You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study
Abstract 1:
Background Telehealth ( TH ) and telecare ( TC ) interventions are increasingly valued for supporting self-care in ageing population s ; however , evaluation studies often report high rates of non-participation that are not well understood . This paper reports from a qualitative study nested within a large r and omised controlled trial in the UK : the Whole System Demonstrator ( WSD ) project . It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial . Methods Qualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention ( n = 19 ) , or who withdrew from the intervention arm ( n = 3 ) . Participants were recruited from the four trial groups ( with diabetes , chronic obstructive pulmonary disease , heart failure , or social care needs ) ; and all came from the three trial areas ( Cornwall , Kent , east London ) . Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home . Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes . Results Barriers to adoption of TH and TC  associated with non-participation and withdrawal from the trial were identified within the following themes : requirements for technical competence and operation of equipment ; threats to identity , independence and self-care ; expectations and experiences of disruption to services . Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderst and ings . Respondents ’ views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance , and views that interventions could undermine self-care and coping . Finally , participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued . Conclusions These findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake . These insights have implication s for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction . It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation


Title 2:
Health professionals' responses to the introduction of a home telehealth service
Abstract 2:
An ethnographic ( participant observation ) study was undertaken of the socio-technical processes involved in the implementation , within a r and omized controlled trial , of a home telehealth nursing service for patients with chronic obstructive pulmonary disease ( COPD ) . Ethnographic field notes were taken about technology-related tasks and the interplay between the research team and the 12 nurses who were to use the telehealth equipment .  Views of the technology were linked to views of professional self-image and status . The technology was sometimes seen as unhelpful in establishing effective relationships with patients . Considerable work by all participants , over a period of months , was required to develop the technology in ways that minimized the risk to the stability of the specialist service and existing nurse – patient relationships . Our work highlights the complex problems that health professionals encounter when they try to integrate new technologies into routine service delivery . The concerns arising from the interplay of new technology with existing professional practice s and relationships go beyond simple issues of training


Title 3:
A systematic review of the cost and cost-effectiveness of telehealth for patients suffering from chronic obstructive pulmonary disease
Abstract 3:
We conducted a systematic review of the evidence on the costs and cost-effectiveness of telehealth for patients with chronic obstructive pulmonary disease ( COPD ) . A literature search identified six relevant economic evaluations that were assessed according to the Consensus Health Economic Criteria list ( CHEC list ) . Three studies were from North America and three studies were from Europe . All studies reported the use of home monitoring devices that measured and transmitted different physical indicators to nurses who provided personalised feedback to patients during weekdays . The six studies involved a total of 559 COPD patients of whom 281 were r and omised to telehealth .  The review demonstrated a potential for cost savings . All six studies reported a lower average cost per patient with telehealth plus usual care compared with usual care alone . However , the quality of the economic evidence was poor . Five studies were evaluated as low quality and one study was evaluated as moderate quality , with CHEC list scores of 21–68 % . Caution is advised for healthcare decision-makers seeking large-scale implementation of telehealth in routine clinical practice . The clinical effectiveness of such implementations with follow-up exceeding 12 months has not yet been demonstrated


Title 4:
Organizational and Environmental Factors Affecting the Utilization of Telemedicine in Rural Home Healthcare
Abstract 4:
ABSTRACT In the last five years , home health agencies have become increasingly interested in telemedicine as a potential means to meet the future healthcare needs of their aged and chronically ill clientele . This case study examines the organizational and environmental conditions that affected the implementation of a telemedicine program in one rural home healthcare organization . Several factors restricted the utilization of telemedicine , including Medicare 's Prospect i ve Payment System and corresponding documentation ( Outcome Assessment and Information Set ) , the organization controlling grant funding for the program , and several environmental factors . Findings suggest that in rural communities , older homecare patients may have less opportunity to benefit from telemedicine . The study demonstrates the importance of environmental and organizational factors when implementing a telemedicine program . Recommendations are offered for home healthcare organizations considering development of telemedicine programs


Title 5:
Continuity, but at what cost? The impact of telemonitoring COPD on continuities of care: a qualitative study.
Abstract 5:
BACKGROUND Continuity of care is widely regarded as an important marker of quality in the management of patients with long-term conditions . New services that integrate telemonitoring into care pathways have potential to change aspects of continuity in both positive and negative ways . AIMS A telemonitoring service for patients with chronic obstructive pulmonary disease ( COPD ) was introduced in Lothian , Scotl and , in 2009 . A qualitative study , nested within the TELESCOT COPD r and omised control trial , was undertaken to explore the views of patients and professionals on  telemonitoring . The perceived impact of telemonitoring on continuity of care was investigated as part of the research . METHODS Semi-structured interviews were undertaken with 38 patients ( 47 % male , mean age 67.5 years ) . A maximum variation sample in relation to age , sex , socio-economic background , disease severity , and compliance with telemonitoring was recruited . Thirty-two stakeholders ( healthcare professionals and managers ) were interviewed . Transcribed coded data were analysed thematically using the framework approach . Interpretation was supported by multidisciplinary discussion . RESULTS Patients and healthcare professionals considered that relationship-based continuity of care was important in the delivery of telemonitoring services . Managers placed emphasis on improved continuity of clinical management as a means of reducing healthcare costs . However , professionals described many operational challenges arising from the ' bolting-on ' of telemonitoring provision to existing usual care provision which , they considered , result ed in the proliferation of additional managerial discontinuities . CONCLUSIONS Managers and healthcare professionals face major challenges in meeting dem and s for both relationship continuity and continuity of clinical management in the development of telemonitoring services


Title 6:
Understanding factors that inhibit or promote the utilization of telecare in chronic lung disease
Abstract 6:
Objectives : To perform a process evaluation of a r and omized controlled trial ( RCT ) of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease ( COPD ) , using the normalization process model ( NPM ) as an explanatory framework . Methods : Semi-structured interviews were carried out with patients ( n = 9 ) and nurses ( n = 11 ) participating in a RCT . A framework approach to data analysis was used . Results : The telecare service did not provide an interactional advantage for the nurses providing this service and did not fit with the nurses ' views of the most appropriate or preferred use of their skills . The telecare service seemed unlikely to become normalized as part of routine healthcare delivery , because the nursing team lacked confidence that it was a safe way to provide healthcare in this context and it was not perceived as improving efficiency . Discussion : The NPM effectively mapped onto the study findings and explained those factors that inhibited the routine delivery of COPD services by telecare
The findings of this systematic review provide implication s for sustained usage of tele-homecare programs by home health nursing agencies and can help such programs realize their potential for chronic disease management