Cost_minimization_of_a_telehomecare_prog.pdf

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TELEMEDICINE AND e-HEALTH Volume 12, Number 2, 2006 © Mary Ann Liebert, Inc.

Original Research Cost-Minimization Analysis of a Telehomecare Program for Patients with Chronic Obstructive Pulmonary Disease GUY PARÉ, Ph.D.,1 CLAUDE SICOTTE, Ph.D.,2 DANIELLE ST.-JULES, R.N., M.Sc.,3 and RICHARD GAUTHIER, M.D.3

ABSTRACT A cost-minimization analysis was performed on a telehomecare program for patients with a chronic obstructive pulmonary disease (COPD). The research was quasi-experimental and included a control group. We compared the effects and costs of care provided to a group of 19 patients under a telehomecare program to a comparable group of 10 patients receiving regular home care without telemonitoring. Our results clearly indicate that there were fewer home visits by nurses and hospitalizations for patients in the experimental group. However, these patients made more telephone calls than patients in the control group, although this difference was not statistically significant. Of utmost importance, the cost-minimization analysis yielded positive results. Indeed, telemonitoring over a 6-month period generated $355 in savings per patient, or a net gain of 15% compared to traditional home care. Our study confirms the findings of previous studies that analyzed the efficacy of telemonitoring for patients with COPD. Patients were found to easily accept the idea of using the technology, and the telehomecare program demonstrated significant clinical benefits. Financial advantages of the program could have been more pronounced had it not been for the cost of technology that effectively erased a good portion of the savings. INTRODUCTION

C

HRONIC

OBSTRUCTIVE

PULMONARY

DISEASE

(COPD) is a long-term illness characterized by breathing difficulties that are accompanied by a progressive deterioration of functional capacity. Home care for patients with COPD ensures a better quality of life and prevents hospitalizations. In recent years, it has become

common for patients with COPD to be given an expanded role in their own treatment.1,2 This therapeutic approach generally consists of patients managing the use of prophylactic medication and following personalized treatment plans in the home. Clinical studies have shown that this therapeutic strategy is associated with significant improvements seen in both clinical results and quality of life.3,4 Re-

1HEC

Montreal, Quebec, Canada. of Montreal, Quebec, Canada. 3Maisonneuve Rosemont Hospital, Montreal, Quebec Canada. 2University

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cent studies nevertheless report that patients often do not always follow their personalized treatment plans.5,6 Information technologies now provide an opportunity to address this problem through remote monitoring of the home patient’s clinical condition. Telehomecare, also called telemonitoring, consists of remotely monitoring the health of patients with information and communication technologies. The technology may comprise several different functions, such as detecting problems as they arise and proposing palliative solutions. Electronic data transmission can reduce measurement detection and transmission errors. Telemonitoring has other potential advantages, such as patient education, more patient responsibility in the management of his or her care, and cost reductions.7 Better integration of care provided from a variety of service points, the introduction of preventive medical practices and effective and continuous remote monitoring may also alleviate crowding in emergency rooms.8 Finally, telehomecare can prevent hospitalization or even extend life.9–11 Scientific literature on this subject offers a relatively limited number of telehomecare experiments for patients with COPD. Dale et al.2 remotely monitored 55 patients with COPD over a 3-month period and noted 36 escalations, of which 29 (81%) were remotely managed in the home while the other 7 required patient hospitalization. The actual number of hospitalizations was 50% less than what had been predicted for this cohort of patients. In a study based on a pre–post assessment, Miaolo et al.1 followed a cohort of 23 patients with COPD for 24 months. Hospitalizations and acute attacks decreased 50% and 55%, respectively, over the 24 months of home monitoring using telemedicine. Telemedicine, therefore, offers attractive advantages in terms of improved accessibility and superior care, but what of the cost effectiveness of these programs? We found no study that could clearly demonstrate the financial viability of this type of program for managing pulmonary disease. Our study offers to fill this gap. Precisely, this paper presents the findings of an economic analysis of a telemonitoring program for patients with COPD. Using a quasi-experimental research design with a con-

115

trol group, we examined the effects and costs of care, comparing a group of patients receiving telecare to a comparable group receiving home care without remote monitoring services.

