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J Telemed Telecare OnlineFirst, published on March 11, 2015 as doi:10.1177/1357633X15574807
RESEARCH/Original article
Evaluation of a Telehealth Service for COPD and HF patients: Clinical outcome and patients’ perceptions
Journal of Telemedicine and Telecare 0(0) 1–6 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15574807 jtt.sagepub.com
Bassel Odeh1, Reem Kayyali1, Shereen Nabhani-Gebara1, Nada Philip2, Patricia Robinson3 and Catherine Russell Wallace4
Abstract NHS Croydon Health Services and NHS Croydon Clinical Commissioning Group have been providing telehealth services for the past 36 months. The aim of this study was to measure the impact of telehealth when implemented as a service within a standard patient care pathway. To measure the clinical outcomes, the number of A&E visits and hospital admissions, recorded on the NHS Secondary Uses Service database, were compared before and after the implementation of the telehealth service. The number of all events despite its cause and the number of events related to the patients’ diagnosed condition were collected. To elicit patients’ perceptions about the telehealth service, a cross sectional survey of patients registered on the triage manager database was used to explore their perceptions, concerns and general satisfaction with the telehealth service via a 4 point likert scale questionnaire. The data of 48 patients were collected and telehealth reduced the number of both A&E and hospital admission due to all causes by 13% (P ¼ 0.42) and 22% (P ¼ 0.048), respectively. When only the events directly related to the patient’s diagnosed condition were considered, a reduction by 36% (P ¼ 0.03) and 28% (P ¼ 0.02) was recorded for A&E visits and hospital admission respectively. 27 patients consented to participate in the survey. Overall, patients were very satisfied with telehealth services. Patients agreed that telehealth had improved their health, it was a convenient form of health care delivery for them and they were more involved in the decisions about their care or treatment. In addition, since being on telehealth, patients’ confidence in managing their health increased from somewhat confident to confident. Telehealth, when provided as a service within a standard care pathway, seems to decrease hospital admissions and A&E visits. Good patient satisfaction suggests that the current service is accepted and it could be further expanded to include a larger number of patients. Accepted: 28 January 2015
Introduction UK is facing an aging population caused by both a rising life expectancy rate and a declining fertility rate. In England, more than 15 million people have long term conditions (LTC), including chronic obstructive pulmonary disease (COPD) and heart failure (HF), and this number is expected to rise to 18 million by 2018.1 Both COPD and HF are considered among the leading causes of death in the world,2 with COPD potentially affecting one in four adults by the age of 80 years,3 and over 25,000 new cases of HF is recoded in the UK every year.4 To deliver sustainable care for the aging populations, healthcare systems are seeking cost-effective strategies for delivering sustainable care, including promoting selfcare, shifting care into the community, and using technological solutions.5,6 Technology can play an important role in LTC management. A wide range of technologies can be used including: sensor technology and wearable monitoring systems, internet-based peripheral monitoring
devices, videophones, telephone-linked care and nanotechnology.7 Telehealth can deliver enhanced care to HF and COPD patients and help avoid negative health outcomes, by providing early detection and warning when health status deteriorates.8–12 Several systematic reviews have found that telehealth, when compared with usual care, shows benefits in terms of reduced mortality rates, hospital admissions and A&E visits, enhanced quality of life, and improvements in 1
School of Pharmacy and Chemistry, Kingston University, UK School of Computing and Information Systems, Kingston University, UK 3 NHS Croydon Health Services, UK 4 NHS Croydon Clinical Commissioning Group, UK 2
Corresponding author: Bassel Odeh, School of Pharmacy and Chemistry, Kingston University, Penrhyn Road, Kingston upon Thames, Surrey, KT1 2EE, UK. Email: [email protected]
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patient self-care.13–17 In particular, the Whole System Demonstrator, a large telehealth study conducted by the Department of Health (DH) between May 2008 and December 2009, showed that telehealth had significantly decreased admission proportion, mortality rate within 12 month follow-up, length of hospital stay and emergency department visits per head.18 However, it also found that implementing telehealth could cause organisational challenge which can act as a barrier to its implementation. When telehealth is implemented as randomised control trial (RCT), the standardised elements of an RCT could be perceived as overriding the local contextual differences in terms of prior experiences and needs, leading to the loss of organisational goodwill and stakeholders’ relationships.19 Despite the mixed evidence of benefit, there is a strong policy push to expand telehealth in the UK. The DH launched, on the 19th of January 2012, the 3millionlives