Descritores:
Telemedicina; Cardiopatias; Autogestão; Qualidade de Vida; Telerreabilitação; Autocuidado
Destaques:
(1) Principais recursos observados foram: telemonitoramento, ligação e telerreabilitação. (2) A telemedicina pode ser uma ferramenta efetiva no cuidado de condições cardíacas. (3) O impacto real na qualidade de vida em relação às doenças cardíacas ainda é incerto. (4) Estudos relacionados aos aspectos da qualidade de vida ainda são necessários.
Objetivo: sintetizar la evidencia científica sobre la efectividad de las intervenciones basadas en telemedicina en la mejora de la calidad de vida relacionada con la salud y en el autogestión de pacientes con enfermedades cardíacas.
Método: revisión sistemática de efectividad, siguiendo las recomendaciones del Joanna Briggs Institute y la guía de reporte Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist. La búsqueda se realizó en seis bases de datos: Cochrane Library, Biblioteca Virtual en Salud, PubMed, CINAHL, Web of Science Core Collection y Scopus, sin restricción de período, en los idiomas inglés, portugués o español. La calidad metodológica y el riesgo de sesgo de los estudios fueron evaluados utilizando la herramienta de evaluación crítica de la JBI y la certeza de la evidencia fue clasificada mediante la herramienta GRADE.
Resultados: de los 44 ensayos clínicos aleatorizados incluidos, las principales intervenciones analizadas fueron telemonitoreo, contacto telefónico y telerrehabilitación. De los estudios evaluados, el 88,63% demostró una mejora en la calidad de vida relacionada con la salud, con el 45,45% de estos presentando una diferencia estadísticamente significativa.
Conclusión: la telemedicina se muestra prometedora como una herramienta valiosa para el cuidado y autogestión de individuos con condiciones cardíacas. Sin embargo, se necesitan más estudios para confirmar su efectividad e impacto en los resultados de salud.
Descriptores:
Telemedicina; Cardiopatías; Automanejo; Calidad de Vida; Telerrehabilitación; Autocuidado
Destacados:
(1) Los principales recursos observados fueron: telemonitoreo, llamadas telefónicas y telerrehabilitación. (2) La telemedicina puede ser una herramienta efectiva en el cuidado de condiciones cardíacas. (3) El impacto real en la calidad de vida en las enfermedades cardíacas aún es incierto. (4) Se requieren más estudios relacionados con los aspectos de la calidad de vida.
Introduction
Chronic non-communicable diseases (NCDs) represent a significant portion of the causes of death worldwide, accounting for approximately 74% of deaths globally(1). Among them, cardiovascular diseases (CVDs) are an alarming factor, having been responsible for approximately two million deaths in the Americas in 2019(2).
In this scenario, addressing the challenge of CVDs has become a priority, especially due to the continuous aging of the world’s population and the multifactorial complexity that characterizes these diseases(3). In addition, NCDs, especially heart disease, are becoming a growing marker of global inequalities, being highly prevalent in developing countries(4).
Heart diseases are pathological conditions involving the heart, in terms of its structure and function(5). The development, progression and worsening of these conditions are directly related to risk factors, which can be classified as potentially modifiable, such as controlling blood pressure, blood glucose and lipid profile, or modifiable, such as smoking cessation, reducing excessive alcohol consumption, combating obesity, sedentary lifestyle, among others(6). Thus, the use of educational initiatives that seek to promote health literacy is recommended, since these actions have the potential to act on such risk factors, mitigating adverse events and hospital readmissions, while at the same time increasing the health-related quality of life (HRQoL) of affected individuals(7). In this context, it is observed that populations at high risk of CVD have more unfavorable HRQoL results(7). Thus, this variable emerges as a crucial indicator, being a strong predictor of both mortality and hospitalization for heart failure (HF), regardless of the severity of symptoms or ejection fraction(8). Thus, in order to address this reality, telemedicine emerges as a promising strategy to reduce mortality in individuals with heart problems and promote HRQoL and self-care(9). Furthermore, as shown in a systematic review on the effectiveness, acceptability and costs of telemedicine carried out in 2015, when considering strategies to improve risk factors, there was an improvement in HRQoL, a decrease in levels of glycated hemoglobin, low-density lipoproteins and blood pressure in individuals with NCDs(10).
It is undeniable that during the coronavirus pandemic there was widespread adoption of this remote care format as an alternative to in-person consultations, in response to restrictions on direct contact, demonstrating the system’s ability to adapt to emerging challenges(11).
