Pamela Whitten

Systematic review of cost effectiveness studies of telemedicine interventions

Abstract Objectives: To systematically review cost benefit studies of telemedicine. Design: Systematic review of English language, peer reviewed journal articles. Data sources: Searches of Medline, Embase, ISI citation indexes, and database of Telemedicine Information Exchange. Studies selected: 55 of 612 identified articles that presented actual cost benefit data. Main outcome measures: Scientific quality of reports assessed by use of an established instrument for adjudicating on the quality of economic analyses. Results: 557 articles without cost data categorised by topic. 55 articles with data initially categorised by cost variables employed in the study and conclusions. Only 24/55 (44%) studies met quality criteria justifying inclusion in a quality review. 20/24 (83%) restricted to simple cost comparisons. No study used cost utility analysis, the conventional means of establishing the “value for money” that a therapeutic intervention represents. Only 7/24 (29%) studies attempted to explore the level of utilisation that would be needed for telemedicine services to compare favourably with traditionally organised health care. None addressed this question in sufficient detail to adequately answer it. 15/24 (62.5%) of articles reviewed here provided no details of sensitivity analysis, a method all economic analyses should incorporate. Conclusion: There is no good evidence that telemedicine is a cost effective means of delivering health care.

Home telecare for COPD/CHF patients: outcomes and perceptions

We evaluated the use of home telehealth for patients with chronic obstructive pulmonary disease (COPD) and/or congestive heart failure (CHF). Patients diagnosed with COPD and/or CHF who were prescribed home health-care services were randomly assigned to an experimental group where they received home health care through a combination of traditional face-to-face and telemedicine visits (n = 83), and a control group where only conventional home care was employed (n = 78). Data were collected via the Short Form 36 (SF-36), Outcome and Assessment Information Set (OASIS) and patient charts. In the experimental group, patient perceptions of the home telecare services were collected via telephone interviews. Overall, the addition of telehealth to COPD/CHF patient care was not a significant predictor of health and wellbeing, either positively or negatively. Although those receiving telehealth had worse ratings on the SF-36 general health subscale after the intervention, this measure was only significant when controlling for a number of key variables in the model. In regard to patient perceptions of home telecare, patients were satisfied with the technology and the way that care was delivered via this modality.

Results of a meta-analysis of cost-benefit research: is this a question worth asking?

We attempted a meta-analysis of telemedicine research studies of the costs associated with telemedicine. First, we performed a search of six well known databases with a variety of relevant keywords. After discarding non-English publications, books and duplicate publications resulting from the same study, we were left with 551 articles for analysis. Our second step was to separate the articles into two groups: those with and those without quantitative cost data. Only 38 articles contained any type of real data. Because many of these 38 studies proved to be inadequately designed or conducted, we were unable to peform a traditional meta-analysis. Furthermore, there were a number of disturbing features common to these studies, including the omission of the number of consultations or patients, almost non-existent longitudinal data collection and lack of uniformity in cost analyses. We conclude that it is premature for any statements to be made, either positive or negative, regarding the cost-effectiveness of telemedicine in general.

Telemedicine and patient satisfaction: current status and future directions.

One of the most researched areas in telemedicine concerns the issue of satisfaction. However, most of this research lacks any consistent methodological approach. As a result, it is difficult to conclude whether patients and providers are satisfied with telemedicine. However, this paper postulates that there is a bigger problem within the satisfaction literature than the quality of the research to date. Instead, the bigger question is whether the results from a specific telemedicine project can actually be generalized across all telemedicine contexts. This paper argues that research should focus on specific questions of interest rather than continue the tradition of generic satisfaction research if we hope to gain specific knowledge that will inform the field of telemedicine as a whole.

Success and failure: a case study of two rural telemedicine projects

We studied two rural telemedicine projects in the state of Michigan: one that enjoyed success and steady growth in activity, and one that experienced frustration and a lack of clinical utilization. Multiple data collection strategies were employed during study periods, which lasted approximately one year. Both projects enjoyed a grassroots approach and had dedicated project coordinators. However, the more successful project benefited from resources and expertise not available to the less successful project. In addition, the more successful project possessed a more formalized organizational structure for the telemedicine application. A comparison of the two projects leads to a simple conclusion. Telemedicine programmes are positioned within larger health organizations and do not operate in a vacuum. It is crucial that the organization in which it is intended to launch telemedicine is examined carefully first. Each organization operates within a larger environment, which is often constrained by fiscal, geographical and personnel factors. All these will affect the introduction of telemedicine.

