Hci315 Telehealth and Telemedicine

Purpose

The purpose of this Activity is to demonstrate your understanding of the concepts learned in this week’s readings/ educational videos.

Action Items

• Explain how telemedicine help in the delivery of healthcare in the rural areas?

Submission Instructions

Complete and submit this assignment according to your professor’s instruction Week 4 Interactive Activity is now accessible in the Course Materials and Activities section under Module 4. The activity is titled “W04: Interactive Activity.”

To successfully complete this activity, please follow the provided instructions:

1. Carefully read the attached article, which is relevant to the topic of the week.
2. Answer the corresponding questions for each given answer. Remember to write down the question for each response.
3. Your answers should consist of a minimum of six lines, demonstrating your comprehension of the article content. Take the time to express your thoughts clearly and concisely. It is recommended to double-check for any spelling mistakes before submitting your answers. Using a word document for spelling check is highly recommended.
4. You have two options for submitting your answers: either through text submission or by attaching a word document.

Wade et al. BMC Health Services Research 2010, 10:233
http://www.biomedcentral.com/1472-6963/10/233
RESEARCH ARTICLE
Open Access
A systematic review of economic analyses of
telehealth services using real time video
communication
Victoria A Wade1*, Jonathan Karnon1, Adam G Elshaug1,2, Janet E Hiller1,2
Abstract
Background: Telehealth is the delivery of health care at a distance, using information and communication
technology. The major rationales for its introduction have been to decrease costs, improve efficiency and increase
access in health care delivery. This systematic review assesses the economic value of one type of telehealth
delivery – synchronous or real time video communication – rather than examining a heterogeneous range of
delivery modes as has been the case with previous reviews in this area.
Methods: A systematic search was undertaken for economic analyses of the clinical use of telehealth, ending in
June 2009. Studies with patient outcome data and a non-telehealth comparator were included. Cost analyses, noncomparative studies and those where patient satisfaction was the only health outcome were excluded.
Results: 36 articles met the inclusion criteria. 22(61%) of the studies found telehealth to be less costly than the
non-telehealth alternative, 11(31%) found greater costs and 3 (9%) gave the same or mixed results. 23 of the
studies took the perspective of the health services, 12 were societal, and one was from the patient perspective. In
three studies of telehealth to rural areas, the health services paid more for telehealth, but due to savings in patient
travel, the societal perspective demonstrated cost savings. In regard to health outcomes, 12 (33%) of studies found
improved health outcomes, 21 (58%) found outcomes were not significantly different, 2(6%) found that telehealth
was less effective, and 1 (3%) found outcomes differed according to patient group. The organisational model of
care was more important in determining the value of the service than the clinical discipline, the type of
technology, or the date of the study.
Conclusion: Delivery of health services by real time video communication was cost-effective for home care and
access to on-call hospital specialists, showed mixed results for rural service delivery, and was not cost-effective for
local delivery of services between hospitals and primary care.
Background
Telehealth is the delivery of health care services at a distance, using information and communication technology
(ICT). Telehealth became a separate field of study from
the 1970’s[1], and innovation increased from the 1990’s,
due to the development of new technologies such as cellular phones and the internet[2]. The field was originally
known as telemedicine, but was later broadened to telehealth[3], although these terms continue to be used
interchangeably. It is a subset of e-health, which
* Correspondence: victoria.wade@adelaide.edu.au
1
Discipline of Public Health, The University of Adelaide, North Tce., Adelaide,
5005, Australia
Full list of author information is available at the end of the article
encompasses all uses of ICT in health, including electronic records and decision support systems, however telehealth is particularly characterised by the geographical
separation of patient and provider[4]. Tulu[5] categorises telehealth according to its purpose, such as clinical, educational or administrative; its healthcare
discipline area; the environmental setting; the type of
communication infrastructure used; and the delivery
modality. Telehealth applications are very diverse, ranging from home care for chronic diseases, to remote primary care and subspecialist services such as paediatric
cardiology. Telehealth can be delivered synchronously,
also known as real-time, where the participants interact
with each other simultaneously, and asynchronously,
© 2010 Wade et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Wade et al. BMC Health Services Research 2010, 10:233
http://www.biomedcentral.com/1472-6963/10/233
also known as store-and-forward, in which information
such as X-rays or photographs are collected, transmitted, and then utilised at a later time.
Economic analysis is of central importance to telehealth because the main rationales for its introduction
have been to decrease the cost of delivering health care,
make more efficient use of the health workforce, and
improve timely and equitable access to services. Expansive promises have been made about the potential to
achieve these ends. For example Cusack[6]modelled cost
savings of $4.3 billion a year if telehealth were implemented to facilitate consultations between healthcare
providers in the USA, and this is without considering
savings associated with the provision of care direct to
the patient. However, the ability to deliver these results
needs to be tested in the real world.
Three reviews published in 2000 covered the early economic analyses of telehealth[7-9], and each reported that
the studies were methodologically flawed; lacking appropriate outcome measures, consistency and clarity. Thus,
no conclusions could be made about the cost-effectiveness
of telehealth at that time. In 2001, Roine[10] included economic assessments in a general review of telemedicine,
and noted that most were poor quality cost comparisons
of short term pilot projects, however there was evidence
for cost savings in teleradiology. Whitten’s review in 2002
[11] appraised the quality of telehealth articles containing
cost data, also finding that most were simple cost comparisons, with no definitive comparison of telemedicine to
traditionally organised care. They also noted the difficulty
of generalising results of individual economic studies due
to the variability of applications and the effect of unique
local factors on each telehealth service. Jennet reviewed
the broader socio-economic impacts of telehealth in 2003
[12] and combining cost, cost-effectiveness and health
system utilisation measures into one category, concluded
that there was evidence of benefit of at least fair to good
quality in paediatrics, geriatrics, home care, radiology,
mental health and rehabilitation. Hailey’s review[13] of the
benefits of telemedicine in 2004 rated 25 health economic
analyses, using Drummond’s criteria[14], finding 13
studies met 5 or more criteria and were rated as fair to
good. These indicated cost savings in radiology, geriatric
care, and intensive care, and conflicting evidence in
dermatology.
