Leo Lewis

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

Abstract Objectives To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers. Design Cost consequences study alongside randomised controlled trial. Setting Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales. Participants 3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments. Main outcome measures NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction. Results Overall six months costs were greater for the virtual outreach consultations (£724 per patient) than for conventional outpatient appointments (£625): difference in means £99 (

Home telemonitoring and quality of life in stable, optimised chronic obstructive pulmonary disease

162; €138) (95% confidence interval £10 to £187, P=0.03). If the analysis is restricted to resource items deemed “attributable” to the index consultation, six month costs were still greater for virtual outreach: difference in means £108 (£73 to £142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost £8 (£5 to £10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost £11 (£10 to £12, P < 0.0001). Conclusion The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

Does Home Telemonitoring after Pulmonary Rehabilitation Reduce Healthcare Use in Optimized COPD?? A Pilot Randomized Trial

We conducted a six-month randomised controlled trial of home telemonitoring for patients with chronic obstructive pulmonary disease (COPD). A total of 40 stable patients with moderate to severe COPD who had completed pulmonary rehabilitation took part. They were randomised to receive standard care (controls) or standard care plus home telemonitoring (intervention). During the monitoring period, patients in the telemonitoring group recorded their symptoms and physical observations twice daily. The data were transmitted automatically at night via the home telephone line. Nurses could access the data through a website and receive alerting email messages if certain conditions were detected. The patients completed the St Georges Respiratory Questionnaire, Hospital Anxiety and Depression and the EuroQoL EQ-5D quality of life scores before and after pulmonary rehabilitation, and then periodically during the trial. There were significant and clinically important improvements in the scores immediately following pulmonary rehabilitation, but thereafter there were no differences in quality of life scores between the groups at any time, or consistently within either group over time. The study showed that telemonitoring was safe but, despite being well used, it was not associated with changes in quality of life in patients who had stable COPD.

Design and performance of a multi-centre randomised controlled trial and economic evaluation of joint tele-consultations (ISRCTN54264250)

ABSTRACT Aim. To see if home telemonitors reduce healthcare use in those with optimized chronic obstructive pulmonary disease (COPD). Methods. We randomized 40 stable patients with moderate to severe COPD, who had completed at least 12 sessions of outpatient pulmonary rehabilitation (PR), to receive standard care (Controls) for 52 weeks or standard care plus Docobo HealthHUB monitors at home for 26 weeks followed by 26 weeks standard care (Tm Group). During the monitoring period, the Tm Group completed symptoms and physical observations twice daily which were stored and then uploaded at 2 am through a freephone landline. Nurses could access the data through a secure web site and received alerting e-mails if certain combinations of data occurred. Results. There were fewer primary care contacts for chest problems (p < 0.03) in the Tm group, but no differences between the groups in emergency room visits, hospital admissions, days in hospital or contacts to the specialist COPD community nurse team, during the monitoring period. After the monitors were removed, there were no differences between the groups for any of the health care contacts (p > 0.20 throughout). Conclusion. In stable, optimized COPD patients who have already completed PR, telemonitoring in addition to best care, reduces primary care chest contacts but not hospital or specialist team utilization.

Education and training of practice nurses

BackgroundAppropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic.MethodsJoint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments.ResultsA total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups.ConclusionWe have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation.

Design and Performance of a Multicentre, Randomized Controlled Trial of Teleconsulting

Seventeen nurses in eight rural general practices participated in a distance education project. Low-cost videoconferencing equipment was assessed for its suitability in two training sessions, concerning asthma and travel immunization. The intended learning outcomes were reached and although initially apprehensive, the nurses quickly became accustomed to the medium. Videoconferencing has now become an accepted part of in-service training. Technical reliability remains the most important problem.

VP132 Cost Effectiveness Of A Predictive Risk Model In Primary Care

We have designed and performed a multicentre, randomized controlled trial of teleconsulting. The trial investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing as an alternative to general practitioner referral to a hospital specialist. The participating general practitioners referred a total of 3170 patients who satisfied the entry criteria. Of these, 1040 (33%) failed to provide consent or otherwise refused to participate in the trial. Of the patients recruited to the trial, a total of 1902 (91%) completed and returned the baseline questionnaire. Although the trial was successful in recruiting sufficient patients and in obtaining high questionnaire response rates, the findings will require careful interpretation to take account of the limits which the protocol placed on the ability of general practitioners to select patients for referral.

VP172 Clinical Effectiveness Of A Predictive Risk Model In Primary Care

The deterministic ICER was GBP7,654/QALY (quality adjusted life year) for combination therapy versus monotherapy. The mean difference in ICER uncertainty for the evidence-based vs. ±15 percent variation method was GBP3,251/QALY (p = .0096). Six inputs had a mean difference in ICER uncertainty of >10 percent of GBP7,654/QALY (that is, mean difference in ICER uncertainty > GBP765) for the evidence-based variation method, compared to only two inputs for the constant percentage variation method.

‘Letting Go’: delegating responsibility for non-clinical tasks in a telehealth service

New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient’s risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.

Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations

Introduction The implementation of telehealth into the delivery of chronic conditions management within Hywel Dda Health Board has provided an opportunity to enhance close working relationships with Carmarthenshire County Council’s well-established telecare team. The responsibilities of the telecare team were initially limited to the installation and removal of telehealth devices in patients’ homes and training on its use but as the use of telehealth has widened, an increasing number of non-clinical tasks, several of which were previously undertaken by clinical staff, have been delegated to members of the telecare team and linked to the monitoring centre. In addition, all the tasks associated with managing and administering the patients on the telehealth system backend are undertaken by the chronic conditions management administrative support team within the Health Board. Aims and objectives This presentation will describe our experience of bringing together clinical and non-clinical staff from two separate organisations to deliver a more appropriate, comprehensive and timely telehealth service to patients. It will explain how strong working relationships have developed, the importance of a clear understanding of different roles within the team and the need for building trust and confidence in colleagues, resulting in the clinical nurse specialists ‘letting go’ and responding to change that supports effective monitoring and still providing quality care. We will report on the lessons learned during the process, from both staff groups’ perspectives and the patient’s perspective, as tasks previously undertaken by clinicians have shifted to non-clinical staff. Results Our current approach to telehealth has evolved into a model which ensures that the specialist nursing team are able to focus solely on delivering quality clinical care enabled and supported by telehealth where appropriate. All the non-clinical tasks are now undertaken by the telecare team staff and chronic conditions management administrative support and include: Installing devices in patients’ homes and providing education and training First-line monitoring/triage of uploaded patient data Escalation of clinical alerts to nursing team by Telephone Resolving technical alerts and missing uploads/data Provision of refresher training to patients as required (telephone-based or face-to-face) Responding to patient or nurse-reported technical problems, including battery/faulty device replacement Providing advice on home set-up e.g., recommending changes System administrator, patient administration and management function of backend The results of patient and staff questionnaires seeking feedback on our model will be given together with an economic evaluation comparing the current approach, which utilises telecare and specialist staff to deliver the service compared to the previous delivery model using specialist nursing staff only. We will also show that through embedding telehealth into a well-established community specialist nursing service has the following impact and outcomes: Patients to take more responsibility for their day-to-day care Nurses to monitor patients remotely and contact those who need support reducing the number if inappropriate home visits Reducing travelling for the nursing service Improving relationships between patient and nurse Supporting carers Conclusions We have embedded our telehealth service into existing service models which have now been enhanced utilising a partnership approach and ensuring the best use of the skills and expertise, across the organisations involved. This has been a key factor in developing an efficient, effective and sustainable approach.