We performed a systematic review of telemedicine in chronic liver disease. In consultation with a biomedical librarian, we searched for English-language articles for relevant studies with adult participants from July 1984 to May 2017 in PubMed, OVID Medline, American Association for the Study of Liver Disease, EMBASE, Web of Science, ClinicalTrials.gov, Elsevier/Science Direct, and the Cochrane Library (the search strategy is shown in the Supplementary Material at https://doi.org/10.1016/j.cgh.2017.10.004). The references of original publications and of review articles additionally were screened for potentially relevant studies. Abstracts that later resulted in no publications and studies in which telemedicine was used to deliver care, but was neither an exposure nor outcome, were excluded. Social media studies were not considered telemedicine if no patient care was involved. Studies of purely medical education interventions or those that evaluated the accuracy of technology to aid in diagnosis also were excluded.
Supplementary Table 1 (https://doi.org/10.1016/j.cgh.2017.10.004) shows the 20 published articles of telemedicine studies. Among these, there were 9 prospective trials, 3 retrospective studies, 2 case reports, and 6 small case series. One of the studies was randomized prospectively and 10 were uncontrolled.
Telemedicine in hepatitis C treatment
Much of the published literature of telemedicine in liver disease (Supplementary References at https://doi.org/10.1016/j.cgh.2017.10.004) has described the use of video teleconferencing for the management of hepatitis C virus (HCV), both in the era of interferon-based treatment and with new direct-acting antivirals. Several studies in the United States and throughout the world retrospectively evaluated the use of live telemedicine/videoteleconferencing to deliver HCV therapy to incarcerated patients, those living in rural areas, and in the VA using the spoke-and-hub model. Generally, sustained virologic response rates were similar or higher with telemedicine than among patients receiving in-person visits, whereas discontinuation rates were generally low and side effects were well managed. Visits generally were led by nurses or specialty-care physicians and were associated with high patient satisfaction. A randomized study comparing a telephone-based self-management intervention of cognitive behavioral therapy vs. usual care for 19 veterans undergoing HCV treatment with interferon-based regimens showed that the telephone-based cognitive behavioral therapy group had lower depression and anxiety symptoms and reported a better quality of life. Several more recent abstracts have described successful use of telemedicine for HCV treatment (Supplementary Table 2 and Supplementary References [https://doi.org/10.1016/j.cgh.2017.10.004]). One of the most cited examples of telemedicine for HCV has been the Extension for Community Healthcare Outcomes (ECHO), or Project ECHO.7 This care model initially was designed to increase access to interferon-based treatment for patients with HCV in rural areas of New Mexico. In contrast to previously cited examples in which subspecialty or physician nurses directly provided clinical care in HCV, ECHO targeted front-line primary care providers to enhance expertise and enable problem-based learning via live video teleconferencing. Primary care providers participating in ECHO presented cases to content experts through video-linked knowledge networks; didactic presentations also were developed for provider education. The program has been expanded to Utah and Arizona and showed success with high rates of HCV treatment initiation and sustained virologic response.8 As an early adopter of telemedicine and after the success of Project ECHO in 2011, the VA developed and implemented the Specialty Care Access Network–ECHO to increase access, training, and provide real-time expert consultation for primary care physicians in multiple chronic conditions, including HCV and chronic liver disease.1 Several recent unpublished abstracts in the VA have reported on the use of telemedicine via videoteleconferencing to increase access to hepatology care in cirrhosis with high patient satisfaction.
