Does evidence support expanding telehomecare in Ontario?
Telehomecare programs offer remote monitoring for people living with chronic diseases, linking patients to providers without requiring an in-person visit.
Ontario is currently developing a number of large-scale telehomecare programs with the promise that they are patient centred, cost effective approaches to care.
While there is great enthusiasm for telehomecare programs from patients, providers and policy makers, the evidence is mixed around the ability of these programs to deliver on these expectations.
Every morning, 71-year-old Bill Whillans steps on a set of weigh scales and slips a blood pressure sleeve on his arm. A computer voice housed in a small monitor then asks him about his breathing and whether he’s experiencing any swelling in his body from water retention.
“Then, the voice says thank you,” explains the Stittsville, Ontario resident who suffers from congestive heart failure. His information is immediately transmitted over the phone to the University of Ottawa Heart Institute. If there is any cause for concern, he’ll hear promptly from one of the advanced practice nurses who analyze the data.
The Heart Institute’s nurse-run cardiac telehealth program began operating in 2005 with 20 home monitors. Nurses now monitor 100 patients a day, and patients have monitors at home for an average of three to four months. Results of an evaluation released by the Heart Institute in 2009, but never published, found the program improved patients’ quality of life and cut hospital readmission rates by more than 50%. However, a published randomized controlled trial of a 3 month telehomecare program at the Heart Institute had less impressive results, showing reduced admissions for patients with angina, but no benefit in those with heart failure.
The Promise of Telehomecare
Telemedicine that provides for the in-home management of chronic disease has been around for a couple of decades. The Veterans Administration in the United States has an extensive program, and Britain’s publicly funded Whole System Demonstrator trial involved more than 6000 participants suffering from heart disease, diabetes and chronic obstructive pulmonary disease (COPD). Full results from that trial — dubbed the largest-ever trial of telehealth — have not yet been published.
Now the Ontario Telemedicine Network (OTN), with funding from the province and Canada Health Infoway, is poised to introduce telehomecare services into three Local Health Integration Networks (LHINs).
It is expected that about 2500 patients with heart failure and COPD will be enrolled in the first year; most will have monitors that transmit information through telephone lines, while a select few patients will also have video links.
Worldwide, intense interest in telehomecare is driven by the belief that it can improve management of chronic disease and patients’ access to care, and help to contain health care costs by reducing preventable hospital visits. However, some caution that telehomecare programs are expensive, do not work for all patients, and that care should be used to select appropriate patients and parameters for these programs.
Onil Battacharyya, a researcher and family doctor at St. Michael’s Hospital, has a particular interest in chronic disease management. He thinks that telehomecare has promise, but says rigorous evaluation is essential to ensure that patients most likely to benefit can be identified and to avoid a situation where home monitoring becomes an expensive add-on to existing health care provision.
Telehomecare in Ontario: Testing, Experimentation and Expansion
Edward Brown, a doctor and chief executive officer of OTN, is an enthusiastic proponent of telehomecare. and says that to manage the growing burden of chronic diseases, new models of care that are patient-centered are necessary. “I think this [telehomecare] is a vanguard of what we need to do and how we need to organize care. I think things like this will drive new models of care” says Brown.
The pilot project that preceded the imminent Ontario rollout of telehomecare involved more than 600 patients, average age 77, who suffered from heart disease, COPD and diabetes, he said. Patients were connected to health care professionals at eight different Family Health Teams in the province and they spent on average of six months with a monitor in their home.
There was an evaluation commissioned to study the pilot, that has never been publicly released, which found a 65% reduction in hospitalization and a 75% drop in emergency room visits for enrolled patients. However, many suggest these findings are ‘too good to be true’ and that the evaluation lacked scientific rigour.
The Ontario program will begin working with the “low hanging fruit” — patients with heart failure and COPD, where evidence to support home monitoring appears to be the strongest. But Brown expects the program, which has been promised an initial three years of funding, to eventually expand to patients with other chronic conditions. Brown said he could not disclose financing details of the program, which have not yet been finalized.
Telehomecare programs that don’t also include case management and self care have mixed results, he says, adding that the “secret sauce” is empowering patients to be self managing. The model to be used in the LHINs is based on connecting patients with nurses who act as coaches and help patients improve in areas that are important to them. However, the nurses will need to contact associated doctors if any important changes to the patients’ management are deemed to be necessary.
The new LHIN telehomecare program is quite different from the program that Whillans participates in at the Ottawa Heart Institute, notes Christine Struthers, the advanced practice nurse who heads up the Institute program and is also on the advisory board for the OTN project. The Heart Institute’s program links patients to a specialized heart care centre. “Ours is an acute intervention model, allowing us to assess over the phone, and our nurses have medical directives to allow us to intervene in a timely fashion.”
The LHINs involved in the new project — Toronto Central, North East and Central West— will each determine how they organize the telehomecare service in their area. The nurse-coaches, who undergo OTN training, may for example be based in a Community Care Access Centre or a Family Health Team, Brown says.
The fact that LHINs will be deploying telehomecare in a variety of ways complicates the task of evaluating the project. That job has been assigned to the Institute for Clinical Evaluative Sciences (ICES) and the Toronto Health Economics Technology Assessment (THETA) Collaborative.
“We need to be sure that we are measuring the right things and that it is not just about the equipment and the ease of use of the equipment,” says Struthers, “I always says it is not equipment that produces a good outcome, it is the nurse looking at the data who will be the one who produces change in the patient.”
The Challenges of Evaluating Telehomecare
Cost effectiveness is one aspect of telehomecare that has not been extensively evaluated, according to a recent publication in the Journal of Telemedicine and Telecare.
The article presents an evidence synthesis that examines the results of 141 randomized controlled trials of telemedicine used to manage chronic disease. Author Richard Wootton, of the Norwegian Centre for Integrated Care and Telemedicine, notes that more recent studies are giving less positive results than older studies. And he concludes that, based on the trials he reviewed, it’s not possible to state that a particular type of telemedicine will be cost-effective in the management of one or more chronic diseases. “After nearly 20 years of randomized trials work, this seems both surprising and disappointing.”
The same day that this healthydebate.ca story was posted, the results of the Whole System Demonstrator Project in the UK, one of the largest randomized controlled trials of telehomecare ever conducted, which included over 3000 participants with diabetes, chronic lung disease and heart failure was published. The study found that patients who received telehomecare had a decrease in the chances of being admitted to hospital (43% compared with 48% in the control group), and fewer deaths (8% versus 5%). Some have pointed out that the decrease in admissions was small, and while this study found a benefit in terms of mortality, other randomized trials of telehomecare found that telehomecare increased mortality.
Trisha Greenhalgh, a Professor of Primary Health Care at the University of London also questions the cost effectiveness of this program, noting that an unpublished analysis has shown that the cost per quality adjusted life year to keep people at home with telehealth is about 88,000 pounds (about $140,148 CAD), an amount that is “massively more expensive” than low tech solutions, she said.
An accompanying editorial cautions that the study’s results should not be interpreted to suggest that telehomecare will work for every patient. The reasons why telehomecare works in some patients and not others are complex, and are likely related to the type of patient and how health care workers respond to the information collected through telehomecare.
Before retirement, Whillans worked for the YMCA in Africa and South America, on warfronts and in refugee camps. His life is more restricted now, but he’s very impressed with his home monitor and the service the Heart Institute nurses provide. It seems patients like the service. However, the task for policy makers is to ensure that it’s also a cost effective approach to providing good chronic care management. If these programs turn out not to be cost effective, will it be possible to cancel or make major modifications to them?