Evaluation of the National Health Service (NHS) Direct Pilot Telehealth Program: Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost-effectiveness of a pilot telehealth program applied to a wide population of patients with chronic obstructive pulmonary disease (COPD). DESIGN: Vital signs data were transmitted from the home of the patient on a daily basis using a patient monitoring system for review by community nurse to assist decisions on management. SETTING: Community services for patients diagnosed with COPD. PARTICIPANTS: Two Primary Care Trusts (PCTs) enrolled 321 patients diagnosed with COPD into the telehealth program. Two hundred twenty-seven (n = 227) patients having a complete baseline record of at least 88 days of continuous remote monitoring and meeting all inclusion criteria were included in the statistical analysis. INTERVENTION: Remote monitoring. METHODS: Resource and cost data associated with patient events (inpatient hospitalization, accident and emergency [A&E], and home visits) 12 months before, immediately before and during monitoring, equipment, start-up, and administration were collected and compared to determine cost-effectiveness of the program. MAIN OUTCOME MEASURES: Cost-effectiveness of program, impact on resource usage, and patterns of change in resource usage. RESULTS: Cost-effectiveness was determined for the two PCTs and the two periods before monitoring to provide four separate estimates. Cost-effectiveness had high variance both between the PCTs and between the comparison periods ranging from a saving of £140,800 ($176,000) to an increase of £9,600 ($12,000). The average saving was £1,023 ($1,280) per patient per year. The largest impact was on length of stay with a fall in the average length of inpatient care in PCT1 from 11.5 days in the period 12 months before monitoring to 6.5 days during monitoring, and similarly in PCT2 from 7.5 to 5.2 days. CONCLUSION: There was a wide discrepancy in the results from the two PCTs. This places doubt on outcomes and may indicate also why the literature on cost-effectiveness remains inconclusive. The wide variance on savings and the uncertainty of monitoring cost do not allow a definitive conclusion on the cost-effectiveness as an outcome of this study. It might well be that the average saving was £1,023 ($1,280) per patient per year, but the variance is too great to allow this to be statistically significant. Each locality-based clinical service provides a service to achieve the same clinical goal, but it does so in significantly different ways. The introduction of remote monitoring has a profound effect on team learning and clinical practice and thus distorts the cost-effectiveness evaluation of the use of the technology. Cost-effectiveness studies will continue to struggle to provide a definitive answer because outcome measurements are too dependent on factors other than the technology.

A better way to evaluate remote monitoring programs in chronic disease care: receiver operating characteristic analysis.

BACKGROUND: This foundational study applies the process of receiver operating characteristic (ROC) analysis to evaluate utility and predictive value of a disease management (DM) model that uses RM devices for chronic obstructive pulmonary disease (COPD). The literature identifies a need for a more rigorous method to validate and quantify evidence-based value for remote monitoring (RM) systems being used to monitor persons with a chronic disease. ROC analysis is an engineering approach widely applied in medical testing, but that has not been evaluated for its utility in RM. Classifiers (saturated peripheral oxygen [SPO2], blood pressure [BP], and pulse), optimum threshold, and predictive accuracy are evaluated based on patient outcomes. MATERIALS AND METHODS: Parametric and nonparametric methods were used. Event-based patient outcomes included inpatient hospitalization, accident and emergency, and home health visits. Statistical analysis tools included Microsoft (Redmond, WA) Excel(®) and MedCalc(®) (MedCalc Software, Ostend, Belgium) version 12 © 1993-2013 to generate ROC curves and statistics. Persons with COPD were monitored a minimum of 183 days, with at least one inpatient hospitalization within 12 months prior to monitoring. Retrospective, de-identified patient data from a United Kingdom National Health System COPD program were used. Datasets included biometric readings, alerts, and resource utilization. RESULTS: SPO2 was identified as a predictive classifier, with an optimal average threshold setting of 85-86%. BP and pulse were failed classifiers, and areas of design were identified that may improve utility and predictive capacity. Cost avoidance methodology was developed. CONCLUSIONS: RESULTS can be applied to health services planning decisions. Methods can be applied to system design and evaluation based on patient outcomes. This study validated the use of ROC in RM program evaluation.

Mobile health is worth it! Economic benefit and impact on health of a population-based mobile screening program in new Mexico.

BACKGROUND: HABITS for Life was a 3-year initiative to broadly deliver a statewide biometric and retinal screening program via a mobile unit throughout New Mexico at no charge to participants. The program goal-to identify health risk and improve population health status-was tested over a 3-year period. Value to participants and impact to the healthcare system were measured to quantify impact and value of investing in prevention at the community level. MATERIALS AND METHODS: We used the Mobile Health Map Return-on-Investment Calculator, a mobile screening unit, biometric screening, retinography, and community coordination. Our systems included satellite, DSL, and 3G connectivity, a Tanita® (Arlington Heights, IL) automated body mass index-measuring scale, the Cholestec® (Alere™, Waltham, MA) system for biomarkers and glycosylated hemoglobin, a Canon (Melville, NY) CR-1 Mark II camera, and the Picture Archiving Communication System. RESULTS: In this report for the fiscal year 2011 time frame, 6,426 individuals received biometric screening, and 5,219 received retinal screening. A 15:1 return on investment was calculated; this excluded retinal screening for the under-65 year olds, estimated at $10 million in quality-adjusted life years saved. Statistically significant improvement in health status evidenced by sequential screening included a decrease in total cholesterol level (p=0.002) (n=308) and an increase in high-density lipoprotein level after the first and second screening (p=0.02 and p=0.01, respectively), but a decrease in mean random glucose level was not statistically significant (p=0.62). Retinal results indicate 28.4% (n=1,482) with a positive/abnormal finding, of which 1.79% (n=93) required immediate referral for sight-threatening retinopathy and 27% (n=1,389) required follow-up of from 3 months to 1 year. CONCLUSIONS: Screening programs are cost-effective and provide value in preventive health efforts. Broad use of screening programs should be considered in healthcare redesign efforts. Community-based screening is an effective strategy to identify health risk, improve access, provide motivation to change health habits, and improve physical status while returning significant value.

