Details of study characteristics, critical appraisal, and study findings are located in Appendices 2, 3, and 4, respectively.
Quantity of Research Available
A total of 186 citations were identified in the literature search. Following screening of titles and abstracts, 178 citations were excluded and eight potentially relevant reports from the electronic search were retrieved for full-text review. No potentially relevant publications were retrieved from the grey literature search. Of these potentially relevant articles, six publications were excluded for various reasons, while two RCTs met the inclusion criteria and were included in this report.11,12 No relevant systematic reviews or meta-analyses, non-randomized controlled trials or economic evaluations were identified. Appendix 1 describes the PRISMA flowchart of the study selection.
Summary of Study Characteristics
Study Design
The treatment effect of telehealth relative to conventional on-site therapy was assessed in two RCTs conducted by Grogan-Johnson and colleagues.11,12 The 2013 Grogan-Johnson study included school-age children with speech sound disorders,11 and the 2010 Grogan-Johnson study enrolled preschool- and school-age children.12 Randomization in the first trial was carried out by drawing students’ names out of a hat and alternately assigning them to one of the two treatment groups thereafter,11 while the method of randomization was not reported in the second trial.12 A power calculation was not reported in either study.
Country of Origin
The RCTs that evaluated the treatment effect of telehealth on speech disorders were conducted in the US.11,12
Patient Population
Fourteen children with speech sound impairments, aged from 6 to 10 years old were enrolled in the 2013 Grogan-Johnson study.11 The mean age for the participants was 8.4 years (range: 6.4 to 9.9 years) in the telehealth group and was 9.0 years (range: 7.9 to 10.0 years) in the comparator group.
In the 2010 Grogan-Johnson study, 38 children aged from 4 to 12 years old, with communication impairments (i.e., articulation, language and/or fluency disorders) and followed an Individualized Education Plan that encompassed the provision of SLP services, were included.12 The results for six children were not reported in this study: three did not receive baseline evaluation, two did not complete therapy and one was dismissed from SLP services due to a change in her condition. The demographic characteristics of the study participants were not reported, so it is unclear how many of them were preschoolers.
Interventions and Comparators
The 2013 Grogan-Johnson study was conducted to compare a speech sound intervention delivered via a telehealth model with a conventional side-by-side service delivery model.11 Students participating in a 5-week summer speech sound intervention program were assigned to either the telehealth group (computer-based videoconferencing) or the side-by-side treatment group. During the 5-week period, a 30-minute individual session was provided twice a week in both groups. Seven students were assigned to the telehealth group, and another seven to the side-by-side treatment group.
In the 2010 Grogan-Johnson study, participants were randomly assigned to 4-month telehealth therapy (computer-based videoconferencing) followed by conventional on-site therapy (Group A), or 4-month conventional on-site therapy following by 4-month telehealth therapy (Group B).12 There was no washout period between the two treatments. Seventeen students were assigned to Group A, and another 17 students were assigned to Group B.
Outcomes
The outcome measures in the 2013 Grogan-Johnson study were improvement in speech sound production, which was measured using a standardized assessment tool, the Sounds-in-Words and Sounds-in-Sentences subtests of the Goldman-Fristoe Test of Articulation 2 (GFTA-2), and listener judgments that were performed by graduate SLP students to identify improvement in productions of error phonemes noted at baseline evaluation.
The outcome measures in the 2010 Grogan-Johnson study included student progress and participant satisfaction through a survey.12 Student performance was rated with the scale, Mastered, Making Adequate Progress, Making Inadequate Progress and Objective Not Initiated. Two other scales were employed to measure communication impairments and articulation. The Functional Communication Measures (FCMs) are a series of 7-point scales to rate the student’s functional change at the start and the end of treatment. The second scale was GFTA-2, which was commonly used in schools to assess articulation and was administered by the investigators at the beginning, middle and end of the study. The data after the first 4-month treatment period were reported in the study.
Summary of Critical Appraisal
Both studies stated their objectives and inclusion/exclusion criteria. Even though they both indicated that they were RCTs, the quality of these two studies was compromised. In the 2013 Grogan-Johnson study, treatment allocation was assigned on the basis of a pseudo-random sequence (i.e., alternation), and the method of randomization was not described in the 2010 Grogan-Johnson study. The power calculation and sample size determination were not reported in either study. The study results should be interpreted with caution given the range of sample sizes (n = 1411 to 3812 participants). Also, the 2013 Grogan-Johnson study did not specify if the intention-to-treat approach was used in the statistical analyses, while in the 2010 study, the results were reported based on the participants who had completed the treatment. In the 2010 Grogan-Johnson study, participant satisfaction was reported. The results, however, must be interpreted with caution given the survey response rates among the students (76.3%), parents (66.7%) and staff (55.6%).
English was the primary language in the study participants. In addition, participants in both studies were recruited in Ohio, US, so it is unclear whether the findings can be generalized to broader patient populations.
Summary of Findings
1. What is the clinical effectiveness of telehealth for the delivery of speech language pathology services to children with speech and language disorders or impairments?
In the 2013 Grogan-Johnson study, the mean number of sessions attended by the study participants was similar between the two treatment groups, 9.3 sessions in the telehealth group and 9.4 sessions in the side-by-side treatment group. The results showed that children in both groups demonstrated some improvement in their speech sound production at the end of the intervention; however, there were no statistically significant between-group differences in assessments after the treatment. The authors concluded that both models helped improve children’s speech sound productions.
The 2010 Grogan-Johnson study evaluated the effect of telehealth SLP services and conventional on-site SLP services on articulation disorders in young children. The performance of the majority of the preschool- and school-age students from both groups was rated as Mastered or Making Adequate Progress. This rating was not defined in the article. At the end of the first treatment period, there was no statistically significant difference in GFTA-2 scores between telehealth and on-site service (p=0.06). The authors indicated that telepractice was a viable approach to deliver services to children with articulation disorders in a public school setting.
2. What is the cost-effectiveness of Telehealth for the delivery of Speech Language Pathology services to children with speech and language disorders or impairments?
There were no economic evaluations identified.
3. What are the evidence-based guidelines regarding the use of Telehealth for the delivery of Speech Language Pathology services to children with speech and language disorders or impairments?
There were no evidence-based clinical practice guidelines identified.
Limitations
The literature search did not identify health technology assessments, systematic reviews, non-randomized controlled trials, or economic evaluations regarding the comparative clinical and cost-effectiveness of telehealth relative to conventional in-person SLP services. The evidence from two RCTs (n = 1411 and 3812 participants) was reported. The method for randomization was questionable in one study and unknown in another. Given that there was no power calculation in either study and an intention-to-treat analysis was not reported, study findings should be interpreted with caution. Also, the generalization of the study results to other populations remained uncertain because of the patient characteristics in these two studies, where eligible participants were all from Ohio, US, and English was required to be their primary language.
In the study that enrolled preschoolers,12 the proportion of children younger than 5 years old was not reported, and there were no results available for this particular subgroup. Furthermore, videoconferencing was the only telehealth technology that was examined in the included studies. Patient-reported outcomes, such as health-related quality of life, functional status and long-term academic performance, were not evaluated in these studies that ranged from five weeks11 to eight months12 in duration.
