Simon Brownsell

An evaluation of second and third generation telecare services in older people's housing

Summary In a controlled study of older people living in sheltered housing (retirement housing), 24 people provided with telecare were compared with a control group of 28 people. The intervention consisted of second generation telecare equipment, such as automatic flood or falls detectors, a third generation lifestyle reassurance system and an Internet café. After a 12-month monitoring period, there was no noticeable change in the fear of falling. There was no significant difference for eight of the nine SF-36 domains. However, the Social Functioning domain showed a significant difference (P = 0.049), with scores 8% higher in the intervention group, suggesting a beneficial effect of telecare. Positive trends were also evident in areas such as an increase in the length of time spent out of the home, improved feelings of safety during the day and night, and a reduction in the fear of crime. The Internet café was used by 25% of people for at least 20 min per week. The results suggest that second generation telecare systems and Internet facilities could be more widely used in service delivery, but that lifestyle reassurance requires further development.

Automatic fall detectors and the fear of falling

We studied the effect of automatic fall detection units on the fear of falling. Participants were community alarm users living in the community aged over 75 years or those aged 60–74 years who had experienced a fall in the previous six months. Of those approached, 31% consented to take part; the main reason given for potential participants declining involvement was that they were happy with the technology they already had. Subjects were assigned to a control group (n = 21) or intervention group (n = 34) based on age, the number of self-reported falls in the previous six months and their score on the self-administered Falls Efficacy Scale (FES), which measures fear of falling on a scale of 0–100, with higher scores indicating less fear. The monitoring period lasted a mean of 17 weeks (SD 3.1). There was no significant difference between the intervention and control groups in their mean ratings of fear of falls (40.3 vs 37.5, difference 2.8, 95% CI 6.2 to 11.8), health-related quality of life or morale. Differences in fear of falling between an intervention subgroup who wore their detector at least occasionally (62%) and those who did not (38%) suggested that some people may benefit from a fall detector while others may lose confidence if they are provided with one. Most users who wore their detectors at least occasionally felt more confident and independent and considered that the detector improved their safety.

Attitudes to telecare among older people, professional care workers and informal carers: a preventative strategy or crisis management?

This paper reports findings from an attitudinal survey towards telecare that emerged from 22 focus groups comprising 92 older people, 55 professional stakeholders and 39 carers. These were convened in three different regions of England as a precursor to telecare service development. The results from this study suggest that informants’ views were shaped by prior knowledge of conventional health and social care delivery in their locality, and the implication is that expectations and requirements with respect to telecare services in general are likely to be informed by wider perceptions about the extent to which community care should operate as a preventative strategy or as a mechanism for crisis management.

A systematic review of lifestyle monitoring technologies

The evidence base for lifestyle monitoring is relatively weak, even though there are significant numbers of commercial installations around the world. We conducted a literature review to summarize the current position with regard to lifestyle monitoring based on sensors in the home. In total, 74 papers met the inclusion criteria. Only four papers reported trials involving 20 or more subjects, with a further 21 papers reporting trials involving one or more subjects. Most papers (n = 49) were concerned with technology development. Motion detection was the most common of the technologies employed, followed by door and electrical appliance usage. The predominant monitoring strategy was that of detecting changes in activity. However, little attention has been given to determining when or how changes in the profile of activity should be used to raise a call for assistance from a health or care professional. Lifestyle monitoring remains a relatively immature research area in which there is little detailed understanding of how to provide comprehensive and effective systems.

Home telehealth uptake and continued use among heart failure and chronic obstructive pulmonary disease patients: a systematic review.

BackgroundHome telehealth has the potential to benefit heart failure (HF) and chronic obstructive pulmonary disease (COPD) patients, however large-scale deployment is yet to be achieved.PurposeThe aim of this review was to assess levels of uptake of home telehealth by patients with HF and COPD and the factors that determine whether patients do or do not accept and continue to use telehealth.MethodsThis research performs a narrative synthesis of the results from included studies.ResultsThirty-seven studies met the inclusion criteria. Studies that reported rates of refusal and/or withdrawal found that almost one third of patients who were offered telehealth refused and one fifth of participants who did accept later abandoned telehealth. Seven barriers to, and nine facilitators of, home telehealth use were identified.ConclusionsResearch reports need to provide more details regarding telehealth refusal and abandonment, in order to understand the reasons why patients decide not to use telehealth.

Future systems for remote health care

As the number of elderly people in society increases, the use of technology to support the care system is being examined. However, there is no agreed model of a technology-based health-care system that fully integrates the technical and social aspects to meet the needs of both clients and care providers. This paper examines a possible model from the perspective of both the client and the service provider, and estimates the costs, and hence the potential savings, associated with the introduction of a health-care system based on this model. Cost data are presented in the context of an installation as might be anticipated within a city such as Birmingham, UK. Installation costs of an advanced telecare system would be higher than the set-up costs of conventional systems. Expected savings in control centre costs and emergency services costs would be small. However, a reduction in the average annual length of hospital stay by one day and a reduction in the proportion of elderly people being treated in hospital from 32.4% to 32.0%, directly as a result of the use of advanced telecare, would produce significant savings. A financing scheme with a 5-year or 10-year repayment period would then be financially viable for a 10,000-home advanced telecare system.

