A cost-consequence analysis comparing patient travel,outreach,and telehealth clinic models for a specialist diabetes service to Indigenous people in Queensland

Abstract

Introduction

The delivery of specialist health services to people living in Indigenous communities is an important challenge. Specialist diabetes outpatient clinics may be delivered via a patient travelling to a metropolitan hospital, during an outreach clinic, or by telehealth. The aim of this study was to compare the costs and consequences of different service models for delivering specialist diabetes clinics for a remote Indigenous community.

Method

Patient travel, outreach and telehealth clinic models were compared using a cost-consequence analysis principles. The setting was Cunnamulla, a remote Indigenous community in Western Queensland. Costs were calculated by quantifying the staff resources and travel costs for each clinic model. Costs were reported in Australian dollars and reported from the health service perspective.

Results

The marginal cost per patient for each clinic were $692 for patient travel, $482 for the outreach and $284 for telehealth. If a patient travel appointment was replaced with telehealth, approximately $517 in costs for patient travel reimbursement would be avoided. While replacing an entire outreach clinic with a telehealth clinic would reduce costs by approximately $3961.

Conclusion

The marginal cost of patient travel to a metropolitan clinic and outreach clinic appointments was greater than telehealth. Telehealth is unlikely to completely replace the need for patient travel or outreach clinics. However, replacing a proportion of these appointments with telehealth may reduce the overall costs of providing specialist diabetes care in remote communities. Telehealth may have advantages beyond economic as it reduces the time away from usual activities for both the patient and endocrinologist.

Keywords

Diabetes telehealth telemedicine Indigenous cost-consequence analysis health economics

Introduction

Australia’s Indigenous people have four times the rate of diabetes mellitus than their non-Indigenous counterparts.¹ One-fifth of Australia’s Indigenous people live in remote regions.² Timely access to endocrinology services for Indigenous Australian’s living in remote regions can be challenging due to the distance to metropolitan hospitals where specialist services are offered. Consequently, the responsibility for the management of chronic conditions like diabetes mellitus often remains with the local primary care services, if they exist. As a result, specialist endocrinology services to manage diabetes are often provided through periodic outreach clinics. Outreach clinics involve the specialist travelling to the community to see patients. Alternatively, patients can travel to attend an outpatient appointment at a metropolitan hospital. Videoconsultation offers another method that enables timely access to specialist opinion and mitigates the travel costs for both the endocrinologist and the patient.

There is a growing body of evidence to support the effectiveness of specialist diabetes services provided by videoconference (telehealth or telediabetes) when compared to conventional in-person consultations.^3,4 However limited information is available about the economics of telediabetes services within Indigenous communities.⁵ Some of the challenges in determining the cost implications of telehealth in this context include the variable consultation times, actual attendance rates and the availability of trained health workers at the remote end.^6–8 In other contexts, integrating telehealth alongside outreach clinics and metropolitan outpatient appointments has been identified as both an economical and convenient method of providing specialist care.⁹

The aim of this study was to compare both the costs and consequences of three methods of delivering specialist care for patients with diabetes who access services through the Cunnamulla Aboriginal Corporation for Health (CACH) in Queensland.

Methods

This study was approved by The University of Queensland Ethics Committee for research (2015001105). All costs are reported in 2017 Australian dollars (AUD). For the purpose of this evaluation, we have assumed that the clinical outcomes of specialist diabetes services are comparable, irrespective of consultation method.

Setting

Cunnamulla is a small, remote community in Western Queensland approximately 679 km from the nearest metropolitan hospital in Toowoomba.¹⁰ Patients who require specialist endocrinology consultations have historically had the option of either travelling to Toowoomba, or waiting for the next visiting outreach clinic. Telehealth appointments by videoconference provide a third option for remote Indigenous patients to access specialist services. At CACH videoconference has only been used intermittently, when an appointment is required and the specialist is unable to travel for outreach. These intermittent telediabetes instances, and those proposed here to be incorporated as part of routine care, are provided by the specialist endocrinology team at the Princess Alexandra Hospital (PAH) in Brisbane. This is the same specialist team who provide the outreach clinics four times per year in Cunnamulla.

Cost-consequence analysis

Costs were estimated from the perspective of the health service provider. The costs and outcomes for the telehealth, the outreach, and the patient travel service models were calculated and compared using cost-consequence analysis (CCA) principles.^11,12 This method was selected to allow for alternative clinic costing structures (block funding for outreach clinics versus individual for others) and the unique consequences of each clinic to be presented in a disaggregated form. Unlike other economic analyses, CCA allows decision makers to compare service costs and outcomes independently. The aim of this presentation format is to enable independent conclusions to be drawn, rather than other methods where calculations result in a single final cost and outcome number.^12,13 Additionally, in a CCA there is no requirement to choose one single outcome or consequence from the service, making it an appropriate method for this study.

