Home Telehealth for Chronic Disease Management

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Canadian Agency for Drugs and Technologies in Health Agence canadienne des médicaments et des technologies de la santé t e c h n o l o g y HTA Issue…
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Canadian Agency for Drugs and Technologies in Health Agence canadienne des médicaments et des technologies de la santé t e c h n o l o g y HTA Issue 113 December 2008 r e p o r t Home Telehealth for Chronic Disease Management Supporting Informed Decisions Until April 2006, the Canadian Agency for Drugs and Technologies in Health (CADTH) was known as the Canadian Coordinating Office for Health Technology Assessment (CCOHTA). Publications can be requested from: CADTH 600-865 Carling Avenue Ottawa ON Canada K1S 5S8 Tel. (613) 226-2553 Fax (613) 226-5392 Email: a class= __cf_email__ href= /cdn-cgi/l/email-protection data-cfemail= 136366716053707277677b3d7072 [email protected] /a script data-cfhash='f9e31' type= text/javascript /* ![CDATA[ */!function(t,e,r,n,c,a,p){try{t=document.currentScript||function(){for(t=document.getElementsByTagName('script'),e=t.length;e--;)if(t[e].getAttribute('data-cfhash'))return t[e]}();if(t&&(c=t.previousSibling)){p=t.parentNode;if(a=c.getAttribute('data-cfemail')){for(e='',r='0x'+a.substr(0,2)|0,n=2;a.length-n;n+=2)e+='%'+('0'+('0x'+a.substr(n,2)^r).toString(16)).slice(-2);p.replaceChild(document.createTextNode(decodeURIComponent(e)),c)}p.removeChild(t)}}catch(u){}}()/* ]] */ /script or downloaded from CADTH’s website: http://www.cadth.ca Cite as: Tran K, Polisena J, Coyle D, Coyle K, Kluge E-H W, Cimon K, McGill S, Noorani H, Palmer K, Scott R. Home telehealth for chronic disease management [Technology report number 113]. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2008. Production of this report is made possible by financial contributions from Health Canada and the governments of Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Northwest Territories, Nova Scotia, Nunavut, Ontario, Prince Edward Island, Saskatchewan, and Yukon. The Canadian Agency for Drugs and Technologies in Health takes sole responsibility for the final form and content of this report. The views expressed herein do not necessarily represent the views of Health Canada or any provincial or territorial government. Reproduction of this document for non-commercial purposes is permitted provided appropriate credit is given to CADTH. CADTH is funded by Canadian federal, provincial, and territorial governments. Legal Deposit – 2008 National Library of Canada ISBN: 978-1-897465-76-9 (print) ISBN: 978-1-897465-77-6 (online) H0475 – December 2008 PUBLICATIONS MAIL AGREEMENT NO. 40026386 RETURN UNDELIVERABLE CANADIAN ADDRESSES TO CANADIAN AGENCY FOR DRUGS AND TECHNOLOGIES IN HEALTH 600-865 CARLING AVENUE OTTAWA ON K1S 5S8 Canadian Agency for Drugs and Technologies in Health Home Telehealth for Chronic Disease Management Khai Tran, MSc PhD1 Julie Polisena, MSc1 Doug Coyle, MA MSc PhD2 Kathryn Coyle, BScPhm MSc3 Eike-Henner W. Kluge, PhD4 Karen Cimon, MLT1 Sarah McGill, BSc MLIS1 Hussein Noorani, MSc1 Krisan Palmer, RN5 Richard Scott, PhD6 December 2008 1 Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, ON Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON 3 Coyle Consultancy, Ottawa, ON 4 Department of Philosophy, University of Victoria, Victoria, BC 5 Atlantic Health Sciences Corporation, Saint John, NB 6 Global eHealth Research and Training Program, University of Calgary, Calgary, AB 2 Reviewers These individuals kindly provided comments on this report: External Reviewers Silvana Bosca, BSc.P.T Director, Research and Development Telehealth Coordinator Health Region A Bathurst, NB Edward M. Brown, MD BM CCFP(EM) CEO The Ontario Telemedicine Network Toronto, ON Marion E. Jones, PhD Economics Associate Professor University of Regina Regina, SK Rick Audas, BBA MBA MA (Econ) PhD Assistant Professor, Faculty of Medicine Memorial University of Newfoundland St. John’s, NL Brian Hutton, MSc Methodologist OHRI Ottawa, ON Natasha Wiebe, MMath PStat Research Associate University of Alberta Edmonton, AB Nola M. Ries, MPA LLM Research Associate, Health Law Institute University of Alberta Adjunct Assistant Professor, Faculty of Human & Social Development University of Victoria Victoria, BC Tanya Horsley, PhD Research Associate, RCPSC Department of Epidemiology and Community Medicine University of Ottawa Ottawa, ON CADTH Peer Review Group Reviewers Penny Jennett, BA MA PhD CCHRA(C) Professor Emeritus, Faculty of Medicine University of Calgary Calgary, AB Michelle L. McIsaac, MA Health Economist University of Sydney Sydney, AU Industry: The following manufacturers were provided with an opportunity to comment on an earlier version of this report: McKesson Canada, New IT Healthcare, Philips Medical Systems Canada, Honeywell HomMed. All comments that were received were considered when preparing the final report. This report is a review of existing public literature, studies, materials, and