From 2004, telehealth reviews diverge into specific
areas of clinical practice, some of which contained economic outcomes. Two reviews of telepsychiatry concluded that cost-effectiveness could not be
demonstrated because the volume of consulting was too
low[15,16], while another found conflicting results of
both increased and decreased costs[17]. Brebner[18]
reviewed telehealth provision of accident and emergency
support to primary care, and found seven studies with
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economic data, all indicating cost-effectiveness, however
he concluded that the case was far from proven. A
review of the use of telehealth in intensive care units
found two clinical trials which showed cost savings[19].
Pare [20] summarised a number of reviews of home
care for chronic disease, and reported that very few
detailed economic analyses had been done, leading to
no confirmation of economic viability. However, in
regard to heart failure, Martinez concluded that home
monitoring reduced costs of hospital admissions[21],
and Seto reported initial costs, but substantial long term
cost savings[22]. Recently, Bergmo[23] reviewed the
quality of economic evaluations in telemedicine, and
echoed the earlier findings of highly diverse evaluations,
many of which did not adhere to standard economic
evaluation techniques. Specifically, statistical, sensitivity,
and marginal analyses, and information on the perspective of the studies were often lacking. Whereas this
review pointed out methodological deficiencies, it did
not aim to draw conclusions about the cost-effectiveness
of telemedicine.
These reviews have covered a broad variety of telehealth applications, from synchronous videoconferencing, to remote monitoring, telephone follow-up, call
centre advice lines, email and web-based systems. Each
mode of telehealth has requirements for particular technology, staffing, services, and means of organisation, and
consequently has different cost components, and can
deliver particular types of outcomes. Not surprisingly, it
has been difficult to compare results across studies and
offer consistent guidance for cost-effective health services development. Therefore this review will focus on
one mode of telehealth: real-time or synchronous video
communication.
Real-time video can be regarded as the traditional
form of telehealth, and despite new developments such
as interactive software for chronic disease management,
“smart houses” to measure resident’s activity levels, and
a range of monitoring devices such as scales, glucometers, and peak flow meters now able to send data
remotely, real-time video remains in common use across
a wide range of disciplines, particularly in mental health,
primary care, specialist consulting, and multidisciplinary
teamwork. It has particular requirements, and hence
associated costs, for video screens, connectivity of sufficient bandwidth and reliability for real time communication, physical space at each location, and health
providers’ time to deliver the services. Research has
been able to directly compare remote consultations with
in-person consultations because the health providers’
activities are similar to usual care. The intention of this
review is to synthesise the economic analyses of this distinct form of telehealth, and determine whether conclusions can be made about its value.
Wade et al. BMC Health Services Research 2010, 10:233
http://www.biomedcentral.com/1472-6963/10/233
Methods
Search Strategy
The following electronic databases were searched using
these strategies:
• MedLine: (“Telemedicine”[Mesh] OR “Videoconferencing”[Mesh] OR “Telemetry”[Mesh] OR telehealth
[Title/Abstract] OR telemedicine[Title/Abstract])
AND (cost[Title/Abstract] OR economic[Title/
Abstract]) limited to English language and Humans.
• PsycInfo: (telehealth OR telemedicine OR videoconf* OR telemetry) AND (cost OR economic), limited to humans and peer reviewed journals
• CINAHL: (Telehealth OR telemedicine OR videoconf*) AND (cost OR economic)
• Scopus: (telemedicine OR telehealth OR videoconf*) AND (cost OR economic) for title, abstract or
keywords, limited to articles
• Cost Effectiveness Analysis Registry (CEAR), produced by the Center for the Evaluation of Value and
Risk in Health (CEVR), at the Institute for Clinical
Research and Health Policy Studies at Tufts Medical
Center: searched by the individual words telemedicine, telehealth and video
• NHS Economic Evaluations Database (NHS-EED):
telehealth OR telemedicine OR videoconf*
The time frame for all searches was from the commencement of the databases until June 2009, or 2009
alone, when the database did not allow months to be
specified.
In addition, review articles which were primarily about
economic analysis of telehealth services, or included an
economic component in the review had their reference
lists searched for additional articles.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria were developed to
ensure the review consisted of economic analyses relevant to direct patient care.
Inclusion Criteria
• Economic evaluations of telehealth services which
used synchronous video communication as the
major mode of delivery
• Telehealth services which directly delivered patient
care, either provider to patient or provider to provider, if the latter application was in the context of
direct patient care.
• Health economic analyses that included or cited
health outcomes data obtained from telehealth services. This data included patient health status and
health utilisation measures, but not patient satisfaction measures. Analyses were accepted as cost
Page 3 of 13
minimisation if they either produced original data or
cited evidence that the outcomes of health care
delivery were equivalent or non-inferior for synchronous video compared to usual care. Citations were
checked to see that they were of methodologically
sound research, and could be validly generalised to
the particular telehealth setting, to determine
whether a cost-minimisation analysis could be
undertaken.
