Victoria Wade

A systematic review of economic analyses of telehealth services using real time video communication

BackgroundTelehealth is the delivery of health care at a distance, using information and communication technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase access in health care delivery. This systematic review assesses the economic value of one type of telehealth delivery - synchronous or real time video communication - rather than examining a heterogeneous range of delivery modes as has been the case with previous reviews in this area.MethodsA systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in June 2009. Studies with patient outcome data and a non-telehealth comparator were included. Cost analyses, non-comparative studies and those where patient satisfaction was the only health outcome were excluded.Results36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of care was more important in determining the value of the service than the clinical discipline, the type of technology, or the date of the study.ConclusionDelivery of health services by real time video communication was cost-effective for home care and access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for local delivery of services between hospitals and primary care.

Therapist-Assisted, Internet-Based Treatment for Panic Disorder: Can General Practitioners Achieve Comparable Patient Outcomes to Psychologists?

Background Mental illness is an escalating concern worldwide. The management of disorders such as anxiety and depression largely falls to family doctors or general practitioners (GPs). However, GPs are often too time constrained and may lack the necessary training to adequately manage the needs of such patients. Evidence-based Internet interventions represent a potentially valuable resource to reduce the burden of care and the cost of managing mental health disorders within primary care settings and, at the same time, improve patient outcomes. Objective The present study sought to extend the efficacy of a therapist-assisted Internet treatment program for panic disorder, Panic Online, by determining whether comparable outcomes could be achieved and maintained when Panic Online was supported by either GPs or psychologists. Methods Via a natural groups design, 96 people with a primary diagnosis of panic disorder (with or without agoraphobia) completed the Panic Online program over 12 weeks with the therapeutic assistance of their GP (n = 53), who had received specialist training in cognitive behavioral therapy, or a clinical psychologist (n = 43). Participants completed a clinical diagnostic telephone interview, conducted by a psychologist, and a set of online questionnaires to assess panic-related symptoms at three time periods (pretreatment, posttreatment, and 6 month follow-up). Results Both treatments led to clinically significant improvements on measures of panic and panic-related symptomatology from pretreatment to posttreatment. Both groups were shown to significantly improve over time. Improvements for both groups were maintained at follow-up; however, the groups did differ significantly on two quality of life domains: physical (F1,82 = 9.13, P = .00) and environmental (F1,82 = 4.41, P = .04). The attrition rate was significantly higher among those being treated by their GP (χ 2 1 = 4.40, P = .02, N = 96). Conclusions This study provides evidence that Internet-based interventions are an effective adjunct to existing mental health care systems. Consequently, this may facilitate and enhance the delivery of evidence-based mental health treatments to increasingly large segments of the population via primary care systems and through suitably trained health professionals.

Clinician Acceptance is the Key Factor for Sustainable Telehealth Services

Telehealth, the delivery of health care services at a distance using information and communications technology, has been slow to be adopted and difficult to sustain. Researchers developing theories concerning the introduction of complex change into health care usually take a multifactorial approach; we intentionally sought a single point of intervention that would have maximum impact on implementation. We conducted a qualitative interview study of 36 Australian telehealth services, sampled for maximum variation, and used grounded theory methods to develop a model from which we chose the most important factor affecting the success of telehealth. We propose that clinician acceptance explains much of the variation in the uptake, expansion, and sustainability of Australian telehealth services, and that clinician acceptance could, in most circumstances, overcome low demand, technology problems, workforce pressure, and lack of resourcing. We conclude that our model offers practical advice to those seeking to implement change with limited resources.

Drug companies' evidence to justify advertising

Ten international pharmaceutical companies were asked by letter to supply their best evidence in support of marketing claims for seventeen products. Fifteen replies were received. Seven replies cited a total of 67 references: 31 contained relevant original data and only 13 were controlled trials, all of which had serious methodological flaws. There were four reports of changes in advertising claims and one company ceased marketing nikethamide in the third world. Standards of evidence used to justify advertising claims are inadequate.