No time horizon was selected for this analysis. Instead, the results have been presented based on the number of patients who received a consultation, which more realistically represents the potential growth of outpatient services for chronic disease.

Costs

Clinic costs were estimated by identifying the relevant direct costs for running each of the clinic models including medical resource costs and non-medical costs. Direct resource costs included the staff time required for each clinic model multiplied by their hourly salary rates (including on-costs). Direct non-medical costs included videoconference equipment, patient travel reimbursement and staff travel costs.

Physical resources such as clinic rooms and standard office resources such as computers and printers were in place prior to the service commencement and therefore these costs were excluded from all analysis.

Marginal costs were calculated for each clinic type by dividing the total cost of that service type by the standard number of patients per clinic. The number of patients per clinic and the annual frequency of clinics were estimated using clinic service records provided by the health service. The sensitivity of the marginal cost estimate was examined by including a minimum and a maximum number of patients per clinic.

Telehealth non-medical costs

The costs for establishing videoconferencing facilities in both Cunnamulla and the PAH was estimated at $30,000. This includes hardware, installation, training and incidental costs for a mobile trolley in Cunnamulla, and a wall-mounted fixed room system for the PAH.

Due to the nature of telediabetes clinics, more administration time was typically required for scheduling, case preparation and troubleshooting. Additionally, the patient in Cunnamulla required a CACH staff member to accompany them during consultations. These extra costs have been reflected in the analysis.

Independent patient travel non-medical costs

In Queensland, patients are eligible to claim reimbursement for travel expenses from the Patient Travel Subsidy Scheme (PTSS).¹⁴ The scheme reimburses an individual patient $60 per night for accommodation and $0.30 per kilometre for fuel when travelling between home and the nearest available public specialist service. In the case of these clinics, the reimbursed distance would be 662 km from Cunnamulla (assumed to be home) to the Toowoomba Hospital. In this model, patients are booked into one of the weekly outreach endocrinology clinics at Toowoomba Hospital.

Endocrinologist outreach travel costs

Outreach clinic travel costs included a commercial return flight from Brisbane to Charleville (the closest airport to Cunnamulla), car hire for three days, and two nights’ accommodation in Cunnamulla. Market values were used for the estimates, quoted from online travel services in June 2019.

The endocrinologist’s costs were estimated by calculating the cost of wages for three 8-hour days. Travel expenses were estimated using costs from the Domestic Travelling and Relieving Expenses (Directive 09/11) published by the Queensland Treasury, including meals and incidental allowances.¹⁵

Consequences

CCA allows all service consequences to be considered. These can also be termed outcomes or benefits. The three clinic models being examined have many service attributes that were considered for this analysis. These included patient relevant consequences and health system relevant consequences. Patient consequences include time away from usual activities, the maximum wait time to have a consult if required semi-urgently, number of patients that can be seen per clinic and appointment location. Health system consequences included the time the specialist was away from their usual treating facility.

Results

The marginal cost for the patient travel model to a Toowoomba outpatient appointment was $692 per patient, while a regional outreach appointment was $482 per patient. In comparison, the marginal cost of a telehealth appointment was $284 (Table 1). The marginal costs were not sensitive to a change in the number of patients per clinic. Assuming a low minimum number of patients per clinic, telehealth was still the lowest cost, followed by outreach and patient travel to outpatient.

Table 1.

The estimated marginal cost per patient for consultation in each clinic type (AUD).

	Telehealth clinic (minimum–maximum)		Patient travel to outpatient clinic (minimum–maximum)		Outreach clinic (minimum–maximum)
	Units	Cost	Units	Cost	Units	Cost
Direct medical resource costs
Endocrinologist time	4h per clinic	$1260	4h per clinic	$1260	3 work days	$7560
Indigenous health worker	1h per patient	$38.71	1h per patient	$38.71	4h to support clinic	$154.83
Administration time to arrange clinic	8h per clinic	$349.55	4h per clinic	$135.48	10h per clinic	$436.94
Additional administration per patient	1h per patient	$43.69
Direct non-medical costs
Travel costs – transport			1 patient	$397.20	Endocrinologist only	$998
Travel costs – accommodation			1 patient	$120.00	2 nights	$233.33
Travel costs – expense allowance					Meals and miscellaneous	$250.10
Technology infrastructure costs	2 systems (remote and metropolitan sites)	$30,000
Marginal cost estimates
Estimated patients per clinic	8 (5–10)		8 (5–10)		20 (10–25)
Total clinic cost	Non-medical costs not included	$1610	Non-medical costs not included	$1395	All costs included	$9633
Total marginal cost per patient	Marginal with 1h Cunnamulla administration and 1h CACH staff time added	$284 ($404 to $243)	Marginal with 1h CACH staff time and patient travel subsidy added	$692 ($796 to $656)	Marginal	$482 ($963 to $385)

