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Feasibility of in-home telehealth for conducting nursing research |
Smith C E, Cha J J, Kleinbeck F A, Cook D, Koehler J |
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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 The use of in-home telehealth for the follow-up of patients requiring mechanical ventilation for obstructive sleep apnoea. The intervention consisted of technical equipment that allowed the nurse to observe the patients in their home and to administer nursing interventions to the families. Physiologic data and ventilator procedures were observed via residential telephone lines.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised patients with a medical diagnosis of obstructive sleep apnoea (by sleep laboratory polysomnography), who were prescribed night-time positive pressure treatment (mechanical ventilation).
Setting The setting was the community. The economic study was carried out in the USA.
Dates to which data relate The dates during which the effectiveness and resource use data were collected were not provided. 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 conducted prospectively on the same sample of patients as that used in the effectiveness analysis.
Study sample Power calculations were not conducted. Sleep laboratory personnel referred a sample of 5 patients, comprising 3 men and 2 women with a mean age of 51.25 years (median 49.5), and their 7 caregivers (mean age 57.5 years, median age 55 years) for home ventilator care. The sample received both study interventions. The method used to select the sample was not described in detail and it was unclear whether some individuals refused to participate or were excluded from the initial study sample.
Study design This was a prospective within-group comparison study. The location of the study was not explicitly reported. The patients were followed for 6 months, during which time both standard and telehealth nursing visits took place. Each family received a total of 23 visits. More specifically, five in the first week, two in weeks 2 through 4, one in week 5 through 12, and bimonthly visits for the last 2 months. No loss to follow-up was observed. Three months after the conclusion of the telehealth visits, a nurse who was blind to the study contacted individuals to assess patient experience using a validated questionnaire.
Analysis of effectiveness All of the patients included in the initial study sample were accounted for in the effectiveness analysis. The health outcomes used were:
agreement between the telehealth nurse and home nurse readings of patient physiologic data,
characteristics of the transmission equipment,
detection of faulty ventilator equipment,
patient assessment on quality and clarity of the educational materials,
delayed or cancelled visits, and
aspects of privacy and confidentiality.
Effectiveness results There was a 100% agreement between the telehealth nurse and home nurse readings of patient physiological data.
All the telehealth cameras and monitors transmitted without failure.
The length of telehealth visits was similar to that of standard visits.
Faulty ventilator equipment was detected by the telehealth nurse and then confirmed by the home nurse.
The quality and clarity of the educational materials transmitted across telehealth were high, and only 10% of the materials were not rated as easy to read (because they contained small print).
Slightly slowed conversation times were not a problem. With the exception of one patient's rating of "pretty well", all of the patients stated they could see the nurse "very well".
None of the scheduled visits was delayed or cancelled.
The equipment was not considered as an invasion of home privacy.
Clinical conclusions The effectiveness study showed that the telehealth nurse intervention was effective in providing assistance to patients requiring mechanical ventilation in comparison with standard care. The patients were satisfied with the new equipment and no delays in service delivery were observed.
Measure of benefits used in the economic analysis The health outcomes were left disaggregated and no summary benefit measure was used in the economic analysis. In effect, a cost-consequences analysis was conducted.
Direct costs Discounting was not relevant since the costs were incurred during 6 months. The unit costs and the quantities of resources used were not presented separately. The health services included in the economic evaluation were travel mileage, nurse visit reimbursement, equipment rental and teaching materials. The cost/resource boundary of the study was unclear. Resource use was estimated using actual data derived from the sample of patients who were included in the effectiveness study. The source of the cost data was not reported. The price year was not given.
Statistical analysis of costs The costs were treated deterministically.
Indirect Costs The indirect costs were not considered.
Sensitivity analysis Sensitivity analyses were not performed.
Estimated benefits used in the economic analysis See the 'Effectiveness Results' section.
Cost results The cost of all 23 nurse visits for the family was $560 with telehealth care and $1,204 with traditional home care. Other expenses were $800 for the 6-month rental of the telehealth equipment and $1,096 for transportation to traditional home health visits. Therefore, the total cost of the telehealth service was $1,360 ($59 per visit), which was lower than the $2,300 total for 23 traditional home health nurse visits and travel time at $100 per visit.
Synthesis of costs and benefits The costs and benefits were not combined because a cost-consequences analysis was conducted.
Authors' conclusions Data gathering via telehealth was acceptable to the patient and family. Nurse observations of the individual's use of ventilation equipment were feasible. The intervention was cost-saving in comparison with traditional nurse home visits.
CRD COMMENTARY - Selection of comparators The choice of the comparator (home visits) appears to have been appropriate since it reflected standard treatment patterns. You should decide whether this is a valid comparator in your own setting.
Validity of estimate of measure of effectiveness The effectiveness evidence was based on a within-group comparison study, which was appropriate for the study question since no external control group was required. All the patients received both interventions. The outcome assessment was blind as a nurse who was unaware of the intervention performed all interviews. The patients, however, were well aware of the study objectives. The main threat to the validity of the study was the very small sample size and the fact that power calculations were not conducted. However, the authors stressed that this was a feasibility study, which was used to test the reliability of gathering data from home ventilator patients. Such a design is usually associated with low internal validity. Therefore, some caution is required when interpreting the results of the study.
Validity of estimate of measure of benefit No summary benefit measure was used in the study because a cost-consequences analysis was conducted.
Validity of estimate of costs The authors did not report clearly which perspective was adopted in the study. Therefore, it was unclear whether all the relevant categories of costs were included in the analysis. Information on resource use, unit costs and price year was not provided, which limits the possibility of reflating the study results and replicating the cost analysis in another setting. Similarly, the source of the cost data was not reported. No statistical analyses of the costs were conducted and all the estimates appear to have been specific to the study setting. Sensitivity analyses were not conducted.
Other issues The authors stated that the ability of a telehealth service to collect clinical information reliably had been observed in other. However, the issue of the generalisability of the study results to other settings was not addressed and sensitivity analyses were not conducted. This further reduces the external validity of the analysis. The study referred to patients who required home mechanical ventilation and this was reflected in the conclusions of the study.
Implications of the study The authors noted that telehealth services represent an important area of research, as shown in the current feasibility study. The study results suggested that telehealth can reduce costs and the service could be considered, in particular, for those patients located in rural areas, where traditional access to care is difficult.
Source of funding Supported by the University of Kansas School of Nursing Competitive Research Fund.
Bibliographic details Smith C E, Cha J J, Kleinbeck F A, Cook D, Koehler J. Feasibility of in-home telehealth for conducting nursing research. Clinical Nursing Research 2002; 11(2): 220-233 Other publications of related interest Rooney E, Studenski S, Roman L. A model for nurse case-managed home care using televideo. Journal of the American Geriatrics Society 1997;45:1-6.
Indexing Status Subject indexing assigned by NLM MeSH Caregivers; Community Health Nursing; Feasibility Studies; Female; Home Care Services; Humans; Male; Middle Aged; Nursing Methodology Research /methods; Respiration, Artificial /nursing; Telemedicine AccessionNumber 22002007556 Date bibliographic record published 30/11/2004 Date abstract record published 30/11/2004 |
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