Exclusion Criteria
• Articles that did not contain economic data ie
commentary, theory, study design and methodology
articles.
• Articles about telehealth services that were not
about direct patient care ie education, administration
and social uses of the telehealth infrastructure. This
included articles about health provider reimbursement and business models for telehealth services.
• Articles about telehealth services with no or very
little real time video component ie telemonitoring,
store-and-forward of images, telephone, SMS, or
email applications.
• Cost analyses with no health outcomes data.
• Economic analyses where the only health outcomes
were satisfaction data, or where the health outcomes
were not collected equally across comparison groups.
Quality Rating
Articles in the review were assessed according to
Chiou’s grading system of the quality of health economic analyses[24]. This system contains 16 weighted
items developed by an expert committee; some items
are applicable to research in general, such as the clarity
of the study objective, use of reliable and valid health
outcome measures, the methodology for data abstraction, use of statistical analysis, discussion of bias, justified conclusions and disclosure of funding source. Other
items apply particularly to economic analysis, such as a
statement and justification of the economic perspective,
the use of sensitivity or incremental analysis, the length
of the time horizon, the use of discounting, the methodology for cost estimates and measurements, and the
choice of economic model. The reliability and validity of
this method was previously established by testing the
scale with a sample of 60 health economists who each
rated the same set of economic analyses using the criteria. By contrast, other methods for assessing the quality of economic analyses, such as Drummond’s criteria
[14], or the checklists used by the Mair[8] and Bergmo
[23] reviews have been developed by individual experts.
VW and JK graded 3 studies using Chiou’s criteria in
order to reach consensus on the interpretation of the
criteria, and VW graded the remaining papers.
Wade et al. BMC Health Services Research 2010, 10:233
http://www.biomedcentral.com/1472-6963/10/233
Page 4 of 13
Results
Health Outcome Measures
Results of Search
When the purpose of the telehealth service was primarily diagnosis and assessment of patients, diagnostic accuracy was used as an outcome, as well as the related
measure of the percentage of patients referred for
further investigation. However, when patient management was the main intention, a variety of validated
instruments were used to assess patient status, including
the SF-36, the Global Assessment of Functioning, or the
Brief Psychiatric Rating Scale. In some studies measures
were chosen for particular settings, such as time taken
to achieve self-care, patient adherence to treatment, or
quality ratings of medical decisions. In heart failure and
intensive care settings, mortality was also used as an
outcome. Various healthcare usage rates were reported,
such as hospital length of stay, re-admissions, and attendance at emergency departments and outpatient clinics.
In tele-dermatology, a measure often used was the percentage of patients requiring further consultations: a
proxy for patient outcome, as the dermatological problem is taken as resolved if the patient no longer
required specialist care.
Using the strategies described above, MedLine produced
1187 search results, PsycInfo 286, CINAHL 393, Scopus,
1887, CEAR 10, and NHS-EED 197.
The reference lists of 24 review articles that were
entirely or in part about the economic analysis of telehealth were searched, and did not produce any additional studies that met the criteria. A flow chart of
exclusions is shown in Figure 1
Study Characteristics
Table 1 summarises the characteristics of the 36 studies
included in the review. The clinical disciplines delivered
by the telehealth services were diverse: dermatology (7),
mental health (6), paediatric cardiology (4), home nursing (4), intensive care (2), emergency medicine (2), and
neurology (2), and single studies in six medical disciplines (infections diseases, internal medicine, general
practice, cardiology, oncology, and pain management),
and four surgical disciplines (ear nose and throat surgery, orthopaedics, gynaecology, and neurosurgery).
Eighteen of the studies were randomised controlled
trials, 6 were studies of diagnostic accuracy, 5 were
before and after studies, 2 were prospective case control,
2 were retrospective cohort studies, and there was one
each for the categories of non-random trial, prospective
cohort and economic modelling.
Figure 1 Flow chart of study inclusions.