The morningside initiative: collaborative development of a knowledge repository to accelerate adoption of clinical decision support.

The Morningside Initiative is a public-private activity that has evolved from an August, 2007, meeting at the Morningside Inn, in Frederick, MD, sponsored by the Telemedicine and Advanced Technology Research Center (TATRC) of the US Army Medical Research Materiel Command. Participants were subject matter experts in clinical decision support (CDS) and included representatives from the Department of Defense, Veterans Health Administration, Kaiser Permanente, Partners Healthcare System, Henry Ford Health System, Arizona State University, and the American Medical Informatics Association (AMIA). The Morningside Initiative was convened in response to the AMIA Roadmap for National Action on Clinical Decision Support and on the basis of other considerations and experiences of the participants. Its formation was the unanimous recommendation of participants at the 2007 meeting which called for creating a shared repository of executable knowledge for diverse health care organizations and practices, as well as health care system vendors. The rationale is based on the recognition that sharing of clinical knowledge needed for CDS across organizations is currently virtually non-existent, and that, given the considerable investment needed for creating, maintaining and updating authoritative knowledge, which only larger organizations have been able to undertake, this is an impediment to widespread adoption and use of CDS. The Morningside Initiative intends to develop and refine (1) an organizational framework, (2) a technical approach, and (3) CDS content acquisition and management processes for sharing CDS knowledge content, tools, and experience that will scale with growing numbers of participants and can be expanded in scope of content and capabilities. Intermountain Healthcare joined the initial set of participants shortly after its formation. The efforts of the Morningside Initiative are intended to serve as the basis for a series of next steps in a national agenda for CDS. It is based on the belief that sharing of knowledge can be highly effective as is the case in other competitive domains such as genomics. Participants in the Morningside Initiative believe that a coordinated effort between the private and public sectors is needed to accomplish this goal and that a small number of highly visible and respected health care organizations in the public and private sector can lead by example. Ultimately, a future collaborative knowledge sharing organization must have a sustainable long-term business model for financial support.

Global forum on telemedicine: connecting the world through partnerships.

The American Telemedicine Association (ATA) held the Global Forum on Telemedicine: Connecting the World Through Partnerships in September 2007 with sponsorship by the Telemedicine and Advanced Technology Research Center (TATRC), U.S. Army Medical Research and Materiel Command (USAMRMC). The goal was to bring together key stakeholders in global healthcare outreach to explore a flexible framework and sustainable business model that can leverage telemedicine and information technology (IT) to expand healthcare services internationally. Dr. Hon S. Pak, President of the ATA, opened the forum with a call for collaboration and partnership, and encouraged continued international dialogue to create a framework that leverages the telemedicine community to improve global disparity in healthcare. Keynote addresses included speakers from the World Health Organization (UN) and United Nations (UN) Global Alliance for Information and Communities Technologies and Development (GAID). Presentations from 15 government and nongovernment aid organizations (NGOs) and 12 international programs covered 5 key areas: (1) NGO perspective; (2) governmental/military programs; (3) financial sustainability; (4) disaster response; and (5) emerging opportunities. The forum resulted in an International Roadmap for Action that was developed by the authors based on the presentations and interactions from the 335 attendees and establishing a set of priorities and actions to improve healthcare using telemedicine and IT. Recommendations include: (1) continued dialogue in creating a telemedicine framework; (2) identification and leverage of resources; (3) provision of education to funding organization and expand training programs to build competency in the healthcare workforce; (4) alignment of international policy to support integration of telemedicine into country plans and support cross-country partnerships; (5) development of communications infrastructure; and (6) integration of telemedicine into disaster relief programs.

Patient satisfaction with telemedical access to specialty services in rural California.

We assessed patient satisfaction with the use of telemedicine in rural California, in comparison with usual face-to-face care. A standardized patient satisfaction questionnaire was developed using a five-point scale to measure dimensions of care in a telemedicine environment. Twenty-four primary care sites in 18 Californian counties submitted satisfaction data. The patient response rate was 61% (n = 793). Consultations were provided in 27 specialties. The responses to the questionnaires indicated that telemedicine made it easier for patients to receive specialty care (91% of patients satisfied, mean score 4.6). There was general satisfaction with telemedicine (87%, mean 4.5), a willingness to continue receiving services (90%, mean 4.6) and most patients felt that they would not receive better care in person (61%, mean 2.3). Patients stated that they received the necessary information from specialists (85%, mean 4.5) and had their questions answered by a primary care provider or nurse (89%, mean 4.7). Seven hundred and forty-one patients submitted travel information. There was an average decrease in travel distance of 170 km and time savings of 130 min using telemedicine. The average cost of travel to a specialty appointment was $83 (n = 310). The present study suggests that telemedicine is acceptable to patients as a method of improving access to specialty expertise, and compares favourably with face-to-face care.