When comparing the patient and health system consequences for each of the clinic types the telehealth model offers more flexibility for both parties (Table 2). As outpatient clinics are routinely run on a weekly basis, the average wait time for an appointment (if required) is 7–14 days depending on the urgency. Patient travel offers similar benefits but requires the patient to be away from their usual activities for up to three days. The outreach clinic is less flexible with clinic appointments only available periodically throughout the year, and during these outreach clinics, the specialist is not in attendance at their main service for three full days. Telehealth and outreach appointments also promote a close engagement with local health services and opportunities for education and training during consultations with specialists. Whereas patient travel to outpatient appointments risks disengagement because services are provided remotely without the involvement of local staff.

Table 2.

Patient and health service consequences for consultation in each clinic type.

	Telehealth	Patient travel	Outreach
Patient consequences
Patient time away from usual activities	1–2 h	Up to 3 days(2 nights)	1–2 h
Availability of next appointment (as required)	7 days	14 days	3 months
Number of Cunnamulla patients seen in block	1	1	5 to 15
Appointment location	Local –Cunnamulla	Remote –Toowoomba	Local –Cunnamulla
Health system consequences
Endocrinologist time away from primary workplace	Nil, conducted on-site	Nil, conducted on-site	3 days
Opportunity for direct interaction with local health care providers	Yes	No	Yes
Opportunity for a specialist to provide training and education to local health care providers	Yes	No	Yes
Flexibility to incorporate multidisciplinary team or multiple specialists as part of the consultation	Yes	Yes	Yes
Empowering patient and local health care providers and promoting continuity of care	Yes	No	Yes
Local health workers involved in the pre-appointment collection of information	Yes	No	Yes

Break-even analysis

Figure 1 shows the cumulative cost for every additional patient seen in each clinic type. When the infrastructure is in place at a facility, the telehealth clinic is the least expensive method for providing care. If telehealth infrastructure costs are included ($30,000 for this model), a certain workload (73 for patient travel, 140 for outreach) has to be reached before savings are realised. Outreach clinic appointments had a lower marginal cost than patient travel to outpatient clinics after a workload of 40 patients was reached. For every instance where patient travel was replaced with telehealth, approximately $517 in patient travel costs was saved.

Figure 1:

Marginal cost per patient per consultation for each clinic model, including and excluding infrastructure cost for telehealth (AUD).

While it is neither feasible nor appropriate to replace all outreach clinics with telehealth, using telehealth to replace one or two outreach clinics each year would reduce the overall cost. Substituting alternate outreach clinics for telehealth consultations would reduce the overall cost of treating that patient cohort by approximately $3961, as telehealth clinics have a lower marginal cost per patient than outreach clinics (Figure 1). Additionally, using telehealth is likely to increase the flexibility and responsiveness of the service and reduce patient and specialist time away from usual activities.

Discussion

Telehealth has the potential to improve access to specialist health services for people living with diabetes and other health conditions in remote Indigenous communities.¹⁶ Whilst the benefits of telehealth are clear, the establishment of telehealth alongside other conventional methods of service delivery needs to be carefully planned.¹⁷ A successful telehealth service requires appropriate infrastructure, trained staff and revised processes to support the service (such as referral procedures, documentation, and billing). Introducing telehealth also requires effective change management strategies to assist with the different processes and service delivery methods. These strategies need to support both the service staff (clinical and administration) and patients involved in the telehealth service model.

Whilst telehealth may be clinically appropriate, some Indigenous patients prefer outreach services because of the in-person interaction with the specialist.^18,19 There are some reports that it is easier to establish rapport with Indigenous patients by meeting in person, and this is considered very important for patients with chronic health needs.²⁰ However, outreach programmes also have the difficulty of retaining specialists long-term, and risk abrupt termination of services due to human resource or financial constraints. Telehealth promotes a model of care that involves local health services potentially increasing continuity of care. Telehealth also allows the patient to attend an appointment in a familiar environment with the support of staff from their community health service, which reduces stress and improves convenience.^21,22 Additionally, telehealth can promote continuity of care if services can arrange for patients to see the same specialist via telehealth that they have seen previously at an outreach clinic.