Economic Analysis Characteristics
The economic analyses were classified by their health
outcome measures, with 18 studies assessed as being
cost-consequences, reflecting the diversity of measures
described above, 13 cost-minimisation, two cost-
Wade et al. BMC Health Services Research 2010, 10:233
http://www.biomedcentral.com/1472-6963/10/233
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Table 1 Summary of Economic Analyses
Article
Service
Setting
Clinical
Discipline
Study
Type
Ec Analysis Type &
Quality Score
Technology &
Connectivity
Perspective Cost
Telehealth outcome
Outcomes vs usual care
Ruskin 2004
[51]
Rural
outpatient
Psychiatry
RCT
CMA 84
Computer,
ISDN
Health
service
More
Same
Modai 2006
[72]
Rural
outpatient
Psychiatry
ProspCC
CCA 45
Not specified,
ISDN
Health
service
More
Same
O’Reilly 2007
[73]
Rural
outpatient
Psychiatry
RCT
CMA 54
VC, ISDN
Health
service
Less
Same
Shore 2007
[29]
Rural
outpatient
Psychiatry
DiagAcc
CMA 57
VC, ISDN
Health
service
Mixed1
Same
Crow 2009
[35]
Rural
outpatient
Psychology
RCT
CEA 77
Not specified, T1
line
Societal
Less (HS
less)
Less2
Persaud 2005
[53]
Rural
outpatient
Psychiatry &
dermatology
RetCoh
CMA 46
Not specified,
384 kbits/sec
Societal
Less (HS
more)
Same
Oakley 2000
[74]
Rural
outpatient
Dermatology
RCT
CCA 15
Computer, ISDN
Patient
Less
Same
Loane 2001a
[32]
Rural
outpatient
Dermatology
RCT
CMA 70
Computer, ISDN
Societal
Less (HS
more)
Same
Loane 2001b
[59]
Rural
outpatient
Dermatology
RCT
CMA 40
VC, ISDN
Health
service
More
Same
Chua 2001
[36]
Rural
outpatient
Neurology
RCT
CCA 25
VC, ISDN
Health
service
More
Less
Bergmo 1997 Rural
[52]
outpatient
Ear nose &
throat
RetCoh
CMA 68
VC, ISDN
Societal
Less (HS
less)
Same
Ohinmaa
2002[33]
Rural
outpatient
Orthopaedics
RCT
CMA 71
VC, ISDN
Societal
Less (HS
more)
Same
Bishai 2003
[62]
Rural
outpatient
Gynaecology
DiagAcc
CCA 84
VC, T1 line
Societal
More
More
Pronovost
2009[31]
Rural
outpatient
Pain
management
RCT
CMA 93
VC, broadband
Societal
Less (HS
more)
Same
Johnston
2000[39]
Home care Nursing
RCT
CCA 19
Not specified
Not specified
Health
service
Less
Same
Smith 2002
[42]
Home care Nursing(CPAP)
DiagAcc
CMA 25
Custom, PSTN
Health
service
Less
Same
Bohnenkamp
2004[41]
Home care Nursing
NRT
CCA 35
TV, PSTN
Health
service
Same
More
Finkelstein
2006[38]
Home care Nursing
RCT
CCA 67
TV, PSTN
Health
service
Less
More
Chan 2000
[58]
Residential
care
DiagAcc
CCA 32
VC, ISDN
Health
service
Less
Less3
DeMaio 2001
[43]
Home care Infectious
diseases
B&A
CMA 15
Vphone, ISDN
Health
service
Less
Same
Jerant 2001
[37]
Home care Cardiology
RCT
CCA 67
Not specified
PSTN
Health
service
Less
More
Eron 2006[40] Home care Internal
medicine
ProspCC
CCA 67
Not specified
PSTN
Health
service
Less
More
Rendina 1997 Rural
[75]
inpatient
Paediatric
Cardiol
B&A
CBA 56
VC, T1 line
Health
service
Less
Same
Sable 1999
[55]
Rural
inpatient
Paediatric
Cardiol
DiagAcc
CBA 27
Computer ISDN
Health
service
Less
More
Sicotte 2004
[56]
Rural
inpatient
Paediatric
Cardiol
DiagAcc
CEA 63
VC, ISDN
Health
service
More
More
Dowie 2007
[71]
Rural
inpatient
Paediatric
Cardiol
ProspCoh CCA 85
VC, ISDN
Societal
Mixed4
(HS more)
More
Ehlers 2008
[76]
Rural
inpatient
Neurology
EcModel
Computer, Not
specified
Societal
Less (HS
more)
More
Dermatology
CUA 65
Wade et al. BMC Health Services Research 2010, 10:233
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Table 1 Summary of Economic Analyses (Continued)
Wong 2006
[64]
Rural
inpatient
Neurosurgery
RCT
CCA 64
VC, ISDN
Health
service
More
Same
Noble 2005
[61]
Rural
inpatient
Emerg med
RCT
CCA 60
Not spec, ISDN
Societal
More
Same
Duchesne
2008[57]
Rural
inpatient
Emerg med
B&A
CCA 34
VC, T1 line
Health
service
Less
More
Kunkler 2007
[60]
Rural
inpatient
Oncology
RCT
CMA 64
VC, ISDN
Health
service
Less
Same
Loane 2000
[45]
Hosp to
PCare
Dermatology
RCT
CMA 54
VC, ISDN
Health
service
More
Same
Wootton
2000[46]
Hosp to
PCare
Dermatology
RCT
CCA 81
VC, ISDN
Societal
More
Same
Jacklin 2003
[47]
Hosp to
PCare
General
practice
RCT
CCA 92
Computer, ISDN
Societal
More
Same
Rosenfeld
2000[50]
Specialist
on-call
Intensive Care
B&A
CCA 80
Computer, Not
specified
Health
service
Less
More
Breslow 2004
[49]
Specialist
on-call
Intensive Care
B&A
CCA 53
VC, T1 line
Health
service
Less
More
B&A = before and after study, DiagAcc = diagnostic accuracy study, EcModel = economic modelling, NRT = non-random trial, ProspCC = prospective case control,
ProspCoh = prospective cohort, RCT = randomised controlled trial, RetCoh = retrospective cohort study
ISDN = Integrated Services Digital Network, VC = videoconferencing, Vphone = videophone, Hosp to PCare = Hospital outpatients clinic to local health centre
CMA cost-miminisation analysis, CCA cost-consequences analysis, CBA cost-benefit analysis, CEA cost-effectiveness analysis
1. Cost more in 2003, and less in 2005
2. Less effective, but increased patient access to services
3. Worse diagnostic accuracy, but increased patient access to services
4. Cost less for neonates, more for other patient groups
effectiveness, two cost-benefit and one cost-utility study.
Six of the cost-minimisation studies relied on citations
of previous work for health outcomes data; in five of
these the authors cited their own work in the same clinical settings[25-29], and one study cited a very similar
setting[30], therefore these citations were taken as valid
evidence of equivalence. 23 studies took the perspective
of the health services, 12 were societal, and one was
from the patient perspective alone. Using Chiou’s criteria for quality assessment, it was apparent that Criterion 4, which states that if the analysis is carried out on
a subgroup then the subgroups should be pre-specified
at the beginning of the study, was not applicable in 35
of the 36 cases. This criterion was therefore deleted
from the grading, leaving the total quality scores out of
99 rather than 100.