MATERIALS AND METHODS Description of the telehomecare intervention Maisonneuve Rosemont Hospital provides specialized pulmonary care in the homes of adults living in the Montreal metropolitan area, and suffering from chronic pulmonary problems. At the time of this study, the hospital was serving 2393 patients. In response to the continually growing demand for care, a telehomecare program was introduced to confirm the clinical and economic viability of this type of intervention. Tested over 6 months in 2003 and 2004, the program was intended to provide intensive and continuous telemonitoring that would improve the hospital’s ability to assist and provide support to patients while reducing to a strict minimum the number of home visits made by nurses. Faced with a serious shortage of professional staff, the hospital wanted to confirm how effectively the technology could reduce nursing hours per patient. The technology consisted of a Webphone with an integrated touch screen and modem (New IT Technologies Inc., Montreal, Quebec). The device was programmed with a personalized protocol for monitoring several parameters of patient health. The patient received complete training about the device during the first meeting with the nurse and was then required to collect and send clinical data over the Internet. Each day, patients had to complete a data entry form, documenting their peak flow rate, their symptoms, and any medication taken. This tool was designed to help patients understand relationships between their state of health, environment, lifestyle, and management of medication. This would enable the preparation of therapeutic action plans for better management of the illness. Once the information was transferred, it was reviewed daily by the nurse responsible for remote monitoring of the patient’s health and compliance with prescribed treatment. The de-

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PARÉ ET AL.

vice also automatically analyzed the data transferred, alerting the patient and the nurse when readings fell outside previously established parameters. The patient also received preprogrammed advice on the recommended response. The nurse was able to remotely monitor the patient’s reactions and intervene directly by telephoning the patient or by informing the attending physician, who decided on an appropriate response. Changes represented by the home telemonitoring system included how patients collected and transmitted clinical data concerning their condition and, above all, the resulting response: patient advice provided in real time (intelligent functions programmed into the system) and in non-real time (the case manager regularly consulting the electronic database to monitor the intervention). The telemonitoring system’s added value, as compared to the traditional system, was that (1) there was continuous remote monitoring of the patient’s state of health and behavior; (2) the system reacted immediately when state of health or behavior fell outside of recommended parameters; and (3) the advice tailored to the patient’s specific condition effectively reinforced desired behaviors. Design The research project was designed as an experiment conducted with an equivalent control group. Patients were selected according to a strict set of inclusion and exclusion criteria.

TABLE 1.

NUMBER

AND

TYPES

OF

This evaluative project dealt solely with newly admitted patients. These patients had to have severe COPD that required frequent home visits. Patients were excluded from the cohort if they had psychological or psychiatric disorders, if they had a cognitive deficiency that made them unable to participate in their selftreatment, or if they had a visual or motor deficiency that rendered them incapable of using the telemonitoring technology (unless a spouse or an informal care giver was able to help). From a total of 337 newly admitted subjects having received an eligible diagnosis between December 1, 2003 and June 1, 2004, 30 patients satisfied all the inclusion and exclusion criteria and agreed to participate in a 6-month pilot project. From this group, 20 were assigned to the experimental group with home telemonitoring, while the other 10 became the control group and were monitored through the traditional system of home visits. The 30 subjects formed a homogeneous group of patients. As shown in Table 1, the number of diagnoses of pulmonary and related conditions per patient is the same for both groups. The most common diagnoses in the two groups were respiratory failure, emphysema and asthma. The most common secondary diagnoses were arteriosclerotic heart disease (AHD), heart failure, diabetes and hypertension. There were no significant differences noted in the composition of the two groups in terms of age, gender, or oxygen dependence. The mean age was 69 years in the

PULMONARY

Experimental group (n
19) Mean Pulmonary and related diagnoses

Secondary diagnoses

AHD, arteriosclerotic heart disease.

