When this editor was running a telecare & telehealth programme in Surrey, there was always the dread when meeting professionals that one of the daily internet newssheets would publicise another paper about the Whole System Demonstrator (WSD) that ‘proved’ that one or other form of remote patient monitoring (RPM) cost more per QALY than a voyage on Virgin Galactic. The day was then spent unconstructively, making some or all of the points encapsulated in my original post on 22 July last year entitled “Time to bid farewell to the WSD”.
Thankfully the flow of WSD papers has since dwindled. Doubtless many hoped they had stopped for good, in view of their total irrelevance to the real world in 2014. However, on the offchance that some poor reader has found themselves being challenged about the abstract of a recent paper picked up by Pulse, on the high cost per QALY of telecare by one of the few professionals who still do not accept the value of appropriated technology, here is what you might tell them:
- In Newham we prepared to bid for the WSD, including selecting the equipment we would use, in the autumn of 2006 – that’s nearly six Moore’s Law doublings ago, when the only RPM equipment available was basic and used proprietary protocols that locked a user into a single supplier;
- Specifically for telecare, the subject of this paper, even proprietary equipment has at least halved in price since 2006 and using mHealth/open technologies can reduce costs dramatically, further – for example SIM-enabled sensors, such as those for smoke or low temperature, or cheap/free apps downloaded onto existing smartphones to turn them into falls detectors or panic button apps – as well as providing a better service; (there is still much concern by users about the stigma of a worn falls detector or pendant, whereas there is no stigma to having a smartphone…and the smartphone works outside the house too);
- In Newham we were encouraged to believe that to establish our credentials for the WSD bid we needed to install many telecare users so before our win was announced in May 2007 we already had an installed base of some 3000 telecare users (1% of total population), which were chosen from among the highest risk frail/elderly people in the Borough, so when the randomised controlled trial (RCT) was subsequently chosen by the academics as the preferred evaluation method these people, who might be expected to benefit greatest from telecare, were excluded from the trial, massively biasing any eventual result against showing benefit from telecare;
- Telecare is not a single technology: it is a wide range of different sensor technologies that in turn require very different alerting and responding behaviour – a smoke detector alert typically requires a fire service response, though even if fast the time taken for a remote responder to get to a person who has alerted a fit sensor could still be far too long to save their life, so fit detectors have to be terminated with someone very close by;
- This wide range of technologies means that an RCT that allocates ‘telecare’ to a test group can only work with a standard installation that does not respond to the individual needs of users, and does not allow installers to use their immense creativity in choosing and applying those technologies – it cannot for example capture the saving of over £100/person/day of reducing ‘waking nights’ by installing fit/enuresis detectors for those prone to night-time fits/enuresis, which by avoiding unnecessary intrusion into people’s bedrooms at night also improves their quality of life, or capture the saving from a cancelled home care visit when sensors indicate the user has got out of bed that day without needing help;
- Finally, repeatedly studies of RPM show that the greatest benefits are only realised if the technology is used to deliver care differently – the resulting ‘complex intervention’ is extremely hard for an RCT to capture as such trials work best when only one variable is changed (such as ‘telecare’ or ‘no telecare’) and the change in outcome(s) easily measured: to give another example, apart possibly from the reduction in hospital admissions, little if anything from a falls detector that transforms the support arrangement in a family and therefore enables a lawyer wife to go back to work, stop receiving benefits, pay more taxes and spend more money locally could be captured by a standard RCT, yet that transformation is regularly the reality of well-installed telecare, time after time.
As many academics have privately agreed with me that for the above reasons such papers serve only to strengthen the faith of flat earthers and tell us nothing useful about technology implementation eight years on, I had hoped when I read the full paper to find that they did indeed refer to some or all of the above, and perhaps even offered calculations updated for the vastly reduced cost of the kit. Sadly, even though the WSD was publicly funded to the tune I am told of over £30m, on the understanding (again I am told) that research produced would be made freely available, the full paper is not currently freely available…and I am not prepared to enrich the publisher by even the few pounds that buying an online copy would cost because that just might encourage them to keep publishing such material.