Are benefits of telehealth care worth the cost?

‘NHS remote monitoring costs more’ BBC News reports after the publication of a new study looking at the cost-effectiveness of telehealth.

Telehealth involves using technology to enable healthcare professionals to remotely monitor data on certain aspects of a patient’s health. It may include sensors that can monitor the amount of oxygen in a person’s blood, or more straightforward examples, such as telephone check-ups.

The news is based on a large randomised controlled trial which examined the costs of a range of telehealth services and their effect on the quality of life in patients with:

• heart failure
• diabetes
• chronic obstructive pulmonary disease (COPD) 

It should be noted that telehealth systems are also used to monitor people with disabilities, as well as patients with a range of conditions, including dementia, and that this study only looked at a small range of the services available.

Overall, the study suggested that adding telehealth to standard care increased costs by about 10% (including costs of the intervention and additional healthcare services) for only a very minimal gain in quality of life. This led the researchers to conclude that telehealth was not a cost-effective addition for these patients.

However, they also point out that there may be other health conditions and populations in which telehealth may be cost effective. Further research into this issue is warranted.

Where did the story come from?

The study was carried out by researchers from London School of Economics and Political Science and other UK institutions and was published in the peer-reviewed British Medical Journal. Funding was provided by the Department of Health.

The BBC News reporting of the study was accurate. However, it is important to note that this study looked at cost-effectiveness of telecare, not whether it has beneficial health outcomes for people.

What kind of research was this?

This was a cost effectiveness study examining telehealth in addition to ‘standard care’ and monitoring, compared to standard care and monitoring alone.

The researchers describe how evidence has developed over recent years to suggest that telehealth can be beneficial for managing chronic conditions such as heart disease, respiratory diseases and diabetes.

Telehealth includes things such as telephone support, where patients report signs and symptoms of their disease to healthcare professionals over the phone, and telemonitoring, where patients link up to a monitor which transmits data allowing health care professionals to remotely monitor aspects of their condition in real-time. However, the researchers say that despite growing interest in using these services to help manage chronic conditions, there has been little study into how the benefits measure up against the costs.

This cost effectiveness analysis was carried out for a randomised controlled trial which used data to examine the effect of telehealth on general practice, hospital, and social care use by individuals with long term conditions, in three demographically diverse sites.

Telehealth was defined in this study as ‘the remote exchange of data between a patient and healthcare professional to assist in the diagnosis and management of a healthcare condition’.

What did the research involve?

In the trial, the patients of 179 GP practices were randomised to 12 months of standard care or standard care in addition to telehealth. Eligible patients were adults with at least one of three long-term conditions – chronic obstructive pulmonary disease (COPD), heart failure, or diabetes. Those in the ‘intervention’ group received a package of telehealth equipment and monitoring services (such as a blood pressure cuff or a blood glucose measuring device) for 12 months, in addition to the standard health and social care services available in their area.

Of the 3,230 patients taking part in the trial, a subset of them (1,573) were invited to take part in a questionnaire study to look at effectiveness, acceptability and cost effectiveness of telehealth as a supplement to standard care. This was the EQ-5D questionnaire, which is a widely accepted tool for measuring health status and quality of life.

Of the people selected to take part in this questionnaire study, only 61% (534 in the telehealth intervention and 431 in the usual care group) actually completed the 12-month questionnaires face-to-face or over the phone.

The researchers calculated the per person costs to purchasers of telehealth equipment and support (such as personnel costs for monitoring, supervision or staff training) and the cost of health and social care services used in the telehealth group compared to the usual care group. The main outcome measure for the cost effectiveness analysis was the cost per quality adjusted life year (QALY) gained, using data from the EQ-5D.

A QALY is a measure that combines the duration of life lived and adjusts it for quality of life.

For instance, a person living for one year in perfect health would be considered to have accumulated one quality adjusted life year. A person living for a year with a condition that limits certain aspects of their quality of life (such as their ability to care for themselves, or move about freely) might be considered to accumulate 0.80 quality adjusted life years during that same time.

While not necessarily an intuitive measure to understand, using the QALY can be useful to help capture important health related outcomes and compare the cost-effectiveness of different treatments.

What were the basic results?

Comparing people who completed the questionnaires with those who didn’t, ‘non-completers’ in the telehealth group included a higher proportion of those in the most deprived areas. The average cost per participant for telehealth equipment and support was estimated as £1,847 per year. When looking at cost of services used by the participants (such as GP consultations, hospital attendances and drug costs) in the final three months of the intervention, health and social care costs were about £200 or 10% higher in the telehealth group compared to the usual care group.

The difference between the two groups in terms of QALYs was small, just 0.012 QALYs gained by the intervention. This is equivalent to only a few additional days of good quality health gained as a result of the intervention. The extra cost per QALY gained with the telehealth intervention was estimated at £92,000. Usually the threshold of willingness to pay, as recommended by NICE when assessing new drugs and technologies, is below £30,000 per additional QALY.

The probability that the intervention would be cost effective and fall below this threshold was only estimated to be 11%.

The researchers found that to achieve a probability over 50% so the addition of telehealth services would be a cost effective use of healthcare funds, the NHS would need to be willing to pay over £90,000 per QALY gained. This is three times the commonly used threshold. However, the researchers made the case that if equipment costs could be reduced and patients made optimal use of the telehealth services, the 11% probability could be increased to 61%.

How did the researchers interpret the results?

The researchers say that ‘the QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher’. They conclude that ‘telehealth does not seem to be a cost effective addition to standard support and treatment’.

Conclusion

This study benefits from using data from a large randomised controlled trial examining the cost and effectiveness (in terms of quality of life) of a telehealth intervention over a 12-month period in the UK. The study suggests that the intervention incurs additional costs for only a very minimal gain in quality adjusted life years.

However, there are some limitations to the study:

• Information on use and cost of healthcare services came from self-reported use of services by the participants on questionnaire and this may not be completely accurate as frequent service users may under-report how often they use primary and secondary care services. Also, as the study was conducted across healthcare trusts within the UK there may have been regional differences in the range of health and social care services available.
• Questionnaires at 12 months were completed by only 61% of the study population. It is not known how service costs and health outcomes may have differed between those who completed the study and those who did not.
• Outcome data focuses on self-reported quality of life and health status of the participants. It does not look at other outcomes related to the individual chronic condition such as blood pressure or blood sugar control or long-term survival outcomes.
• The 12-month timeframe for evaluation may also be too short to show improvements in quality of life, which may become evident over a longer time scale.

As the researchers say, there remain questions as to which patient populations and characteristics (for example, looking at specific chronic health conditions and interventions, rather than examining them collectively) would benefit most from telehealth. These health and sociodemographic issues need to be further examined.

Analysis by NHS Choices. Follow Behind the Headlines on Twitter.