Understanding heart failure; explaining telehealth - a hermeneutic systematic review.
Understanding heart failure; explaining telehealth - a hermeneutic systematic review.
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DOI：
10.1186/s12872-017-0594-2
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发表时间：
2017-06-14
影响因子：
2.1
通讯作者：
Shaw S
中科院分区：
文献类型：
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作者：
Greenhalgh T;A'Court C;Shaw S
远程医疗的爱好者称赞其支持心力衰竭管理的潜力。但随机试验招募进展缓慢，并且得出了相互矛盾的结果；现实世界的推出进展缓慢。我们试图通过理解有关心力衰竭及其远程管理的复杂文献来为政策提供信息。通过数据库检索和引文跟踪，我们确定了 7 篇系统综述，32 篇系统综述（包括 17 篇荟萃分析和 8 篇定性综述）；六项大型试验和 60 多项其他相关实证研究和评论。我们使用伯尔的解释学方法来综合这些内容，进行系统回顾，强调对理解的追求。心力衰竭是一种复杂而严重的疾病，具有频繁的合并症和多种表现，包括严重疲劳。患者常常感到害怕、困惑、与社会隔离，并且自我管理能力参差不齐。远程监控技术多种多样；它们创造了新的知识形式和新的护理可能性，但需要对临床角色和服务模式进行根本性改变，并给患者、护理人员和工作人员带来沉重负担。远程生物标志物监测的政策创新能够及时调整药物，由“活跃”患者介导，这是基于高效、合理、技术介导和指南驱动（“冷”）护理的现代主义愿景。它与一些临床医生和年龄较大、病情较重且技术水平较低的患者所重视的基于关系（“温暖”）的护理形成鲜明对比。远程医疗的有限采用可以根据关键的紧张关系进行分析：整齐的“教科书”心力衰竭与多种合并症的现实之间；基本远程医疗和强化远程医疗之间的关系；活跃的、得到良好支持的患者和脆弱的、得不到支持的患者之间；在“冷”和“热”远程医疗之间；以及固定和敏捷护理计划之间的关系。心力衰竭远程医疗的采用有限具有复杂的临床、专业和机构原因，这些原因不太可能通过在已经拥挤的文献中添加更多关于技术开启与技术关闭的随机试验来阐明。提出了一种替代方法，基于自然主义研究设计、社会和组织理论的应用以及基于社会技术原理的新服务模型的共同设计。解释学评论（其目标是加深理解）可以有效地补充传统的系统评论（其目标是综合数据）。本文的在线版本 (doi:10.1186/s12872-017-0594-2) 包含补充材料，可供授权用户使用。
Enthusiasts for telehealth extol its potential for supporting heart failure management. But randomised trials have been slow to recruit and produced conflicting findings; real-world roll-out has been slow. We sought to inform policy by making sense of a complex literature on heart failure and its remote management. Through database searching and citation tracking, we identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta-analyses and 8 qualitative reviews); six mega-trials and over 60 additional relevant empirical studies and commentaries. We synthesised these using Boell’s hermeneutic methodology for systematic review, which emphasises the quest for understanding. Heart failure is a complex and serious condition with frequent co-morbidity and diverse manifestations including severe tiredness. Patients are often frightened, bewildered, socially isolated and variably able to self-manage. Remote monitoring technologies are many and varied; they create new forms of knowledge and new possibilities for care but require fundamental changes to clinical roles and service models and place substantial burdens on patients, carers and staff. The policy innovation of remote biomarker monitoring enabling timely adjustment of medication, mediated by “activated” patients, is based on a modernist vision of efficient, rational, technology-mediated and guideline-driven (“cold”) care. It contrasts with relationship-based (“warm”) care valued by some clinicians and by patients who are older, sicker and less technically savvy. Limited uptake of telehealth can be analysed in terms of key tensions: between tidy, “textbook” heart failure and the reality of multiple comorbidities; between basic and intensive telehealth; between activated, well-supported patients and vulnerable, unsupported ones; between “cold” and “warm” telehealth; and between fixed and agile care programmes. The limited adoption of telehealth for heart failure has complex clinical, professional and institutional causes, which are unlikely to be elucidated by adding more randomised trials of technology-on versus technology-off to an already-crowded literature. An alternative approach is proposed, based on naturalistic study designs, application of social and organisational theory, and co-design of new service models based on socio-technical principles. Conventional systematic reviews (whose goal is synthesising data) can be usefully supplemented by hermeneutic reviews (whose goal is deepening understanding). The online version of this article (doi:10.1186/s12872-017-0594-2) contains supplementary material, which is available to authorized users.