other information and documentation (collectively the “source documentation”) that are available to CADTH. The accuracy of the contents of the source documentation on which this report is based is not warranted, assured, or represented in any way by CADTH, and CADTH does not assume responsibility for the quality, propriety, inaccuracies, or reasonableness of any statements, information, or conclusions contained in the source documentation. i Home Telehealth for Chronic Disease Management CADTH takes sole responsibility for the final form and content of this report. The statements and conclusions in this report are those of CADTH and not of its Panel members or reviewers. Authorship Khai Tran, the research lead, coordinated the research project and wrote the clinical sections of the report. Khai Tran and Julie Polisena selected studies and extracted, tabulated, and analyzed data. Julie Polisena participated in the clinical review and the writing of the clinical sections, performed the primary economic analysis (cost analysis), and wrote the section on home telehealth programs in Canada. Karen Cimon contributed to article selection, study quality assessment, data extraction, tabulation of data including the table of technologies available in Canada, and preparation of the report. Sarah McGill was responsible for the design and execution of the literature search strategies, for the associated appendix, and for the bibliographies. Doug Coyle and Kathryn Coyle were responsible for the economics sections. They selected studies; extracted, tabulated, and analyzed data; and wrote the economic sections of the report. Eike-Henner W. Kluge contributed to research and acquisition of data on the ethical and legal issues, analysis and interpretation of data, and writing of the ethics and legal section. Hussein Noorani assisted in the conception and design of the project and reviewed the health services impact section. Krisan Palmer contributed to the conception and definition of the research questions, provided consultations during development and execution of the study, and approved the document. Richard Scott contributed to conceptual development of the study, provided consultations during development and execution of the study, and approved the document. All authors critically reviewed and commented on the draft report. Acknowledgements The authors are grateful to Pat Reynard for project management support, to Krystle Griffin for coordination with external reviewers, and to Don Husereau for critical reading of the report and feedback. Conflicts of Interest No conflicts of interest were declared by the authors. Dr. Edward Brown is the CEO of The Ontario Telemedicine Network, which manages one of the telehomecare programs that are listed in the study. Home Telehealth for Chronic Disease Management ii iii Home Telehealth for Chronic Disease Management EXECUTIVE SUMMARY Issue The in-home management of chronic diseases that occur in an aging population presents a challenge to the Canadian health care system. The issues include the improvement and maintenance of patients’ quality of life (QoL) and health status, the avoidance of unnecessary trips to emergency departments, a reduction in hospital readmissions, and a reduction of costs. Objective The aim of this review was to systematically evaluate the clinical benefit and to review the costeffectiveness of home telehealth versus usual care or no care for the management of diabetes, heart failure, and chronic obstructive pulmonary disease (COPD). Other chronic diseases that could be managed by using home telehealth; the criteria and tools that are used to identify eligible patients; the strategies for the integration of home telehealth into the Canadian health care system; the technologies that are available in Canada; the health care resource implications; the risk management frameworks; and the ethical, legal, and psychosocial issues were also presented. Questions and Findings 1. What chronic diseases have been managed through real-time and asynchronous home telehealth approaches in Canada and internationally? This review covers diabetes, heart failure, and COPD. In addition, home telehealth has been used in Canada and elsewhere to manage other chronic diseases, including cardiovascular diseases, hypertension, asthma, renal failure (hemodialysis, peritoneal dialysis), chronic wound care, HIV/AIDS, mental health (bulimia nervosa, dementia, Alzheimer disease, depression, schizophrenia), inflammatory bowel disease, pediatric oncology, sleep disorders, cancer, cystic fibrosis, chronic brain injury, chronic migraine, chronic pain, arthritis, and obesity. 2. What criteria and tools have been developed to identify patients for whom the provision of home telehealth services would be suitable? Criteria and tools that could be used to identify patients for whom the provision of home telehealth would be suitable were not found. This remains an essential area for future research if home telehealth is to become an integral part of health care services delivery. 