Telemedicine is defined as the provision of health services remotely(12), i.e., the patient and the provider are separated by distance, mediated by a technological tool(13). There are several resources in this type of health care, such as consultations with health professionals (teleconsultation, hotlines and support lines), telemonitoring, telerehabilitation, storage and forwarding of health data (such as images, notes and videos) to care providers and teleconsultation between health professionals who provide care, communicating in search of other opinions for case management(13-14).
In view of this, telemedicine plays an essential role in global health care, being able to structure therapeutic initiatives that encompass educational objectives, accurate diagnoses and continuous monitoring(15-16). Furthermore, by overcoming geographic limitations(15), it has the potential to increase access to care, reduce costs and improve overall health outcomes(16). Thus, there is concern among health professionals regarding the ability of individuals to self-manage their own conditions in this care format(9).
Self-management is the “ability to manage symptoms, treatment, physical and psychosocial changes, and lifestyle changes that patients develop when dealing with chronic diseases”(17), usually requiring the support of a health professional(18). In this context, it is believed that telemedicine has a positive impact on supporting self-management, consequently improving the HRQoL of patients with heart disease.
To date, previous systematic reviews that addressed heart disease and telemedicine have not focused specifically on self-management and changes in HRQoL over time, addressing other outcomes such as mortality, hospitalization, and others(19-23). Furthermore, studies related to HRQoL perceived by patients have shown divergent results(19-20,23-24) and, as shown in a systematic review, studies using standardized measures to assess HRQoL, self-care and satisfaction are needed(10).
In view of this, this review aimed to synthesize the scientific evidence on the effectiveness of telemedicine-based interventions in improving HRQoL and self-management of patients with heart disease.
Method
This is a systematic review, conducted according to the recommendations of the Joanna Briggs Institute (JBI): Evidence Synthesis Groups(25) and reported according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA Checklist(26). The protocol was previously published in the Open Science Framework(27) on January 22nd, 2021, under DOI number 10.17605/OSF.IO/HQWGT. The search was conducted in March 2023.
The research was guided by the acronym PICOS (P – Population; I – Intervention; C – Comparison; O - Outcomes; S -Study)(25), with P (individuals aged 18 years or older with heart disease), I (telemedicine resources that support self-management), C (usual care, based on outpatient consultations), O (HRQoL) and S (Randomized controlled clinical trials). Based on this acronym, the following guiding question was developed: How effective are telemedicine interventions based on self-management compared to usual care on the HRQoL of adult patients with heart disease?
Eligibility criteria
Randomized controlled trials (RCTs) that compared usual care with the use of telemedicine in adult patients (≥ 18 years) with heart disease, evaluating the outcomes in HRQoL and self-management of these individuals, were included. The exclusion criteria were: RCTs that did not detail the methodology used and articles that included other clinical conditions (e.g., cancer and diabetes).
Data sources
To select the articles, the search strategy was implemented by the main researcher in the following databases: Cochrane Library (Wiley), Virtual Health Library (Portal BVS), Medical Literature Analysis and Retrieval System Online (MEDLINE, PubMed), CINAHL (EBSCOhost), Web of Science Core Collection and Scopus (via Portal Periódicos CAPES website).
Search strategy
The search strategy was specific to each database using two controlled vocabularies in health: Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS). The descriptors used were: “Telemedicine”, “Heart Diseases”, “Self-Management”, “Cardiac Rehabilitation” and “Health Education”, appropriate for each database. The complete search strategies can be found in the Supplementary Material (https://doi.org/10.48331/scielodata.MI2JBD).
Data selection and extraction
Two independent reviewers selected the studies, and a third reviewer resolved disagreements. First, titles and abstracts related to the research question and study objective were identified, and those potentially eligible were pre-selected. In the second stage, two independent reviewers evaluated the full texts of the pre-selected studies to confirm their eligibility. The selection process was performed using the Rayyan QCRI platform(28).
Data were extracted from the studies included in the review by two independent reviewers using a predetermined data extraction form. The form included the following axes: methodological details, intervention, and results [the form can be found in the Supplementary Material (https://doi.org/10.48331/scielodata.MI2JBD)]. Due to the complexity of the interventions, the selected studies were categorized according to the population studied and the intervention performed, considering the resources used. The extracted data included specific details about the participants, study methods, interventions, and results significant for the purpose of the review. Any disagreements that arose between reviewers were resolved through discussion or with a third reviewer. It was not necessary to contact the authors of the articles for additional information.
