Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ 344:e3874

The Nuffield Trust, London W1G 7LP, UK.
BMJ (online) (Impact Factor: 17.45). 06/2012; 344(jun21 3):e3874. DOI: 10.1136/bmj.e3874
Source: PubMed


Objective: To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality. Design: Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat. Setting: 179 general practices in three areas in England. Participants: 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009. Interventions: Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients' diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth. Main outcome measure: Proportion of patients admitted to hospital during 12 month trial period. Results: Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P

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    • "According to recent systematic reviews, emergency admissions due to AECOPD could be reduced through home telemonitoring [21]. Furthermore, telehealth interventions have proven to reduce mortality [22]. However, more evidence on the benefits of telehealth strategies is required [23]. "
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    ABSTRACT: Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease of the lung with a great prevalence and a remarkable socio-economic impact on patients and health systems. Early detection of exacerbations could diminish the adverse effects on patients' health and cut down costs burdened on patients with COPD. A group of 16 patients were telemonitored at home using a novel electronic daily symptoms questionnaire during a 6-months field trial. Recorded data were used to train and validate a Probabilistic Neural Network (PNN) classifier in order to enable the automatic prediction of exacerbations. The proposed system was able to predict COPD exacerbations early with a margin of 4.8±1.8 days (average ± SD). Detection accuracy was 80.5% (33 out of 41 exacerbations were early detected); 78.8% (26 out of 33) of theses detected events were reported exacerbation and 87.5% (7 out of 8) were unreported episodes. The proposed questionnaire and the designed automatic classifier could support the early detection of COPD exacerbations of benefit to both physicians and patients.
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    • "Furthermore, although general practices in the intervention and control arms typically provided similar numbers of patients for the current study (median 3 patients in each arm), some intervention practices supplied up to 38 patients, compared with up to 16 for control practices. This pattern was also not systematic across the wider trial, and indeed the primary study found differences in cluster sizes in the opposite direction [19]. "
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    ABSTRACT: The Whole Systems Demonstrator was a large, pragmatic, cluster randomised trial that compared telehealth with usual care among 3,230 patients with long-term conditions in three areas of England. Telehealth involved the regular transmission of physiological information such as blood glucose to health professionals working remotely. We examined whether telehealth led to changes in glycosylated haemoglobin (HbA1c) among the subset of patients with type 2 diabetes. The general practice electronic medical record was used as the source of information on HbA1c. Effects on HbA1c were assessed using a repeated measures model that included all HbA1c readings recorded during the 12-month trial period, and adjusted for differences in HbA1c readings recorded before recruitment. Secondary analysis averaged multiple HbA1c readings recorded for each individual during the trial period. 513 of the 3,230 participants were identified as having type 2 diabetes and thus were included in the study. Telehealth was associated with lower HbA1c than usual care during the trial period (difference 0.21% or 2.3 mmol/mol, 95% CI, 0.04% to 0.38%, p = 0.013). Among the 457 patients in the secondary analysis, mean HbA1c showed little change for controls following recruitment, but fell for intervention patients from 8.38% to 8.15% (68 to 66 mmol/mol). A higher proportion of intervention patients than controls had HbA1c below the 7.5% (58 mmol/mol) threshold that was targeted by general practices (30.4% vs. 38.0%). This difference, however, did not quite reach statistical significance (adjusted odds ratio 1.63, 95% CI, 0.99 to 2.68, p = 0.053). Telehealth modestly improved glycaemic control in patients with type 2 diabetes over 12 months. The scale of the improvements is consistent with previous meta-analyses, but was relatively modest and seems unlikely to produce significant patient benefit. Trial registration number International Standard Randomized Controlled Trial Number Register ISRCTN43002091.
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    • "However, a debate on the validity of the conclusions in the Whole System Demonstrator Project study is ongoing in Denmark for at least two reasons. First, the conclusion of the UK study might be biased since trial recruiters had foreknowledge of the allocation groups in many cases [16]. Second, its transferability to a Danish context is an issue since the trial did not consider all community and healthcare resources [15]. "
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    ABSTRACT: Several feasibility studies show promising results of telehealthcare on health outcomes and health-related quality of life for patients suffering from chronic obstructive pulmonary disease, and some of these studies show that telehealthcare may even lower healthcare costs. However, the only large-scale trial we have so far - the Whole System Demonstrator Project in England - has raised doubts about these results since it conclude that telehealthcare as a supplement to usual care is not likely to be cost-effective compared with usual care alone. The present study is known as ‘TeleCare North’ in Denmark. It seeks to address these doubts by implementing a large-scale, pragmatic, cluster-randomized trial with nested economic evaluation. The purpose of the study is to assess the effectiveness and the cost-effectiveness of a telehealth solution for patients suffering from chronic obstructive pulmonary disease compared to usual practice. General practitioners will be responsible for recruiting eligible participants (1,200 participants are expected) for the trial in the geographical area of the North Denmark Region. Twenty-six municipality districts in the region define the randomization clusters. The primary outcomes are changes in health-related quality of life, and the incremental cost-effectiveness ratio measured from baseline to follow-up at 12 months. Secondary outcomes are changes in mortality and physiological indicators (diastolic and systolic blood pressure, pulse, oxygen saturation, and weight). There has been a call for large-scale clinical trials with rigorous cost-effectiveness assessments in telehealthcare research. This study is meant to improve the international evidence base for the effectiveness and cost-effectiveness of telehealthcare to patients suffering from chronic obstructive pulmonary disease by implementing a large-scale pragmatic cluster-randomized clinical trial. Trial registration, http://NCT01984840, November 14, 2013.
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