Quality varied widely ranging from 15 to 93 points,
with four studies rated at 25 or less. The criterion least
often fulfilled was having an analytic horizon that
allowed time for all relevant and important outcomes to
be assessed. This was achieved by only 7 (19%) of studies. Other lower scoring criteria were including a justification for the perspective of the study (36%), and
performing an incremental analysis between alternatives
for resources and costs (33%). Most studies met the criteria of presenting their objectives in a clear, specific
and measurable manner (90%) and provided conclusions
that were justified and based on the study results (78%).
There were no clear associations between the quality of
the studies and the clinical discipline, the organisational
model of care, or the year of publication.
Costs and Effects
Overall, 22 (61%) of the studies found telehealth to be
less costly than the non-telehealth alternative, 11 (31%)
found greater costs, 2 (6%) gave mixed results and in
one (3%) the costs were the same. The 8 studies that
reported lower costs from the societal perspective were
looked at in more detail, and 6 of these showed higher
health services costs. Excluding the single study that
reported only on the patient perspective, the results
from the health service perspective were 17 (49%) found
telehealth more costly, 16 (46%) less costly, 1 (3%)
found costs changed from more to less over time, and 1
(3%) found costs to be the same. These differences are
largely accounted for because in delivering services to
rural areas, the health services paid more for telehealth,
but the societal perspective demonstrated cost savings
due to reductions in patient travel[28,31-34]. In studies
where both the societal and the health services perspective showed lower costs, the health services were paying
for health care workers to travel[30,35].
Regarding health outcomes, 12 (33%) of studies found
improved health outcomes, 21 (58%) found outcomes
were not significantly different, 1 (3%) found outcomes
differed according to the patient group, and 2 (6%)
Wade et al. BMC Health Services Research 2010, 10:233
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found that telehealth was less effective. Both of the latter
studies were of outpatient services to rural areas; one
found that more investigations were ordered in a telehealth neurology clinic[36], and the other delivered
treatment of bulimia nervosa by videoconferencing,
which was clinically effective, but less so than in-person
treatment[35]. Neither of these services compromised
patient safety. Table 1 sets out the cost and effectiveness
results of all studies.
The 18 RCTs showed evenly divided results, with 9
studies reporting telehealth to be more costly and 9 less
costly than the non-telehealth comparison, and 15
reported the health outcomes to be the same. The 18
non-RCTs showed results more favourable to telehealth,
with 12 reporting telehealth to be less costly, 3 more
costly, and 3 giving equal or mixed results. Ten reported
improved and 8 similar health outcomes.
There was no indication that the more recent studies
were more likely to be cost saving, or to offer improved
outcomes, nor were there patterns by clinical discipline.
However, when the studies were grouped into five different organisational settings, patterns of costs and
effects became apparent:
1. Home care
There were 8 economic analyses of telehealth in this
group, 7 delivered to the home, and one to an aged care
facility, which was the patients’ normal place of residence. All were conducted from the perspective of the
health care services, with 7 showing cost savings and
one no difference in costs. Three studies were RCTs,
and these reported reduced hospital admissions[37],
reduced transfer to nursing home care[38], and greater
satisfaction, but no other differences in outcomes[39].
Two of the non-random comparisons found the telehealth groups improved their functioning more rapidly
[40,41]. The only study on delivery of services to an
aged care facility showed a mixed result of increasing
accessibility to dermatology services, but reduced diagnostic accuracy. Three of the studies in this group had
low quality ratings, of 25 or less, for their economic analysis; two were small scale feasibility projects[42,43]),
and the third included an economic analysis as part of a
larger study[44].
2. Specialist consultation to primary care
These studies of telehealth from the hospital to local
primary care services were all RCTs, two for dermatology services and one for a variety of specialist consultations. In each study, the telehealth intervention involved
the patient sitting with a general practitioner whilst consulting with the specialist at a hospital via video link,
and the comparison was usual care in which the patient
was referred to the hospital for an outpatient consultation. All studies showed similar patient outcomes and
increased costs for the health services[45-47]. Two of
Page 7 of 13
the economic analysis reported modest time and money
savings for patients, but from the societal perspective,
telehealth remained more costly. Although two of these
studies[45,48] reported that they used both urban and
rural settings, the distances concerned were of the order
of 10 to 20 kms, so they have been classified as local
care.
3. Specialist on-call to hospital
Both of these before and after studies were conducted in
intensive care units, where telehealth provided off-site
intensivist coverage to hospital wards that had not previously had this service available. Each found lower
costs and reductions in patient mortality when the telehealth service was operating; additionally Breslow[49]
reported shorter hospital stays, and Rosenfeld reported
lower complications[50].
4. Rural outpatient care
This was the largest group, with 14 studies, including all
six of the services delivering mental health care, 4 dermatology services, ENT, orthopaedics, gynaecology, and
pain management. Nine of the studies were RCTs, and
of these, 5 showed telehealth was less costly, and 4
showed increased costs. In regard to patient outcomes,
6 RCTs reported that telehealth was as effective as usual
care, and 2 reported reduced effectiveness. Of the 5
non-randomised studies, one showed reduced costs and
4 showed increased costs, and for patient outcomes, one
showed better outcomes and 4 found equal outcomes.
When sensitivity analyses were done, the cost outcomes
depended on the distance between sites, or the frequency of use that was made of the telehealth facilities.
