Abstract
We analysed the costs of two kinds of dementia clinic. In the conventional clinic, held in a rural area, the specialist travels to the clinic from the city. In the videoconferencing clinic, patients are also seen in a rural area, but the specialist conducts the assessment by video from the city. The fixed costs common to both modalities, such as clinic infrastructure, were ignored. The total fixed cost of a monthly conventional clinic was $522 and the total fixed cost of a monthly videoconferencing clinic was $881. The additional variable cost of the specialist travelling to the conventional clinic was $2.62 per minute of the specialist's travelling time. The break-even point at which the cost of the two modalities is the same was just over two hours (138 min round trip). A sensitivity analysis showed that the break-even point was not particularly sensitive to changes in staff wages, but slightly more sensitive to the non labour costs of videoconferencing. Air travel is not an efficient alternative to travel by car. Reducing the number of clinics to six per year results in a much higher cost of running the videoconferencing service compared to the conventional service. Videoconferencing for the purpose of diagnosing dementia is both a reliable and cost effective method of health service provision when a specialist is required to drive for more than about two hours (round trip) to provide a memory disorder clinic service.
Introduction
Dementia is a common condition: in 2008, dementia was the fourth most common cause of death for Australians living outside a major city. 1 Management of dementia often requires patients to attend clinics in major cities or specialists to see patients in rural clinics. Travel distances for both patients and specialists may be substantial. Videoconferencing therefore offers potential advantages over face-to-face (FTF) assessment.
A recent study of different models of care in an Australian metropolitan memory clinic 2 found that videoconference assessment was as reliable as conventional FTF assessment in the diagnosis of dementia. It would therefore be useful to know when it is efficient to provide services in a conventional FTF format and when to provide services remotely. We are not aware of previous economics studies of videoconferencing for the diagnosis of dementia.
The aim of the present study was to compare the costs of two kinds of dementia clinic. In the conventional clinic, held in a rural area, the specialist travels to the clinic from the city. In the videoconferencing clinic, patients are also seen in a rural area, but the specialist conducts the assessment by video from the city.
Methods
The analysis took the perspective of the health funder who provides clinics in regional centres. Specialist support for such clinics may be provided by the consultant in person, or remotely by videoconference.
A model was developed using a spreadsheet (Excel 2010, Microsoft) to estimate the point where the costs of providing a regional clinic using specialist support in person were equal to those of providing the clinic using specialist support by videoconferencing. The data were based on a sample of older adults (n = 205) who participated in a trial of two models of cognitive assessment: conventional (face-to-face) or videoconferencing, and from literature sources. Details of the recruitment and randomisation process have been published elsewhere.2,3
Two models of service delivery were compared: conventional regional clinic and videoconference clinic.
Conventional regional clinic
The specialist travels to the regional clinic from their usual workplace in the city centre, in order to provide services face-to-face. A series of standardised cognitive assessments are administered either by the specialist or a geriatrics nurse at the clinic, and a formal assessment is carried out by the specialist on the same day. This may include a physical examination. If there is sufficient evidence of dementia a diagnosis is made, otherwise referral for additional testing or review by a different specialist is made.
Videoconference clinic
Patients attend the regional clinic in exactly the same way as for the conventional model. However, the specialist conducts the clinic from their usual workplace in the city centre by videoconference. The same set of standardised tools is administered by a nurse in person, followed by a videoconference assessment by the specialist, after which a case meeting is held to confer on diagnosis and management. Additional tests such as MRI scans are ordered if warranted. Management is followed up by the referring practitioner (usually the general practitioner).
Assumptions
The primary assumption is that the outcome is the same for each modality. This is based on the outcomes of a previous diagnostic accuracy study.
2
Additional assumptions are:
Clinics are conducted by one specialist and one nurse. Annual training is required for the nurse. This is conducted in Brisbane and takes four hours. A full day’s pay is assumed, plus $500 travel costs to attend. 12 clinics are conducted in one year, so that the annual costs of videoconferencing and training are divided by 12. Travel by the specialist is assumed to be by car.
Measurements
The fixed costs common to both modalities, such as clinic infrastructure, were ignored. The fixed cost of videoconferencing equipment was also ignored, as the facilities were assumed to be present in all the health department's facilities. The variable costs were the travel costs for the specialist and the specialist's time while travelling.
