Paolo Zanaboni

Systematic Review of Telemedicine Services for Patients Affected by Chronic Obstructive Pulmonary Disease (COPD)

The aim of the present study was to conduct a systematic literature review focused on telemedicine services for patients affected by chronic obstructive pulmonary disease (COPD). In particular, it addresses (1) which telemedicine applications and related organizational models have been adopted for patients affected by COPD and (2) the impact of these applications. A computerized literature search was performed utilizing MEDLINE and Cochrane Library databases, selecting articles published between 1996 and 2008 using the following combination of keywords: [COPD] AND [telemedicine OR telehealth OR ehealth OR telecare] and after exclusions, 40 articles were considered. The adoption of telemedicine inevitably resulted in the reconfiguration of the existing practices and sociomaterial relationships. These organizational changes must be understood and addressed.

Assessment of a remote monitoring system for implantable cardioverter defibrillators

We conducted a multicentre study in five Italian hospitals to assess the feasibility of a remote monitoring service for the follow-up of implanted cardiac devices. The system was designed to monitor device performance as well as physiological aspects of the patients condition. Sixty-seven patients (mean age 64 years) affected by chronic heart failure and with a biventricular implantable cardioverter defibrillator for cardiac re-synchronization therapy (CRT-D) were enrolled for a three-month observation period. A total of 267 device recordings were transmitted through the ordinary telephone network, with a success rate of 99%. The telemonitoring service was more efficient than conventional face-to-face follow-up in terms of the time savings: both for physicians (4.7 minutes versus 15 minutes for remote and conventional monitoring) and for patients (6.6 minutes versus 116.3 minutes). In addition, a total of 23 clinical events occurred during the study, but only two cases required a clinic visit, thus reducing inappropriate hospital admissions. Finally, the service was well accepted by all the users.

Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness

BackgroundNowadays, new organisational strategies should be indentified to improve primary care and its link with secondary care in terms of efficacy and timeliness of interventions thus preventing unnecessary hospital accesses and costs saving for the health system. The purpose of this study is to assess the effects of the use of teleconsultation by general practitioners in rural areas.MethodsGeneral practitioners were provided with a teleconsultation service from 2006 to 2008 to obtain a second opinion for cardiac, dermatological and diabetic problems. Access, acceptance, organisational impact, effectiveness and economics data were collected. Clinical and access data were systematically entered in a database while acceptance and organisational data were evaluated through ad hoc questionnaires.ResultsThere were 957 teleconsultation contacts which resulted in access to health care services for 812 symptomatic patients living in 30 rural communities. Through the teleconsultation service, 48 general practitioners improved the appropriateness of primary care and the integration with secondary care. In fact, the level of concordance between intentions and consultations for cardiac problems was equal to 9%, in 86% of the cases the service entailed a saving of resources and in 5% of the cases, it improved the timeliness. 95% of the GPs considered the overall quality positively. For a future routine use of this service, trust in specialists, duration and workload of teleconsultations and reimbursement should be taken into account.ConclusionsManagerial and policy implications emerged mainly related to the support to GPs in the provision of high quality primary care and decision-making processes in promoting similar services.

Cost-Utility Analysis of the EVOLVO Study on Remote Monitoring for Heart Failure Patients With Implantable Defibrillators: Randomized Controlled Trial

Background Heart failure patients with implantable defibrillators place a significant burden on health care systems. Remote monitoring allows assessment of device function and heart failure parameters, and may represent a safe, effective, and cost-saving method compared to conventional in-office follow-up. Objective We hypothesized that remote device monitoring represents a cost-effective approach. This paper summarizes the economic evaluation of the Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators (EVOLVO) study, a multicenter clinical trial aimed at measuring the benefits of remote monitoring for heart failure patients with implantable defibrillators. Methods Two hundred patients implanted with a wireless transmission–enabled implantable defibrillator were randomized to receive either remote monitoring or the conventional method of in-person evaluations. Patients were followed for 16 months with a protocol of scheduled in-office and remote follow-ups. The economic evaluation of the intervention was conducted from the perspectives of the health care system and the patient. A cost-utility analysis was performed to measure whether the intervention was cost-effective in terms of cost per quality-adjusted life year (QALY) gained. Results Overall, remote monitoring did not show significant annual cost savings for the health care system (€1962.78 versus €2130.01; P=.80). There was a significant reduction of the annual cost for the patients in the remote arm in comparison to the standard arm (€291.36 versus €381.34; P=.01). Cost-utility analysis was performed for 180 patients for whom QALYs were available. The patients in the remote arm gained 0.065 QALYs more than those in the standard arm over 16 months, with a cost savings of €888.10 per patient. Results from the cost-utility analysis of the EVOLVO study show that remote monitoring is a cost-effective and dominant solution. Conclusions Remote management of heart failure patients with implantable defibrillators appears to be cost-effective compared to the conventional method of in-person evaluations. Trial Registration ClinicalTrials.gov NCT00873899; http://clinicaltrials.gov/show/NCT00873899 (Archived by WebCite at http://www.webcitation.org/6H0BOA29f).