project. This project is a joint Government-telehealth industry initiative to save the life of at least three million people with long-term conditions and/or social care needs by 2017. The main objectives of this project are for the DH and industry to work together to remove barriers to the delivery and develop the market of telehealth.20 Furthermore, the DH, at the end of 2012, issued a new Directed Enhanced Service for remote care, or the Telehealth DES. This DES would help general practices to agree with their CCGs to implement remote care monitoring by paying them 21p for each patient they sign up and get them ready to start on the service in 2014/ 2015.21 It has been identified that patient acceptance is one of the most important factors influencing the future implementation of a successful telehealth project,22 considering that many patients may refuse or quickly abandon telehealth.23,24 A recent systematic review25 found that 32% of patients refused telehealth when it was offered to them and 20% of those who accept to participate later abandoned telehealth. The main barriers reported were that telehealth was difficult to use, concern about the loss of personal contact with healthcare professionals, problems with trusting the equipment to work and not understanding the purpose of telehealth.25 Croydon Primary Care Trust (PCT), currently NHS Croydon Clinical Commissioning Group (CCG) has been providing telehealth services since July 2011. Remote patient monitoring (RPM) telehealth service has been provided for patients diagnosed with HF and COPD. The RPM system consisted of a set of peripheral devices at the patient’s home including a blood pressure monitor, a pulse oximeter, a thermometer, a weighing scale, and a peak-flow monitor/spirometer. This study was a service evaluation to determine whether telehealth had an impact on patients’ clinical outcomes and to elicit patients’ perception regarding the service. The work was conducted in collaboration with the NHS Croydon Health Services and NHS Croydon CCG.
Methods Clinical outcome To measure clinical outcomes, the number of A&E visits and hospital admissions before and after the implementation of the telehealth service were compared for each patient. To collect an accurate number of A&E visits and hospital admissions, the Secondary Uses Service (SUS) database was used. SUS is a data warehouse containing patient-based information generated when a patient or service user is treated or cared for. It manages commissioning data sets (CDS) covering NHS commissioned care at patient level for A&E visits, admitted patient care and outpatients.26 The ICP Triage manager database was searched for patients who have been receiving telehealth service for more than 12 Months. A list of those patients was sent to the Southwest London NHS Informatics Department to extract the available raw data from the SUS database. The events were extracted for each patient individually covering the past 24 months. For each patient, the 12 months period prior to starting telehealth was considered the control period and the 12 months since being on telehealth was considered as the intervention period. A&E visits and hospital admissions were compared between the control and intervention periods. This was done for two scenarios: including all events despite its cause (e.g. gastrointestinal tract, urinary tract and skin disorders) and only events related to the patients’ diagnosed COPD and/or HF conditions.
Patients perceptions To explore patients’ perceptions, concerns and general satisfaction with the provided telehealth service, a 15-items questionnaire, using 4-points Likert scale, was used. The first section was designed as agree/disagree statements to explore patients’ views regarding whether telehealth has changed their general health, their involvement in treatment management, and their perception regarding the technology used. Sections two and three measured how much patients were concerned about telehealth and how confident they are in managing their own health, respectively. The last section was used for an overall satisfaction and for any comments the patients may have regarding the use of telehealth. This was developed by reviewing the relative literature and using related quality of life questionnaires. Patients registered on the ICP Triage manager database were considered eligible to participate in the study. The inclusion criteria were as follow: . Currently active on telehealth . Have been on the service for more than three months . Contact information is available. Patients were contacted by phone and asked to participate and answer the questionnaire. If a patient was not
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80 Patients Registered on the Triage Manager 25 patients suspended
55 Patients active on Service
7 Patients have been on service for less than three months 48 Patients active
14 Patients temporarily suspended/had no contact information
34 Patients are selected for the questionnaire
7 Patients did not participate
27 Patients responded
Figure 1. Patients selection criteria.
available, or they preferred to answer in their own time, a letter was sent by post to their address with a stamped selfaddressed envelope. The survey was carried out between Jun and Sep 2013.
generated scale is. Nunnaly27 has indicated 0.7 to be an acceptable reliability coefficient.
