Journal_1_2014_final_WEB

10.8% lower (statistically significant) in the intervention
group, corresponding to an odds ratio of 0.82. The difference
could be ascribed to the number of patients admitted
to hospital within the first 3 months of the study period.
Correction for differences in baseline data and patient useof-services
in the 3 years before enrollment did not change
the conclusion. Overall mortality in the control group
was 8.3% and in the intervention group 4.6% which is
a statistically significant difference, corresponding to an
odds ratio of 0.5.
Effect on health-related quality-of-life
In the study examining health-related quality-of-life,
the sample size was calculated on the basis of detecting
an improvement of 0.3-fold of the standardized average
of the effect variables, and included a total of 1,650 patients
10 . Health-related quality-of-life was measured with
the Health Survey Short Form SF-36 v2. Data were
collected by personal interview at the time of baseline
measurement acquisition and also by postal questionnaires
after 4 and 12 months of enrollment. A total of 1,573
patients took part in the measurements at inclusion. After
12 months 62% returned the questionnaire.
The trial showed that patients using telemedicine had no
statistically significant better effect on quality-of-life, fear,
or depression. The authors concluded that the study did
not demonstrate any detrimental effect of using telemedicine
on patient health-related quality-of-life.
Economic effects
The purpose of the economic analysis was to estimate
the costs and cost-effectiveness of telehealth. Data from
questionnaires to patients and health professionals taking
part in the study were used 11 . The study adopted a health
and social services perspective including use of hospitals,
primary care clinics, and other sources of community care.
Concerning the costs of the intervention, the following
were assessed: Telemedicine equipment, licenses, mounting
of equipment and its maintenance, and personnel
used in the telehealth monitoring teams. The drop-out
rate from questionnaire return to investigators was 38%.
The authors estimated that the groups were comparable
overall even though there were some statistically significant
differences. For example the proportion of patients with
heart failure was higher in the usual care group whereas
the proportion of patients with COPD was higher in the
telemedicine group. Table 3 shows that the costs per patient
in the telehealth group were 15% higher compared
to the control group (during a 3-month period before
Table 3. Average costs per patient ± SEM during the period
from months 9-12 a . Numbers in 2009 GBP
Type of cost Control group Telemedicine group
Hospital costs 666.2 ± 74.9 518.7 ± 67.8
Primary care costs 244.2 ± 21.4 211.0 ± 17.1
Care home respite costs 1.5 ± 1.5 1.7 ± 1.7
Community care costs 193.0 ± 39.6 140.3 ± 29.6
Mental healthcare costs 8.4 ± 4.5 5.8 ± 2.6
Day care costs 42.7 ± 11.4 28.2 ± 9.6
Adaptations costs 1.9 ± 0.6 2.0 ± 0.5
Equipment costs 0.4 ± 0.2 0.5 ± 0.2
Medication costs 222 ± 7.4 230.4 ± 7.1
Total costs excluding telehealth
delivery and equipment
1380.3 ± 102.4 1138.6 ± 88.6
Total costs including telehealth
delivery and equipment
1389.7 ± 102.6 1596.1 ± 88.6
SEM = standard error of the mean. a Based on [11, Table 2]
the 12-month study enrollment). The main reason is that
the average annual cost per participant for the telehealth
equipment and support was £1,847 per patient for whom
cost data were available at the 12-month final follow-up.
These costs more than outweighed the savings in hospital
costs. However, none of these results were significantly
different between the two patient groups.
Two sensitivity analyses were performed on the consequences
of an 80% reduction of telehealth equipment
costs and an assumption of full utilization of equipment
capacity 11 . Both scenarios show a reduction in the costs per
patients using telehealth by 7–8%, but the costs remained
higher than in the control group. The authors calculated
the incremental costs per gained quality-adjusted life-year
to be £92,000 and concluded that telehealth is not costeffective
when used as an add-on to standard patient support
and treatment.
Organizational effects
An evaluation of the organizational factors having an impact
on telehealth implementation was performed in parallel
to the randomized study 12 , as a longitudinal case-study.
Data collection was performed by triangulating data from
interviews with health personnel and administrator, from
observations during implementation, and from document
analysis. This evaluation showed that the implementation
lessons and organizational learning amongst the trial sites
were hindered by the requirements of the randomized trial
design. An example of this includes the possible lack of
directed intervention to patients with special needs and
the lack of experienced-based adjustment during the trial
among the healthcare professionals. The full organizational
potential is thus not expected to be achieved.
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EWMA Journal 2014 vol 14 no 1