Ruskin[51] found that telepsychiatry was more expensive
if the psychiatrist needed to travel less than 22 miles to
an outlying clinic. Bergmo[52] calculated that ENT teleconsultation became cost-effective if more than 52
patients were seen in a year, Ohinmaa[33] conducted a
similar analysis showing that 80 patients a year were
needed to break even for orthopaedic outpatient teleconsultations, and Persaud[53] calculated that at present
workloads, the telehealth option was more expensive,
but would become less expensive at a practically attainable level. One of the studies in this group was a limited
analysis from the patient perspective only, and it had a
low score (of 15) on the economic analysis quality rating[54].
5. Rural inpatient care
These 9 studies involved specialty clinicians in a central
tertiary level hospital consulting with health providers in
rural and regional hospitals about patients who were
either admitted or were emergency patients, known as
the hub-and-spoke model. Four of the studies were in
the clinical area of paediatric cardiology. Three studies
were RCTs and all showed similar health outcomes to
the non-telehealth alternative, with 2 demonstrating
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increased costs and one lower costs than usual care. The
6 non-random comparison studies found results that
were more favourable to telehealth, with 5 reporting
better and one equal health outcomes, and 5 reporting
reduced costs, and one increased costs. The improved
health outcomes included reduced numbers of patients
transported out of rural areas[55,56], and reduced time
to transportation[57].
Technology
Videoconferencing equipment was used most commonly, in 18 studies, followed by computers (7), home
televisions (2), videophones (1), a custom-designed unit
(1), and unspecified equipment (7). Sicotte[56] noted
that equipment was 78% of the total cost of the telehealth modality of delivery and Chan[58] stated that
their viewstation was the single largest cost of their service. Persaud[53] and Loane[59] both reported that capital costs were the main reason that telehealth was more
costly per consultation, although Loane[59] noted that
equipment prices had reduced by the time of publication to the point that if updated costs were used in their
analysis, telehealth would have been less costly than
conventional care. Kunkler[60] reported that halving the
technology cost would reduce their breakeven point
from 40 to 20 multidisciplinary meetings per year,
although Noble[61] and Ohinmaa[33] found that reducing the annual equipment cost had no impact on the
overall cost outcomes.
For connectivity, 22 studies used Integrated Services
Digital Network (ISDN) lines, which deliver 128 kilobits/second of data each, and four studies used T1 lines,
which are considerably more costly, and can carry 1.5
megabits/second of data. Five studies, all of which were
home care, used the PSTN (Public Switched Telephone
Network), which is the standard low-bandwidth telephone line supplied to households, and three studies did
not specify the connectivity. One study reported using
“broadband”[31], and it was assumed that this meant
Digital Services Lines (DSL). Connectivity was a significant cost for many telehealth services, with Bishai[62]
reporting T1 line charges as their largest single cost,
and Chua[36] noting that the hourly cost of ISDN communication was almost identical to the hourly pay of a
consultant neurologist. Meilonen[63] commented that
differences in telecommunications costs made telehealth
cost-saving in some countries and uneconomical in
others, and Shore[29] found that telehealth changed
from being more costly in 2003 to less costly in 2005,
due to reductions in ISDN line charges. However, sensitivity analyses in some studies showed the cost of connectivity to be irrelevant, for example Jacklin found that
telehealth remained more expensive even if the cost of
telecommunications was reduced to zero, but on the
Page 8 of 13
other hand, Crow[35] found that despite using T1 lines,
telehealth was always less expensive than usual care.
Three studies reported significant technical problems
with their video communication. Persuad[53] said that
29% of their teleconsultations had technical problems,
which took an average of 7.2 minutes each to fix, Sable
[55] found 8 of the 60 transmitted real time echocardiograms had significant technical problems and 5
could not be transmitted at all, and Wong[64] noted
an unacceptably high failure rate of 30.1% for
videoconferencing.
Discussion
The literature on telehealth is extensive, however there
are a relatively small number of economic analyses that
met the review criteria. Identification and review of evidence of equivalence for all economic studies that did
not claim or cite equivalence was beyond the capacity of
this study, and so a pragmatic approach was taken that
excluded economic studies that either did not claim
equivalence or provided no direct or indirect (cited) evidence of effectiveness. Cited evidence of equal health
outcomes was reviewed to establish that the evidence
was relevant to the setting of the economic analysis.
This approach resulted in the exclusion of some wellconducted cost analyses[65-68]. Identification of evidence around the effect of the services analysed in these
studies would increase the pool of evidence on the costeffectiveness of telehealth services.
Those studies in which the only health outcomes
reported were patient satisfaction ratings were also
excluded because telehealth studies report almost uniformly high patient satisfaction, which is likely to be a
positive bias due to social desirability and acquiescence
[69]. Finally, studies were excluded in which the health
outcomes were not comparable, such as where participants receiving telehealth were asked to rate the success
or accuracy of the teleconsultation, but this was not
done for the usual care comparator.
Quality assessment using Chiou’s criteria[24] gave
similar results to those of Bergmo’s recent review of
economic analyses in telehealth[23]. Bergmo reported
that studies were most lacking in providing information
on the perspective of the study, statistical comparison,
sensitivity analyses, and marginal analysis. The criterion
least fulfilled in this review, allowing sufficient time to
assess all important outcomes, was not used by Bergmo,
who developed a new set of criteria based on issues
mentioned in the telehealth literature. By comparison,
Chiou’s criteria were developed and validated by a study
of health economists. Also in line with earlier reviews
[11,23], there was great variability in methodology and
outcome measures. The majority of studies were costconsequences analyses, utilising outcomes specific to
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each service, and therefore a quantitative meta-analysis
could not be attempted.
