Telehealth and Telemedicine in the Management of Adult Patients after Liver Transplantation: A Scoping Review

SEARCH STRATEGY AND SELECTION CRITERIA

The following four English databases and three Chinese databases will be searched: The PubMed, CINAHL, Web of Science, Cochrane Library, Embase, Google Scholar, CNKI, Wan Fang data, and Wei Pu data. The search terms will be based on two key terms, namely, “Liver transplantation,” “telemedicine.” The search field will be Title/Abstract. The language will be limited to English and simplified Chinese. The time period will be set as the day that the database was built to March 1, 2024. In addition, hand search will be performed for reference lists of the included literature.

DATA EXTRACTION AND SYNTHESIS

Information from the 16 articles was summarized in Table 1, which presented: (1) author(s)’ name, (2) Year of publication, (3) country of the study, (4) type of study, (5) sample size of control and intervention group, (6) the intervention methods of the control group, (7) patient reported outcomes, and (8) technology used in the study, duration and elements of the intervention group.

INTERVENTION FORMS

The forms of telemedicine for continuous care of liver transplant recipients mainly include network information platforms applications, network communication software, and portable devices, specific descriptions are provided in Table 2. A total of eight studies used network information platforms to provide transitional care, including a doctor terminal app, patient terminal app, and management platforms—Wen Juan Xing platform to monitor health status and a WeChat public account to provide health guidance. ^{11,37 –43} A total of eight studies were supported by applications, which were installed on patients’ smartphones, ⁴² tablets, computers, ⁴⁴ and other devices. ⁴⁵ The application can record the development and changes of the patient’s condition, ⁴⁶ and provide the appointment and follow-up service. ⁴⁷ It can also be configured with alarm system, such as immunosuppressant drug miss alarm, ¹⁵ test critical value alarm, etc. In addition is supports online video communication between medical staff and patients and their caregivers, and provides health education such as rehabilitation exercises and drug taking methods. ⁴⁸

A total of four studies used network communication software, using social media software such as WeChat and QQ to establish group chat, ⁴² relying on public accounts to carry out disease monitoring, peer support, health education and other work. ⁴⁴ In addition, the use of Tencent conference, Facetime, and mobile phones facilitates online diagnosis and treatment, data collection, and other work. ^5,46 A total of four studies used portable devices, with a wearable watch connected to an APP to remind patients to take their medication, ⁴⁶ and tele-rehabilitation recipients equipped with aerobic steppers, resistance bands, and exercise pads. ³⁸ Bluetooth technology ¹¹ recorded and uploaded the health data obtained by electronic blood pressure (BP) monitor, oxygen saturation and heart rate (HR), body weight scale, and blood glucose (BG). ⁴⁴

INTERVENTION ELEMENTS

The content elements of telemedicine for continuous care of liver transplant patients include telemonitoring, remote health guidance, telerecords, teleconsultation and telerehabilitation, details are described in Table 3. Twelve articles carried out remote health guidance, ^{11,39,41 –44,47,49} and the contents included disease knowledge, immunosuppressant medication, diet and nutrition knowledge, ³⁷ wound care, ⁴⁶ BG, mood and sleep management, sexual behavior, vaccination and skin cancer screening, ⁴⁵ recognition and prevention of complications, and self-care skills. ³⁸ Seven studies involved telemonitoring, ^41,44 which monitored body temperature, BP, HR, blood oxygen saturation, ³⁷ body weight, BG, ⁴⁶ and electrocardiogram. BG and immunosuppressant use ¹¹ were the key indicators of monitoring. Besides, infection alerts, ⁴⁵ diet, sleep, gastrointestinal function, exercise, and T-tube drainage also important. ⁴⁰

Eight studies remotely recorded the patient’s condition, including the patient’s name, age, temperature, systolic blood pressure, ^11,42,46 skin color, diet and sleep, ¹⁴ psychological status, ^37,41 medication use, fluid intake and discharge, ⁴⁵ wound status, uncomfortable symptoms, ⁴² and the reason for readmission. Four studies conducted remote consultation, in which medical staff consulted by fax, text message, email, online video, and telephone, ⁵ which is generally used during public health emergencies, such as COVID-19. The consultation mainly included laboratory tests ⁵ and adjustment of immunosuppressive drugs. ^15,40,45 Five studies provided telerehabilitation, with programs provided by transplant specialists and exercise physiologists ⁴⁸ and consisting of aerobic step training and resistance training. ^38,39 The specific rehabilitation content and skills were sent to the patients in the form of video, and the simple evaluation indicators were the number of steps, HR, sleep, and exercise capacity. ^11,40

