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Pressure injury is a common complication after a spinal cord injury. Long-term multidisciplinary follow-up is difficult after such patients have been discharged. Telemedicine promises to provide convenient and effective support for the prevention and treatment of pressure injury, but previous attempts to demonstrate that have produced inconsistent results.
The aim of this study is to evaluate the effectiveness of telemedicine in preventing and treating pressure injury among community-dwelling patients with spinal cord injury, and determine which telemedicine form is more effective.
This systematic review was performed according to the PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Network Meta-Analysis) standards. Ten databases were searched to identify randomized controlled trials and quasi-experimental studies related to the effectiveness of telemedicine intervention in patients with spinal cord injury. Two researchers worked independently and blindly selected studies, extracted data, and assessed the risk of bias. The results were described as relative risk (RR) and weighted mean difference and 95% CI.
The 35 studies comprised 25 randomized controlled trials and 10 quasi-experimental studies involving 3131 patients. The results showed that telemedicine can significantly (
Telemedicine is a feasible way to prevent pressure injury among patients with spinal cord injuries. It can decrease the incidence and severity of pressure injury and accelerate patients’ healing without imposing economic burden. It is best used in tandem with other, more conventional interventions. Due to the limited quality and quantity of included studies, large-scale and well-designed randomized controlled trials are warranted.
Spinal cord injury (SCI) is a disabling and costly disease, the incidence of which is increasing year by year. The incidence of SCI is estimated to be between 12 and 65 cases per million globally [
There are well-understood measures that can reduce the incidence of pressure injury, and prevention is more cost-effective than treatment [
Until now, there has been no systematic review of the applicability of telemedicine in preventing and treating pressure injury among community-dwelling patients with SCI. That motivated this systematic review and network meta-analysis. Network meta-analysis can assess both direct and indirect evidence [
This systematic review and network meta-analysis was performed according to the PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Network Meta-Analysis) standards [
The databases searched were the China National Key Information corpus, Wanfang, CBM, VIP, Embase, PubMed, Cochrane Library, Web of Science, Scopus, and ProQuest. The dates searched were from establishment of each database to September 30, 2021.
Only randomized controlled trials (RCTs) and quasi-experimental studies were included in the systematic review, and only RCTs were included in the network meta-analysis. Beyond that, 4 other criteria were applied.
Participants: community-dwelling persons with an SCI.
Interventions: complete or partial telemedicine intervention. In complete telemedicine intervention, there was no face-to-face contact during the trial, only telemedicine intervention by telephone, video, or mobile app. Treatment involving only one form of telemedicine intervention was designated as a single complete telemedicine intervention, while therapy combining two or more forms of telemedicine intervention was called a mixed complete telemedicine intervention. Partial telemedicine intervention designated treatment combining telemedicine with a nontelemedicine intervention (such as an outpatient follow-up visit or a home visit).
Controls: The “no telemedicine” cases included nontelemedicine intervention and also health guidance only before discharge treated as a blank control. A second type of control was where there was another group treated differently from the experimental group, such as when the experimental group used video and the control group used the telephone. A third case was self-control studies with no control group.
Outcomes: Primary and secondary outcomes were considered. The primary outcomes were the incidence of pressure injury, the rate of healing of the pressure injury, and pressure injury severity (size, depth, and Pressure Ulcer Scale for Healing [PUSH]). Any economic data reported were treated as a secondary outcome.
Certain reports had to be excluded, for example, academic meeting abstracts or papers without full text; papers published repeatedly; and papers for which adequate data could not be obtained even after contacting the authors.
Two authors (the first and the second author) worked independently and blindly to screen titles, abstracts, and full texts, and select studies applying the inclusion and exclusion criteria. Any disagreements were resolved by discussion or by consulting the corresponding author. EndNote X9 software (Clarivate) was first used to exclude duplicates. Then, reading the title and abstract was enough to exclude clearly irrelevant papers. Finally, reading the full text allowed us to determine whether or not a study should be included. If necessary, authors were contacted by email or telephone for further information.
The first and second authors also worked independently and blindly to extract data and assess the risk of bias, again consulting the corresponding author if necessary. The data extracted included each study’s characteristics, participant characteristics, intervention and control treatments, and outcomes. The Cochrane risk of bias tool [
Song [
The search found 3152 studies. Of those, 948 duplicates were excluded through EndNote. Reading the titles and abstracts of 2204 reports led to 2148 being excluded as irrelevant. Finally, 56 studies were screened in full text, of which 21 were excluded and 35 were finally included (
The 35 studies included 25 RCTs [
Mixed complete telemedicine interventions mainly used the WeChat app and telephone. The average utilization was about 1 hour every day to answer questions, once weekly to convey relevant knowledge, and perhaps a weekly face-to-face video chat if necessary. Telephone calls were made on average once per month, when needed. Single complete telemedicine interventions were mainly delivered via telephone. The average frequency was about once per week. Partial telemedicine intervention was usually a combination of telephone or video telemedicine with outpatient follow-up or home visits. The frequency was about once per week by telephone or face-to-face video, and once per month for outpatient follow-up or home visit. The main form of nontelemedicine intervention was outpatient follow-up or home visit. The frequency was about once per month. The blank control group only received health education before discharge, but the patients could call a medical professional when they needed help.
Flowchart for search and selection of the included studies.