3. What strategies could be, or are being, used for the integration of home telehealth into existing delivery models in Canada? Six of 10 Canadian provinces have established home telehealth programs. Other jurisdictions and health authorities have pilot or planned projects. 4. What have been the clinical outcomes when chronic medical conditions are managed through real-time and asynchronous home telehealth in comparison with regular home care? A systematic review was performed to examine the clinical outcomes of home telehealth compared with those of usual care. In this report, home telehealth was classified as home telemonitoring, which involves data transmission and audio or video monitoring, and Home Telehealth for Chronic Disease Management iv telephone support, where patients are followed up using telephone calls. Usual care was the only comparator that was identified. Seventy-nine reports describing 78 unique studies were selected for inclusion. Of these, 26 studies examined type 1 and type 2 diabetes, 35 examined heart failure, nine examined COPD, and eight examined mixed chronic diseases. The study quality varied from very high (18 RCTs) to very low (three observational studies). Among patients with diabetes or heart failure, home telehealth interventions were generally found to be clinically effective (better glycemic control and lower mortality). Studies on COPD reported a higher mortality among patients using home telehealth. The number of studies, however, is small (n=1 for home telemonitoring and n=3 for telephone support), so the outcomes should be interpreted with caution. In terms of health services utilization, the study results were more varied. The overall trend suggests that patients using home telehealth interventions use fewer health services, such as hospitalizations, emergency department visits, and bed days of care. In contrast, patients in the home telehealth group had a greater number of primary care, specialist, office (visit to family physician, specialist, nurse), and home care visits. The number of studies on these outcomes was limited (n<5), so the findings must be interpreted with caution. No patient adverse events were reported in any of the studies. QoL and patient satisfaction outcomes were qualitatively reviewed for diabetes, heart failure, COPD, and mixed chronic diseases. QoL and patient satisfaction were measured using various instruments. The study results indicate that home telehealth interventions were similar or favourable to usual care in terms of QoL, patient satisfaction, adherence to treatment, or compliance. 5. What technologies have been available in Canada to provide home telehealth for chronic medical conditions? Equipment and the accompanying software are available in or to Canada and offer an array of complexity, modalities, and approaches (patient monitoring, prompts, reminders). Peripheral devices are used to measure blood pressure, pulse, respiration, glucose, and body temperature. 6. What have been the economic impacts of using real-time and asynchronous home telehealth for chronic medical conditions? The review adopted a strategy in which full economic evaluations (considering incremental costs and outcomes) and cost analyses (considering only costs) were included. No attempt was made to quantitatively synthesize the studies that were identified. Instead, data from all included studies were summarized and appraised to identify common results and the related strengths and weaknesses. Twenty-two studies were found to be relevant for inclusion in the literature review. One study was a formal full economic evaluation (cost-utility study). The others were cost- v Home Telehealth for Chronic Disease Management analyses or cost-minimization analyses. No published study of home telehealth involved a formal assessment of utilities or the impact of the program on long-term outcomes. Most of the studies (12) focused on home telehealth for patients with heart failure. Five studies focused on patients with diabetes, and three focused on patients with COPD. The two remaining studies included patients with different diseases (both studies included patients with diabetes, heart failure, and COPD). Most of the studies found that home telehealth was cost-saving from the health care system perspective. This was consistent by disease area and by the mode of home telehealth. The quality of these studies in terms of economic evaluations, however, was very poor, so the validity of the study results was questionable. Most of the studies included only comparisons of costs and can not be considered full economic evaluations. Thus, their relevance to decision makers is limited. 