Data synthesis
The findings were presented in narrative form. The narrative synthesis included a detailed description of the included studies, categorized according to the study population, questionnaires used to measure HRQoL, follow-up time and the telemedicine interventions performed. Tables and figures were used to assist in the presentation of the data.
Critical evaluation of studies
Two independent reviewers performed a critical appraisal of all studies that met the inclusion criteria. Any discrepancies between the reviewers were resolved by consensus or by the intervention of a third reviewer. The methodological quality of the studies was assessed using the JBI critical appraisal checklist for randomized controlled trials. This checklist consists of 13 questions whose answers can be “yes”, “no”, “unclear” or “not applicable”(29). All studies were classified into five different domains, resulting in classifications of low risk of bias, moderate risk of bias or high risk of bias. The certainty of the evidence for the HRQoL outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument(30).
Results
The initial literature search identified a total of 2,341 studies from databases, in addition to four additional studies found through manual searches of reference lists of included articles. Of these, two studies were included in the primary search to develop the search strategy, while the other two were identified after analysis of the study protocols found in the final search.
After removing duplicates and reviewing the titles and abstracts, 80 studies were selected for full reading. The reasons for exclusion at this stage were mainly related to criteria such as population, intervention, comparison or outcome. Details on the reasons for exclusion can be found in the Supplementary Material (https://doi.org/10.48331/scielodata.MI2JBD).
Based on the full reading and analysis of the methodological quality of the studies, considering the eligibility criteria, the final sample was constituted, which included 44 randomized clinical trials. Figure 1 presents the detailed flowchart of the selection process of the studies included in this systematic review.
The descriptive summary of the RCTs included in this review is presented in following Figure 2.
The 44 RCTs included in this review involved a total of 12,732 patients, of whom 6,233 were allocated to the control group and 6,499 to the intervention group. The research was conducted on four continents, with 40.91% (n = 18) of the studies conducted in Europe(32,34-35,38-42,44,48,52,54,56-57,63-64,67,71), 36.36% (n = 16) in North America(37,43-46,51-53,59-60,62,65-66-67,63-64,66,68-70,72-74), 13.64% (n = 6) in Oceania(33,36,50,55,58,61) and 9.09% (n = 4) in Asia(31,45,47,49). The follow-up period ranged from one to 26 months, with an average follow-up of 8.4 months.
This systematic review reveals that the scientific literature on the subject is constantly expanding, especially with the inclusion of studies of high methodological quality. The first articles were published in 2003(73-74), and since then there has been no reduction in the number of publications. On the contrary, a significant increase in studies was observed, especially after the advent of the pandemic, when the results related to the use of telemedicine gained even more relevance.
The articles that met the inclusion criteria were subjected to a critical evaluation of their methodological quality (n=44). The results ranged from 53.85% to 92.31% of congruence with the instrument used(29). It is important to note that the main inconsistencies were found in the blinding of the outcome evaluators, the intervention applicators and the patients. Full details of the evaluations can be found in the Supplementary Material (https://doi.org/10.48331/scielodata.MI2JBD).
Regarding the characteristics of the population of the included studies, most patients were followed up with HF (68.18%, n = 30)(31,34,37,38,41,44-48,50-54,56,59-60,62,64-74), acute coronary syndrome (ACS) (15.22%, n = 7)(32-33,36,40,58,61,63) or coronary artery disease (CAD) (10.64%, n = 5)(35,40,42,54,57). In four studies(40,43,54,71), the intervention was aimed at a mixed population of patients with different heart diseases.
With regard to the resources and interventions adopted, the telemedicine modalities varied considerably, with emphasis on hybrid interventions that employ multiple tools to maximize treatment efficacy. Telemonitoring was the most frequently used intervention, appearing in 31 studies (68.89%)(31-32,34-35,38-46,48-49,51-53,56-60,62-64,67,68,70,73-74). In addition to telemonitoring, another intervention that stood out as a widely used support resource was the telephone call present in 23 articles (51.11%)(34,36,37,39,41-42,45,47,51-52,57,60-62,65-73). In most cases, they were used as complementary support(34,39,41-42,45,47,51-52,57,60-62,67-68,70,73), assisting in communication and patient monitoring. In some situations, however, they constituted the main form of intervention(36-37,65-66,69,71-72), highlighting their importance in scenarios where other technologies may not be available or feasible.
