Since one of the Whole Systems Demonstrator (WSD) let drop at the King’s Fund conference last March that the telehealth Quality Adjusted Life Years (QALY) cost calculation was coming out at £80,000 the actual paper has been ‘eagerly’ awaited, with speculation and concern that the calculation included management and other study-related costs that would not apply in a normal service setting. The paper is published by the BMJ today and a) such costs were excluded and b) the QALY figure is actually £92,000. Well, that’s the headline figure that is already being headlined by Pulse but, of course, the calculations are more nuanced. Foe example:
Whether telehealth is considered to be cost effective will depend on the willingness to pay for the outcomes generated. Figure 1 presents the probability that telehealth would be seen as cost effective as an addition to usual care, using an acceptability curve for different values of willingness to pay. At the £30,000 threshold (associated with NICE recommendations), the probability of cost effectiveness was 11%. Figure 1 also shows the probability of cost effectiveness if costs related to project management were excluded: at the £30,000 threshold, the probability of cost effectiveness was 17%. Indeed, this probability including management costs only exceeded 50% at threshold values of willingness to pay above £90,000. Excluding project management costs, the probability exceeded 50% only at values above about £79,000.
The discussion is also worth reading carefully, as is the final conclusion:
A community based, telehealth intervention is unlikely to be cost effective, based on health and social care costs and outcomes after 12 months and the willingness to pay threshold of £30,000 per QALY recommended by NICE. A reduced cost of telehealth per QALY may be possible by combining the effects of equipment price reductions and increased working capacity of services; On the assumption of reduced equipment costs and increased working capacity, the probability that telehealth is cost effective would be about 61%, assuming a willingness to pay threshold of £30,000 per QALY.
BMJ paper: Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial BMJ 2013;346:f1035
Related items
Mike Clark’s Updated list of WSD results papers.
Interview with Professor Martin Knapp As “telehealth” grows, experts question cost benefits Reuters.
David Brindle, in The Guardian anticipated these results last month and, in a follow up article commented “Fourteen months on from its launch, 3millionlives seems to be going nowhere. Intuitively, telecare/telehealth feels like a key pillar of the future care system. To be that, however, it does need a credible evidence base.”
3millionlives press release: 3millionlives – enabling change to benefit patients and carers. (PDF)
GP Online Telehealth ‘not good use of NHS money’, finds DH-backed study.
NHS Choices Are benefits of telehealth care worth the cost?
I have repeated perhaps one time too many that the WSD results are the direct result of the straitjacket imposed on implementation by the strict RCT methodology, so I won’t repeat that again…other than to say that when there is freedom to implement it as the complex intervention it is, using telehealth as a catalyst to change the way care is delivered, in my experience the results, that can realistically only be measured on a one year vs the next or a matched control basis, are far superior.
The important point I want to make is to ask readers to remember that in Newham when we were selecting the telehealth equipment to bid for the WSD, we were in the Autumn of 2006, 6 1/2 years ago, or four Moore’s Law cycles ago, when for example 256mb USB sticks still sold for real money (I paid £16.99 on Amazon shortly before then). Telehealth kit is now significantly lower in price, and the functionality – of both the kit and importantly the clinical user interface – is vastly improved. And Florence is leading the way to a time when hopefully there won’t be any need for a separate piece of telehealth kit that the patients needs to use – it’ll all be done using a patient’s own smartphone and a very few peripherals.
Telehealth is a young technology: improvements in the benefits of implementation will come from constructive criticism, which is always welcomed. Bashing the technology now for a cost basis that is long past is however not constructive, and serves only to increase the cost of implementation by raising the cost of engaging stakeholders affect by such publicity.
Further to Charles Lowe’s good points, the RCT ensured that the telecare service was additional to the normal service, so no wonder it cost more! Because current care services are unsustainable, the objective of telecare must be to change the way care is delivered, and the WSD trials did not permit that. So this report does not make a useful contribution. The big opportunity for making significant savings is for care stakeholders to get joined up, enabling them to work as virtual teams for their patients, and be able to do this at the scale of 3 million lives. While Health and Wellbeing Boards are a step in the right direction, care stakeholders will not really work together unless they have an ICT infrastructure platform that enables them to do so easily, which they do not have. This means including in the telecare service not just the NHS and Social Services, but at least pharmacists, charities, domiciliary carers, as well as the families of people who need the care in their own homes.
Anyway, how do you correlate the report’s conclusion of only a minor improvement of QALYs with the headline findings of WSD that the telecare intervention reduced mortality by 45%?