The EU project "United4Health": Results and experiences from automatic health status assessment in a Norwegian telemedicine trial system.

INTRODUCTION: Patients with chronic obstructive pulmonary disease require help in daily life situations to increase their individual perception of security, especially under worsened medical conditions. Unnecessary hospital (re-)admissions and home visits by doctors or nurses shall be avoided. This study evaluates the results from a two-year telemedicine field trial for automatic health status assessment based on remote monitoring and analysis of a long time series of vital signs data from patients at home over periods of weeks or months. METHODS: After discharge from hospital treatment for acute exacerbations, 94 patients were recruited for follow-up by the trial system. The system supported daily measurements of pulse and transdermal peripheral capillary oxygen saturation at patients' homes, a symptom-specific questionnaire, and provided nurses trained to use telemedicine ("telenurses") with an automatically generated health status overview of all monitored patients. A colour code (green/yellow/red) indicated whether the patient was stable or had a notable deterioration, while red alerts highlighted those in most urgent need of follow-up. The telenurses could manually overwrite the status level based on the patients' conditions observed through video consultation. RESULTS: Health status evaluation in 4970 telemonitor datasets were assessed retrospectively. The automatic health status determination (subgroup of 33 patients) showed green status at 46% of the days during a one-month monitoring period, 28% yellow status, and 19% red status (no data reported at 7% of the days). The telenurses manually downrated approximately 10% of the red or yellow alerts. DISCUSSION: The evaluation of the defined real-time health status assessment algorithms, which involve static rules with personally adapted elements, shows limitations to adapt long-term home monitoring with adequate interpretation of day-to-day changes in the patient's condition. Thus, due to the given sensitivity and specificity of such algorithms, it seems challenging to avoid false high alerts.

Health economic evaluations of patient education interventions a scoping review of the literature.

OBJECTIVES: To provide a comprehensive overview of health economic evaluations of patient education interventions for people living with chronic illness. METHODS: Relevant literature published between 2000 and 2016 has been comprehensively reviewed, with attention paid to variations in study, intervention, and patient characteristics. RESULTS: Of the 4693 titles identified, 56 articles met the inclusion criteria and were included in this scoping review. Of the studies reviewed, 46 concluded that patient education interventions were beneficial in terms of decreased hospitalization, visits to Emergency Departments or General Practitioners, provide benefits in terms of quality-adjusted life years, and reduce loss of production. Eight studies found no health economic impact of the interventions. CONCLUSIONS: The results of this review strongly suggest that patient education interventions, regardless of study design and time horizon, are an effective tool to cut costs. This is a relatively new area of research, and there is a great need of more research within this field. PRACTICE IMPLICATIONS: In bringing this evidence together, our hope is that healthcare providers and managers can use this information within a broad decision-making process, as guidance in discussions of care quality and of how to provide appropriate, cost-effective patient education interventions.

Assessing alcohol use and smoking among patients admitted to the medical ward.

BACKGROUND: The objective of the study was to investigate the incidence of risky alcohol consumption in patients admitted to medical wards, and to examine possible differences in how smoking habits and alcohol consumption are assessed and monitored by health personnel. MATERIAL AND METHOD: The study was conducted on medical wards at Southern Norway Hospital Trust in autumn 2013. Out of 998 patients who were successively admitted, 536 were included in the analysis. A questionnaire was used to survey smoking and risky alcohol consumption, and to determine whether patients could remember being asked and advised about these during their hospitalisation period. RESULTS: Fifty patients (9.3%) fulfilled the criteria for risky alcohol consumption. A lower percentage reported having been asked about their drinking habits than about their smoking habits (44% versus 62%, p < 0.001). Compared to those who smoked, a lower percentage of those with risky alcohol consumption reported that they had been recommended to reduce their consumption or quit; 10% vs. 29% (p = 0.009). INTERPRETATION: The patients' experience was that they were asked less about their alcohol consumption than about smoking. They also reported receiving less health-promoting advice in relation to alcohol. Doctors should be more conscious of including alcohol consumption when taking regular case histories.

Cost effectiveness of a smoking cessation program in patients admitted for coronary heart disease.

BACKGROUND: Smoking cessation is probably the most important action to reduce mortality after a coronary event. Smoking cessation programs are not widely implemented in patients with coronary heart disease, however, possibly because they are thought not to be worth their costs. Our objectives were to estimate the cost effectiveness of a smoking cessation program, and to compare it with other treatment modalities in cardiovascular medicine. METHODS: A cost-effectiveness analysis was performed on the basis of a recently conducted randomized smoking cessation intervention trial in patients admitted for coronary heart disease. The cost per life year gained by the smoking cessation program was derived from the resources necessary to implement the program, the number needed to treat to get one additional quitter from the program, and the years of life gained if quitting smoking. The cost effectiveness was estimated in a low-risk group (i.e. patients with stable coronary heart disease) and a high-risk group (i.e. patients after myocardial infarction or unstable angina), using survival data from previously published investigations, and with life-time extrapolation of the survival curves by survival function modeling. RESULTS: In a lifetime perspective, the incremental cost per year of life gained by the smoking cessation program was euro 280 and euro 110 in the low and high-risk group, respectively (2000 prices). These costs compare favorably to other treatment modalities in patients with coronary heart disease, being approximately 1/25 the cost of both statins in the low-risk group and angiotensin-converting enzyme inhibitors in the high-risk group. In a sensitivity analysis, the costs remained low in a wide range of assumptions. CONCLUSIONS: A nurse-led smoking cessation program with several months of intervention is very cost-effective compared with other treatment modalities in patients with coronary heart disease.