Results Sample characteristic
Data Analysis Clinical outcome The quantitative data generated from the SUS database was entered into Microsoft Excel. Descriptive statistics were used to analyse the data (average, median, mode, and variance) and the significant difference between the two study periods was measured using a paired T-test.
A total of 80 patients were registered on the telehealth triage database. However, 48 patients met the inclusion criteria for the measurement of the clinical outcomes, and 34 were eligible to participate in patient perception questionnaire. Figure 1 summarises the patients’ selection criteria and Table 1 summarizes the patients’ characteristics.
Clinical outcome Patients’ perceptions Patient responses are presented as percentages of the total and as number of responders. To determine the reliability of the questionnaire, Cronbach’s Alpha coefficient was calculated. Cronbach’s Alpha coefficient ranges in value from 0 to 1 and the higher the score, the more reliable the
Table 2 summarises the telehealth clinical outcomes. A&E visits and emergency admissions were reduced by 13% (P ¼ 0.42) and 22% (P ¼ 0.048), respectively, when including all reasons for each event. However, when excluding events not directly related to the patients’ diagnosed conditions, a reduction by 36% (P ¼ 0.03) of A&E visits
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Journal of Telemedicine and Telecare 0(0) and helped them discuss what is most important about their own health. Furthermore, 82% (n: 22) and 93% (n: 25) of patients had no concerns about confidentiality, or the absence of direct contact with GP/Nurse during a telehealth consultation, respectively. 78% (n: 21) of patients agreed that telehealth had saved them time, but only 8% (n: 2) agreed that it saved them money. The majority of patient didn’t find the use of necessary equipment to be difficult and two thirds found it to be reliable. Finally, since being on telehealth, the number of patients confident in managing their health increased from 11% (n: 3) to 78% (n: 21).
and 22% (P ¼ 0.02) of emergency admissions was observed.
Patients perceptions Out of the 48 active patients on the telehealth triage database, 34 were eligible and 27 consented to participate (79.4% response rate) with an average age (SD) of 71.1(10.4). The questionnaire had a Cronbach’s alpha of 0.811, suggesting good internal consistency and reliability. Overall, 89% (n: 24) of patients were satisfied with telehealth services and 82% (n: 22) of patients agreed that telehealth had improved their health. 89% (n: 24) and 85% (n: 23) agreed that telehealth was a convenient form of healthcare delivery for them and they were more involved in the decisions about their care or treatment, respectively. In addition, 89% (n: 24) agreed that using telehealth enabled the GP/Nurse to better monitor their conditions
Discussion Telehealth has significantly reduced hospital admissions caused by all events (P ¼ 0.048) and those events only directly related to the patients’ diagnosed conditions (P ¼ 0.02). It also significantly reduced A&E visits caused by patients’ COPD/HF related conditions. These finding are similar to those reported by other reviews and studies.13–15,19 The cost of these events was not available for this study. Patients’ positive engagement in telehealth service is a crucial factor for the success of the service and understanding how patients perceive telehealth can influence its acceptability and diffusion28. Several barriers had been identified to affect the level of telehealth uptake by patients with HF and COPD, including preference for one-to-one with their healthcare professionals, technology anxiety, technical problems, the belief that telehealth to be unnecessary, 25 However, the high patients’ satisfaction in this study suggests that the current telehealth service is well accepted. Patients found telehealth easy to use and they did not have concern about the loss of personal contact with healthcare professionals, nor with trusting the equipment to work or understanding the purpose of telehealth. Furthermore, the work done by the research team found that nurses working with the patients described the patients’ engagement and attitude regarding using
