Background: Wittgenstein distinguished between questions that require data and those that require understanding. Systematic review methodology has focused almost exclusively on the former. But complex policy topics are sometimes characterised by a surfeit of data, synthesised in a succession of systematic reviews and meta-analyses that fail to provide the hoped-for clarity. Boell, et al. (in the field of information systems) developed a new methodology, hermeneutic review, which seeks to generate understanding by close reading and iterative synthesis.
1. To make sense of the literature on telehealth in heart failure.
2. To explain why RCTs have been slow to recruit and produced conflicting findings, and why real-world roll-out has been slow.
Method: Through database searching and citation tracking, we identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta-analyses and 8 qualitative reviews); six mega-trials and over 60 additional relevant empirical studies and commentaries. We synthesised these using hermeneutic methodology, which emphasises close reading of documents and iterative generation of an account that makes sense of the topic.
Main findings: Our review revealed several tensions: between 'textbook' heart failure and multiple comorbidities; between basic and intensive telehealth; between 'activated', well-supported patients and vulnerable, unsupported ones; between 'cold telehealth' (technology-mediated biomarker monitoring enabling semi-automated adjustment of medication) and 'warm telehealth' (relationship-based care delivered by a known clinician via telephone or video consultation); and between fixed and agile care programmes.
Conclusion: Conventional systematic reviews (whose goal is synthesising data) can be usefully supplement by hermeneutic reviews (whose goal is deepening understanding). The limited adoption of telehealth for heart failure has complex and inter-related clinical, professional and institutional causes. These are unlikely to be resolved by undertaking new RCTs or meta-analyses of telehealth-on versus telehealth-off. We offer suggestions for new avenues of research.