Journal_1_2014_final_WEB

Scientific Communication
Barriers to patient
As part of the WSD, interviews were performed with patients
who declined to participate in the intervention 13 . In
the WSD, 36.7% of invited individuals did not want to
take part after receiving a home visit and being provided
information on study goals and inclusion requirements.
Of the patients that declined to participate in the study
only 22 of 61 patients accepted to go through an interview
regarding their reasons for not taking part in the trial. The
answers obtained from the interview can be categorized
into the following:
Requirements for technical competence and operation
of equipment.
Some patients declined because they felt that they were
unable to operate equipment in a satisfactory manner. As
an example some found it difficult to get the equipment
to work and others had problems with false alarms due
to faulty readings.
Threats to identity, independence, and self-care.
Some patients felt that the required medical equipment
contributed to a feeling of morbidity, and furthermore,
thought that the equipment should be used by sicker individuals.
Some patients also found that the regular measurements
required posed a threat to their independence.
Expectations of and experienced disruptions to health
and social care services.
Some patients were quite satisfied with their current treatment
approaches and health care professionals, and they
did not want to make any changes to these arrangements.
The authors concluded that forthcoming projects related
to telemedicine must assure that intervention does not
threaten patient self-perception of independence, their
ability to use required equipment, or inadvertently cause
individuals feel sicker than they actually are. Also, time
should be spent on thoroughly introducing and clarifying
of all potential sources of uncertainty among the patients.
DISCUSSION
The WSD trial has demonstrated reduced mortality from
8.3 to 4.6% by using telemedicine to manage chronic diseases
(i.e., chronic lung disease, chronic heart disease, and
diabetes). The number of hospital admissions was reduced
by 11% during a 12-month period. Patient health-related
quality-of-life remained unchanged. The achieved savings
however, were less than the costs related to establishing
and implementing telehealth approaches, and overall costs
per patient was increased by 15%.
Central to interpreting the methodology and results of
the WSD is the choice of patient sample, which included
a heterogeneous group of individuals with either of three
chronic diseases, i.e., diabetes, chronic obstructive lung
disease, or chronic heart disease. So far, the WSD study
organizers have published the effects of telehealth on the
group as a whole (9 , and uncertainty remains on diseasespecific
outcomes within the specific patient subgroups.
Important issues have thus not yet been addressed in the
primary articles.
The WSD was criticized in a BMJ commentary 14 for not
being precise in describing the influence caused by the
sponsor (i.e., the Department of Health). Also, criticism
has been raised that the Ministry of Health presented preliminary
study data in a fairly positive manner before these
data underwent rigorous peer-review and publication. Although
the randomized design can secure the study design
internal validity, it can also be potentially problematic 15 .
There is a danger that organizational gains are overlooked
because improvements of the organization were not allowed
during the trial. A lack of blinding of information
on participating patients and healthcare professionals can
additionally lead to bias in favor of telemedicine benefits.
If an á priori expectation is that telemedicine will contribute
strongly in solving imminent demographic challenges
in the healthcare system, the results from WSD are disappointing.
The study did not show an overall reduction in
costs per patient; nor did it show cost-effectiveness of using
telemedicine. On the other hand, the study demonstrated
a health gain by a significant reduction in patient mortality
in the telemedicine group versus conventionally treated patients.
Therefore, more clinical trials are needed before we
can definitively assess the potential of telemedicine use for
special patient subgroups, and to increase our knowledge
of specific telemedicine mechanisms that govern health
outcomes. Furthermore, it is important to stress that the
technologies studied in the WSD are fairly old, having
been selected for this project in May of 2008.
The WSD thus fits nicely into the overall picture of
telemedicine that was clarified in a review from 2012 6 .
Telemedicine may have positive clinical impact, but only
rarely will it, in its current format, reduce overall healthcare
costs. Should we overtly reject the idea of telemedicine
being a possible solution for the future problems of
healthcare delivery in an increasingly elderly population?
Should we simply discount the initiatives for testing new
telemedicine solutions for people suffering from chronic
EWMA Journal 2014 vol 14 no 1 47