Table 1. Patients’ Characteristics. Gender n (%) Male (%) Female (%) Diagnosis COPD n (%) HF n (%) COPD&HF n (%) Age mean (SD) Age Group n (%) 41–50 51–60 61–70 71–80 81–90
19 (39.58%) 29 (60.42%) 23 17 8 70.4 1 10 11 17 9
(48%) (35%) (17%) ( 10.5) (2%) (21%) (23%) (35%) (19%)
Table 2. Telehealth Clinical Outcomes. Control Period
All Events A&E Visits Hospital Admission Related A&E Visits Hospital Admission
Telehealth
Total Event
Mean (STD) per patient
Total Event
Mean (STD) per patient
Event Reduction %
p
152 134
3.3 (5.38) 3.12 (4.33)
133 105
2.89 (4.54) 2.44 (3.87)
13% 22%
0.42 0.048
74 117
2.00 (1.58) 2.85 (4.19)
47 84
1.27 (1.79) 2.05 (3.63)
36% 28%
0.03 0.02
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telehealth to be very positive and that patients were easy to recruit29. Old age has been reported as a barrier for accepting telehealth30, however, this study had an average patients’ age of 70.4 years and age did not seem to be a barrier for the adaption and use of telehealth. One patient in particular commented: ‘‘I find it amazing that 3 little items can have such an impact on my health. . . I am happy with Telehealth because I am confident that I can be understood without feeling embarrassed’’ The relatively small sample size, the use of satisfaction measures, the bias risk arising from comparing outcomes before and after the intervention and the absence of a control group are limitations that should be recognised. This was because the study was designed as an evaluation for a service being provided by the CCG.
Conclusions Telehealth, when provided as a service in addition to the standard care pathway, seems to decrease hospital admissions and A&E visits and good patients’ satisfaction suggests that the current service is well accepted. Declaration of Conflicting Interests The Authors declare that there is no conflict of interest.
Acknowledgments The authors would like to acknowledge John Chang, Christine Griffiths and Belinda Wigmore at NHS Croydon Health Services and Andrew Maskell at Croydon Council for their support during this study. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Telehealth service was being provided by TunstallÕ
References 1. DH. Raising the Profile of Long Term Conditions Care: A Compendium of Information. London: Department of Health 2008. 2. Cowie MR, Fox KF, Wood DA, et al. Hospitalization of patients with heart failure: a population-based study. European heart journal 2002;23:877–85. 3. Gershon AS, Warner L, Cascagnette P, Victor JC, To T. Lifetime risk of developing chronic obstructive pulmonary disease: a longitudinal population study. The Lancet 2011;378:991–6. 4. Townsend N, Wickramasinghe K, Bhatnagar P, et al. Coronary Heart Disease Statistics: A Compendium of Health Statistics, 2012 ed. British Hearth Foundation: London, UK. 2012. 5. Scottish Executive. Building a health service fit for the future: A national framework for service change in the NHS in Scotland. Edinburgh: Scottish Executive. 2005. 6. Department of Health. Our health, our care, our say: a new direction for community services. Stationery Office, 2006. 7. Artinian NT. Telehealth as a Tool for Enhancing Care for Patients With Cardiovascular Disease. Journal of Cardiovascular Nursing 2007;22:25–31.