Standard deviation

1.2 1.0 Respiratory failure (53%) Emphysema (26%) Asthma (16%) 2.5

2.1 AHD (37%) Heart failure (26%) Diabetes (21%)

AND

SECONDARY DIAGNOSES Control group (n
10)

Mean

Standard deviation

t-test t

p

0.8 0.8 Respiratory failure (40%) Emphysema (20%)

1.2

0.245

2.1 2.0 Hypertension (40%) AHD (30%) Diabetes (30%)

0.5

0.644

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COST-MINIMIZATION ANALYSIS OF A TELEHOMECARE PROGRAM

experimental group and 72 years in the control group. Men represented 63% of the experimental group and 50% of the control group. Oxygen dependence stood at 53% in the experimental group and 50% in the control group. Analysis strategy The strategy for the economic analysis was to examine cost minimization.12 Costs were compared for interventions with clinical outcomes considered similar in order to identify the least costly alternative. The analysis undertaken in this study sought to identify the extent to which telemonitoring could reduce costs compared to the traditional model. Under this perspective, the analysis was based on an identification of the additional costs incurred and gains obtained when implementing a telemonitoring program. This was a “with/without” comparison in which “without telehomecare” served as the benchmark for evaluating the intervention’s cost-effectiveness. The economic analysis focused on evaluating the costs associated with running the program as well as the gains made and the costs avoided by implementing the telehomecare program. Only direct costs were taken into account. Finally, it should be noted that this economic analysis was conducted from the point of view of the healthcare system as a whole. This means that it did not take into consideration costs incurred by the patient. It is our view that these costs would not have affected the results of the economic evaluation, inasmuch as the cost of the telemonitoring technology was covered by the healthcare network and both types of interTABLE 2.

VARIABLES USED

IN THE

vention took place in the patient’s home— hence the patient’s expenses should be similar in both cases. Variables used and sources of information The main measures used to assess the effects of the telemonitoring deployment were: (1) less time spent by nurses on clinical monitoring of patients and (2) fewer hospitalizations. Six variables were used to arrive at estimates of these results. Three variables measured different aspects of home visits, two more dealt with telephone communication between nurses and patients, and the last variable measured the costs associated with hospitalizations. Table 2 provides a summary of the variables used and sources of data. We also assessed patient satisfaction in the experimental group by conducting a telephone survey 1 week before the end of the experiment. More specifically, we assessed their perception of ease of use of the system, the quality of the technical support, and the perceived overall usefulness of the telemonitoring program. Method for calculating costs The cost of nursing services was calculated based on the mean hourly rate set by collective agreement for graduate nurses multiplied by the time they spent caring for each patient, both in the home and over the telephone. The cost of services by graduate nurses is higher than the typical cost for this type of personnel because a graduate nurse has a 3-year university degree. This level of education was a require-

ECONOMIC ANALYSIS

Variables Time spent by nurses in home visits (number of minutes) Travel time spent by nurses in order to make home visits (number of minutes) Distance covered by the nursing staff/home visits (number of kilometers) Time spent by nurses in telephone interventions (number of minutes) Time spent in emergency telephone interventions by on-call personnel (number of minutes) Number of hospitalizations and length of hospital stay

AND

SOURCES

OF

DATA

Sources Management control system: home visit logbooks maintained by nurses Management control system: home visit logbooks maintained by nurses Management control system: home visit logbooks maintained by nurses Patient medical records: notes in medical records— nature of intervention and time spent (in minutes) Patient medical records: notes in medical records— nature of intervention and time spent (in minutes) Patient medical records

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in the experiment at the time the experiment took place. This strategy enabled us to conduct our economic analysis using recent costs that reflected a trend towards falling prices, since current costs would have differed from those used in our experiment. Costs were amortized using the straight-line method over a 5-year period. Detailed information is provided in Table 3.

ment in this program, because the nurses are required to work independently in the homes of patients. Travel costs take into account the actual time nurses spent traveling and the reimbursement of mileage according to rates set by collective agreement. Finally, the cost of hospitalization was estimated on a patient-by-patient basis. We used average costs calculated according to the DRG method (3M™) used by the Montréal University Hospital for all patients who had had a COPD as their primary diagnosis for hospitalization (DRG #88) in 2003–2004.13 This average cost of hospitalization was adjusted based on four different levels that reflected the seriousness of the cases. We used an average hospitalization cost corresponding to the patient’s length of stay for each of the patient hospitalizations in the two groups. The cost of the technology was estimated on the basis of the current price of the device used TABLE 3.

