Binder, et al. [9]

Before and after study

16 patients with 45 leg ulcers of different origin were included.

Wound care center at the Department of Dermatology, Medical University of Graz, Graz, Austria.

Tele-dermatological follow-ups done by home care nurses. Digital images of the wound and surrounding skin were transmitted weekly via a secure Web site to an expert at the wound care center.

3 months or until wound healed- leg ulcer size measured again.

Before study- leg ulcer size measured.

1. Amount of change in leg ulcer size

Before study- mean size 10.92 cm²; SD 29.16

After 3 months - mean size 7 cm²; SD 16.88

- 32 (71%) decreased in size

- 14 (31%) healed completely

- 10 (22%) increased in size.

- 3 (7%), no measurement due to overly large size of the ulcers

- 3 no notable change in size

Procedure followed protocol. No bias observed.

Santamania, et al. [6]

Prospective randomised controlled trial

93 patients with chronic lower leg and foot ulcers in four sites in the Kimberley region of Western Australia.

Intervention = 50 patients

Control group = 43 patients

Intervention group subjects also had their wound photographed and measured at each clinic attendance;

However, these images and measurements were electronically transferred every 2 weeks to a wound care consultant.

Control group subjects received standard wound care as determined by the local wound care clinician and had their wound photographed and measured at each clinic attendance.

1. Healing rate expressed as the percentage change in wound size divided by the number of weeks since enrolment in the trial

2. The clinical cost of wound treatment was considered to be the cost between admission and discharge from trial

Mean healing rate difference between the groups was 11.7%.

Intervention group healed at 6.8% per week

Control group patients (n = 43) healed at -4.9% per week.

Total cost savings in the intervention group compared to the control group costs was $191,935.

Procedure followed protocol. Randomization was done to avoid selection bias and avoid potential for confounding due to changes in clinician knowledge, unstable staffing at each site and variability in wound management practices.

However, there was inadequate data for meta-analysis input.

Terry, et al. [5]

Randomized controlled study

103 subjects with 160 wounds (pressure ulcers, non-healing surgical wounds, stasis ulcers) recruited from 2 counties in the state of Maryland, all of the District of Columbia (DC), and counties in the Northern Virginia area that border DC and Maryland. Referred.

Subjects were randomly assigned to 1 of 3 groups.

Group A (n = 40): weekly visits with telemedicine and wound care specialist (WCS) consults.

Group B (n = 28): weekly visits with weekly consults with WCSs.

customary care.

Group A: Wounds assessed using telemedicine. Nurses taking digital images of the wounds and forwarding them electronically to WCSs as part of a weekly consultation.

Group C: Wounds clinically assessed each week per agency policy but had no telemedicine and no consults with the WCSs unless specifically requested by the study nurse.

1. Time to heal
2. Number of nursing visits
3. Length of stay (LOS)
4. Change in size
5. Wound status
6. Costs

At time of discharge:

Wound outcomes:

- Deteriorated ( A = 5/62; C = 3/51)

- No change ( A = 4/62; C = 3/51)

- Improved but not healed ( A = 46/62; C = 37/51)

- Healed ( A= 7/62; C = 8/51)

Days to heal:

Intervention: 51 days (SD 34)

Control: 35 days (SD 25)

Change in wound size:

Intervention: 158 cm³ (SD 592)

Control: 130 cm³ (SD 256)

Conversion from cm³ to cm²: http://www.endmemo. com/cconvert/cm3cm2.php

Patients and nurses were randomized into groups to avoid selection bias and avoid confounding factors. Double blinding was not possible due to nature of intervention.

Vowden, et al. [4]

Randomized controlled pilot study

26 patients involving 34 wounds in 16 Bradford nursing homes recruited into the study.

Intervention group: 17 patients involving 23 wounds.

Control group: 9 patients involving 11 wounds.

The care-home staff completed a weekly wound-assessment form.

The wound diagnosis made by the care-home staff, the state of the wound and information on pain, exudate levels and treatments were recorded.

Wound images were taken using a smart phone camera and these data were electronically linked to the digital paper form. The data collected, the wound images and information were uploaded together to a secure server for assessment by the remote nurse consultant.

The care-home staff collected the same wound care data as recorded in the intervention and received standard care from the nursing home staff. Patients continued to be referred to the tissue viability nurses when the nursing-home staff felt it to be appropriate.

1. Wound outcomes

At the end of 6 month:

Intervention (n = 23)

Healed: 16

Not healed: 2

Died: 4

Withdrawn: 1

Lost to follow-up: 0

Control (n = 11)

Randomization done by computer to generate random sequence and randomization was stratified according to the home's known bed numbers, to ensure an even distribution of nursing home beds potential patients between groups. Procedure followed protocol. One patient was withdrawn from the interventional group due to protocol violation (the District Nursing team did not comply with the expert remote treatment plan)

Zarchi, et al. [8]

Prospective Cluster Controlled Study

90 patients in 4 home-care organizations in eastern Denmark were included.

Telemedicine group = 50

Control group = 40

Home-care nurses updated the web-based charts, including digital images, as frequently as possible, but at a minimum of every second week and stored the clinical data in the Plejenet. A team of wound-care experts, consisting of physicians and a nurse at a hospital-based wound-care center reviewed the stored data daily and provided the home-care nurses with the treatment strategy. The treatment was delivered only by home-care nurses on the basis of the instructions given by the wound-expert team.

Routine wound care provided by home-care nurses and patients received wound therapy at any wound care center or hospital ward that the treating physicians or nurses considered necessary or beneficial.

Time to complete wound healing

1-year follow-up:

Complete wound healing:

Telemedicine group = 35 patients (70%)

Control group = 18 patients (45%)

Randomization was not carried out as implementation of telemedicine had to be carried out in the only home-care organization with no certified wound care nurse. Ethical principle was prioritized over randomization. Several important covariates were adjusted in the results to minimize the bias caused by non-randomization.

Besides, patients in the telemedicine group being significantly older than those in the control group, no other significant differences were found in the baseline characteristics between the two groups

Blinding of information transfer within a group of nurses working in a home-care setting was not considered feasible.

To ensure the measured effect of using telemedicine on wound healing was not contaminated by treatments provided elsewhere, wound care prescribed outside than through telemedicine was considered a protocol deviation and patients would be excluded from the study.