In addition to these interventions, telerehabilitation was identified in 13 studies (28.88%)(32,35,39,41-42,47,50,52,54-58). Among the hybrid approaches, the combination of telemonitoring and telerehabilitation stands out, present in nine studies (20%)(32,35,39,41-42,52,56-58). This approach offers real-time monitoring of vital signs and patient progress, in addition to remote exercise prescription. In turn, the use of short message services (SMS) alone is less common, cited in only one article(33), but frequently combined with other interventions(36,43,47,54-55,62) due to its ability to send reminders, instructions and ongoing motivations.
Of the 44 studies analyzed, the primary or secondary outcomes included a pre- and post-intervention comparison of HRQoL between the intervention and control groups. In this sense, a diversity was observed among the instruments used, with 81.81% (n=36) of the studies opting to use a single questionnaire(31-33,36-42,44-49,51-56-58,60-66,68-72,74), while 11.36% (n=5) used two questionnaires(50,55,59,67,73) and 6.81% (n=3) used three questionnaires(34-35,43). Among the scales used, the Short Form Health Survey-36 (SF-36) was the most common, being adopted in 17 (38.63%) of the clinical trials(34,39,41-44,52,55,59-61,63-64,67,70-74), while 12 (26.66%) studies adopted the Minnesota Living With Heart Failure Questionnaire (MLHFQ) scale(38,45-48,50,59,62,67-69,73). Variations of the EuroQol questionnaire were used in ten studies (24.44%)(32,35-36,43,49-50,55,58,71-72).
The GRADE assessment(30) revealed a serious risk of bias, the heterogeneity in the reports of measurement of effects prevented the performance of a pooled analysis. Figure 3 presents the evidence profile, separating the studies by questionnaires used and showing that the certainty of the evidence varied from low to very low.
Regarding the HRQoL results, none of the selected studies showed a worsening effect on the HRQoL of the telemedicine-based IG throughout the follow-up. Furthermore, 45.45% (n = 20) of the studies had a positive, statistically significant relationship with the HRQoL scores in the intervention group(33-34,41,45,47-49,51,54-55-58-60-65-68-70). However, the comprehensive analysis of the studies revealed that 11.36% (n = 5) did not observe any impact on HRQoL throughout the follow-up(36,38,40,66-67). In contrast, 43.18% (n = 19) demonstrated positive improvements in HRQoL, without reaching a statistically significant difference between the groups(31-32,35,37,39,42-44,46,50,52-53,56,57,59,71,74). Table 1 provides a detailed summary of the HRQoL results of the evaluated studies.
Discussion
Telemedicine interventions focused on self-management demonstrated a positive relationship in improving the HRQoL of patients with heart disease in 45.45% of the included studies(33-34,41,45,47-49,51,54-55-58-60-65-68-70). These interventions were mostly applied to individuals with HF(31,34,37-38,41,44-48,50-54,56,59-60,62,64-74), ACS(32-33,36,40,58,61,63) and CAD(35,40,42,54,57). Among the main resources used were telemonitoring, telephone calls, telerehabilitation, SMS and video consultations(31-74).
The scientific literature on telemedicine has shown steady growth since the first studies were published in 2003, with a significant increase in research during the COVID-19 pandemic(11). This systematic review analyzed 44 randomized clinical trials, involving a total of 12,732 patients. Despite a slight numerical disparity between the control (6,233) and intervention (6,499) groups, the distribution was considered balanced by the authors of the included studies. The studies were conducted mainly in Europe (40.91%) and North America (36.36%), with significant participation also from Oceania (13.64%) and Asia (9.09%). This geographic distribution highlights the broad acceptance and application of telemedicine technologies in diverse cultural and infrastructural contexts.
However, the expansion of telemedicine during the pandemic has also highlighted weaknesses, inequalities, and limitations in health systems that may have previously been less noticeable(11). Despite the positive geographic dissemination across continents, geographic gaps have been identified, especially in regions such as Latin America and Africa. The shortage can be attributed to the limited technological infrastructure and lower investments in telemedicine research in these locations(11). This highlights the need for multifaceted approaches to address these challenges and ensure a more comprehensive representation of telemedicine research on a global scale.
The measurement and assessment of HRQoL are challenges frequently faced in scientific research due to the multidimensional nature and the diverse definitions associated with this concept(75). Thus, considering this complexity, a variety of instruments have been developed and have been used to assess HRQoL(75). Overall, in the present review, the use of 17 different instruments was observed, with the predominance of a single questionnaire(31-33,36-42,44-49,51-56-58,60-66,68-72,74) for the assessment of the HRQoL outcome.
