Evidence of telehealth effectiveness versus in-person care ‘weak’

A review of clinical evidence shows that telehealth is comparable to in-person care across various outcomes and clinical areas; however, researchers caution that the available evidence is “weak and heterogeneous.”

Published in the journal npj digital medicine, the study compared clinical evidence on the effectiveness of telehealth during the COVID-19 pandemic. Telehealth adoption and use skyrocketed during the pandemic, spurred by in-person restrictions and fears around COVID-19 exposure. Though adoption and utilization have declined, these metrics remain far higher than pre-pandemic levels. Thus, research is needed to determine whether telehealth is as effective as in-person care to guide best practices for telehealth use and make policy decisions.

Researchers from the Johns Hopkins School of Medicine and Johns Hopkins Bloomberg School of Public Health conducted a systematic literature review comparing the effectiveness of telehealth with in-person care. They used various databases, including PubMed, CINAHL, and PsycINFO, to find studies assessing pandemic-era telehealth from March 2020 to April 2023.

They identified 77 eligible studies, the majority of which were observational studies (96 percent). Almost half of the studies (43 percent) compared telehealth during the pandemic to in-person care before the pandemic.

Additionally, the researchers identified 12 study outcomes and grouped these into three categories: healthcare utilization, clinical outcomes, and process outcomes.

They found that healthcare utilization and process outcomes were the most commonly reported outcome categories. The most studied clinical area was care for specific conditions other than pregnancy or COVID-19. However, fewer studies addressed clinical areas like care for general behavioral and mental health conditions.

Overall, researchers observed that the differences between telehealth and in-person care with regard to healthcare utilization and clinical outcomes were generally small and not clinically meaningful.

For condition-specific clinical outcomes, the evidence of telehealth effectiveness versus in-person care varied by patient populations, clinical areas, and outcomes assessed across the studies and follow-up periods.

Within the process outcomes category, clinical evidence revealed a “mostly lower rate of missed visits, lower rate of change in therapy/medication, and higher rates of therapy/medication adherence” associated with telehealth compared to in-person care. However, it also showed that patients receiving initial telehealth visits had lower rates of up-to-date labs and paraclinical assessments.

Though the evidence comparing telehealth and in-person care showed similar effectiveness, researchers noted that the majority of studies — 59 percent of observational studies and all three randomized controlled trials — had a serious or high risk of bias and did not adjust their results for the demographic, socioeconomic, or clinical characteristics of the study population. Further, studies mostly had small sample sizes and were performed in a small single facility.

Thus, even though researchers “found that the use of telehealth during COVID-19 in many, though not all, instances is comparable to in-person care across different clinical areas and different healthcare utilization, clinical, and process outcomes,” they emphasized that “the available evidence on the effectiveness of telehealth versus in-person care during the pandemic [is] weak and heterogeneous.”

The assessment comes as lawmakers consider telehealth policy post-2024. Currently, pandemic-era flexibilities that significantly expand access to telehealth are set to expire on December 31, 2024. However, stakeholders are mounting pressure on Congress to make the flexibilities permanent.

These flexibilities include eliminating geographic requirements and expanding originating sites for telehealth services, delaying prior in-person exam requirements for telemental healthcare services, and allowing coverage of audio-only telehealth under the Medicare program.

Congress has indicated it will extend these flexibilities by another two years rather than make them permanent. Both the House Energy and Commerce Subcommittee on Health and the House Ways and Means Committee advanced bills with the two-year extension last month.