8. Giamouzis G, Mastrogiannis D, Koutrakis K, et al. Telemonitoring in chronic heart failure: a systematic review. Cardiology research and practice. 2012; 1–7, Art. No.: 410820. 9. Whitten P, Mickus M. Home telecare for COPD/CHF patients: outcomes and perceptions. Journal of telemedicine and telecare 2007;13:69–73. 10. LaFramboise LM, Woster J, Yager A, Yates BC. A technological life buoy: patient perceptions of the health buddy. Journal of Cardiovascular Nursing 2009;24:216–24. 11. Rahimpour M, Lovell NH, Celler BG, McCormick J. Patients’ perceptions of a home telecare system. International journal of medical informatics 2008;77:486–98. 12. Maric B, Kaan A, Ignaszewski A, Lear SA. A systematic review of telemonitoring technologies in heart failure. European journal of heart failure 2009;11:506–17. 13. Inglis S. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Journal of Evidence-Based Medicine 2010;3:228. 14. Polisena J, Tran K, Cimon K, et al. Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. Journal of Telemedicine and Telecare 2010;16:120–7. 15. McLean S, Nurmatov U, Liu J, Pagliari C, Car J, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011; 7: 1–55, Art. No.: CD007718. 16. Purcell R, McInnes S, Halcomb EJ. Telemonitoring can assist in managing cardiovascular disease in primary care: a systematic review of systematic reviews. BMC family practice 2014;15:43. 17. Cruz J, Brooks D, Marques A. Home telemonitoring effectiveness in COPD: a systematic review. International journal of clinical practice 2014;68:369–78. 18. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. Brit Med J. 2012; 344: e3874. 19. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. Brit Med J. 2012; 344: e3874. 20. 3 millionlives. Improving your access to telehealth and telecare. 2013. 21. BMA. GP contract: new Directed Enhanced Services. In: Association BM, (ed.). London: British Medical Association, 2013. 22. Broens TH, Vollenbroek-Hutten MM, Hermens HJ, van Halteren AT, Nieuwenhuis LJ. Determinants of successful telemedicine implementations: a literature study. Journal of telemedicine and telecare 2007;13:303–9. 23. Or CK, Karsh B-T. A systematic review of patient acceptance of consumer health information technology. Journal of the American Medical Informatics Association 2009;16:550–60. 24. Joseph V, West RM, Shickle D, Keen J, Clamp S. Key challenges in the development and implementation of telehealth projects. Journal of telemedicine and telecare 2011;17:71–7. 25. Gorst SL, Armitage CJ, Brownsell S, Hawley MS. Home Telehealth Uptake and Continued Use Among Heart Failure and Chronic Obstructive Pulmonary Disease
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Patients: a Systematic Review. Annals of Behavioral Medicine. 2014; 48(3): 323–336. 26. Health & Social Care Information Centre (2014) Secondary Uses Service (SUS). http://www.hscic.gov.uk/sus. Accessed 28/08/2014. 27. Nunally JC, Bernstein IH. Psychometric theory. New York: McGraw-Hill, 1978. 28. Lorenzi NM, Ash JS, Einbinder J, McPhee W, Einbinder L. Transforming Health Care Through Information. NY: Springer, 2005.
29. Odeh B, Kayyali R, Nabhani-Gebara S, Philip N. Implementing a telehealth service: nurses’ perceptions and experiences. British Journal of Nursing 2014;23:1133–7. 30. Dang S, Dimmick S, Kelkar G. Evaluating the evidence base for the use of home telehealth remote monitoring in elderly with heart failure. Telemedicine and e-Health 2009;15:783–96.
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J Telemed Telecare OnlineFirst, published on March 11, 2015 as doi:10.1177/1357633X15574807
RESEARCH/Original article
Evaluation of a Telehealth Service for COPD and HF patients: Clinical outcome and patients’ perceptions
Journal of Telemedicine and Telecare 0(0) 1–6 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15574807 jtt.sagepub.com
Bassel Odeh1, Reem Kayyali1, Shereen Nabhani-Gebara1, Nada Philip2, Patricia Robinson3 and Catherine Russell Wallace4
Abstract NHS Croydon Health Services and NHS Croydon Clinical Commissioning Group have been providing telehealth services for the past 36 months. The aim of this study was to measure the impact of telehealth when implemented as a service within a standard patient care pathway. To measure the clinical outcomes, the number of A&E visits and hospital admissions, recorded on the NHS Secondary Uses Service database, were compared before and after the implementation of the telehealth service. The number of all events despite its cause and the number of events related to the patients’ diagnosed condition were collected. To elicit patients’ perceptions about the telehealth service, a cross sectional survey of patients registered on the triage manager database was used to explore their perceptions, concerns and general satisfaction with the telehealth service via a 4 point likert scale questionnaire. The data of 48 patients were collected and telehealth reduced the number of both A&E and hospital admission due to all causes by 13% (P ¼ 0.42) and 22% (P ¼ 0.048), respectively. When only the events directly related to the patient’s diagnosed condition were considered, a reduction by 36% (P ¼ 0.03) and 28% (P ¼ 0.02) was recorded for A&E visits and hospital admission respectively. 27 patients consented to participate in the survey. Overall, patients were very satisfied with telehealth services. Patients agreed that telehealth had improved their health, it was a convenient form of health care delivery for them and they were more involved in the decisions about their care or treatment. In addition, since being on telehealth, patients’ confidence in managing their health increased from somewhat confident to confident. Telehealth, when provided as a service within a standard care pathway, seems to decrease hospital admissions and A&E visits. Good patient satisfaction suggests that the current service is accepted and it could be further expanded to include a larger number of patients. Accepted: 28 January 2015