In this sense, the choice between using generic and condition-specific instruments to measure this variable has distinct advantages. Generic instruments allow the comparison of HRQoL between different health conditions, offering a broad and comparative view in different clinical situations. On the other hand, condition-specific measures focus directly on the assessment of HRQoL related to the condition under study, making them clinically more relevant instruments for understanding the specific impact of the disease on patients’ lives(76).
In this way, the use of dual perspectives provides more complete and complex interpretations in the approach to HRQoL in health research, allowing a more precise and informative analysis of the challenges faced by patients in different life contexts(76). Therefore, in this review, only nine studies performed HRQoL analysis based on two or three questionnaires(34-35,43,50,55,59,67,73-74).
In the population studied, a predominance of patients with HF was observed, representing 68.18% of the total(31,34,37-38,41,44-48,50-54,56,59-60,62,64-74). HRQoL in these patients was assessed using 10 questionnaires, including six specific to this population: MLHFQ(38,45-48,50,59,62,67-69,73), KCCQ(34,51,53,37), MacNew(31), HeartQol(54), HFSS(65), 70-item Quality of Life Index – Cardiac(73), and four generic questionnaires: SF-36(34,41,44,52,56,59-60,64,66,67,70,74), SF-8(66), WHO-5(34), and ED-5Q(50,71-72). Considering the context of HF, the use of the MLHFQ instrument is considered positive, as shown in a previous systematic review, which indicated it as the most suitable scale to measure HRQoL in these individuals, with the KCCQ as a secondary option(77).
Regarding the impact on patients’ HRQoL, a significant portion of the included studies (45.45%) showed positive results, with statistical significance, in the intervention group(33-34,41,45,47-49,51,54-55-58-60-65-68-70). Approximately 11.36% of the RCTs indicated no impact whatsoever(36,38,40,66-67), while another 43.18% indicated improvements in HRQoL, although without reaching a statistically significant difference(31-32,35,37,39,42-44,46,50,52-53,56,57,59,71,74). This diversity of results highlights the complexity and multifaceted nature of HRQoL as a health outcome, highlighting the importance of considering contextual and intervention-specific factors when assessing its impact on patients’ lives(75-76). Furthermore, although telemedicine is promising, its effectiveness varies due to methodological differences, characteristics of the populations included, and types of intervention. This finding is in line with a meta-analysis on the effectiveness of telemedicine in the management of NCDs, which indicated an improvement in HRQoL in studies on cardiovascular diseases, although without statistical significance(78).
In this sense, another important point to be highlighted is that the results of telemedicine interventions can be compared to traditional in-person care, without demonstrating inferiority. None of the included studies identified deterioration in HRQoL among participants. This suggests that the implementation of telemedicine in the care of cardiovascular conditions does not have adverse consequences on patients’ HRQoL and may even generate benefits for other health outcomes, such as repercussions on physical activity(32,34,39-42,47,52,54,57,61), use of health resources (hospitalizations, days of hospitalization, emergency room visits)(45,69,71,73), repercussions on mental health(38,46,53,63,73) and self-care(31,38,48,60,62).
Regarding the interventions used in the studies, it was observed that telemonitoring was the most comprehensive resource. When used in isolation, it presented positive repercussions on HRQoL in only 36.36% (4 of 11) of the studies(48-49,63-64). Similarly, RCTs that addressed only telephone calls demonstrated positive repercussions on HRQoL in only 33.33% (1 of 3)(61). However, combined interventions, such as the association of telemonitoring with phone calls, video consultations or SMS, showed statistically significant differences in 7 of 11 studies (63.63%)(34,45,51,60,62,68,70). In the case of telerehabilitation, which was always associated with another listed resource, a positive repercussion on HRQoL was observed in 38.46% (5 of 13) of the RCTs(41,47,54-55,58). These mixed results were also reflected in a systematic review of 19 studies on telemonitoring in heart failure, which identified heterogeneity in the studies that measured HRQoL, as well as questionable methodological quality and sample limitations(79). Regarding telerehabilitation, there was an improvement in HRQoL in eight studies, but without superiority in relation to usual care(32,35,39,42,50,52,56-57), which is corroborated by a systematic review comparing telerehabilitation to center-based rehabilitation, which demonstrated that this intervention is as effective in improving HRQoL(23).