A systematic review of research methodology in telemedicine studies

We conducted a systematic review of 15 relevant databases for articles about telemedicine. After eliminating articles that did not meet the inclusion criteria, 1615 remained for analysis. Three raters coded the articles to assess various theoretical and methodological variables. Only 5% (n = 85) of the telemedicine articles made mention of any theory or paradigmatic approach. Studies commonly reported the objectives (96%) but rarely stated a research question or hypothesis (11%). Randomized selection of the subjects was reported in 11% of patient studies and 4% of studies where providers were the subject. There was a wide range in the number of subjects employed, although the majority of studies were based on sample sizes of less than 100. Only 26% of the studies reported a time frame. Until the telemedicine field adheres to agreed standards of reporting methodological details it will be difficult to draw firm conclusions from review studies.

Telemedicine services to a county jail.

Local and county jails rarely offer telepsychiatry services to their inmates. We have established a telepsychiatry pilot project between the Kansas University Medical Center and the Lyon County Jail in Emporia, Kansas. A total of 264 telepsychiatry consultations were conducted with jail inmates. Of these, 70 were initial evaluations and 194 were follow-up visits; only one inmate refused to be seen. Approximately one-third of all inmates were seen for psychiatric consultation within one week of their incarceration and 68% were seen within one month of incarceration. Among lessons learned during the first year of service were: the monthly demand for consultations was five times greater than projected; moderately to severely ill inmates with a broad range of psychiatric illness can be seen and treated effectively using videoconferencing; and the technology was accepted by the jail personnel and the inmates alike and integrated into the jails routine in terms of the delivery of psychiatric care.

Home telenursing in Kansas: patients` perceptions of uses and benefits

Elderly individuals involved in a home telenursing project were studied. The project nurses provided home health services from ‘telenursing cockpits’ located in three separate sites in Kansas. A cable television-based interactive video system was used to transmit video pictures at 30 frames/s, with 288 horizontal lines of resolution. During phase 1 of the study, interview data were collected from 22 subjects(4 men, 18 women). During phase 2, the original participants were contacted but only 9(1 man, 8 women) were still receiving home health services. Contrary to expectations, the technology was not an important issue for the participants. They did not express any particular worry or excitement about it. Nor did they describe difficulties in adapting to its use. Use of telemedicine technology did not appear to have any negative effects on communication. The results suggests that further thought needs to be given to defining clearly the purpose and goals of telemedicine projects.

Perspectives from the Veterans Health Administration about opportunities and barriers in telemedicine.

We used qualitative interviews to examine the perceptions of direct providers of telemedicine services, primary care providers (PCPs) and hospital administrators about opportunities and barriers to the implementation of telemedicine services in a network of Veterans Health Administration hospitals. A total of 37 interviews were conducted (response rate of 28%) with 17 direct telemedicine providers, nine PCPs and 11 administrators. The overall inter-coder reliability across all themes was high (Scotts π = 0.94). Direct telemedicine providers generally agreed that telemedicine improved rapport with patients, and respondents in all three groups generally agreed that telemedicine improves access, productivity, and the quality and coordination of care. Respondents mentioned several benefits to home telemedicine, including the ability to better manage chronic diseases, provide frequent clinician contact, facilitate quick responses to patient needs and provide care in patients homes. Most respondents anticipated future growth in telemedicine services. Barriers to telemedicine implementation included technical challenges, the need for more education and training for patients and staff, preferences for in-person care, the need for programme improvement and the need for additional staff time to provide telemedicine services.

Telehospice in Michigan: Use and patient acceptance

Telehospice, the use of telemedicine technologies to provide services to hospice patients, offers an innovative solution to the challenges of providing high-quality, cost-effective end-of-life care. Specifically, the technology allows caregivers to transmit video images of patients, which provide off-site nurses with the information they need to assist the caregiver. Our telehospice project was conducted in urban and rural Michigan between 2000-2002 and collected data from 187 patients receiving telehospice services in their homes during this study. Overall, nurses were the primary providers of telehospice services and initiated the majority of routine televisits. Often, patients who described themselves as “overwhelmed” at the time of enrollment declined telehospice. However, patients were extremely satisfied with telehospice and often expressed frustration that nurses did not use the telehospice equipment more frequently.