Introduction UK is facing an aging population caused by both a rising life expectancy rate and a declining fertility rate. In England, more than 15 million people have long term conditions (LTC), including chronic obstructive pulmonary disease (COPD) and heart failure (HF), and this number is expected to rise to 18 million by 2018.1 Both COPD and HF are considered among the leading causes of death in the world,2 with COPD potentially affecting one in four adults by the age of 80 years,3 and over 25,000 new cases of HF is recoded in the UK every year.4 To deliver sustainable care for the aging populations, healthcare systems are seeking cost-effective strategies for delivering sustainable care, including promoting selfcare, shifting care into the community, and using technological solutions.5,6 Technology can play an important role in LTC management. A wide range of technologies can be used including: sensor technology and wearable monitoring systems, internet-based peripheral monitoring
devices, videophones, telephone-linked care and nanotechnology.7 Telehealth can deliver enhanced care to HF and COPD patients and help avoid negative health outcomes, by providing early detection and warning when health status deteriorates.8–12 Several systematic reviews have found that telehealth, when compared with usual care, shows benefits in terms of reduced mortality rates, hospital admissions and A&E visits, enhanced quality of life, and improvements in 1
School of Pharmacy and Chemistry, Kingston University, UK School of Computing and Information Systems, Kingston University, UK 3 NHS Croydon Health Services, UK 4 NHS Croydon Clinical Commissioning Group, UK 2
Corresponding author: Bassel Odeh, School of Pharmacy and Chemistry, Kingston University, Penrhyn Road, Kingston upon Thames, Surrey, KT1 2EE, UK. Email: [email protected]
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patient self-care.13–17 In particular, the Whole System Demonstrator, a large telehealth study conducted by the Department of Health (DH) between May 2008 and December 2009, showed that telehealth had significantly decreased admission proportion, mortality rate within 12 month follow-up, length of hospital stay and emergency department visits per head.18 However, it also found that implementing telehealth could cause organisational challenge which can act as a barrier to its implementation. When telehealth is implemented as randomised control trial (RCT), the standardised elements of an RCT could be perceived as overriding the local contextual differences in terms of prior experiences and needs, leading to the loss of organisational goodwill and stakeholders’ relationships.19 Despite the mixed evidence of benefit, there is a strong policy push to expand telehealth in the UK. The DH launched, on the 19th of January 2012, the 3millionlives project. This project is a joint Government-telehealth industry initiative to save the life of at least three million people with long-term conditions and/or social care needs by 2017. The main objectives of this project are for the DH and industry to work together to remove barriers to the delivery and develop the market of telehealth.20 Furthermore, the DH, at the end of 2012, issued a new Directed Enhanced Service for remote care, or the Telehealth DES. This DES would help general practices to agree with their CCGs to implement remote care monitoring by paying them 21p for each patient they sign up and get them ready to start on the service in 2014/ 2015.21 It has been identified that patient acceptance is one of the most important factors influencing the future implementation of a successful telehealth project,22 considering that many patients may refuse or quickly abandon telehealth.23,24 A recent systematic review25 found that 32% of patients refused telehealth when it was offered to them and 20% of those who accept to participate later abandoned telehealth. The main barriers reported were that telehealth was difficult to use, concern about the loss of personal contact with healthcare professionals, problems with trusting the equipment to work and not understanding the purpose of telehealth.25 Croydon Primary Care Trust (PCT), currently NHS Croydon Clinical Commissioning Group (CCG) has been providing telehealth services since July 2011. Remote patient monitoring (RPM) telehealth service has been provided for patients diagnosed with HF and COPD. The RPM system consisted of a set of peripheral devices at the patient’s home including a blood pressure monitor, a pulse oximeter, a thermometer, a weighing scale, and a peak-flow monitor/spirometer. This study was a service evaluation to determine whether telehealth had an impact on patients’ clinical outcomes and to elicit patients’ perception regarding the service. The work was conducted in collaboration with the NHS Croydon Health Services and NHS Croydon CCG.
