Telehealth –Pros & Cons
Keir Lewis
Summary
• The need for different working
• Definitions
• Evidence Base so far (for COPD)
• Future developments
COPD is the only major cause of death that has increased significantly in recent years
–59 –64 –35 +163 –7 –80 –40 0 40 80 120 160
CHD Stroke CVD COPD All other causes Ch an g e in a g e -ad ju st e d d ea th r at e in t h e US A f ro m 1 965 199 8 (% )
CHD = coronary heart disease; CVD = cerebrovascular disease Mannino DM & Kiri VA. Int J Chron Obstruct Pulmon Dis 2006;1:219–233.
Moreover 825,000 diagnosed but up to 2.8 M sufferers….
Summary
• The need for different working
• Definitions
• Evidence Base so far (for COPD)
• Future developments
Definitions
• Telecare:
Use of technology to help people stay at home • Telemonitoring:
Use of information technology to monitor patients at a distance
• Telehealth:
Use of technology for diagnosis and monitoring
Supporting patient and expectations
• Ability to provide care any time and any place • Connecting patients to a system before they get
sick
• Helping people age in place
• Better clinical integration (across speciality, across country?)
Summary
• The need for different working
• Definitions
• Evidence Base so far (for COPD)
n=20
Baseline QoL Baseline QoLn=20
QoL and HCCs Docobo 6 months
Standard care 6 months QoL and HCCs
QoL and HCCs Standard care 6 months
Standard care 6 months QoL and HCCs
Randomised Post PR
Primary outcome: Safe and feasible.
Secondary outcomes:
Well-used with 97% median compliance!
Halved hospital admissions p=0.40 No difference in other contacts
p<0.03
Problems
• Small study
• 6 months active treatment only
• Very motivated and optimised patients
• Already under CDM etc
12% vs 22% readmission
HR 0.25 (0.09-0.69) 14% reduction in ‘other’
But….
• Screened 1784 patients to get 50 per group
• Lots of exclusion criteria
• Tele-videoconferencing for median 11 days
post-discharge
• Set times of day
Other studies
Name Type Popln Intervention Main Finding
Maiolo 2003 Pre-post Italy 20 COPD (LTOT) Tm 6 months Admissions Contacts Pare 2006 QE Canada 20 vs 20 COPD Tm 6 months Admissions Trappenburg 2008 Pre-post Holland 59 vs 56 COPD Tm 6 months Admissions QoL Vitaccia 2008 RCT Italy 57 vs 44 mixed Tm 12 months Admissions Vontetsianos 2005 Pre-post Greece 18 COPD
Tm during home visit 9 months Bed days QoL Dang 2006 Pre-post Holland 17 COPD 59 total Tm 6 months Admissions Contacts Koff 2009 RCT Germany 19 COPD Tm 3 months ?Admissions QoL
•Bensink M, Hailey D. et al. (2006) A systematic review of successes and failures in home telehealth: preliminary results. J Telemed Telecare; 12: 8-16 [TH]
•Bergmo, T. (2009) Can economic evaluation in telemedicine be trusted? A systematic review of the literature. Cost effectiveness and resource allocation; 7:18 [TM]
•Davalos M., French M et al. (2009) Economic evaluation . J Telemed Telecare; 15(10):933-948 [TH]
•Jennett P, Hall L (2003) The socio-economic impact of telehealth: A systematic review.
Journal of Telemedicine and Telecare; 9(6): 311-320. [TH]
•Kairy, D., P. Lehoux, et al.(2009) A systematic review of clinical outcomes, clinical
process, healthcare utilization and costs associated with telerehabilitation. Disability and Rehabilitation; 31(6): 427-447. [TR]
•Polisena J, Tran K et al. (2009b). Home telehealth for chronic disease management: A systematic review and an analysis of economic evaluations. International Journal
Technology Assessment in Health Care; 25(3): 339-349. [TH]
•Rojas, S., Gagnon, M. P. (2008) A systematic review of the key indicators for assessing telehomecare cost-effectiveness. Telemedicine and e-Health; 14(9): 896-904 [TC]
•Seto, E. (2008) Cost comparison between telemonitoring and usual care of heart failure: a systematic review. Telemedicine and e-Health; 14(7): 679-686 [TH]
•Wade, V. A., J. Karnon, et al. (2010) A systematic review of economic analyses of
telehealth services using real time video communication. BMC Health Services Research
10:1-13 [TH]
General Consensus
• Evidence is weak • See also
– Bolton et al Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD. doi: 10.1111/j.1365-2753.2010.01536.x J Eval Clin Prac 2010
– Jaana M et al. Home telemonitoring for respiratory conditions: a systematic review. Am J Manag Care 2009;15:313-20.
• So it is hard to draw conclusions from available studies
Weaknesses
• Small samples, short term
• Combine heterogeneous populations • Combine heterogeneous interventions • ‘Before and after’ (no control groups) • Blinding? (placebo effect)
• Generisability to local services (mainly US studies) • Too many ‘interested parties’
– Manufacturers
– Governments /managers – Lobby groups
Weaknesses – the less obvious?
• Not enough patient centred outcomes (QoL?)
• Multi-agency and needs to be integrated e.g with social care (?) but budgets go to silos
• Could identify more needs!
• No minimum clinical standards but Association ‘code of practice’
Summary
• The need for different working
• Definitions
• Evidence Base so far (for COPD)
• Phase 2, WAG funded
• 2 centre, powered, crossover RCT
• Any admissions COPD within last 2 years • Irrespective of PR or severity
Patient using Tm
90% ‘technical’ alerts Telecare+ team
10% true clinical alerts CDM / hospital nurses
1% GP Consultant
Costs
AE attendances saved 84x £691 = £58,044
Hospital admissions saved 36 x £21311 = £76,716 GP contacts saved 780x £322 = £24960 TOTAL Savings Yr 1 = £159,720 Start-up Costs £115,783 Running Costs £35,147 TOTAL Costs Yr 1 £150,930
1. Int J Clin Pract 2007; 61: 1112-1120
Tunstall™ Docobo™ Docobo-GPRS Start-up £198,512 £115,783 £130,183 Ongoing £35,055 £35,147 £35,147 TOTAL Yr 1 -£73,847 +£8,790 -£5,610 Potential savings per Yr (after Yr 1) £124,665 £124,573 £124,573
Can it be done at scale?
• Veterans Health Administration (VHA)
• Now standard integrated care (home telehealth) • By 2007 had 31,570 patients, 5000 staff
•19% reduction in admissions (hosp and NH)
•25% reduction in bed days
•86% mean satisfaction score
Themes:
Utilisation of resources Participants and Carers Cost-effectiveness
Demonstrators of Assisted Living Lifestyles at Scales
Changes to technology (including costs…!)
