Telemonitoring for COPD – lessons learned and cost evaluation

Keir Lewis, Sarah Rees, Jeanette Munn, Joe Annandale, Claire Hurlin, Lynda Anderson, Daniel

Warm, Hayley Blyth, Leo Lewis

1-3rd March, Kings Fund London

Summary• Disease prevalence and setting

• Combining results from a RCT pilot with experience of a current larger study to estimate cost-effectiveness

• Other lessons we have learned

Respiratory diseases• Kill more than 1 in 4 people in the UK1

• Most common form of chronic illnesses1

• “Strategies aimed at preventing admissions and instituting supportive environments in the community ….would dramatically improve the availability of beds for unplanned episodes of care’’2

• COPD is the only 1 of the top 5 causes of death that is still

rising3 and costs over £900m /yr in direct costs alone4

1.Burden of Lung Disease. A statistics report from the British Thoracic Society,2001. http://www.brit-thoracic.org.uk/pdf/BTSpages.pdf

2. Designed for Life: Creating world class Health and Social Care for Wales in the 21st Century, WAG, May 2005. Available at: http://www.wales.nhs.uk/documents/designed-for-life-e.pdf

3. Goldcopd.com4. Chief Medical Officer. On the state of the Public health: Department of Health, 2005

National Strategy

Local Strategy

Carmarthenshire, Wales

•Population 240,000

•19.5% elderly, ex-industrial, semi-rural,

•Pockets of deprivation, 22% adults smoke

•Higher than average COPD referral rate to hospital

Our sad figures 2004(National Audit RCP&BTS 2003)

Admissions per 100,000

349 183

Prev Admissions 75% 64%

No social support 83% 57%

Still smoking 50% 39%

D/C > 15 days 28% 16%

PPH UK average

Telehealth

Costs:EqptStaff(Start-upOngoing)

Savings:ContactsPrimary CareSecondary Care

Projected savings based on a small pilot RCT

• 40 patients with severe COPD post PR• 20 standard care12 months• 20 received Tm 6 months then 6 months Standard Care

http://www.betterbreathing.org

• During 6 months active monitoring (ITT)Telemonitoring (n=20)

Standard Care(n=20)

P-value

AE attendances 6 13 0.16

Hospital admissions

4 7 0.43

GP Contacts (Chest)

46 82 0.02

GP Contacts (other)

23 52 0.10

Journal COPD 2010; 7:44-50 J Telemed Telecare 2010; 16: 253-9

Would you consider using telehealth routinely for COPD?

0

1

2

3

4

5

6

stronglydisagree

disagree neither agree stronglyagree

• Phase 2, WAG funded • 2 centre, powered, crossover RCT• Any admissions COPD within last 2 years• Irrespective of PR or severity

• Registered http://www.controlled-trials.com/ISRCTN18443546

Patient using Tm

90% ‘technical’ alerts Telecare+ team

10% true clinical alertsCDM / hospital nurses

1% GPConsultant

Costs

Estimated costs for Docobo™ for first year

AE attendances saved 84x £691 = £58,044

Hospital admissions saved 36 x £21311 = £76,716

GP contacts saved780x £322 = £24960

TOTAL Savings Yr 1 = £159,720

Start-up Costs £115,783

Running Costs £35,147

TOTAL Costs Yr 1 £150,930

1. Int J Clin Pract 2007; 61: 1112-1120

2. Unit Costs of Health and Social Care 2010. http://www.pssru.ac.uk/uc/uc2010contents.htm

Costs

Estimated costs for Tunstall for first year

Tunstall Docobo Docobo-GPRS

Start-up £198,512 £115,783 £130,183

Ongoing £35,055 £35,147 £35,147

TOTAL Yr 1 -£73,847 +£8,790 -£5,610

Potential savings per Yr (after Yr 1)

£124,665 £124,573 £124,573

• Very many assumptions with data but• Using Telecare+ staff for most alerts and a CDM

/respiratory nurse back-up

…could save around £1000 /patient/yr….after a big initial outlay in money and time

• Approximate cost savings of Pulmonary Rehab1

1. Griffiths et al; Thorax 2001; 56: 779-884

Other lessons?• Phone and power sockets far apart• Non BT telephone providers• Many have mobile phones only• Instructions on equipment!• Pulse oximeters!

•Changing patient behaviour is difficult•Changing staff behaviour is much more difficult!

Other lessons?• Clinicians will remain sceptical until RCTs

(well meaning managers can be driven by political pressures or led by Industry)

• Need an installation / technical support team that is NOT clinical

• Start with simplest technology and small numbers of motivated (and stable?) patients

Summary• Disease prevalence and setting

• Combining results from a RCT pilot with experience of a current larger study to estimate cost-effectiveness

• Other lessons we have learned

Hospital• Dr Keir Lewis• Joe Annandale• Dr Syed Yasir• IT / EBME

• CDM Team

• Claire Hurlin• Lynda Anderson,• Helen Rees• Hayley Blyth (sec)

•Informing Healthcare Wales•Leo Lewis•Daniel Warm•Sarah Rees

•Careline+ Telecare Team•Jeanette Munn et al

Also . ..our patients!