Home Videophones Improve Direct Observation in Tuberculosis Treatment: A Mixed Methods Evaluation

Background The use of direct observation to monitor tuberculosis treatment is controversial: cost, practical difficulties, and lack of patient acceptability limit effectiveness. Telehealth is a promising alternative delivery method for improving implementation. This study aimed to evaluate the clinical and cost-effectiveness of a telehealth service delivering direct observation, compared to an in-person drive-around service. Methodology/Principal Findings The study was conducted within a community nursing service in South Australia. Telehealth patients received daily video calls at home on a desktop videophone provided by the nursing call center. A retrospective cohort study assessed the effectiveness of the telehealth and traditional forms of observation, defined by the proportion of missed observations recorded in case notes. This data was inputted to a model, estimating the incremental cost-effectiveness ratio (ICER) of telehealth. Semi-structured interviews were conducted with current patients, community nursing and Chest Clinic staff, concerning service acceptability, usability and sustainability. The percentage of missed observations for the telehealth service was 12.1 (n = 58), compared to 31.1 for the in-person service (n = 70). Most of the difference of 18.9% (95% CI: 12.2 – 25.4) was due to fewer pre-arranged absences. The economic analysis calculated the ICER to be AUD

Uptake of telehealth services funded by Medicare in Australia

1.32 (95% CI:

The costs and benefits of technology-enabled, home-based cardiac rehabilitation measured in a randomised controlled trial.

0.51 –

A qualitative study of ethical, medico-legal and clinical governance matters in Australian telehealth services:

2.26) per extra day of successful observation. The video service used less staff time, and became dominant if implemented on a larger scale and/or with decreased technology costs. Qualitative analysis found enabling factors of flexible timing, high patient acceptance, staff efficiency, and Chest Clinic support. Substantial technical problems were manageable, and improved liaison between the nursing service and Chest Clinic was an unexpected side-benefit. Conclusions/Significance Home video observation is a patient-centered, resource efficient way of delivering direct observation for TB, and is cost-effective when compared with a drive-around service. Future research is recommended to determine applicability and effectiveness in other settings.

Investigating the preferences of older people for telehealth as a new model of health care service delivery: A discrete choice experiment.

OBJECTIVE The aim of this study is to identify the extent to which the Medicare item numbers and incentives, introduced in July 2011, have been effective in stimulating telehealth activity in Australia. METHODS A retrospective descriptive study utilising data on the uptake of telehealth item numbers and associated in-person services, from July 2011 to April 2014, were obtained from Medicare Australia. The main outcome measures were number of telehealth services over time, plus uptake proportionate to in-person services, by jurisdiction, by speciality, and by patient gender. RESULTS Specialist consultations delivered by video communication and rebated by Medicare rose to 6000 per month, which is 0.24% of the total number of specialist consultations. The highest proportional uptake was in geriatrics and psychiatry. In 52% per cent of video consultations the patient was supported by an on-site healthcare provider, most commonly a general practitioner. There were substantial jurisdictional differences. A significantly lower percentage of female patients were rebated for item 99, which is primarily used by surgeons. CONCLUSIONS Medicare rebates and incentives, which are generous by world standards, have resulted in specialist video consultations being provided to underserved areas, although gaps still remain that need new models of care to be developed. WHAT IS KNOWN ABOUT THE TOPIC?: Video consultations have been rebated by Medicare since July 2011 as a means of increasing access to specialist care in rural areas, aged care facilities and Aboriginal health services. WHAT DOES THIS PAPER ADD?: The uptake of this telehealth initiative has grown over time, but still remains low. For half the video consultations the patient was supported by an on-site healthcare provider, most commonly a general practitioner. Geriatrics and psychiatry are the specialties with the highest proportional uptake. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: New models of care with a greater focus on consultation-liaison with primary care providers need to be developed to realise the potential of this initiative and to fill continuing gaps in services.

Transitioning a home telehealth project into a sustainable, large-scale service: a qualitative study

We conducted a cost benefit analysis of a home telehealth-based cardiac rehabilitation programme compared to the standard hospital-based programme. A total of 120 participants were enrolled in a trial, with 60 randomised to the telehealth group and 60 randomised to usual care. Participants in the telehealth group received a mobile phone, Wellness Diary and a Wellness web portal, with daily text messaging. Participants in the usual care group received the standard 6-week hospital-based outpatient cardiac rehabilitation programme, including gym sessions. The cost of delivery by telehealth was slightly lower than for patients attending a rehabilitation service in person. From the providers perspective, the telehealth intervention could be delivered for