Costs were obtained from the diagnostic accuracy study 2 and from local data. Costs for the routine administration (set-up and testing) of videoconferencing hardware were taken from an Australian study 4 , and from the commercial rental rate of room hire. Wage rates were calculated from Queensland Health award rates for the staff concerned. Vehicle costs were estimated from Australian Tax Office rates per kilometre and converted to rates per minute by estimating the time and distance for three common destinations from Brisbane.
Results
Costs.
Annual training requires one full day for the clinic nurse plus 2 h for a nurse trainer, a total of 10 h
Annual training requires 2 h of neuropsychology time
Fixed cost of videoconferencing ignored, as facilities assumed to be present in Queensland Health facilities
Each clinic assumed to require one full day; daily room rental calculated from annual cost
Set up requires 30 min of nurse time
Equipment is periodically tested by a central technical department to ensure equipment functions for clinic appointment
Total equals the cost of conventional clinic plus additional videoconferencing costs
travel time per minute based on per km rate allowed by Australian Tax Office adjusted for travelling time to three regional centres in Queensland
The break-even point is the specialist's travel time at which the cost of the two modalities is the same. The extra cost of a videoconferencing clinic is $359, so the travelling cost must be at least as much in order to break even. Therefore the break-even point is just over two hours (138 min round trip). If the specialist's total travelling time is greater than this, it is more efficient to provide the service by videoconferencing; if the travelling time is less than this, it is more efficient to provide a conventional face-to-face service.
Sensitivity analysis. See text for details of the different scenarios analysed.
The analysis is somewhat sensitive to the non labour costs of videoconferencing. If videoconferencing costs increase by 50% then the travelling time required to break-even increases by about one hour.
The base case assumes that a nurse will be available at the remote centre to conduct the clinic. If this is not feasible the nurse may travel with the consultant to the clinic. For this scenario, the cost of training the nurse at the remote centre was excluded for the conventional clinic resulting in a lower cost of $436 for the clinic. Despite this, the overall result is very similar as the increased travel costs of the additional staff member cancel out the lower clinic cost.
A further analysis assumes a travelling cost associated with air travel rather than car travel. This analysis assumes the cost of air travel to be $4.00 per minute based on travel times and economy prices from three common regional destinations to Brisbane: from Mt Isa, Townsville or Winton (approximately 1800, 1350 and 1350 km from Brisbane, respectively). Since air travel is substantially more costly than car travel, the breakeven point is about one hour.
Reducing the number of clinics to six per year results in a much higher cost of running the videoconferencing service compared to the conventional service, as costs such as service testing fees and annual broadband (DSL) fees are averaged over half the number of clinics. This increases the travel time required for the services to break-even. Indeed a five hour round trip would be required before it would be more efficient to provide videoconferencing than conventional clinics.
Discussion
Previous research has shown that using videoconferencing for cognitive assessments is equally effective in detecting cognitive impairment and dementia as a conventional model.2,3,5,6,7,8 The present study adds to that research in determining where videoconferencing is a more efficient alternative to conventional care when certain distances for travel are reached. The analysis indicates that videoconferencing would be a more efficient alternative to face-to-face clinics if the specialist's total (round trip) travelling time by car is more than about two hours. Air travel is not an efficient alternative, as the costs reduce the break-even travel time to about one hour, which is not practical given flight times, waiting times at the airport and travel to and from airport terminals. If a face-to-face clinic is conducted, it is also more efficient to have a nurse available at the remote centre, rather than have a nurse travel with the consultant.
The present analysis did not take into account the opportunity costs of specialist travel. If the consultant has to travel, that time is time that could otherwise have been spent in treating patients. Thus the breakeven points calculated in the analysis could be considered as underestimates.
‘Urban’ telehealth is the use of technologies such as videoconferencing for patients who find travel difficult, for example, residents of city-based long term care facilities.9,10 These residents may be frail and have multiple comorbidities, making even a relatively short trip to a city clinic impossible. Very few long term care facilities have a regular geriatrician consultation service available at the facility. Although the present study was based on the question of travel time for the clinician, there may be similar benefits for patients who find travel difficult.
In conclusion, videoconferencing for the purpose of diagnosing dementia is both a reliable and cost effective method of health service provision when a specialist is required to drive for more than about two hours (round trip) to provide a memory disorder clinic service.
Footnotes
Acknowledgements
Costs and timing data for the analysis was funded as part of the Diagnostic Accuracy Study by the National Health and Medical Research Council, grant no 456135.