Methods Clinical outcome To measure clinical outcomes, the number of A&E visits and hospital admissions before and after the implementation of the telehealth service were compared for each patient. To collect an accurate number of A&E visits and hospital admissions, the Secondary Uses Service (SUS) database was used. SUS is a data warehouse containing patient-based information generated when a patient or service user is treated or cared for. It manages commissioning data sets (CDS) covering NHS commissioned care at patient level for A&E visits, admitted patient care and outpatients.26 The ICP Triage manager database was searched for patients who have been receiving telehealth service for more than 12 Months. A list of those patients was sent to the Southwest London NHS Informatics Department to extract the available raw data from the SUS database. The events were extracted for each patient individually covering the past 24 months. For each patient, the 12 months period prior to starting telehealth was considered the control period and the 12 months since being on telehealth was considered as the intervention period. A&E visits and hospital admissions were compared between the control and intervention periods. This was done for two scenarios: including all events despite its cause (e.g. gastrointestinal tract, urinary tract and skin disorders) and only events related to the patients’ diagnosed COPD and/or HF conditions.
Patients perceptions To explore patients’ perceptions, concerns and general satisfaction with the provided telehealth service, a 15-items questionnaire, using 4-points Likert scale, was used. The first section was designed as agree/disagree statements to explore patients’ views regarding whether telehealth has changed their general health, their involvement in treatment management, and their perception regarding the technology used. Sections two and three measured how much patients were concerned about telehealth and how confident they are in managing their own health, respectively. The last section was used for an overall satisfaction and for any comments the patients may have regarding the use of telehealth. This was developed by reviewing the relative literature and using related quality of life questionnaires. Patients registered on the ICP Triage manager database were considered eligible to participate in the study. The inclusion criteria were as follow: . Currently active on telehealth . Have been on the service for more than three months . Contact information is available. Patients were contacted by phone and asked to participate and answer the questionnaire. If a patient was not
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80 Patients Registered on the Triage Manager 25 patients suspended
55 Patients active on Service
7 Patients have been on service for less than three months 48 Patients active
14 Patients temporarily suspended/had no contact information
34 Patients are selected for the questionnaire
7 Patients did not participate
27 Patients responded
Figure 1. Patients selection criteria.
available, or they preferred to answer in their own time, a letter was sent by post to their address with a stamped selfaddressed envelope. The survey was carried out between Jun and Sep 2013.
generated scale is. Nunnaly27 has indicated 0.7 to be an acceptable reliability coefficient.
Results Sample characteristic
Data Analysis Clinical outcome The quantitative data generated from the SUS database was entered into Microsoft Excel. Descriptive statistics were used to analyse the data (average, median, mode, and variance) and the significant difference between the two study periods was measured using a paired T-test.
A total of 80 patients were registered on the telehealth triage database. However, 48 patients met the inclusion criteria for the measurement of the clinical outcomes, and 34 were eligible to participate in patient perception questionnaire. Figure 1 summarises the patients’ selection criteria and Table 1 summarizes the patients’ characteristics.
Clinical outcome Patients’ perceptions Patient responses are presented as percentages of the total and as number of responders. To determine the reliability of the questionnaire, Cronbach’s Alpha coefficient was calculated. Cronbach’s Alpha coefficient ranges in value from 0 to 1 and the higher the score, the more reliable the
Table 2 summarises the telehealth clinical outcomes. A&E visits and emergency admissions were reduced by 13% (P ¼ 0.42) and 22% (P ¼ 0.048), respectively, when including all reasons for each event. However, when excluding events not directly related to the patients’ diagnosed conditions, a reduction by 36% (P ¼ 0.03) of A&E visits
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Journal of Telemedicine and Telecare 0(0) and helped them discuss what is most important about their own health. Furthermore, 82% (n: 22) and 93% (n: 25) of patients had no concerns about confidentiality, or the absence of direct contact with GP/Nurse during a telehealth consultation, respectively. 78% (n: 21) of patients agreed that telehealth had saved them time, but only 8% (n: 2) agreed that it saved them money. The majority of patient didn’t find the use of necessary equipment to be difficult and two thirds found it to be reliable. Finally, since being on telehealth, the number of patients confident in managing their health increased from 11% (n: 3) to 78% (n: 21).
and 22% (P ¼ 0.02) of emergency admissions was observed.
