Dr Julian Neal is a GP in Portsmouth (UK) and clinical adviser to Telehealth Solutions. In this article he picks his way through the Whole Systems Demonstrator (WSD) trial results published in the BMJ and looks forward to a more positive future – if telehealth (as in remote vital signs monitoring) is given the right conditions.
Following some frankly over-optimistic headline findings published by the UK Government in December 2011, there has been a great deal of publicity about telehealth during the last few months. Much has been cautious and some openly negative. Even the BMJ has got in on the act, publishing last month the first of five detailed papers from the WSD trial to assess the effect of telehealth on the use of secondary care and mortality. A total of 3,154 patients were recruited into this trial, approximately half of whom were provided with a variety of telehealth interventions and studied for a year. This was followed up by a thoughtful BMJ editorial a few weeks later by amongst others, Josip Car from Imperial College, London, the main thrust of which was combining caution with a need for more observational analysis.
The main findings from the first publication in the BMJ are interesting… Over the 12 months of the trial those patients provided with telehealth had 20% fewer emergency admissions than the control group who were cared for ‘in the usual way’. More significantly, over the same 12 month period, only 4.6% of those provided with telehealth died compared with 8.3% of the control group. The study in the BMJ also concluded that for those patients with telehealth the overall costs of hospital care were £188 per patient less than those for control patients though interestingly this was not thought to be a statistically significant difference.
Both these findings are statistically significant and are consistent with over a decade’s experience from the US Veterans Health Administration where in 2011, some 50,000 patients received telehealth services. These findings are also consistent with a study my practice undertook two winters ago when 100 patients with COPD were provided with telehealth monitoring and 11 hospital admissions were prevented in just 3 months.
So where does this more detailed analysis of the WSD trial leave our current understanding of telehealth?
I think the editorial in the BMJ got it about right when it stated, “Telehealth does not just ‘work’ or ‘not work'”. Particular interventions may be successful, but this depends on many factors, including the specific contributions of the type of technology and of the context, such as the willingness of clinical staff to change their care processes; the disease stage and severity of disease in the patients involved, their social backgrounds, and their needs and expectations; the predictive power of any monitoring data that are collected; and, indeed, the endpoints that are used to specify success.
For my part it is clear that telehealth is good for carefully selected patients; clinical outcomes are improved, lives are saved and admissions are prevented. Patient engagement with their long term conditions also increased. However I agree that more detailed research needs to be undertaken to prove that the undoubted clinical benefits to patients can be achieved at a significantly lower cost to the NHS.
My own experience of telehealth suggests that significant cost savings can only be generated if a central nurse-led triage service is at the heart of any telehealth service. Much of the WSD trial imposed the use of technology on community and primary care staff with no significant service redesign. Opportunities were lost for vast economies of scale whereby one specialist nurse could cost effectively monitor 300 patients. Too often telehealth became an additional cumbersome layer rather than a focused cost-effective improvement.
In Portsmouth, my own practice, Portsdown Group Practice, in conjunction with Telehealth Solutions Ltd and Professor Nick Bosanquet from Imperial College London, is currently almost 6 months into a robust 2 year observational study of the effects of telehealth on hundreds of patients with COPD, chronic heart failure and diabetes. In addition to recording clinical outcomes and a large range of socio-economic factors, we are analysing total NHS usage for 2 years before and after deployment of telehealth. The potential to reduce usage of general practice and out of hours services is enormous but the WSD study in the BMJ failed to assess this. In effect we are already establishing the sort of robust observational study that the BMJ editorial called for.
It is always a risky business extrapolating from large trials but a wealth of data from overseas exists confirming the clinical and financial benefits of telehealth. Reproducing these gains in the NHS will require much more than just the deployment of technology. More sensitive patient selection and more intelligent and integrated implementation on a very large scale are essential prerequisites for greater success. This should involve the simultaneous adoption of improved care pathways that are enshrined within telehealth algorithms and implemented at the time of deployment.
However I also believe that the Department of Health also needs to do its bit by avoiding the temptation to broadcast hyperbole and by providing strong incentives for clinical commissioning groups and GP practices to adopt telehealth, not as an add on, but as an integral new way of managing chronic disease. The NHS can simply not afford to continue to do more of the same. The provision of a new ‘Telehealth tariff’ by the Department of Health should encourage the roll out of telehealth services on a much larger scale which, in turn, will drive down industry costs and encourage telehealth provision in the NHS by the ‘Any Qualified Provider’ route. It will also encourage the adoption of cheaper and smarter technological solutions, including mobile phone apps.
Dr Julian Neal
Senior Partner, Portsdown Group Practice
9 August 2012