Wednesday, May 02, 2012

Is This Another Evidence Free Intervention From DoHA? It Might Not Be But More Work Is Needed To Be Sure.

The following appeared a little while ago.

Consider broad telehealth benefits

A NEW US study which showed “underwhelming” clinical outcomes from telemonitoring still adds to the knowledge base about telehealth and should not dissuade doctors from its benefits, according to Australian experts.
Professor Len Gray, director of the Centre for Online Health at the University of Queensland, said the study, published in Archives of Internal Medicine, was well designed but examined only clinical outcomes, when there were many other potential benefits of telehealth. (1)
In the trial, 205 older adults with multiple illnesses were randomly allocated to receive usual self-directed care, or daily sessions of telemonitoring for assessment of symptoms and measurement of biometrics such as weight, blood pressure, blood glucose levels, oximetry and peak flow, with the use of videoconferencing.
In the 12 months following enrolment there were no differences in rates of hospitalisation and emergency department visits between patients receiving telemonitoring and those receiving usual care.
The study authors said the results provided “further evidence of a lack of efficacy of telemonitoring on hospitalisations and ED visits”.
“Given the potential costs of telemonitoring and the lack of efficacy, it may be important for physicians and funding organizations to evaluate which patient groups might be most responsive and which implementation strategies will be most useful”, they said.
Professor Gray said telehealth came in many forms and had an array of outcomes other than clinical, such as lowering costs for patients and allowing doctors to be more efficient, which were not measured by this study.
He said that in Australia the goals of telehealth were not necessarily confined to clinical improvements but were also about providing health services to rural and remote communities and increasing efficiency for doctors.
More here:
One really has to wonder what is going on here - if we are not doing things for overall clinical benefit just what are we on about?
Clearly we need to consider just what all this means. I fear we might be a bit trapped in a definitional mess.
The Government announced a $620 Million Telehealth Initiative in June 2011.
Here is the release.
The abstract reports a rather limited type of telehealth - and certainly does not address some issues of concern in far-flung rural Australia.

A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits

Paul Y. Takahashi, MD, MPH; Jennifer L. Pecina, MD; Benjavan Upatising, MSIE, PhD; Rajeev Chaudhry, MBBS, MPH; Nilay D. Shah, PhD; Holly Van Houten, BA; Steve Cha, MS; Ivana Croghan, PhD; James M. Naessens, ScD; Gregory J. Hanson, MD
Arch Intern Med. Published online April 16, 2012. doi:10.1001/archinternmed.2012.256
Background  Efficiently caring for frail older adults will become an increasingly important part of health care reform; telemonitoring within homes may be an answer to improve outcomes. This study sought to assess differences in hospitalizations and emergency department (ED) visits among older adults using telemonitoring vs usual care.
Methods  A randomized controlled trial was performed among adults older than 60 years at high risk for rehospitalization. Participants were randomized to telemonitoring (with daily input) or to patient-driven usual care. Telemonitoring was accomplished by daily biometrics, symptom reporting, and videoconference. The primary outcome was a composite end point of hospitalizations and ED visits in the 12 months following enrollment. Secondary end points included hospitalizations, ED visits, and total hospital days. Intent-to-treat analysis was performed.
Results  Two hundred five participants were enrolled, with a mean age of 80.3 years. The primary outcome of hospitalizations and ED visits did not differ between the telemonitoring group (63.7%) and the usual care group (57.3%) (P = .35). No differences were observed in secondary end points, including hospitalizations, ED visits, and total hospital days. No significant group differences in hospitalizations and ED visits were found between the preenrollment period vs the postenrollment period. Mortality was higher in the telemonitoring group (14.7%) than in the usual care group (3.9%) (P = .008).
Conclusions  Among older patients, telemonitoring did not result in fewer hospitalizations or ED visits. Secondary outcomes demonstrated no significant differences between the telemonitoring group and the usual care group. The cause of greater mortality in the telemonitoring group is unknown.
Here is the link to the abstract.
But this report needs to be considered in the light of this work from the UK:

UK telehealth saves lives and money

The results are in on how the UK is doing telehealth, and the numbers are staggering. Will Turner reports.
The Challenge: One quarter of the UK population living with long term chronic illness.
The Approach: A trial of 6,000 patients involving biometric monitoring where patients take and transmit health readings through to clinicians who then monitor and advise the patient.
The Outcomes: Major reductions in mortality rates and hospital admissions.
The Lessons Learned: Upfront investment in telehealth based prevention saves public health dollars and improves patient quality of life.
The Upside for:
Clinicians: Better able to focus on work requiring their clinical expertise.
Patients: Empowered to better manage their own health and greater confidence in their access to care that keeps them out of hospital.
The Organisation: A more cost effective model of primary and secondary care that at the same time delivers better quality of care in a sustainable manner.
In Australia the term telehealth typically refers to video consultation: doctors talking to doctors, doctors talking to patients. By contrast telehealth in the UK is more about biometric monitoring: patients taking personal device readings in their own homes, transmitting them through to clinicians who then monitor and advise the patient.
Lots more here:
I suspect the last paragraph is the clue here. Defining Telehealth, Telemonitoring and so on is the only way to compare with apples with other apples and not oranges. The two trials look quite similar, but quite different to what is being funded here in OZ.
I think we need to wait for the evaluations of what is being done here and to see more studies in the telemonitoring area (given the different US and UK experiences) before clear conclusions can be drawn.
Bottom line, you have to be sure what you are talking about!
David.

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