There are very few published studies that explore the substitution of outreach with telehealth clinics for diabetes care within remote Indigenous communities. However, findings from other telehealth interventions involving non-Indigenous patients with diabetes show that there are considerable benefits.^23–25 Telehealth can improve continuity of care and access to specialist services when used in conjunction with an outreach program.^26,27 Furthermore, telehealth-supported outreach services have led to the increased utilisation of clinical services by Indigenous people.^7,28

Policy constraints leading to deficient reimbursement schemes for telehealth and telehealth-related support activity also affect adoption and growth of teleconsultation services in remote communities.^29,30 Ideally, however, the decision for an Indigenous community to set up a telehealth service should not be based on initial or ongoing costs, but on the unmet health needs of the community.

Limitations

The analysis was dependent on various assumptions associated with salary, travel and accommodation costs, which have been outlined throughout. Cost comparisons between clinics would change if outreach costs were to increase significantly (e.g. chartered flight used for outreach clinic transport) or if telehealth initial implementation costs were to be reduced or mitigated. Reduction in telehealth equipment costs has reduced barriers to starting telehealth services³¹ in remote Indigenous communities. Workload increases resulting in lower telehealth consultation unit costs have been previously described by others.^32,33

Conclusion

The marginal costs of patient travel to an outpatient clinic and outreach clinic appointments were greater than telehealth due to the associated travel costs and salary expenses. The use of telehealth will not completely replace the need for patient travel or outreach clinics. However, it may be appropriate to substitute a proportion of outreach clinics and some instances of patient travel. This could reduce the overall cost of providing diabetes services to patients in Cunnamulla. Telehealth may have advantages beyond economic as it reduces the time away from usual activities for both the patient and endocrinologist. Furthermore, telehealth may be more responsive for urgent appointments than alternative consultation methods. This study has implications for the planning of a broad range of specialist outreach services in remote Indigenous communities where telehealth could be used to optimise the delivery of specialist outreach services by using it in conjunction with other service delivery models.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is conducted for the NHMRC Partnership Centre for Health System Sustainability (Grant ID #: 9100002) administered by the Australian Institute of Health Innovation, Macquarie University. Along with the NHMRC, the funding partners in this research collaboration are: The Bupa Health Foundation; NSW Ministry of Health; Department of Health, WA; and The University of Notre Dame Australia. Their generous support is gratefully acknowledged. Health System Sustainability disclaimer: available at:

References

Australian Institute of Health and Welfare. Diabetes, http://aihw.gov.au/diabetes/ (2016, accessed 19 June 2017).

Australian Bureau of Statistics. Population distribution, Aboriginal and Torres Strait Islander Australians, 2006, http://www.abs.gov.au/ausstats/abs@.nsf/mf/4705.4700 (2007, accessed 19 June 2017).

Lee

SWH

Ooi

, and Lai

YK.

Telemedicine for the management of glycemic control and clinical outcomes of type 1 diabetes mellitus: a systematic review and meta-analysis of randomized controlled studies.

Front Pharmacol 2017; 8: 330.

Marcolino

Maia

Alkmim

, et al. Telemedicine application in the care of diabetes patients: systematic review and meta-analysis. PLoS One 2013; 8: e79246.

Wade

Karnon

Elshaug

, et al. A systematic review of economic analyses of telehealth services using real time video communication. BMC Health Serv Res 2010; 10: 233.

Mashru

Kirlew

Saginur

, et al. Management of infectious diseases in remote northwestern Ontario with telemedicine videoconference consultations. J Telemed Telecare 2017; 23: 83–87.

Arora

Kurji

, and Tennant

MT.

Dismantling sociocultural barriers to eye care with tele-ophthalmology: lessons from an Alberta Cree community.

Clin Invest Med 2013; 36: E57–E63.

Caffery

Bradford

Wickramasinghe

, et al. Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: a systematic review. Aust NZ J Public Health 2017; 41: 48–53.

Caffery

Hobbs

Hale-Robertson

, et al. Telehealth substitution of rural outreach services: an economic analysis In: 14th national rural health conference proceedings (ed L Coleman), Cairns, Australia 26 April–29 April 2017, paper no. A2, pp. 1--6. Deakin: National Rural Health Alliance Inc., http://www.ruralhealth.org.au/14nrhc/content/caffery

10.

