Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial

Abstract

Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.Design Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat. Setting 179 general practices in three areas in England.Participants 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009. InterventionsTelehealth involved remote exchange of data between patients and healthcare professionals as part of patients' diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.Main outcome measure Proportion of patients admitted to hospital during 12 month trial period.Results Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P<0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P=0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference −0.64 days, −1.14 to −0.10, P=0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group. ConclusionsTelehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect. Trial registration number International Standard Randomised ControlledTrial Number Register ISRCTN43002091. IntroductionEfforts worldwide are dealing with the increasing prevalence of chronic disease among an ageing population. The past decade RESEARCHhas seen the growing use of telehealth as one possible approach to this problem. Telehealth involves the remote exchange of data between a patient and healthcare professionals as part of the patient's diagnosis and healthcare management. 1 2 Examples include the monitoring of blood pressure and blood glucose. Telehealth m...

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“…While new technologies open up the possibilities for new healthcare products and services there has been limited uptake within the medical profession, particularly within the UK [ 29 ]. This means that the potential benefits of telehealth, such as its ability to reduce hospital admissions [ 62 ] and improve quality of life for patients [ 69 ] are not being realized at a large enough scale to generate the benefits that promise to bridge the gap between available health resources and user demand.…”

“…In order to maintain services into the future, healthcare providers and commissioners are beginning to consider new ways of delivering healthcare services that harness technological advancements to improve efficiency and quality by treating people in their own homes; for example, the use of teleconferencing for patient consultations, smart phone apps to deliver healthcare information, and in-home equipment for the monitoring of patient vital signs. There are many examples of how the use of telehealth equipment can not only improve the health of the patient and the quality of the care they receive, but also improve the efficiency and the capacity of existing services [ 62 ]. For example, for the UK prison service, some local hospitals have developed the capability to offer hospital outpatient appointments to prisoners remotely through the use of video conferencing, meaning prisoners can access care without the costly need to leave the prison environment NHS [ 53 ].…”

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“…One of the reasons for this recalcitrance may be the lack of studies that have progressed beyond pilot scale; there is also criticism of the quality of the available evidence [4]. The better known large studies are the UK's Whole System Demonstrator projects [5] and the USA Veterans' Administration's implementation [6]. These found significant reductions in hospital admissions and re-admissions, and other benefits.…”

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“…10 Other studies have shown that telemonitoring is associated with lower rates of mortality for patients. 5,8,14 For people with diabetes, Telehealth programs have resulted in patients making fewer clinic visits 7 and having considerably fewer hyperglycaemic and hypoglycaemic events.…”

“…5 Telehealth has been shown to improve health outcomes [8][9][10][11] and reduce health service use in specialities such as chronic heart failure, respiratory conditions and diabetes management. 8,9,12,13 In chronic heart failure, there is evidence that telemonitoring not only reduces hospital admissions, but may also be effective for disease management in high-risk patients.…”