Overall, nearly two thirds of the studies showed cost
savings in utilising telehealth, according to the perspectives adopted by each. In particular, whenever the
patient perspective was assessed, telehealth was found to
be cost-saving, however when the health services perspective was considered alone, which was possible for
35 of the studies, the proportion reporting cost savings
reduced to half. Most studies showed similar health outcomes, about a third showed improved outcomes, and
only two indicated that telehealth was less effective. Surprisingly, there was no obvious trend for the more
recent studies to indicate more cost savings, which was
expected due to the reduction in technology costs over
time. When seeking to ascertain the particular circumstances within which telehealth was most cost-effective,
the organisational model of care was found to be the
most relevant factor.
Organisational Models
The studies that delivered home care via real time video
produced cost savings; an interesting finding because
reviews of tele-homecare have mainly used telephone
and/or telemonitoring[20,22,70]. The videoconferencing
units used between health care services have been too
expensive for home installation, but this group of studies indicates that various options for home video communication are effective and efficient, allowing for a
greater range of telehealth services to be delivered to
the home than is possible with audio or data communication alone. If the two short-term feasibility studies are
taken out of consideration, one is still left with six studies that show similar results.
Secondly, bringing the expertise of on-call intensive
care specialists to hospital wards via telehealth was
found to lower costs and improve patient outcomes.
This model of care was not a substitution of one
form of delivery for another, but an addition to the
expertise available to an existing service. However,
there were only two studies in this group, and both
were in intensive care, so further work is needed
before conclusions can be generalised to other areas
of hospital care.
When video communication was used between hospitals and local primary care services, there were increased
costs due to medical staff time, and additional costs for
equipment and connectivity. In each study the patients
saved a modest amount of money on travel and reduced
time off work, but this was not sufficient to offset the
greater costs to the health services. The patient outcomes were similar to usual care, therefore it appears
that this model of health service delivery is not economically viable.
Page 9 of 13
Where health care is delivered to rural and remote
areas the economic outcomes are variable for both inpatient and outpatient delivery of care. However in these
settings cost may not be the only factor that determines
implementation, because telehealth is also utilised to
improve accessibility or timeliness of service delivery.
Policies about equity of access, or local political factors,
may contribute to a service that costs more, or is not as
effective, being delivered to a rural area. For example,
although treating bulimia by videoconferencing was less
effective than face to face care, [35], in the real world
there is very limited availability of this service in rural
areas, so the options are no treatment or treatment that
is still genuinely clinically useful. It was notable that
four of the telehealth services to rural inpatients were
for paediatric cardiology. This discipline may be particularly suited to telehealth because it has a combination of
a small number of highly specialised clinicians, only
available in tertiary referral hospitals, high costs of
transporting infants and children for investigation and
consultation, and families that would prefer treatment
closer to home.
Technology
The use of technology is one of the defining characteristics of telehealth, and the costs of technology were critical to the outcomes of many of the studies. The standalone videoconferencing equipment used in most studies
could be very costly, and although prices have come
down over the past decade, expensive tele-presence
units with multiple screens and peripheral devices are
now being marketed as new generation products. The
equipment used in home care was much less expensive,
utilising either the patient’s own television or smaller
video units.
Six of the seven home care studies used the PSTN, ie
the patient’s own telephone lines, which are a minimal
cost to the health service because the patient has already
paid for installation and line rental. The PSTN can be
used for video communication, however the bandwidth
is low, which results in a jerky, reduced quality image,
due to low frame rates, however despite the quality of
the image, these services were still able to produce
improved patient outcomes.
The studies in this review do not reflect the recent
advances in connectivity produced by widespread rollout
of fast broadband or Digital Services Lines (DSL) with
only one recent study utilising DSL[31]. This may be
because of quality and reliability issues with DSL.
Although both types of lines are digital, ISDN lines provide exclusive bandwidth to the purchaser, whereas with
DSL the bandwidth is shared by all the users of the
Internet Service Provider (ISP) that is supplying the connectivity. For DSL to provide good quality real time
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video, it needs to have reliable, high upload and download speeds, but if the ISP has over-sold their available
bandwidth, and/or the health care service has not purchased enough bandwidth, DSL users will have the
experience of poor quality and delays during busy times.
New forms of connectivity, such as wireless broadband
or fast mobile data services have the potential to make
video-based telehealth more flexible and easier to install
in a range of settings, including home care.
Facility space
When using synchronous video communication, the
patient and provider are, by definition, in two different
places at the same time, therefore the cost of each location needs to be taken into account. When one of the
locations is a home, for example when a specialist is oncall or working from home, or the service is being delivered to a patient’s home, there is no additional cost for
office space, but where both locations are health services, each location should be costed. For rural locations, it is often assumed that the patient can attend a
local health service to have a telehealth consultation
with no additional cost to the remote health service, but
this assumes the service has spare rooms, booking, and
reception facilities, which may not be the case.
Health Workforce
One of the reasons that telehealth from a hospital to
local primary health centre was more expensive than
usual care was that a general practitioner was with the
patient during the specialist consultation, hence more
medical workforce time was used per visit[46,47].
Again, the precise model of care is important, because
in serving remote areas this same approach may save
costs by reductions in travel time, or improve patient
outcomes through more immediate treatment[32,52].