Australian Bureau of Statistics. Australian Standard Geographical Classification (ASGC), http://www.abs.gov.au/websitedbs/D3310114.nsf/home/Australian+Standard+Geographical+Classification+ (2014, accessed 19 June 2017)

11.

Kattan

(ed). Encyclopedia of medical decision making. Thousand Oaks, California: SAGE Publications, Inc., 2009.

12.

Mauskopf

Paul

Grant

, et al. The role of cost–consequence analysis in healthcare decision-making. Pharmacoeconomics 1998; 13: 277–288.

13.

Cost-consequence analysis. In: Kirch W (ed.) Encyclopedia of public health. Dordrecht: Springer Netherlands, 2008, pp. 168–168.

14.

Queensland Government. Patient Travel Subsidy Scheme (PTSS) guideline (part A), 2016, http://conditions.health.qld.gov.au/HealthCondition/condition/12/229/501/patient-travel-subsidy-scheme

15.

Government

Domestic Travelling and Relieving Expenses (Directive 09/11), https://www.forgov.qld.gov.au/documents/directive/0911/domestic-travelling-and-relieving-expenses (2018, accessed 19 July 2019 2019).

16.

Jones

Jacklin

, and O'Connell

ME.

Development and use of health-related technologies in indigenous communities: critical review.

J Med Internet Res 2017; 19: e256.

17.

Rufo

RZ.

Use of change management theories in gaining acceptance of telemedicine technology.

Crit Care Nurs Q 2012; 35: 322–327.

18.

Clifford

Shakeshaft

Evidence-based alcohol screening and brief intervention in Aboriginal Community Controlled Health Services: experiences of health-care providers.

Drug Alcohol Rev 2011; 30: 55–62.

19.

O'Brien

Bloomer

McGrath

, et al. Considering Aboriginal palliative care models: the challenges for mainstream services. Rural Remote Health 2013; 13: 2339.

20.

Clarkson

Harris

Brazeau

, et al. Initial therapeutic alliance and treatment engagement of Aboriginal and non-Aboriginal youths in a residential treatment center for substance abuse. J Ethn Cult Divers Soc Work 2013; 22: 145–161.

21.

Caffery

Bradford

Smith

, et al. How telehealth facilitates the provision of culturally appropriate healthcare for Indigenous Australians. J Telemed Telecare 2018; 24: 676–682.

22.

Caffery

Bradford

Wickramasinghe

, et al. Outcomes of using telehealth for the provision of healthcare to Aboriginal and Torres Strait Islander people: a systematic review. Aust NZ J Public Health 2017; 41: 48–53.

23.

Jensen

Rasmussen

OW.

Is a home based video teleconsultation setup cost-effective for lowering Hba1c for patients with type-2 diabetes over a six-month period?

Value Health 2014; 17: A346.

24.

Steventon

Bardsley

Doll

, et al. Effect of telehealth on glycaemic control: analysis of patients with type 2 diabetes in the Whole Systems Demonstrator cluster randomised trial. BMC Health Serv Res 2014; 14: 334.

25.

Robinson

Branham

Locklear

, et al. Measuring satisfaction and usability of FaceTime for virtual visits in patients with uncontrolled diabetes. Telemed J E Health 2016; 22: 138–143.

26.

King

Holloway

, and Walker

Expanding models for rural primary care in West Virginia. W V Med J 2013; 109: 38–44.

27.

Smith

Armfield

, and Caffery

LJ.

Telehealth a game changer: closing the gap in remote Aboriginal communities.

Med J Aust 2019; 211: 43.

28.

Kozera

Yang

, and Murrell

DF.

Patient and practitioner satisfaction with tele-dermatology including Australia’s indigenous population: a systematic review of the literature.

Int J Womens Dermatol 2016; 2: 70–73.

29.

Bradford

Caffery

, and Smith

AC.

Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural Remote Health 2016; 16: 3808.

30.

Bursell

S-E

Jenkins

Brazionis

, et al. Telehealth in Australia: an evolution in health care services. Med J Aust 2013; 199: 23–24.

31.

Achey

Aldred

Aljehani

, et al. The past, present, and future of telemedicine for Parkinson's disease. Mov Disord 2014; 29: 871–883.

32.

Smith

Scuffham

, and Wootton

The costs and potential savings of a novel telepaediatric service in Queensland.

BMC Health Serv Res 2007; 7: 35.

33.

Smith

Scuffham

, et al. A cost minimisation analysis of a telepaediatric otolaryngology service. BMC Health Serv Res 2008; 8: 30.