A systematic review of digital interactive television systems and their applications in the health and social care fields.

We conducted a systematic review of the applications and technical features of digital interactive television (DITV) in the health and social care fields. The Web of Knowledge and IEEE Xplore databases were searched for articles published between January 2000 and March 2010 which related to DITV systems facilitating the communication of information to/from an individuals home with either a health or social care application. Out of 1679 articles retrieved, 42 met the inclusion criteria and were selected for review. An additional 20 articles were obtained from online grey literature sources. Twenty-five DITV systems operating in health and social care were identified, including seven commercial systems. The most common applications were related to health care, such as vital signs monitoring (68% of systems) and health information or advice (56% of systems). The most common technical features of DITV systems were two-way communication (88%), medical peripherals (68%), on-screen messaging (48%) and video communication (36%). Digital interactive television has the potential to deliver health and social care to people in their own homes. However, the requirement for a high-bandwidth communications infrastructure, the usability of the systems, their level of personalisation and the lack of evidence regarding clinical and cost-effectiveness will all need to be addressed if this approach is to flourish.

Predicting need for intervention in individuals with congestive heart failure using a home-based telecare system:

We have studied how well the need for a medical intervention can be predicted by a telecare monitoring system. During a study period of about 18 months, 45 elderly individuals with congestive heart failure used a home health monitor to enter daily information pertaining to their symptoms and health status. A total of 8576 alerts were generated by the monitoring system, although in most cases, patient and service provider interaction was not required. When system alerts were considered to be serious, or if symptoms persisted, the patient was contacted. A total of 171 key medical events (6 deaths; 28 hospital admissions; 59 changes in medication; 54 cases of advice given; 24 instances where immediate medical attention was recommended) were recorded in the monitoring logs. A multivariate logistic regression model was developed to predict these medical interventions/events. The model correctly predicted key medical events in 75% of cases with a specificity of 74% and an overall cross-validated accuracy of 74% (95% CI, 68–80%). Key predictors included the number of system alerts, self-rated mobility, self-rated health and self-rated anxiety. This suggests that subjective measures are useful in addition to physiological ones for predicting health status. A multivariate decision support model has potential to supplement practitioners and current telecare systems in identifying heart failure patients in need of medical intervention.

Fall detectors: Do they work or reduce the fear of falling?

The fear of falling in older people can affect health, well‐being, care needs and quality of life. Fall‐monitoring equipment that can automatically raise a call for assistance is increasingly being developed, and may reduce the fear of falling. This study sought to discover the views of users and providers on technology of this type of and to quantify the impact fall detectors have on the fear of falling. The results of the study suggest that fall‐monitoring equipment is not considered routinely as part of a care package, and knowledge of devices is poor. A trial of automatic fall detectors provided indicated that they may reduce fear of falling for certain users and so should be considered in falls management, but more evidence and understanding are required to appreciate both the benefits and shortfalls of providing equipment of this sort.

TElehealth in CHronic disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation

Objective To develop a conceptual model for effective use of telehealth in the management of chronic health conditions, and to use this to develop and evaluate an intervention for people with two exemplar conditions: raised cardiovascular disease risk and depression. Design The model was based on several strands of evidence: a metareview and realist synthesis of quantitative and qualitative evidence on telehealth for chronic conditions; a qualitative study of patients’ and health professionals’ experience of telehealth; a quantitative survey of patients’ interest in using telehealth; and review of existing models of chronic condition management and evidence-based treatment guidelines. Based on these evidence strands, a model was developed and then refined at a stakeholder workshop. Then a telehealth intervention (‘Healthlines’) was designed by incorporating strategies to address each of the model components. The model also provided a framework for evaluation of this intervention within parallel randomised controlled trials in the two exemplar conditions, and the accompanying process evaluations and economic evaluations. Setting Primary care. Results The TElehealth in CHronic Disease (TECH) model proposes that attention to four components will offer interventions the best chance of success: (1) engagement of patients and health professionals, (2) effective chronic disease management (including subcomponents of self-management, optimisation of treatment, care coordination), (3) partnership between providers and (4) patient, social and health system context. Key intended outcomes are improved health, access to care, patient experience and cost-effective care. Conclusions A conceptual model has been developed based on multiple sources of evidence which articulates how telehealth may best provide benefits for patients with chronic health conditions. It can be used to structure the design and evaluation of telehealth programmes which aim to be acceptable to patients and providers, and cost-effective.