Patients perceptions Out of the 48 active patients on the telehealth triage database, 34 were eligible and 27 consented to participate (79.4% response rate) with an average age (SD) of 71.1(10.4). The questionnaire had a Cronbach’s alpha of 0.811, suggesting good internal consistency and reliability. Overall, 89% (n: 24) of patients were satisfied with telehealth services and 82% (n: 22) of patients agreed that telehealth had improved their health. 89% (n: 24) and 85% (n: 23) agreed that telehealth was a convenient form of healthcare delivery for them and they were more involved in the decisions about their care or treatment, respectively. In addition, 89% (n: 24) agreed that using telehealth enabled the GP/Nurse to better monitor their conditions
Discussion Telehealth has significantly reduced hospital admissions caused by all events (P ¼ 0.048) and those events only directly related to the patients’ diagnosed conditions (P ¼ 0.02). It also significantly reduced A&E visits caused by patients’ COPD/HF related conditions. These finding are similar to those reported by other reviews and studies.13–15,19 The cost of these events was not available for this study. Patients’ positive engagement in telehealth service is a crucial factor for the success of the service and understanding how patients perceive telehealth can influence its acceptability and diffusion28. Several barriers had been identified to affect the level of telehealth uptake by patients with HF and COPD, including preference for one-to-one with their healthcare professionals, technology anxiety, technical problems, the belief that telehealth to be unnecessary, 25 However, the high patients’ satisfaction in this study suggests that the current telehealth service is well accepted. Patients found telehealth easy to use and they did not have concern about the loss of personal contact with healthcare professionals, nor with trusting the equipment to work or understanding the purpose of telehealth. Furthermore, the work done by the research team found that nurses working with the patients described the patients’ engagement and attitude regarding using
Table 1. Patients’ Characteristics. Gender n (%) Male (%) Female (%) Diagnosis COPD n (%) HF n (%) COPD&HF n (%) Age mean (SD) Age Group n (%) 41–50 51–60 61–70 71–80 81–90
19 (39.58%) 29 (60.42%) 23 17 8 70.4 1 10 11 17 9
(48%) (35%) (17%) ( 10.5) (2%) (21%) (23%) (35%) (19%)
Table 2. Telehealth Clinical Outcomes. Control Period
All Events A&E Visits Hospital Admission Related A&E Visits Hospital Admission
Telehealth
Total Event
Mean (STD) per patient
Total Event
Mean (STD) per patient
Event Reduction %
p
152 134
3.3 (5.38) 3.12 (4.33)
133 105
2.89 (4.54) 2.44 (3.87)
13% 22%
0.42 0.048
74 117
2.00 (1.58) 2.85 (4.19)
47 84
1.27 (1.79) 2.05 (3.63)
36% 28%
0.03 0.02
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telehealth to be very positive and that patients were easy to recruit29. Old age has been reported as a barrier for accepting telehealth30, however, this study had an average patients’ age of 70.4 years and age did not seem to be a barrier for the adaption and use of telehealth. One patient in particular commented: ‘‘I find it amazing that 3 little items can have such an impact on my health. . . I am happy with Telehealth because I am confident that I can be understood without feeling embarrassed’’ The relatively small sample size, the use of satisfaction measures, the bias risk arising from comparing outcomes before and after the intervention and the absence of a control group are limitations that should be recognised. This was because the study was designed as an evaluation for a service being provided by the CCG.
Conclusions Telehealth, when provided as a service in addition to the standard care pathway, seems to decrease hospital admissions and A&E visits and good patients’ satisfaction suggests that the current service is well accepted. Declaration of Conflicting Interests The Authors declare that there is no conflict of interest.
Acknowledgments The authors would like to acknowledge John Chang, Christine Griffiths and Belinda Wigmore at NHS Croydon Health Services and Andrew Maskell at Croydon Council for their support during this study. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Telehealth service was being provided by TunstallÕ
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