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Resource costs and quality of life outcomes for homebound elderly using telemedicine integrated with nurse case management |
Noel H C, Vogel D C |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology A service of telemedicine integrated with nurse case management was evaluated for the homebound elderly. Each patient was provided with 24-hour surveillance technology (the Home Assisted Nursing Care, HANC, unit) to monitor his or her condition and to transmit routine physiological data to a nurse-staffed, central nurse station. The HANC unit accommodated peripherals for blood pressure, pulse rate, pulse oxymetry, camera, temperature, lung sounds, and electrocardiogram. A voice system reminded the participants to take their medication and to use peripherals during specific timeframes.
Type of intervention Treatment (telemedicine).
Economic study type Cost-effectiveness analysis.
Study population The study population comprised homebound elderly patients who were high resource users in the 6 months preceding enrolment. In addition, they had at least three chronic and complex conditions (e.g. congestive heart failure, chronic obstructive pulmonary disease, or diabetes), at least three hospitalisations and/or six or more emergency visits, and documented active usual home healthcare services (from 1 to 30 times per month).
Setting The setting was the community. The economic study was carried out in Connecticut, USA.
Dates to which data relate The dates to which the effectiveness and resource use data related were not reported. The price year was not given.
Source of effectiveness data The effectiveness evidence was derived from a single study.
Link between effectiveness and cost data The costing was performed prospectively on the same sample of patients as that used in the effectiveness study.
Study sample Power calculations do not appear to have been performed. Within a 30-day timeframe, a sample of 20 patients was enrolled into the pilot study. The method used to select the sample was unclear. One patient in the control group died immediately after enrolment and was not included in the analysis. There were 9 patients in the control group and 10 in the intervention group. The mean age of the patients was 71.6 years in the control group and 67.5 years in the intervention group. Marital status in both groups was 26%. Only one of the participants was female.
Study design This was a prospective, randomised pilot study, which was conducted in the Connecticut area. The method of randomisation was not described. The patients were followed for 6 months. The patients completed questionnaires at baseline, and 3 and 6 months. No loss to follow-up was observed. Random audits were performed to ensure the reliability of the data.
Analysis of effectiveness It seems that all the patients included in the initial study sample have been taken into account in the effectiveness study. The health outcomes used in the analysis were:
cognitive status, measured using the 10-item Short Portable Mental Status Questionnaire;
functional level, evaluated using the 15-item scale of Barthel's Self-Care Index instrument;
satisfaction with care, measured using the 28-item scale, the short version of the Philadelphia Geriatric Center Morale Scale; and
self-rated health status, evaluated using a 37-item scale of patient-responses.
The baseline comparability of the study groups was not discussed.
Effectiveness results The scores for cognitive status were 19.50 (+/- 1.08) in the intervention group and 19.44 (+/- 1.01) in the control group, (p=0.0672).
The scores for functional level were 43.40 (+/- 2.68) in the intervention group and 41.55 (+/- 7.45) in the control group, (p=0.4667).
The scores for satisfaction with care were 97.10 (+/- 20.73) in the intervention group and 101.11 (+/- 22.14) in the control group, (p=0.2489).
The scores for self-rated health status were 89.60 (+/- 9.01) in the intervention group and 91.22 (+/- 11.63) in the control group, (p=0.2089).
Clinical conclusions The effectiveness study showed that there was no statistically significant difference between the study groups in any of the outcome measures used in the analysis.
Measure of benefits used in the economic analysis No summary benefit measure was used in the economic analysis because the effectiveness study showed that there was no significant difference in any of the outcome measures. Thus, a cost-minimisation analysis (CMA) was conducted.
Direct costs Discounting was not relevant because the costs were incurred during 6 months. The unit costs were not analysed separately from the quantities of resources used. A detailed breakdown of the costs was not provided. The health services included in the economic evaluation referred to home visits, hospitalisations and emergency room. The CareMonitor Corporation provided the telemonitoring system. The cost/resource boundary adopted in the study was that of the hospital. Resource use was derived using individualised data coming from the sample of patients involved in the effectiveness study. He costs came from actual data provided by the study hospital. The price year was not reported.
