Abstract
Introduction
Telehealth is a recent innovation that uses electronic information and telecommunications technologies to support long-distance management of health conditions. 1,2 Telehealth assumes that through the use of distance technologies, healthcare providers can see, hear, measure, question, and counsel the individual patient across a range of healthcare concerns and symptoms while both parties remain at separate physical locations. Telehealth increases the efficacy of the patient-centered approach by facilitating patient–provider interaction. 3 Telehealth encourages patients to take greater responsibility for their healthcare by providing a proactive and timely response to patient need and change in patient medical condition. In terms of healthcare outcomes, the evidence suggests that contact with the healthcare provider through technology is as effective as provider contact during face-to-face office visits.
Home telehealth deploys technologies such as telephone, e-mail, Web-based systems, and other devices directly in a patient's home. Healthcare providers can monitor a patient's symptoms and respond to patient questions and concerns in a timely way, without an office visit. Home telehealth allows patients timely access to support for making healthcare decisions (e.g., when do symptoms necessitate an appointment with a physician, or what lifestyle changes can be made to alleviate discomfort from symptoms).
The Veterans Administration (VA) adopted home telehealth to provide long-term, noninstitutional care for veterans with chronic medical and mental health conditions that require more careful case management than can be provided through traditional primary care alone. The VA's home telehealth program utilizes telehealth devices to monitor symptoms and vital signs and provide health information for patients through disease-focused modules directed at specific diagnoses such as chronic obstructive pulmonary disease, diabetes, and posttraumatic stress disorder. Patients enrolled in the VA home telehealth programs utilize a simple telehealth device that communicates with the VA hospital through their home telephone line. A care coordinator monitors symptoms, and vital signs are monitored remotely through a care coordinator, who responds to patient issues as needed. 4
In 2003, the Salt Lake City Veterans Affairs Medical Center initiated a care-managed polypharmacy module through its local home telehealth program for veterans taking multiple medications. (See Luptak et al. 5 for a detailed description of the module.) This module was based on principles of patient-centered care; that is, the patient was expected to monitor his or her own prescription medication use and report health symptoms to the healthcare provider. The goal of the program was early detection of chronic disease symptoms and the identification of potential adverse responses to prescribed medications that affect functional independence. As reported previously, 70% of patients who continued in the polypharmacy program past the 10th session reported high satisfaction with the home telehealth device. 5
Program adherence was an essential component of the polypharmacy module. This study is a retrospective analysis of adherence to the program with the aims of quantifying the frequency of premature dropout and identifying factors associated with early discontinuation. The purpose of this analysis is to identify baseline factors that predict attrition at the time of enrollment.
Subjects and Methods
Description Of Care Coordination/Home Telehealth Polypharmacy Module
The polypharmacy module was initiated as a local clinical demonstration project for Veterans in the Salt Lake City VA catchment.
Initial eligibility was determined through a query of the electronic medical record system. Eligible patients were 50 years of age or older, prescribed four or more medications, and had more than one hospitalization or emergency room visit and/or more than two primary care visits in the year preceding enrollment.
Patients who met the inclusion criteria received a letter from the care coordinator inviting them to participate. The care coordinators were healthcare professionals (typically nurses) who provided ongoing monitoring of patient symptoms and support for decisions related to disease self-management. Care coordinators served as a consistent contact person to the veteran patient and helped to triage medical concerns as well as support treatment adherence. The program started with one care coordinator, but additional coordinators were hired as part of a larger expansion to the VA's telehealth program. Thus, there was not a consistent care coordinator across the entire span of the data collection period.
Patients enrolled through (1) face-to-face group meeting, (2) individual enrollment meeting, or (3) an individual telephone call, according to their preference. Regardless of enrollment type, the care coordinator described the program and expectations for participation and collected baseline information relevant to care management, including medication use.
In order to enroll in the polypharmacy module, eligible patients were also required to own an active land telephone line and be able to read 18-point font (the font size displayed on the telehealth device screen) or have someone who could read for them. They also had to commit to respond to messages from the telehealth device every day. Patients who did not meet these criteria were not allowed to enroll in the program.
During the face-to-face group and individual enrollment, the care coordinator also demonstrated use of the telehealth device, how to connect it to a telephone, and how to problem solve connectivity issues. She then asked each patient to install the device and assisted those who showed difficulty. 5 For patients who chose telephone enrollment, the device, informational packet, and medication administration box were mailed to the patient's home. Once the packet had been received, the care coordinator explained over the telephone how to install the device and offered a follow-up telephone call if further installation assistance was needed.
The polypharmacy intervention module was delivered through a home telehealth device connected through a standard telephone line. The telehealth device was the size of a telephone answering machine, with a 3-×6-inch liquid crystal display screen displaying interactive questions and educational content. Patients received daily prompts from the device to answer health-related questions to assess their medication usage, compliance, and symptoms and to display educational modules to reinforce appropriate medication use and self-management. Patients responded by pressing one of four buttons on the device that corresponded to a multiple choice response set appearing on the bottom of the screen. Patients used peripheral medical devices (such as a blood pressure cuff or scale) attached to the device to record daily vital signs and other biometric measurements. The telehealth device transmitted responses to health questions and biometric data via the home telephone line to the VA hospital.