7. What are the foreseeable health human resource implications of implementing real-time and asynchronous home telehealth programs? The health care professional-patient relationship is based on good faith, loyalty, and trust. Because home telehealth is not yet an established part of the education and training of health care professionals, targeted professional education and training should precede the application of home telehealth. The success of home telehealth depends on the skills and knowledge of the home telehealth provider. For instance, the qualifications of response personnel in call-in centres or who monitor patient data must be assessed and comparable with those from whom the patients would otherwise receive care (for example, physicians). 8. and 9. What are the foreseeable privacy and ethical concerns associated with the use of real-time and asynchronous home telehealth from a risk-management perspective? The ethical, legal, and psychosocial issues in home telehealth fall into four categories: patient-centred issues, professional issues, technology issues, and issues that derive from the social expectations in the Canada Health Act. Patient-centred issues include privacy and confidentiality, informed consent, patient selection, and the psychosocial implications resulting from the medicalization of the home environment. Professional issues centre on liability and malpractice, because home telehealth involves increased patient participation in their own care, and on training, because home telehealth is an uncommon mode of health care delivery. Technology issues centre on reliability, privacy, and safety. The evidence suggests that these issues present no insurmountable ethical or legal problems and that, in many aspects, home telehealth is more advantageous than current models of health care delivery for the conditions that are being studied. There are ethical and legal concerns about the unique patient identifiers that are necessary for home telehealth to function properly. Current evidence suggests that home telehealth, when appropriately implemented, follows the five principles of the Canada Health Act. Home Telehealth for Chronic Disease Management vi Conclusion Despite the limited evidence, this assessment indicates that, overall, home telehealth is effective and that it can reduce health resource use. The economic studies were highly heterogeneous. More studies of a higher methodological quality are needed to give greater insights into the potential cost-effectiveness of home telehealth interventions. A framework for such studies is suggested. Home telehealth is a useful addition to Canadian health care delivery. It has been applied in the management of several chronic diseases. Many ethical, legal, and psychosocial issues that may arise can be solved using existing models. Some issues regarding the criteria for identifying suitable patients, liability, reimbursement, and unique patient identifiers, which are crucial to home telehealth implementation, require further discussion. vii Home Telehealth for Chronic Disease Management ABBREVIATIONS AIDS acquired immunodeficiency syndrome BDOC bed days of care CI confidence interval COPD chronic obstructive pulmonary disease CHA Canada Health Act CHF congestive heart failure DALY disability adjusted life years FEV1 forced expiratory volume in 1 second HbA1c glycosylated hemoglobin HIV human immunodeficiency virus LOS length of stay NYHA New York Heart Association QALY quality adjusted life years QoL quality of life RCT randomized controlled trial RR relative risk SE standard error Home Telehealth for Chronic Disease Management viii ix Home Telehealth for Chronic Disease Management TABLE OF CONTENTS EXECUTIVE SUMMARY .............................................................................................................iv ABBREVIATIONS .....................................................................................................................viii 1 INTRODUCTION ....................................................................................................................1 1.1 Background ...................................................................................................................1 1.2 Overview of Technology................................................................................................1 2 THE ISSUE .............................................................................................................................2 3 OBJECTIVES .........................................................................................................................2 4 CLINICAL REVIEW ................................................................................................................3 4.1 Methods.........................................................................................................................3 4.1.1 Literature search strategy..................................................................................3 4.1.2 Selection criteria and method ............................................................................4 4.1.3 Data extraction strategy.....................................................................................5 4.1.4 Strategy for quality assessment ...................................
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