There can also be savings in professional time if transfers are avoided, because health care workers are then
not needed to accompany the patient. On the other
hand if urban providers are expected to add telehealth
onto their current workload for no extra recompense,
some resistance would be expected. By contrast, in
home care, the patient is usually unaccompanied and
therefore only one health professional is consulting
with them at a time. However, tele-home care can lead
to additional use of health workforce if the telehealth
visits are added on to, rather than substituting for,
existing services[41].
However, when two health care providers see the
patient at the same time, there is the potential for a
knowledge transfer effect, leading to reduced specialist
referrals, increased and/or improved patient management at the primary care level, and subsequent time and
cost savings. This has been reported for primary care
Page 10 of 13
management of ENT problems[52], colposcopy [62], and
skin conditions[59]. A learning effect leading to 5% less
referrals to orthopaedic outpatient clinics was noted by
one study [33], however this was estimated by local physicians rather than measured directly. Jacklin[47]
hypothesised that joint GP-specialist consultations
would lead to downstream savings through improved
patient management, but their results did not support
this, although the short follow up period of six months
and the broad range of specialist disciplines involved
may not have allowed enough time for a learning effect
to be measurable.
Waiting time
Telehealth can reduce the waiting time to receiving specialist care. For example it has been noted[71] that a visiting paediatric cardiology service was less than monthly,
whereas a teleconsultation could be arranged within two
days, and that telehealth reduced the time for an ENT
consultation from four months to four to six weeks[52].
Researchers have suggested that earlier diagnoses have
value in their own right, by providing reassurance, as
well as from the health effects of earlier treatment[56].
In addition, long waiting times may lead to additional
costs for interim care, or loss of productivity due to
untreated conditions[46], however these issues were not
assessed in the studies included in this review.
Limitations
There were limitations in the quality of many of the
economic analyses that met the criteria for this review,
which in turn limits the strength of the conclusions.
This is of particular importance because reducing cost
and improving efficiency are key arguments for the
introduction of telehealth. The validity of these analyses
could be improved by:
• Longer term studies to detect potential longer term
effects, such as decrease in health services utilisation
that may occur if patient outcomes are improved.
• Measuring additional potential outcomes, such as
knowledge transfer in provider to provider
telehealth.
• Greater homogeneity in study methods and outcome measures, for example, increased use of
QALYs.
• Standardising the method for assessing the quality
of the economic analyses.
It was also not possible to perform a quantitative
meta-analysis of the effects of telehealth because of the
heterogeneity of the outcome measures. A higher proportion of the non-random comparisons showed lower
costs and better outcomes than did the RCTs,
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suggesting that the studies with a lower level of evidence
are biased in favour of telehealth.
Generalisatiblity is a problem for telehealth research as
a whole, due to variability in clinical disciplines, environmental settings, workforce and health care financing.
This review attempts to deal with this by considering
only real time video communication, which has similar
infrastructure and ways of clinical practice, and also by
grouping the results into similar organisational settings;
however this variability means that generalisation should
still be considered with caution. Although there are patterns in the results by organisational setting, numbers in
these groups are low, and the conclusions would be
strengthened by additional research in each area.
Finally, concluding the search at mid-2009, together
with the delay between research and publication, has
meant that more recent research, which could use
higher bandwidth and less costly connectivity, was not
yet available for inclusion.
Conclusion
Reviewing 36 economic analyses of the delivery of health
services by synchronous video communication indicates
that this form of telehealth can offer value to health
care, and it suggests that key factors associated with this
are the settings and particular models of health service
delivery. The health outcomes of the patients were
either equal to or better than conventional care, with
two minor exceptions that did not compromise quality
of care. Therefore the decision as to whether or not to
introduce a telehealth service can be made using costeffectiveness criteria and consideration of the model of
care.
It is concluded that synchronous video delivery is
cost-effective for home care, and for on-call hospital
specialists, and it can be cost-effective for regional and
rural health care, depending upon the particular circumstances of the service. However, it is not cost-effective,
from the health services perspective, for local delivery of
service between hospital specialists and primary care,
particularly due to additional health care staffing. Across
settings, equipment and connectivity costs have been
major factors in setting up telehealth services, but even
as these costs reduce, this will not necessarily make telehealth more cost-effective, unless the other factors such
as health workforce and facility space are also addressed.
Improvement in the quality of economic analyses is
also needed to provide data for more accurate modelling
of the effects of widespread introduction of telehealth
into the health care system.
Acknowledgements
This research was funded by an Australian Postgraduate Award
Page 11 of 13
Author details
1
Discipline of Public Health, The University of Adelaide, North Tce., Adelaide,
5005, Australia. 2Hanson Institute, Institute of Medical and Veterinary
Sciences (IMVS), Frome Rd., Adelaide, 5000, Australia.
Authors’ contributions
VW conducted the searches, analysed the data and wrote the article, JK
analysed some of the data, supervised data analysis, and reviewed the
article, AE supervised and reviewed the article, and JH supervised and
reviewed the article. All authors read and approved the final manuscript.
Competing interests
VW declares that she has a competing interest, being the Medical Director
of Design Networks Pty Ltd, a company that supplies telehealth services.
This position is not salaried, however VW has received reimbursement of
expenses for conference attendance from the company. The company did
not initiate or fund this work. The other authors declare that they have no
competing interests.
Received: 2 May 2010 Accepted: 10 August 2010
Published: 10 August 2010
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1472-6963/10/233/prepub
doi:10.1186/1472-6963-10-233
Cite this article as: Wade et al.: A systematic review of economic
analyses of telehealth services using real time video communication.
BMC Health Services Research 2010 10:233.
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