ECONOMIC ANALYSIS

RESULTS First and foremost, it was important to ensure that the telemonitoring program was well organized and would work. Initially, the 30 patients who agreed to participate in the experiment saw it through to the end, with the exception of one patient from the experimental group who withdrew at the very outset of the project. This patient was excluded from the

OF THE

TELEHOMECARE PROGRAM Estimates for a six-month period

Experimental group (n
19)

Control group (weighted n
19)

Savings/(losses)

$2,623 $391 $1,040

$3,788 $696 $1,820

$1,165 $305 $780

Telephone interventions Remuneration of nurses

$1,166

$491

$(675)

On-call telephone service Remuneration of nurses

$596

$301

$(295)

$16,022

$45,708

$29,686

$2,090 $6,783

$0

$(24,216)

$46,054 $2,424

$52,804 $2,779

$6,750 $355

Cost categories Home Visits Remuneration of nurses (visit time) Traveling expenses Remuneration of nurses (traveling time)

Hospitalizations Total costs Technology Purchase of user licenses for the telemonitoring software Purchase of Web phones Installation costs and costs for support an maintenance of equipment and licences Total Total per patient

$15,343

Assumptions underlying calculation of unit costs: (a) Effects: Cost of nursing staff
$34.21/hr. Traveling cost
$0.37/km. Hospitalization cost (COPD/seriousness 1)
$3,543/hospitalization; (COPD/seriousness 2)
$4,660/ hospitalization; (COPD/seriousness 3)
$7,462/hospitalization; (COPD/seriousness 4)
$14,384/hospitalization. (b) Technology: Amortization on a straight-line basis over a 5-year period for the following costs: purchase of 150 user licenses
$1,615/patient/year; purchase of 150 Web phones
$220/Web phone/year; installation cost
$10/Web phone/year; software updates
$484/license/year; and technical support
$220/Web phone/year. Calculations in Canadian dollars.

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COST-MINIMIZATION ANALYSIS OF A TELEHOMECARE PROGRAM TABLE 4.

PATIENT ATTITUDES TOWARD

THE

TECHNOLOGY

AND THE

TELEHOMECARE PROGRAM n

Mean

Standard deviation

17

3.76

0.75

17 17

3.65 3.47

0.86 1.18

Quality of technical support When I had technical problems with the Web phone, the problem was resolved within 24 hours.

15

3.57

1.09

Perceived usefulness Telehomecare gave me a sense of security. Use of the Web phone helped me adopt new practices that stabilized my state of health.

17 17

3.35 3.65

1.22 0.86

Ease of use During the first visit, the nurse gave me a good explanation of how to use the Web phone and the procedure to follow. The vocabulary used on the Web phone screen was easy to understand. The Web phone was easy to use.

Likert scale of 1 to 4 where 1
strongly disagree and 4
strongly agree.

analysis. Furthermore, the data from the telephone survey of the experimental group showed that patients had no difficulty working with the technology (Table 4). Results from the cost-minimization analysis clearly demonstrate that there were fewer home visits by nurses for the experimental group (Table 5). These patients received an average of 4.2 home visits over the 6-month period, compared to 7.5 visits per patient for the control group (p  0.001). In addition, even if the average stay of a home visit was less for paTABLE 5.

EFFECTS

OF THE

tients in the control group, the total nursing time per patient was still less for the experimental group because they received fewer home visits (p  0.005). Patients with telehomecare made more telephone calls than patients in the control group, although this difference was not statistically significant. The average length of these calls was longer for telemonitoring patients than it was for patients receiving traditional home care (p  0.10). Finally, there were only 2 hospitalizations TELEMONITORING PROGRAM Experimental group (n
19)

Control group (n
10)

Home visits Percentage of patients who received at least one visit Number of visits per patienta Average length of a home visit (in minutes)b Average distance traveled by nursing staff per patient (in kilometers)a Average traveling time per patient (in minutes)a

100% 4.2 57.5 55.6 96.0

100% 7.5 46.6 99.0 168.0

Telephone interventions Percentage of patients who used the service Average number of calls per patient Average intervention length per patient (in minutes)c

84% 6.2 17.5

60% 4.5 10.1

On-call telephone service Percentage of patients who used the service Average number of calls per patient Average length of intervention per patient (in minutes)

79% 2.5 22.2

40% 1.4 19.9

Hospitalizations Percentage of patients who were hospitalized at least once Average number of hospitalizations per patientc Average hospital stay (in days)b

5% 0.1 13.5

40% 0.6 7.3

Types of effects observed

T test: ap  0.001; bp  0.005; cp  0.05.

