Introduction: Telemedicine extends intensivists� reach to critically ill patients cared for by other physicians. Our\r\nobjective was to evaluate the impact of telemedicine on patients� outcomes.\r\nMethods: We searched electronic databases through April 2012, bibliographies of included trials, and indexes and\r\nconference proceedings in two journals (2001 to 2012). We selected controlled trials or observational studies of\r\ncritically ill adults or children, examining the effects of telemedicine on mortality. Two authors independently\r\nselected studies and extracted data on outcomes (mortality and length of stay in the intensive care unit (ICU) and\r\nhospital) and methodologic quality. We used random-effects meta-analytic models unadjusted for case mix or\r\ncluster effects and quantified between-study heterogeneity by using I2 (the percentage of total variability across\r\nstudies attributable to heterogeneity rather than to chance).\r\nResults: Of 865 citations, 11 observational studies met selection criteria. Overall quality was moderate (mean score on\r\nNewcastle-Ottawa scale, 5.1/9; range, 3 to 9). Meta-analyses showed that telemedicine, compared with standard care, is\r\nassociated with lower ICU mortality (risk ratio (RR) 0.79; 95% confidence interval (CI), 0.65 to 0.96; nine studies, n = 23,526;\r\nI2 = 70%) and hospital mortality (RR, 0.83; 95% CI, 0.73 to 0.94; nine studies, n = 47,943; I2 = 72%). Interventions with\r\ncontinuous patient-data monitoring, with or without alerts, reduced ICU mortality (RR, 0.78; 95% CI, 0.64 to 0.95; six\r\nstudies, n = 21,384; I2 = 74%) versus those with remote intensivist consultation only (RR, 0.64; 95% CI, 0.20 to 2.07; three\r\nstudies, n = 2,142; I2 = 71%), but effects were statistically similar (interaction P = 0.74). Effects were also similar in higher\r\n(RR, 0.83; 95% CI, 0.68 to 1.02) versus lower (RR, 0.69; 95% CI, 0.40 to 1.19; interaction, P = 0.53) quality studies. Reductions\r\nin ICU and hospital length of stay were statistically significant (weighted mean difference (telemedicine-control), -0.62\r\ndays; 95% CI, -1.21 to -0.04 days and -1.26 days; 95% CI, -2.49 to -0.03 days, respectively; I2 > 90% for both).\r\nConclusions: Telemedicine was associated with lower ICU and hospital mortality among critically ill patients,\r\nalthough effects varied among studies and may be overestimated in nonrandomized designs. The optimal\r\ntelemedicine technology configuration and dose tailored to ICU organization and case mix remain unclear.
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