The effects of patient education in COPD in a 1-year follow-up randomised, controlled trial.

The aims were to explore the effects and health economic consequences of patient education in patients with COPD in a 12-month follow-up. Sixty-two patients with mild to moderate Chronic Obstructive Pulmonary Disease (COPD) were at our out-patient clinic randomly allocated to an intervention group or a control group. The intervention group participated in a 4h group patient education, followed by one to two individual nurse- and physiotherapist-sessions. Self-management was emphasised following a stepwise treatment plan. Effectiveness was expressed in terms of number of general practitioner (GP) consultations, proportions in need of GP consultations, utilisation of rescue medication and patient satisfaction. Costs related to doctor visits, days off work, dispensed pharmaceuticals, hospital admissions, travel costs, educational and time costs were recorded. Patient education reduced the need for GP visits with 85% (from 3.4 to 0.5, P<0.001) and kept a greater proportion independent of their GP during the 12-month follow-up, compared with no education (73% versus 15%, respectively). Patient education reduced the need for reliever medication from 290 to 125 Defined Daily Dosages (DDD), and improved patient satisfaction with overall handling of their disease at GP. The control and intervention groups induced mean total costs of NOK 19,900 and 10,600 per patient, respectively. For every NOK put into patient education, there was a saving of 4.8. The Number Needed to Educate (NNE) to make one person satisfied with their GP was 4.5 and associated with a concomitant saving of NOK 41,900. Patient education of patients with COPD improved patient outcomes and reduced costs in a 12-month follow-up.

Does smoking affect the outcome of patient education and self-management in asthmatics?

Information on the potential effect of smoking on the outcome of patient education in asthma is lacking. We randomly allocated 78 asthmatics to either a control or intervention group. Intervention consisted of two 2-h group sessions followed by 1-2 individual sessions each by a nurse and a physiotherapist. Self-management was emphasised following a stepwise treatment plan at exacerbations. Smokers experienced more general practitioner (GP) visits (P=0.001) and absenteeism from work (P=0.02), a greater need for rescue medication (P=0.03), a larger drop in FEV1 (P=0.02) and worse St. George's respiratory questionnaire (SGRQ) scores (P<0.001) compared to non-smokers during the 1-year follow-up. In multiple linear and logistic regression models smoking was still associated with worse SGRQ scores, a drop in FEV1, higher need for GP visits and rescue medication and higher total costs. We, thus, conclude that smoking was associated with reduced health related quality of life, a drop in FEV1, increased need for rescue medication and GP visits and higher costs after patient education during the 1-year follow-up, compared to no smoking.

Cost-benefit and cost-effectiveness analysis of self-management in patients with COPD--a 1-year follow-up randomized, controlled trial.

The aims were to explore the effects and health economic consequences of patient education in patients with COPD in a 12-month follow-up. Sixty-two patients with mild-to-moderate chronic obstructive pulmonary disease (COPD) were at our outpatient clinic randomly allocated to an intervention group or a control group. The intervention group participated in a 4-h schooling, followed by one-to-two individual nurse and physiotherapist consultations. Self-management was emphasized following a stepwise treatment plan. Effectiveness was expressed in terms of proportions in need of general practitioner (GP) consultations, patient satisfaction and utilization of rescue medication. Doctor visits, days off work, dispensed pharmaceuticals, hospital admissions, travel costs, educational and time costs were recorded. The control and intervention groups induced mean total costs of NOK 19900 and 10600 per patient, respectively. The results were robustto realistic changes in the assumptions upon which they were based. For every NOK put into patient education, there was a saving of 4.8. The NNE to make one patient independent of their GP was 1.7 (95% CI: 1.3--2.8) and associated with a concomitant saving of NOK 15 800. The corresponding NNE to make one person satisfied with their GP was 4.5 (95% CI: 2.9--10) and NOK 41900, respectively. A reduced need of 100 DDD of rescue medication was associated with a concomitant saving of NOK5600. We conclude that patient education of patients with COPD in a 12-month follow-up improved patient outcomes and reduced costs.

[The effect of patient education in asthma, a randomized controlled trial]. / Effekter av astmaopplaering i en randomisert, kontrollert undersøkelse.

BACKGROUND: Our aim was to evaluate costs and consequences of patient education in asthmatics in a twelve-month follow-up. MATERIAL AND METHODS: 78 asthmatics were randomly allocated to a control or intervention group after having received ordinary outpatient care. Intervention consisted of two two-hour group sessions followed by one or two individual sessions administered by a nurse and a physiotherapist. Self-management was emphasised. Visits to the doctor, prescribed drugs, hospital admissions, travel costs, time costs, and educational costs were recorded. RESULTS: In a twelve-month follow-up, patient education resulted in approximately a 70% reduction in GP visits and days off work due to asthma as well roughly a doubling of proportions with satisfactory steroid inhaler compliance compared to no education. Patient education also improved lung function (FEV1) by 6%, and it improved quality of life. The control and intervention groups had mean total costs of NOK16,000 and 10,500 per patient respectively. A 5% improvement in FEV1 in the intervention group was associated with savings of NOK 4,500 compared to the control group. The number needed to educate (NNE) to make one person symptom free was associated with savings of NOK 12,200. INTERPRETATION: Patient education in asthmatics in a twelve-month follow-up improved patient outcomes and reduced costs.