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among the 19 telehomecare patients, while there were 6 hospitalizations among patients receiving traditional home care (p  0.05). The average hospital stay was longer for telemonitoring patients than it was for patients in the control group (p  0.005). Table 3 presents estimates of costs for the two home care groups (with or without telemonitoring). In order to ensure that we were analyzing comparable data, we weighted our calculation of home care costs without telemonitoring on the basis of 19 patients. The costminimization analysis yielded positive results: the telehomecare program cost $6,750 less than the traditional home care program, representing a saving of $355 per patient. This amounts to a net gain of 15% over traditional patient monitoring, a program that cost $46,054. The principal source of savings in the telemonitoring program was lower hospitalization costs; hospitalizations represented 64% of the cost of the traditional home care program ($29,686/$46,054). To a lesser extent, savings also came from the lower cost of care provided in the home. These savings represented 5% of the total cost of running the traditional home care program ($2,250/$46,054). However, these savings were largely eaten up by the increase in time spent by nurses on telephone calls with patients. Finally, it was the technology that used up most of the program’s savings. The technology cost came to $24,216 or 53% of the total cost of the traditional home care program. This also represented four times the cost of nursing services in the experimental group ($24,216/$5,816) and over 53% of the total cost of the telehomecare program.

DISCUSSION Our study confirms the findings of previous studies that analyzed the efficacy of telemonitoring for patients with COPD. Patients were found to easily accept the idea of using the technology,1,14,15 and telehomecare provided significant clinical benefits, particularly in terms of a reduction in the number of home visits and hospitalizations.1,2,16 In terms of program economics, the telemonitoring program generated significant savings in the form of a

lower hospitalization rate and, to a lesser extent, less frequent home visits. This resulted in a net gain of 15% over traditional home care. As mentioned above, most of the savings were used up by the technology costs. More evaluative research is required in order to confirm the economic viability of this kind of telehomecare program. Future studies should not only examine other patient populations that would be apt to receive telemonitoring but should also compare various technological environments and utilize larger samples. Despite the inherent limitations of this evaluative approach, including the small sample size, we firmly believe that our results are valid to the extent that (1) the telehomecare program was maintained over a relatively long period of time and the technology was used well during this period and (2) significant differences were observed between the two programs in terms of attitudes (as seen in Table 4), structure (Table 5), and costs (Table 3).

ACKNOWLEDGMENT The Canada Research Chairs Program is gratefully acknowledged for providing financial support for this research.

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Address reprint requests to: Guy Paré, Ph.D. Canada Research Chair in Information Technology in Healthcare HEC Montréal 3000 Côte-Ste.-Catherine Road Montreal, Quebec H3T 2A7 Canada E-mail: [email protected]

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Pierce, Janette Gogler, Julie Steinkrug, Ken Sharpe, Christine F. McDonald. 2012. Pilot Study of Remote Telemonitoring in COPD. Telemedicine and e-Health 18:8, 634-640. [Abstract] [Full Text HTML] [Full Text PDF] [Full Text PDF with Links] 14. Charles Chen, Shih-Wei Chou. 2012. Measuring Patients’ Perceptions and Social Influence on Home Telecare Management System Acceptance. International Journal of Healthcare Information Systems and Informatics 5:3, 44-68. [CrossRef] 15. Z. D. Gellis, B. Kenaley, J. McGinty, E. Bardelli, J. Davitt, T. Ten Have. 2012. Outcomes of a Telehealth Intervention for Homebound Older Adults With Heart or Chronic Respiratory Failure: A Randomized Controlled Trial. The Gerontologist 52:4, 541-552. [CrossRef] 16. Charles Chen, Shih-Wei ChouMeasuring Patients’ Perceptions and Social Influence on Home Telecare Management System Acceptance 281-306. [CrossRef] 17. Jeongeun Kim, Sukwha Kim, Heechan Kim, Kyungwhan Kim, Choon-taek Lee, Sukchul Yang, Hyoun-Joong Kong, Yoonju Shin, Kyungsoon Lee. 2012. Acceptability of the Consumer-Centric u-Health Services for Patients with Chronic Obstructive Pulmonary Disease. Telemedicine and e-Health 18:5, 329-338. [Abstract] [Full Text HTML] [Full Text PDF] [Full Text PDF with Links]

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