Statistical analysis of costs The costs were treated deterministically.
Indirect Costs The indirect costs were not included.
Sensitivity analysis Sensitivity analyses were not conducted.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The mean estimated costs in the control group were $11,176 at baseline, $8,360 at 3 months, and $9,504 at 6 months.
The mean estimated costs in the intervention group were $10,912 at baseline, $7,744 at 3 months, and $8,712 at 6 months.
The number of home visits decreased similarly in the two groups.
Synthesis of costs and benefits Not relevant because a CMA was conducted.
Authors' conclusions The study showed that there was no statistically significant difference in the effectiveness outcomes, and that the costs decreased in both study groups. The authors stated that the conclusions of their pilot study supported the design of a large-powered telemedicine project to provide care to homebound elderly patients.
CRD COMMENTARY - Selection of comparators The rationale for the choice of the comparator was clear. Nurse case management was selected as the basic comparator because it represented routine care for the elderly patients involved in the study. Indeed, the aim of the study was to evaluate the active value of a telemonitoring service in addition to standard nurse case management. You should decide whether it represents a valid comparator in your own setting.
Validity of estimate of measure of effectiveness The analysis of effectiveness used a randomised study, which was appropriate for the study question. However, there were several limitations to the internal validity of the analysis. First, the sample was very small and there was no evidence of what would be an appropriate size for the initial study sample. This could account for the lack of statistically significant differences in the outcome measures. Second, the study sample was quite selected and referred to high-risk patients. Thus, it was not representative of the overall population of homebound elderly. Third, the baseline comparability of the study groups was not discussed and it would seem that co-morbidities differed considerably across the patients. Thus, potential bias and confounding factors may have played a role in the analysis. Fourth, the methods of randomisation and sample selection were not described. Finally, the time horizon of the study was too short to evaluate accurately the impact of the telemedicine service. The authors noted most of these limitations. However, it should be borne in mind that this was a pilot study, thus the intention was, reasonably, not to fulfil all the requirements of a standard study.
Validity of estimate of measure of benefit No summary benefit measure was used due to the CMA design.
Validity of estimate of costs The authors stated the perspective adopted in the study, but there were few details of the economic analysis. The unit costs and the quantities of resources used were not analysed separately and the price year was not given. Thus, the reproducibility of the study in other settings was limited. The costs were treated deterministically. The cost estimates were specific to the study setting and no sensitivity analyses were conducted. The source of the cost data was reported.
Other issues The authors did not compare their findings with those from other studies. They also did not address the issue of the generalisability of the study results to other settings. Sensitivity analyses were not conducted, thus the external validity of the analysis was low. The study referred to homebound elderly patients and this was reflected in the conclusions of the analysis. The authors noted some limitations of their analysis.
Implications of the study The study results suggested that longitudinal studies should be conducted to evaluate the long-term outcomes and costs of telemonitoring services among homebound elderly patients. The authors noted some difficulties with the HANC unit. For example, it was bulky, difficult to fit into the home and costly to transport.
Bibliographic details Noel H C, Vogel D C. Resource costs and quality of life outcomes for homebound elderly using telemedicine integrated with nurse case management. Care Management 2000; 6(5): 22-24, 26-82, 30-31 Indexing Status Subject indexing assigned by CRD MeSH Aged; Caregivers; Chronic Disease; Community Health Nursing /organization & Cost-Benefit Analysis; Diabetes Mellitus, Type 2; Heart Failure; Home Care Services /economics; Home Nursing /organization & Homebound Persons; Pulmonary Disease, Chronic Obstructive; Quality of Life; Telemedicine /economics; administration /economics; administration /economics AccessionNumber 22001007693 Date bibliographic record published 29/02/2004 Date abstract record published 29/02/2004 |
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