The overall quality of the studies included was categorized as acceptable. Approximately half of the studies reported randomization, but some reports lacked details about any allocation blinding, which could cause potential selection bias. No study was judged as “low risk” in terms of performance bias because it is very difficult to blind patients in telemedicine intervention trials. About one-quarter of the studies blinded the outcome assessors. There was no evidence of attrition bias, selective reporting bias, and other bias in any of the included studies (
Overall, 27 studies [
The meta-analysis showed that the incidence of pressure injury was significantly lower in the telemedicine intervention group (n=468; RR 0.24, 95% CI 0.14-0.41;
A total of 9 studies [
A total of 4 RCTs [
Only one study (an RCT) [
The effectiveness of telemedicine on the healing rate of pressure injury. ES: effect size.
Comparison of the effectiveness of telemedicine and control on PUSH scores. PUSH: Pressure Ulcer Scale for Healing.
A total of 18 RCTs [
A consistency test did not identify statistically significant inconsistency (
The SUCRA estimates (
Network meta-analysis of eligible comparisons for incidence. 1: blank control; 2: nontelemedicine intervention; 3: single complete telemedicine intervention; 4: mixed complete telemedicine intervention; 5: partial telemedicine intervention.
The surface under the cumulative ranking estimate. 1: blank control; 2: nontelemedicine intervention; 3: single complete telemedicine intervention; 4: mixed complete telemedicine intervention; 5: partial telemedicine intervention.
The effectiveness of telemedicine in preventing pressure injury according to the network meta-analysis.
MCTIa | PTIb | SCTIc | NTId | Blank control |
MCTI | 1.34 (0.59-3.06) | 3.52 (1.95-6.36) | 3.35 (1.07-10.48) | 4.63 (2.16-9.93) |
0.75 (0.33-1.70) | PTI | 2.62 (1.29-5.36) | 2.50 (1.13-5.49) | 3.45 (2.09-5.71) |
0.28 (0.16-0.51) | 0.38 (0.19-0.78) | SCTI | 0.95 (0.33-2.75) | 1.31 (0.67-2.59) |
0.30 (0.10-0.93) | 0.40 (0.18-0.88) | 1.05 (0.36-3.04) | NTI | 1.38 (0.54-3.52) |
0.22 (0.10-0.46) | 0.29 (0.18-0.48) | 0.76 (0.39-1.50) | 0.72 (0.28-1.84) | Blank control |
aMCTI: mixed complete telemedicine intervention.
bPTI: partial telemedicine intervention.
cSCTI: single complete telemedicine intervention.
dNTI: nontelemedicine intervention.
This systematic review and network meta-analysis results show that telemedicine intervention can reduce the incidence and severity of pressure injury and improve the rate of healing of such injuries without increasing the medical economic burden on community-dwelling patients with SCI. In addition, the results indicate that combining telemedicine with conventional interventions is the most effective form of intervention for preventing pressure injury.
Although the overall quality of the studies was regarded as acceptable, none were able to blind the participants and personnel. Some reports mentioned random sequence generation, allocation concealment, and blinding, but without specifics. That may relate to the space limitations of journal publications or the design of the experiments. This review included only studies published in Chinese or English, of which many were Chinese. This may be related to the Quality Nursing Service demonstration project launched by China’s National Health Commission in early 2010 [
The results show that telemedicine intervention can reduce the incidence and severity of pressure injury. As part of rehabilitation, patients with SCI were usually educated in preventive skin care techniques, but they are often not continued after discharge [
The hospital stays of patients with SCI are shorter now than in the past [
The results show that using telemedicine did not increase the economic burden of SCI. Most developed countries provide patients with SCI with any equipment they may need to cope with their injury. They receive training before discharge and then remote written or oral guidance without the need for professionals to enter the patient’s home. That helps to minimize the cost of an SCI [
The network meta-analysis showed that the best intervention for preventing pressure injury combined two or more forms of telemedicine. The most common combination was internet chat (usually WeChat) with telephone conversations. Patients and their carers cannot be assumed able to identify pressure injury early and take countermeasures soon enough of their own accord [
This study was to some unknown extent restricted by being limited to reports in either Chinese or English. Beyond that, some experimental studies were not included because they were unfinished or the relevant data could not be extracted. That may induce a certain degree of publication bias. There were also reports that did not describe the intervention frequency in detail, and some in which the accuracy of individual outcomes was relatively low due to the small number of related studies. More high-quality RCTs with large samples are need for further demonstration.
Current evidence shows that telemedicine is an economical and feasible form of intervention. It can reduce the incidence of pressure injury in community-dwelling patients with SCI. Combining telemedicine with other sorts of intervention is better than using telemedicine alone. Telemedicine can improve the rate of pressure injury healing and reduce the severity of the injury without increasing the medical economic burden on patients with SCI. These above conclusions need to be further verified by additional high-quality RCTs using large samples. Future studies could explore the research on telemedicine in languages other than Chinese and English.
Search details.
Characteristics of the studies included.
Risk of bias assessment summary for each Cochrane item.
Risk of bias assessment for the quasi-experimental studies.
The effectiveness of telemedicine on the incidence of pressure injury (quasi-experimental studies).
Node splitting results.
Relative treatment rankings.
A comparison-adjusted funnel plot of the studies.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Network Meta-Analysis
International Prospective Register of Systematic Reviews
Pressure Ulcer Scale for Healing
randomized controlled trial
relative risk
spinal cord injury
surface under the cumulative ranking
weighted mean difference
This study was supported by the Natural Science Foundation of Guangdong Province (grant 2021A1515011800). The authors thank to Dr Yingchun Zeng of Hong Kong Polytechnic University for her help in statistical analysis.
None declared.