Cardiovascular Disease, Coronary Artery Disease: System Outcomes

Summary

The economic effects of home telehealth can be discussed using direct or indirect measures of costs and cost savings.  Direct measures include figures such as cost per patient, cost per telehealth unit, and annual costs.  Examples of indirect measures are probability of patient hospitalization, number of emergency room visits, and other types of health service use.  Though a formal economic analysis would typically assign these services a fixed dollar value, other study designs often report changes in service use without attempting to translate these changes into costs or cost savings.

Economic analyses are in short supply.  In one study, the cost savings derived from reduced in-person appointments were more than offset by the costs of repeated remote interrogations of patients’ implantable cardioverter defibrillators (ICDs).  Opportunity costs – lost work time, for example – were not included due to the high average age of the participants. Total costs were therefore greater in the intervention group.  Another study came to the opposite conclusion; savings from travel, provider visits, accommodation costs, and sickness allowances made home telehealth significantly cheaper than usual care. Substantial savings were also found in a more recent study of underserved patients, although in this case the savings were derived from reduced hospitalization costs.  As this study was retrieved in a final scan of 2011-2012 literature and was not subject to the same level of analysis as the other studies included in this review, we refer the reader to Zucca et al. (2011) for more details.

Finding on the effects of home telehealth on hospitalization rates are mixed.  Various studies have reported no change, slight reductions, and significant increases.  The last result is, perhaps, the most noteworthy.  The authors of that particular study attribute the increase to a change in clinical pathway rather than a decline in health among users of the system, a conclusion that is supported by their other findings.

At present, there is no evidence that the service use patterns of home telehealth users differ from those of patients under usual care.  This is true of primary care, specialist care, and emergency services.  However, there is so little research on these outcomes that conclusions would be premature.

It is clear that the economic benefits of home telehealth fluctuate according to the technology chosen, the population being treated, and the structure of the health care system.

 

Details

Emergency Services Use

Summary: Emergency services use was reported in 1 study. There is no evidence that home telehealth affects use of emergency services. However, given the small size of the evidence base, it would be inadvisable to draw conclusions at this point.

Study Details: Al-Khatib et al. (2010) reported no significant difference between groups in emergency room visits for cardiac-related causes.

 

(Re-) Hospitalizations

Summary: Three studies reported on hospital admissions or readmissions. Finding on the effects of home telehealth on hospitalization rates are mixed. Various studies have reported no change, slight reductions, and significant increases. The last result is, perhaps, the most noteworthy. The authors of that particular study attribute the increase to a change in clinical pathway rather than a decline in health among users of the system, a conclusion that is supported by their other findings.

Study Details: Al-Khatib et al. (2010) found no significant differences between groups in hospitalizations. Chiantera et al. (2005) reported a slight reduction in hospital readmissions in the intervention group (44% vs. 56%; p-value not given). Waldmann et al. (2008), in a sub-group analysis that divided the intervention group into telehealth users and non-users, found that significantly more users were re-hospitalized (57% vs. 34%; p<.001). This was attributed to a change in clinical pathway. Mean cumulative length of stay for heart-related problems was also significantly higher in the user group (3.9 days (SD=8.1) vs. 2.5 days (SD=8.6)). When interpreting these findings, it is worth noting that no significant difference was found in the percentage of participants reaching the composite endpoint (hospitalization, all-cause mortality, myocardial infarction, and re-vascularization).

 

Primary Care Use

Summary: One study reported on primary care us as part of a combined measure of primary and secondary care. Although use of care increased significantly over the course of the study, there was no significant difference between the intervention and control group. The evidence is not sufficient to support conclusions at this time.

Study Details: Lindsay et al. (2008, 2009) found that both the intervention group and the control group showed significant increases in visits to doctors, nurses, and/or specialists over a 6-month period (respective means of 2.49 increasing to 3.98, p<.010; and 2.1 increasing to 3.5, p=.003). The difference between groups was not significant.

 

Specialist Care Use

Summary: Specialist care use was reported in 2 studies. At present, there is no evidence that home telehealth affects use of specialist care. Although use of care increased significantly over the course of 1 study, there was no significant difference between the intervention and control group.

Study Details: In Al-Khatib et al. (2010), there was no significant difference between groups in unscheduled visits to the electrophysiology clinic for device-related issues. Lindsay et al. (2008, 2009) found that both the intervention group and the control group showed significant increases in visits to doctors, nurses, and/or specialists over a 6-month period (respective means of 2.49 increasing to 3.98, p<.010; and 2.1 increasing to 3.5, p=.003). The difference between groups was not significant.

 

Telehealth Costs and Cost Comparisons

Summary: Telehealth costs and cost comparisons were reported in 2 studies. The findings of one study suggest that it is possible to reduce patient costs through the use of home telehealth, but the lack of cost savings in the other suggest that this finding may not be widely generalizable. It is clear that the economic benefits of home telehealth fluctuate according to the design of the intervention, the characteristics of the population, and the structure of the health care system.

Study Details: In Al-Khatib et al (2010), cost-minimization analysis did not show any cost savings from the intervention. Raatikainen et al., (2008), in contrast, report that patient costs over the 9-month study period were € 743.60 per intervention group patient vs. € 2,167.20 per control group patient. Cost savings were found in provider visits, travelling costs, accommodation costs, and sickness allowance.

Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 additional article that addressed telehealth costs and cost comparisons (Zucca et al., 2011). In this study, a remote monitoring program for underserved patients with chronic heart disease was associated with a substantial reduction in hospitalization costs. As this study was not subject to the same level of analysis as the other studies included in this review, we will not attempt further analysis. See Zucca et al. (2011) for more details.

 

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