Institutionalizing Telemedicine Applications: The Challenge of Legitimizing Decision-Making

During the last decades a variety of telemedicine applications have been trialed worldwide. However, telemedicine is still an example of major potential benefits that have not been fully attained. Health care regulators are still debating why institutionalizing telemedicine applications on a large scale has been so difficult and why health care professionals are often averse or indifferent to telemedicine applications, thus preventing them from becoming part of everyday clinical routines. We believe that the lack of consolidated procedures for supporting decision making by health care regulators is a major weakness. We aim to further the current debate on how to legitimize decision making about the institutionalization of telemedicine applications on a large scale. We discuss (1) three main requirements— rationality, fairness, and efficiency—that should underpin decision making so that the relevant stakeholders perceive them as being legitimate, and (2) the domains and criteria for comparing and assessing telemedicine applications—benefits and sustainability. According to these requirements and criteria, we illustrate a possible reference process for legitimate decision making about which telemedicine applications to implement on a large scale. This process adopts the health care regulators’ perspective and is made up of 2 subsequent stages, in which a preliminary proposal and then a full proposal are reviewed.

Assessment models for telemedicine services in national health systems

Nowadays, decision makers of all national health systems have to correctly assess telemedicine services in order to take responsible decisions on the their adoption into the routine clinical practice. Since the 90s, a wide range of applications were tested, but evidence of benefits is still quite lacking. Scientific literature is mainly characterised, from the one hand, by few relevant theoretical studies which deepen the assessment dimensions or suggest guidelines about the implementation process. From the other hand, empirical and well-designed studies are generally focused on a single dimension, lacking in giving a comprehensive appraisal of the application. As consequence, the aim of this research consists, first of all, in presenting a complete framework that links the main assessment dimensions to the phases of the assessment process. Secondarily, the framework has to be supported by a good empirical analysis and a systematic methodological approach in order to support decision making.

Introduction of a telemonitoring service for patients affected by Chronic Heart Failure

Nuove Reti Sanitarie is a telemonitoring service for patients with Chronic Heart Failure (CHF) successfully implemented in Lombardia Region, Italy, over the period 2006–2008. In particular, the purpose of this paper is to describe the implementation process and the assessment results of this telemedicine service. 609 patients (70 ± 12 years) affected by CHF (91.6% and 8.4% in NYHA III and IV, respectively) have been enrolled. During the telemonitoring period (158 ± 58 days), 1.1 weekly contacts per patient have been performed. The total reimbursement provided to the 24 hospitals that used the service was € 363,880, corresponding to 3,308 telemonitoring months. The service improved the severity of CHF in 34% of patients in NYHA III and in 39% of patients in NYHA IV and decreased the number of hospitalizations. The results of 432 questionnaires reflect a high patient satisfaction.

Assessment of a telemedicine innovation in cardiology

Recently, in all of the national health systems, the need to keep health costs under control and to assure high-quality standards shifted the attention from hospitals to primary cares, territorial structures and patient homes. In this context, telemedicine represents a strong feature to satisfy the need for new clinical management approaches allowing patients with chronic diseases to effectively receive care in a home setting. The application of new telemedicine services always requires an assessment that considers, on the one hand, the responsibility of healthcare manufacturers in supplying high-quality and user-friendly technologies, and, on the other hand, the responsibility of healthcare organisations in providing cost-effective telemedicine services. In this context, this work aims at assessing the adoption of a remote monitoring service for follow-up examinations of chronic heart failure patients implanted with biventricular implantable cardioverter defibrillator. The assessment is conducted through a complete framework that explores the clinical utility, the technical feasibility, the economic implications and the customer satisfaction.