Telehealth Pros & Cons. Keir Lewis AARNS Conference 7 th May 2011

Transcription

1 Telehealth Pros & Cons Keir Lewis AARNS Conference 7 th May 2011

2 Summary The need for different working Definitions Evidence Base so far (for COPD) Future developments

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5 Change in age-adjusted death rate in the USA from (%) COPD is the only major cause of death that has increased significantly in recent years CHD Stroke CVD COPD All other causes CHD = coronary heart disease; CVD = cerebrovascular disease Mannino DM & Kiri VA. Int J Chron Obstruct Pulmon Dis 2006;1: Moreover 825,000 diagnosed but up to 2.8 M sufferers. (

6 Summary The need for different working Definitions Evidence Base so far (for COPD) Future developments

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8 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

9 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?) Reducing CO 2 emissions

10 Summary The need for different working Definitions Evidence Base so far (for COPD) Future developments

11 Stable COPD

12 Randomised Post PR n=20 Baseline QoL Docobo 6 months QoL and HCCs Standard care 6 months QoL and HCCs n=20 Baseline QoL Standard care 6 months QoL and HCCs Standard care 6 months QoL and HCCs

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16 Primary outcome: Safe and feasible. Secondary outcomes: Well-used with 97% median compliance! p<0.03 Halved hospital admissions p=0.40 No difference in other contacts Journal of COPD. 2010; 7: 44-50

17 Problems Small study 6 months active treatment only Very motivated and optimised patients Already under CDM etc 0.30 vs 0.15 admissions per patient per yr

18 Unstable COPD

19 12% vs 22% readmission HR 0.25 ( ) 14% reduction in other et al

20 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 Not randomised but TVC via municipality

21 Other studies Name Type Popln Intervention Main Finding Maiolo Pre-post 20 Tm Admissions 2003 Italy COPD (LTOT) 6 months Contacts Pare QE 20 vs 20 Tm Admissions 2006 Canada COPD 6 months Trappenburg Pre-post 59 vs 56 Tm Admissions 2008 Holland COPD 6 months QoL Vitaccia RCT 57 vs 44 Tm Admissions 2008 Italy mixed 12 months Vontetsianos Pre-post 18 Tm during home visit Bed days 2005 Greece COPD 9 months QoL Dang Pre-post 17 COPD Tm Admissions 2006 Holland 59 total 6 months Contacts Koff RCT 19 Tm?Admissions 2009 Germany COPD 3 months QoL

22 Bensink M, Hailey D. et al. (2006) A systematic review of successes and failures in h telehealth: preliminary results. J Telemed Telecare; 12: 8-16 [TH] Bergmo, T. (2009) Can economic evaluation in telemedicine be trusted? A systemati 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): [TH] Jennett P, Hall L (2003) The socio-economic impact of telehealth: A systematic revie Journal of Telemedicine and Telecare; 9(6): [TH] Kairy, D., P. Lehoux, et al.(2009) A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disability a Rehabilitation; 31(6): [TR] Polisena J, Tran K et al. (2009b). Home telehealth for chronic disease management: systematic review and an analysis of economic evaluations. International Journal Technology Assessment in Health Care; 25(3): [TH] Rojas, S., Gagnon, M. P. (2008) A systematic review of the key indicators for assess telehomecare cost-effectiveness. Telemedicine and e-health; 14(9): [TC] Seto, E. (2008) Cost comparison between telemonitoring and usual care of heart fai a systematic review. Telemedicine and e-health; 14(7): [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 Resea 10:1-13 [TH] ECONOMIC

23 General Consensus Evidence is weak See also Bolton et al Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD. doi: /j x J Eval Clin Prac 2010 Jaana M et al. Home telemonitoring for respiratory conditions: a systematic review. Am J Manag Care 2009;15: So it is hard to draw conclusions from available studies What are the areas of weaknesses?

24 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

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26 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

27 Summary The need for different working Definitions Evidence Base so far (for COPD) Future developments

28 Phase 2, WAG funded 2 centre, powered, crossover RCT Any admissions COPD within last 2 years Irrespective of PR or severity Registered

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30 1% GP Consultant 10% true clinical alerts CDM / hospital nurses 90% technical alerts Telecare + team Patient using Tm

31 Costs Estimated costs for Docobo for first year

32 Start-up Costs 115,783 Running Costs 35,147 TOTAL Costs Yr 1 150, Int J Clin Pract 2007; 61: AE attendances saved 84x 691 = 58,044 Hospital admissions saved 36 x = 76,716 GP contacts saved 780x 32 2 = TOTAL Savings Yr 1 = 159, Unit Costs of Health and Social Care

33 Tunstall Docobo Docobo- GPRS Start-up 198, , ,183 Ongoing 35,055 35,147 35,147 TOTAL Yr 1-73, ,790-5,610 Potential savings per Yr (after Yr 1) 124, , ,573

34 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 $1600 per patient per year

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36 Telemonitoring and ITU??

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39 Themes: Utilisation of resources Participants and Carers Cost-effectiveness Organisational issues (sustainability)

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43 Demonstrators of Assisted Living Lifestyles at Scales (DALLAS)

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45 Changes to technology (including costs!)

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52 Summary The need for different working Definitions Evidence Base so far (for COPD) Future developments

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