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 of home telehealth for COPD management are few. Reduced hospitalizations might reasonably be expected to result in sizable cost savings. 2 studies that found decreased hospital admissions and calculated costs found that this was indeed the case.
Projecting early operational costs of a home telehealth program does not necessarily yield an accurate estimate of future costs. One 5-year study reported that annual program costs per patient in the final year of operation were less than 15% of the cost per patient for the first year of activity. This decrease was attributed to optimization of staff organization, including increases in the time that nurses spent in telehealth delivery and corresponding decreases in physician time. Comparison with the costs of usual care is not provided.
A scan of material from 2011-2012, a time period not covered by our initial searches, found 2 additional articles that addressed telehealth costs and cost comparisons (Dinesen et al., 2012; Sicotte et al., 2011). In these studies, patients experienced improved health status and/or reduced hospital admissions, but cost savings were not significant. As these studies were not subject to the same level of analysis as the other studies included in this review, we will not attempt to extrapolate further. See Dinesen et al. (2012) and Sicotte et al. (2011) for more details.
In short, the impact of home telehealth programs on system costs and costs savings appears highly variable. The applicability of the above findings to the Canadian health care system is difficult to determine.
There is a considerable amount of evidence supporting the ability of home telehealth to significantly reduce hospital admissions. This was the case in 4 of the 6 studies that tracked service use. It is unclear whether this is by improving clinical status or by facilitating earlier detection of problems. The apparent ability of home telehealth to reduce exacerbations suggests the former, but a combination of factors is probable. Use of home telehealth does not appear to affect the average number of days in hospital once a patient has been admitted.
Emergency services use appears to be largely unaffected by home telehealth interventions. That said, there is some indication that home telehealth can reduce unscheduled clinic visits and urgent calls to general practitioners. The fact that emergency department visits do not appear to increase at the same time suggests that this is attributable to a reduction in need for urgent care rather than a change in clinical pathway.
Primary care use that is prompted by urgent symptoms may be reduced by home telehealth interventions, but the evidence is not conclusive. There is no information on the effect of home telehealth on use of specialist services.
Details
Emergency Services Use
Summary: Emergency services use was measured in 4 studies. It appears to be largely unaffected by home telehealth interventions. That said, there is some indication that home telehealth can reduce unscheduled clinic visits and urgent calls to general practitioners. The fact that emergency department visits do not appear to increase at the same time suggests that this is attributable to a reduction in need for urgent care rather than a change in clinical pathway.
Study Details: No significant differences between intervention and control groups were found by de Toledo et al. (2006), Trappenburg et al. (2008), or Lewis et al. (2010b). Vitacca et al. (2009) found no significant difference between groups in total emergency department visits, but found that patients in the intervention group, given 1 emergency department visit, were significantly less likely to have additional visits than those in the control group (p=.003).
(Re-)Hospitalizations
Summary: Intervention effects on hospitalizations were reported in 6 studies. There is a considerable amount of evidence supporting the ability of home telehealth to significantly reduce hospital admissions. It is unclear whether this is by improving clinical status or by facilitating earlier detection of problems. The apparent ability of home telehealth to reduce exacerbations suggests the former, but a combination of factors is probable. Use of home telehealth does not appear to affect the average number of days in hospital once a patient has been admitted.
Study Details: The lifestyle support interventions described by Liu et al. (2008) and the call centre/electronic patient record intervention described by de Toledo et al. (2006) had a positive effect on number of hospitalizations, as did studies by Trappenburg et al. (2008) and Vitacca et al. (2009). However, there is little evidence that home telehealth reduces the average length of a hospital stay once a patient is admitted. Evidence on hospitalization outcomes for consultation-based interventions using videoconferencing is inconclusive. See table, below (Table C.3.3.2: System Outcomes – (Re-) Hospitalizations) for details.
Primary Care Use
Summary: Outcomes related to primary care use are reported by Liu et al. (2008), Lewis et al. (2010a, b), and Vitacca et al. (2009). A variety of indicators were used. Primary care use that is prompted by urgent symptoms may be reduced by home telehealth interventions, but the evidence is not conclusive.
Study Details: Liu et al. (2008) found that the intervention group had significantly fewer unscheduled clinic visits (p<.01). Vitacca et al. (2009) reported that COPD patients who received the intervention made significantly fewer urgent calls to their GP (p<.002), and that those who did make such calls were less likely to make additional urgent calls (p=.0018).
Lewis et al. (2010a, b), on the other hand, while finding fewer chest-related primary care contacts in the intervention group at the end of the intervention period, found no difference between groups in non-chest related primary care contacts or in calls to chronic disease management teams. Nor did the authors find any significant difference in clinic attendance.
See table below (Table C.3.3.3: System Outcomes – Primary Care Use) for additional details.
Specialist Care Use
No studies reported on specialist care use.
Telehealth Costs and Cost Comparisons
Summary: Telehealth costs and cost comparisons were reported in 3 studies. Although there is some evidence of cost savings from decreased hospital admissions, the impact of home telehealth on costs appears highly variable. Furthermore, none of the studies retrieved took place in the context of the Canadian health care system.
Study Details: Vitacca et al. (2009), in a 1-year study of a tele-assistance program, found that the average overall healthcare cost per patient was 33% less for intervention patients than control group patients. The majority of cost savings were from reduced hospitalizations in intervention group patients. When looking only at patients with a COPD diagnosis, the average overall healthcare cost per patient was over 50% lower for intervention group patients than for controls.
Vitacca et al. (2010) presented 5-year results from the same program analyzed in Vitacca et al. (2009). The total intervention cost over this time period, including nurse and medical availability, was £ 731,344. The average cost per patient per year decreased from £ 4962 in year 1 to £ 670 in year 5. These savings – 39% of the total program budget for the first year of activity – are attributed to optimization of staff organization, including increases in the time that nurses spent in telehealth delivery and corresponding decreases in physician time.
de Toledo et al. (2006) found that the cost of the intervention was € 38,932. Equipment accounted for most of the cost, with the remainder arising from communications and training needs. Personnel and software development costs were not included. The authors, using an estimate of € 220per day of hospitalization, calculated that reduced hospitalizations would mean that the system paid for itself within 1 year.
Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 2 articles that addressed telehealth costs and cost comparisons (Dinesen et al., 2012; Sicotte et al., 2011). In these studies, patients experienced improved health status and/or reduced hospital admissions, but cost savings were not significant. As these studies were not subject to the same level of analysis as the other studies included in this review, we will not attempt further analysis. See Dinesen et al. (2012) and Sicotte et al. (2011) for more details.
