title: Automated telephone communication systems for preventive healthcare and management of long-term conditions.
abstract: Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.
  
  
  
  To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.
  
  
  
  We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.
  
  
  
  Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.
  
  
  
  We used standard Cochrane methods to select and extract data and to appraise eligible studies.
  
  
  
  We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.
  
  
  
  ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.
authors.affiliation: Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 3 Fusionopolis Link, #06-13, Nexus@one-north, Singapore, Singapore, 138543.
authors.forename: Pawel
authors.initials: P
authors.lastname: Posadzki
authors.affiliation: Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, St Dunstans Road, London, Hammersmith, UK, W6 8RP.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Mastellos
authors.affiliation: Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia, 3086.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Ryan
authors.affiliation: Public Health Program, Stetson University, 421 N Woodland Blvd, DeLand, Florida, USA, 32723.
authors.forename: Laura H
authors.initials: LH
authors.lastname: Gunn
authors.affiliation: Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, Lancashire, UK, L39 4QP.
authors.forename: Lambert M
authors.initials: LM
authors.lastname: Felix
authors.affiliation: Institute for Health Research, University of Bedfordshire, Park Square, Luton, Bedford, UK, LU1 3JU.
authors.forename: Yannis
authors.initials: Y
authors.lastname: Pappas
authors.affiliation: Centre de recherche du CHU de Québec, Axe Santé des populations - Pratiques optimales en santé, Traumatologie - Urgence - Soins Intensifs, 10 Rue de l'Espinay, D6-727, Québec, QC, Canada, G1L 3L5.
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Gagnon
authors.affiliation: Medical Statistics Group, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, UK, S1 4DA.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Julious
authors.affiliation: Division of Mathematical Sciences, School of Physical and Mathematical Sciences, Nanyang Technological University, 21 Nanyang Link, Singapore, Singapore.
authors.forename: Liming
authors.initials: L
authors.lastname: Xiang
authors.affiliation: Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.
authors.forename: Brian
authors.initials: B
authors.lastname: Oldenburg
authors.affiliation: Centre for Population Health Sciences (CePHaS), Lee Kong Chian School of Medicine, Nanyang Technological University, 3 Fusionopolis Link, #06-13, Nexus@one-north, Singapore, Singapore, 138543.|Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, St Dunstans Road, London, Hammersmith, UK, W6 8RP.|Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
authors.forename: Josip
authors.initials: J
authors.lastname: Car
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002908:Chronic Disease / Q000628:therapy*; D015444:Exercise; D015438:Health Behavior; D058015:Health Communication / Q000379:methods*; D006801:Humans; D007114:Immunization / Q000706:statistics & numerical data; D010349:Patient Compliance; D011314:Preventive Health Services; D011322:Primary Prevention; D016032:Randomized Controlled Trials as Topic; D017010:Reminder Systems; D049250:Speech Recognition Software; D013689:Telephone