Results of a telehealth-enabled chronic care management service to support people with long-term conditions at home

Introduction

In New Zealand, chronic conditions are the leading cause of hospitalizations. ¹ They account for 80% of all preventable deaths and are estimated to consume the major proportion of our health-care funds. ² Chronic conditions contribute to the disparity in life expectancy between Māori and non-Māori people. They also account for a higher proportion of illness and deaths among people on low incomes and Pacific peoples than among the general population. ²

Studies have shown that remote telemonitoring can reduce mortality, reduce hospitalizations, improve quality of life and decrease health-care costs. ^3–10 One large study, ¹¹ a multicentre randomized study which included 460 people, showed significant reductions in hospital readmissions (hazard ratio 0.50; 95% CI 0.34, 0.73) and a probable reduction in mortality (hazard ratio 0.45; 95% CI 0.19, 1.03) in people with congestive heart failure (CHF). Other large studies have often found at least one significant improvement in measures such as hospital readmissions, ED attendances and physician contacts. Most studies have found a high level of patient satisfaction with the technology.

Recently, a Cochrane review of 25 studies evaluated structured telephone support and telemonitoring in the management of patients with CHF. ¹² The review concluded that telemonitoring reduced all-cause mortality (relative risk 0.66, P < 0.0001) and reduced CHF-related hospitalizations (relative risk 0.79; P = 0.0008). However, little is known about the acceptability, utility or cost-effectiveness of telehealth services in a New Zealand context. Both CHF and chronic obstructive pulmonary disease (COPD) are more common among Māori than non-Māori people, and the cultural acceptability of home-based remote monitoring technology has not been tested.

In order to test the acceptability and utility of telehealth monitoring in a NZ environment, a 12-month pilot involving the trial of 10 telemonitoring machines in Turangi and Taupo was conducted. The objectives of the pilot trial were to:

Investigate the acceptability and usefulness of telehealth technology for Māori and other users with CHF or COPD in a rural New Zealand environment;

Methods

Patients living in the Turangi or Taupo areas, who had been discharged from hospital in the previous 12–24 months with a diagnosis of CHF or CODP, were recruited and assigned randomly to either a control or intervention group. Proportions of Māori/non-Māori people, and COPD/CHF were balanced approximately between the telehealth and control groups by allocating them alternately to either a control or intervention group according to surname. There were 10 patients in each group at commencement and at six months, with additional recruitment at six months on a matched basis to replace those who died or withdrew. The pilot lasted from 1 October 2009 to September 2010. The study was approved by the appropriate ethics committee.

Patients in the intervention group had a telehealth terminal installed in their home, with an online link to a web portal that was reviewed regularly by local nurses, supported by clinical algorithms. The telehealth terminal comprised a touch-screen computer with a range of measurement peripherals. The machines enabled people to measure their own bodyweight, oxygen levels, lung function, blood pressure and other clinical signs (Figure 1). The results were transmitted over ordinary telephone lines to a central computer and included in a web-based patient record. Chronic care management nurses used the online patient record to monitor patients and to decide whether to contact patients for clinical intervention.

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Figure 1

The telehealth unit used in the pilot programme

Patients in the control group did not receive the telehealth machine, but both groups of patients received, in addition to usual care through their primary care provider, the Healthright nurse-led disease management programme, which involved regular home visiting and systematic assessment and care planning.

The telehealth machines were used to deliver the quality of life questionnaires at pilot commencement, six months and 12 months. Both intervention and control patients were brought together in a central location in Taupo for this purpose.

Results

The pilot study showed that remote monitoring technology could be successfully applied in a rural New Zealand community to aid chronic disease management. Patient interviews indicated that the technology was acceptable to most patients and their families, including the Māori. Comments suggested that easy access to telehealth monitoring facilitated self management through a deeper understanding of the disease and quick feedback.

People with diabetes or CHF gained insight into how aspects of their life affected their condition, and the relationship between medication doses and the clinical measurements. Some reported that family members felt more confident because of the monitor in the house. The comments suggested that Māori patients adopted the telehealth technology readily, and looked positively at ways to involve other members of the family in the management of their condition. Staff also found the equipment useful. Some reservations were expressed about the telehealth machine, which were mainly to do with its bulky nature.

Telehealth remote monitoring probably improved patient quality of life in the target group. The telehealth group showed a consistent trend towards improved self-reported quality of life on several quality of life instruments including the SF-36, the St George Respiratory Questionnaire and the K10 questionnaire. Patients in the control group, in contrast, showed no clear trend towards improvement. Despite the small sample size, the difference in the K10 scores was significant (P < 0.02), see Table 1.

Patients also commented that they generally found the access to continuous home monitoring resulted in improved confidence, quality of life and in their ability to manage their condition. Most patients felt reassured by the presence of the monitor in their home and reported an increased sense of confidence and well-being, particularly because their telehealth results were being monitored regularly by the nurse and that the nurse would contact them if worrying trends developed.

The alignment between the interview comments and the quantitative results leads to a higher degree of confidence that the effect is likely to be real.

Discussion

The pilot study demonstrated that remote monitoring can be successfully implemented in a New Zealand community to aid chronic disease management. The technology was warmly welcomed by most patients and their families, including by Māori.

The results from the pilot study suggest a trend towards reduced mortality and improved quality of life in the telehealth group relative to the control group. These findings are consistent with the results of much larger studies elsewhere, which have often found significant positive effects from telemonitoring. Based on the interviews with telehealth patients, it is likely that the access to quick and authoritative information on current health status, and early identification of any downward trend, allowed better patient self management and enabled family members to provide informed care. However, no clear difference was found on clinical measures or on service utilisation between the control and telehealth groups. This may be the consequence of the limited sample size or the Healthright disease management programme masking the effect of telehealth remote monitoring. A comparison between telemonitoring and usual primary care (without the HealthRight disease management service) might establish the relative cost and efficacy of telemonitoring and home visiting-based disease management programmes.

Care should be taken in drawing conclusions from the quantitative data in the present study because of the small sample size. It is not possible to conclude whether telemonitoring is cost effective. However, the pilot suggests that wider implementation with a cost benefit evaluation could be worthwhile.