Automated telephone communication systems (ATCS) send voice messages and collect health information from people using their telephone's touch-tone keypad or voice recognition software. This could replace or supplement telephone contact between health professionals and patients. There are several types of ATCS: one-way voice messages to patients (unidirectional), interactive voice response (IVR) systems, those with added functions like referral to advice (ATCS Plus), or those where ATCS are part of a complex intervention (multimodal).
This review assessed the effectiveness of ATCS for preventing disease and managing long-term conditions.
We found 132 trials with over 4 million participants across preventive healthcare areas and for the management of long-term conditions.
Studies compared ATCS types in many ways.
Some studies reported findings across diseases. For prevention, ATCS probably increase immunisation uptake in children, and slightly in adolescents, but in adults effects are uncertain. Also for prevention, multimodal ATCS increase numbers of people screened for breast or colorectal cancers, and may increase osteoporosis screening. ATCS Plus probably slightly increases attendance for cervical cancer screening, with uncertain effects on osteoporosis screening. IVR probably increases the numbers screened for colorectal cancer up to six months, with little effect on breast cancer screening.
ATCS (unidirectional or IVR) may improve appointment attendance, key to both preventing and managing disease.
For long-term management, multimodal ATCS had inconsistent effects on medication adherence. ATCS Plus probably improves medication adherence versus usual care. Compared with control, ATCS Plus and IVR probably slightly improve adherence, while unidirectional ATCS may have little, or slightly positive, effects. No intervention consistently improved clinical outcomes. IVR probably improves test adherence, but ATCS Plus may have little effect.
ATCS were also used in specific conditions. Effects varied by condition and ATCS type. Multimodal ATCS, but not other ATCS types, probably decrease cancer pain and chronic pain. Outcomes may improve to a small degree when ATCS are applied to physical activity, weight management, alcohol use and diabetes.However, there is little or no effect in heart failure, hypertension, mental health or quitting smoking. In several areas (alcohol/substance misuse, addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, high cholesterol, obstructive sleep apnoea, spinal cord dysfunction, carers' psychological stress), there is not enough evidence to tell what effects ATCS have.
Only four trials reported adverse events. Our certainty in the evidence varied (high to very low), and was often lowered because of study limitations, meaning that further research may change some findings.
ATCS may be promising for changing certain health behaviours, improving health outcomes and increasing healthcare uptake.
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.
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.