In this sense, considering that cardiac telerehabilitation seems acceptable to patients and comparable to usual care, it may be an effective way to increase the reach and adherence to rehabilitation(80). However, future studies are needed to explore how telerehabilitation can be effectively integrated into health systems and how health professionals can be trained and supported to provide this type of care appropriately.
Regarding the follow-up period of the studies, a significant variation was observed between the RCTs, with periods ranging from one to 26 months, which may contribute to the heterogeneity of the results. Considering the positive and statistically significant impact on HRQoL, 10 studies performed follow-up for up to six months(47,49,51,54-55,58,61-62,65,68). Eight RCTs followed patients for 12 months(33-34,48,60,63-64,69-70), while one study performed follow-up for 24 months(45) and another for 26 months(41).
In a previous systematic review, it was observed that the improvement in HRQoL appears to be more evident in the short term in patients with CAD and in patients with HF over three months(81). This suggests the need for further studies on the relationship between follow-up time, population, and telemedicine resources to help identify the best care for each patient, considering that the literature is still incipient in this regard.
Thus, the use of more robust and improved methodologies, in addition to the standardization of telemedicine intervention protocols for heart disease, should be encouraged, since this will contribute to a more solid understanding of the real benefits and obstacles of the approach in the clinical context of these conditions.
Regarding the limitations of the selected studies, a predominance of sampling issues was observed, evidenced in the critical analysis of the studies. Only one study reported blinding of participants(63), two studies mentioned the blinding of professionals who performed the interventions(33,47), and 12 studies indicated that the outcome evaluators were blinded to the allocation of participants(32-33,36,40-41,47,50,52-55,64). In addition, other limitations were cited, such as sample size(31-32,37-40,43-45,58,60,62,67,69,74), follow-up time(31,35,41,44,49,56) and selection or recruitment bias(34-35,41,46-47,50-54,66-68,73) often due to the predominance of a specific cardiovascular disease, the majority presence of the male population or even the place of recruitment.
As implications for practice, we have that the use of telemedicine resources can be considered essential support tools to provide comprehensive care to the individual in intra- and extra-hospital environments, mainly considering its benefits for various health outcomes. However, robust studies are still needed to better measure the effect of the telemedicine strategy and its influence on health outcomes, such as follow-up time, patient and professional satisfaction, and equity of access, given that the interactions between outcomes are complex and must consider different contexts and populations.
Regarding the assessment of HRQoL, it is important to emphasize the need for studies with multifaceted approaches, considering the complexity of measuring this variable, due to its multidimensional nature, in order to ensure more accurate interpretations(75-76). In addition, the importance of deepening the relationships between follow-up time, population, and telemedicine intervention can also be mentioned.
Likewise, effective public policies and interventions adapted to the needs of each community(9), based on standardized protocols, are extremely important, since they have the potential to expand access to health, overcoming geographical barriers in promoting care(15).
Among the limitations of this review, we highlight the non-inclusion of gray literature, which could have expanded the search for complementary evidence. Furthermore, the review faced challenges related to the heterogeneity of interventions and resources used, as well as the specificity of the cardiac diseases addressed and the outcomes assessed. These variations made it difficult to conduct a meta-analysis, preventing a robust quantitative synthesis. However, the qualitative results remain valid to assess the effectiveness of the interventions in the contexts studied.
Conclusion
The effectiveness of telemedicine on HRQoL in individuals with CDs is still inconclusive. Although most studies have demonstrated a positive impact, many have not reached statistical significance. The main interventions used in the care and self-management of these conditions include telemonitoring, telephone contact and telerehabilitation. Telemedicine has the potential to be a valuable tool, comparable to face-to-face interventions in health centers. However, more studies are needed to evaluate its safety, cost-effectiveness and other long-term outcomes, especially HRQoL monitoring, to optimize the implementation of these technologies and ensure better outcomes for patients.
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How to cite this article
Alves GCG, Amador FLD, Santos VR, Moreira RSL. Effect of telemedicine on the quality of life of people with heart disease: a systematic review. Rev. Latino-Am. Enfermagem. 2025;33:e4566 [cited]. Available from: . https://doi.org/10.1590/1518-8345.7243.4566
Edited by
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Associate Editor:
Karina Dal Sasso Mendes
Publication Dates
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Publication in this collection
11 July 2025 -
Date of issue
2025
History
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Received
21 Dec 2023 -
Accepted
26 Jan 2025