The care coordinator reviewed responses daily on a secured Web site. The telehealth device flagged responses as high-risk based on a predetermined clinical algorithm developed by the program developers. The clinical protocol also stipulated specific actions based on their responses to the device (e.g., call the patient, refer to primary care provider, etc.). However, the care coordinator had great latitude to use her clinical judgment in care of enrolled patients. The care coordinator consulted with the primary care provider and other healthcare providers to address high-risk issues and to facilitate patient-centered care planning throughout the intervention. Patients with the most active acute symptoms and/or exacerbations of chronic conditions received the most personal attention from the care coordinator, including repeat personal phone consultations. 5
The care coordinator also contacted patients who had not responded during the previous 36 h and prompted them to respond. When veterans withdrew from the program, care coordinators attempted to interview those patients and classify reasons for early discontinuation based on a predetermined set of categories.
Study Procedures
The Institutional Review Board at the University of Utah approved this study. The study was a retrospective analysis of a consecutive cohort of veterans enrolled in the polypharmacy module between January 2003 and December 2007. Selected patient data were extracted from the electronic medical record, including the number of prescribed medications at the point of enrollment and number of scheduled primary care visits during the year prior to enrollment. Program participation data included number of responses to messages in the first 30 and first 60 days of enrollment, total number of days enrolled in the program, and overall number of responses from January 2003 through December 2007. During the 4-year analysis period, 132 veterans enrolled in the polypharmacy module. At the time of data extraction, 59 patients remained enrolled in the program.
Early Discontinuation
The domains describing early discontinuation were collapsed into three groups for this study: (1) “unengaged” patients had zero completed sessions after the enrollment meeting; (2) “ineligible” patients left the program after starting a new treatment plan, moving out of the catchment area, losing phone service, permanent placement in a long term care facility, or death; and (3) “retired” patients discontinued the program for unspecified reasons. A fourth group, “continued” patients, remained in the program at the time data were pulled.
The primary dependent variable was patient discontinuation from the program prior to the end of the study interval. This variable was defined as either (1) patient discontinued from program before December 31, 2007 (coded 0) or continued in the program (coded 1). Independent variables were demographic variables, healthcare utilization measures obtained prior to enrollment, type of enrollment session, number of days enrolled, and the frequency of responses to the home telehealth device.
Results
Seventy-three of the 132 (55.3%) of veterans discontinued participation. Figure 1 depicts the proportion of dropouts across the 1,200-day data review period. Notable findings were the large number of dropouts who did not initiate device use, the unengaged, and rate of dropout tapered off after 250 days. Variables that contributed to overall discontinuation in the polypharmacy module were included through a forced entry method in the following blocks: Block #1, demographics; Block #2, healthcare utilization; Block #3, method of enrollment; and Block #4, response to the device. Only type of enrollment to the program predicted early dropout.
Unadjusted discontinuation rate for all patients (n=132).
Engagement and follow through with the program were further analyzed based on patient subgroup. Table 1 summarizes the discontinued patients by subgroup: “unengaged,” “ineligible,” and “retired.”
Descriptive Statistics of Veterans Who Discontinued the Home Telehealth Program (n=73)
ER, emergency room; PCP, primary care provider; SD, standard deviation; SLC VA, Salt Lake City Veterans Affairs Medical Center.
For the “ineligible” group, five variables (age, active medications, number of primary care visits prior to enrollment, responses within first 30 days, and enrollment type) predicted dropout. For the “retired” group, four variables predicted dropout (distance to care facility, primary care physician visits during the year prior to enrollment, number of responses within the first 30 days of enrollment and enrollment type). For the “unengaged” group, number of emergency room visits and the type of enrollment predicted failure to initially engage.
Discussion
The largest meaningful predictor of dropout from the polypharmacy module was method of enrollment; that is, those veteran patients who attended an in-person meeting with a VA care coordinator were less likely to quit from the program prematurely. The introductory experiences in home telehealth programming, which were defined in this study as “type of enrollment,” influenced patients' ability to obtain the skills needed to use home telehealth technology. From the limited findings of this retrospective analysis it appeared that the early introductory experiences among these veterans with telehealth technology were important for sustained use. We suggest that when patients (1) understand the protocol, (2) know how to connect and respond to the device, (3) can problem solve issues when they arise, and (4) enter the program motivated to use the technology, they have a higher likelihood of remaining in the program. The data from this study argue that an introductory in-person meeting prior to program initiation that encompasses the four points noted above can reduce perceived barriers associated with adhering to a technology-mediated healthcare delivery protocol.
Footnotes
Disclosure Statement
No competing financial interests exist.