Effectiveness of implementation strategies for digital health implementation in chronic disease care: a systematic review and network meta-analysis

Background Digital health technologies (DHTs) have proven to be valuable tools in managing chronic conditions. However, significant barriers remain in the implementation of DHTs. A gap remains in understanding the comparative effectiveness of implementation strategies in the context of digital realm. This study aims to make a comprehensive evaluation of the implementation strategies while also investigating potential moderators influencing strategy effectiveness. Methods This study is a systematic review and meta-analysis. This study searched four databases and hand searched reference lists from inception to July 2024 for randomized and non-randomized trials with a control group and interrupted time series assessing the impact of at least one implementation strategy to improve DHTs implementation using an outcome that could be mapped to the implementation, patient, and service outcomes based on the Implementation Outcome Framework. Random-effects meta-analysis was conducted. We also conducted meta-regression and subgroup analysis to explore the moderators of the strategy effects and heterogeneity. This study was registered with PROSPERO (CRD42025519493). Results We screened 9544 records and selected 32 articles for systematic review and 24 articles were included in the meta-analysis. The most frequently used strategies are “engage consumers”, “support clinicians”, and “train and educate stakeholders”. Most of the articles were with high or serious risk of bias. Implementation strategy as a whole showed a small positive average effect on implementation outcomes compared with no implementation strategy (RD = 0.02, 95% CI: 0.00 to 0.03), but heterogeneity was high (I² = 81.3%). Importantly, after excluding high-risk studies, the pooled effect attenuated to null (RD = -0.00, 95% CI: -0.01 to 0.01) and heterogeneity decreased substantially (I² = 6.6%). The network contained no closed loops, and network meta-analysis estimates were small; 22 of 28 comparative estimates were rated as very low certainty. While the network meta-analysis showed that “train and educate stakeholders” had a relatively favorable effect on implementation outcomes versus no active strategy (RD = 0.03, 95% CI: 0.00 to 0.06, P = 0.047), this result was based on low-certainty evidence and should be interpreted cautiously. No strategy was supported by sufficiently certain evidence as superior. The meta-regression indicates that disease type (e.g., cardiac system diseases, diabetes) is an important moderator. The subgroup analysis shows that certain healthcare providers’ behaviors (e.g., documentation, diagnosis) and the number of strategy components play crucial roles in the effects of implementation strategies. Conclusions Implementation strategies were associated with a small average improvement in DHT implementation, but effects varied substantially across studies and showed little effects to service or patient outcomes. Given the high risk of bias, substantial heterogeneity, and predominantly low-certainty evidence, the results highlight the importance of tailoring strategies to a specific healthcare context. Future research should also explore long-term effects, multi-level strategies, and sites located in low- and middle-income countries for optimizing DHT implementation.