OUTCOME INDICATORS AND EFFECTS OF TELEMEDICINE

The outcome indicators and effects of telemedicine included 9 items, as listed in Table 4. First, three studies found that the weight, waist circumference, ³⁸ BP, and BG of recipients were stable, ⁴⁷ and their exercise capacity was enhanced after tele-rehabilitation intervention. ⁴⁸ Besides, two studies used relevant questionnaires, including Hamilton Anxiety Scale, Hamilton Depression Scale, ⁴⁷ self-rating anxiety scale and self-rating depression scale, ⁴³ to propose that telecare on telemedicine platform had a positive impact on the psychological state. In terms of quality of life, four studies using the related quality of life questionnaire for liver transplant recipients, ⁴³ such as SF-36 ⁴⁶ and SF-12v2, ³⁸ showed that the quality of life of recipients was higher than that before surgery, but still lower than normal people. ⁴⁰ In addition, six studies showed that telemedicine played a role in supervision and improvement of patients. ^{5,37,39,42,43,47}

Exercise of self-care Agency Scale Scores showed that self-care ability and self-management ability of patients had improved. Additionally, nine studies ^5,49 indicated that the use of telemedicine intervention could improve the compliance of recipients in drug therapy, ^45,47 self-monitoring and follow-up examination, ⁴⁴ among which the Mediterranean Diet Adherence Screening ³⁸ scale was used to investigate the dietary compliance of recipients. Basel Assessment of Adherence to Immunosuppressive Medications Scale ⁴⁷ was used to evaluate the medication adherence. ^42,43 About the satisfactory, eight studies pointed out that recipients and medical staff had high satisfaction with the carrier, content, method, system function, operation interface and process, and treatment method of condition changes of remote monitoring of mobile health. Only two studies included complication rate as an outcome measure. ⁴⁷ Tian ⁴⁰ pointed out that there was no significant difference in the incidence of major complications after liver transplantation between the two groups within 12 months of follow-up, but telemonitoring was beneficial for early identification of complications. Readmissions rates at 30 days ⁴⁰ and 90 days ^11,46 were also included as outcome measures.

Of course, feasibility affects patients’ willingness to use telemedicine. Six studies mentioned recipients’ acceptance rate, application mastery rate, and application completion rate and safety of app. ^{11,15,37 –39,41}

LIMITATIONS AND FUTURE DIRECTIONS

The remote follow-up system requires professional information technology personnel to develop, debug and maintain. Mobile medical equipment and wearable equipment are expensive, and an excellent telemedicine team needs to receive systematic training. Therefore, the promotion of telemedicine in the continuous care of liver transplantation requires strong human, financial and material resources. ⁵¹ Therefore, it is recommended that the government provide technical and financial support to the team. Medical workers need to spend time outside work to guide patients on social media, which may increase the burden and cost of personnel. In the future, artificial intelligence robots can be introduced into social media to answer questions, ⁵² and machine learning can also be used to supervise patients’ punching in. Another, larger, challenge concerns the inconsistency and insufficiency of financial reimbursement and insurance coverage. ⁵³

At present, most of the remote home rehabilitation programs for liver transplantation patients are universally applicable, that is, to improve the patient’s exercise capacity and resistance, but there is a lack of personalized evaluation of each recipient by rehabilitation doctors, personalized customization of rehabilitation programs and implementation feedback. ⁵⁴ In addition, there are few studies that use patients’ psychological state as an outcome indicator, and liver transplant recipients are prone to negative emotions due to economic pressure and uncertainty about the prognosis. It is recommended to add real-time interaction content in telemedicine to improve the participation and persistence of patients, and promote the social regression and mental health of patients. The decline of physical function and the relative lack of electronic information skills of the elderly reduce their acceptance of telemedicine. ³⁰ Therefore, the system design should adopt simple procedures, enlarged fonts, and the service content should be provided according to the different educational levels and electronic equipment literacy of the patients.

Few studies have focused on the standardization of services, legal supervision, data security, and privacy protection. Relevant state departments should issue relevant regulatory policies and service specifications for internet-based telemedicine, ⁵⁵ such as the introduction of relevant laws to clearly define the scope of responsibility and access threshold of medical staff, so as to protect both doctors and patients. ⁵⁶ The hospital-community-family cooperation model can be considered in future telemedicine, which is conducive to enhancing the confidence of caregivers and optimizing the allocation of medical resources. ⁵⁷ In the future, the telemedicine team should include liver transplant specialists and nurses, information technology personnel, psychologists, rehabilitation doctors and nurses, and nutrition doctors. Multidisciplinary teams are more likely to meet the needs of patients. ⁵⁸

There are some limitations in the current study. A lot of studies are quantitative studies with small samples and single center, and there is a lack of comprehensive, detailed and accurate high-quality longitudinal research and qualitative research. The evaluation indicators of telemedicine also need to be unified. The most used evaluation indicators are subjective indicators such as satisfaction, ⁵⁹ compliance, and quality of life, and objective and unified evaluation indicators should be explored in future research.