© Nuffield Trust June 22, 2012

Adam Steventon: Evaluating the Whole System Demonstrator trial

Authors: Adam Steventon, Martin Bardsley Nuffield Trust

© Nuffield Trust

What is telehealth?

“the remote exchange of data between a patient and health care professionals as part of the diagnosis and management of health care conditions” Telehealth devices enable items such as blood glucose level and weight to be measured by the patient and transmitted to health care professionals working remotely.

Imag

e is

the

copy

right

of T

unst

all G

roup

Ltd

© Nuffield Trust

© Nuffield Trust

Three whole system demonstrators

• The poorest county in England, with a dispersed rural population

• Population of >500,000 • 46% of the population live in settlements of

<3,000 people • 99.1% White British • 10.3% of the population are aged 65+;

7.2% 75+ and 2.6% 85+ • 21% of the population report a limiting

long-term illness

CORNWALL

• One of the most deprived areas in the UK • Population of 270,442 - GP registered

population of 300,000 • Population increasing at a higher rate than

the London average • 2nd most diverse population in the UK -

>68% black and minority ethnic (BME) >140 first languages

• 8.5% of the population are aged 65+ • 17.3% of the population have a limiting long-

term illness • Highest death rate from stroke and COPD • Highest diabetes rate in the UK • 2nd highest CHD rate in London

NEWHAM

• Combination of rural and urban populations • Population of 1.37m (excluding Medway

Unitary Authority). Two areas already piloting telehealth: Ashford/Shepway (population: 211,100) and Dartford/Gravesham/Swanley (population: 210,00)

• 3.5% BME • 17.3% of the population are aged 65+

8.4% 75+ and 2.2% 85+ • Within the target population, individuals

report having an average of 1.6 of the three target conditions of heart failure, COPD, diabetes

KENT

© Nuffield Trust

Trial design

© Nuffield Trust

Long-term conditions of intervention participants

© Nuffield Trust

Multi-dimensional evaluation

Theme 1

(Nuffield Trust)

Impact of service use and

associated costs for the NHS and social services

All 3,000 people

Theme 2

(City & Oxford)

Participant reported

outcomes

Subset of people plus their

informal carers

Theme 3

(LSE)

Costs and cost- effectiveness

Subset of people

Theme 4

(Manchester & Oxford)

Experiences of service users, informal carers

and professionals

Qualitative interviews

Theme 5 (Imperial)

Organisational factors and sustainable

adoption and integration

Qualitative interviews

Information flows for this analysis

© Nuffield Trust

Predictive risk scores

© Nuffield Trust

Crude (unadjusted) trends in emergency hospital admissions

© Nuffield Trust

Primary measure: Proportion of patients admitted to hospital in twelve months of trial

Control Intervention Absolute

difference

Relative

difference

Proportion of patients

admitted to hospital in 12

months (%)

48.2 42.9 -5.2 -10.8

Endpoint Interpretation Model Estimate [95% confidence interval]

p value

Admission proportion Odds ratio

Unadjusted

0.82

[0.70 to 0.97] 0.017

Adjusted

0.82

[0.69 to 0.98] 0.026

Combined Model adjusted

0.82

[0.69 to 0.96] 0.016

© Nuffield Trust

Differences in secondary measures

Control Intervention Absolute

difference

Relative

difference

Mortality (%) 8.3 4.6 -3.7 -44.5%

Emergency admissions per head 0.68 0.54 -0.14 -20.6%

Elective admissions per head 0.49 0.42 -0.07 -14.3%

Outpatient attendances per head 4.68 4.76 0.08 1.7%

Accident and Emergency visits per head 0.75 0.64 -0.11 -14.7%

Bed days per head 5.68 4.87 -0.81 -14.3%

Tariff costs (£) 2,448 2,260 188 -7.7%

= statistically significant Key:

© Nuffield Trust

Key findings

• Compared to controls, a smaller proportion of intervention patients were admitted to hospital.

• Intervention patients had fewer emergency admissions, deaths and hospital bed days.

• Tariff hospital costs £188 per head lower in intervention group – but this did not reach statistical significance. (Cost of intervention not included in these figures).

• Some reasons for caution:

• Theoretical possibility of differences in characteristics of intervention and control patients

• Differences in emergency hospital admissions were from a low base

• Increases in emergency admissions for controls

© Nuffield Trust

Multi-dimensional evaluation

Theme 1

(Nuffield Trust)

Impact of service use and

associated costs for the NHS and social services

All 3,000 people

Theme 2

(City & Oxford)

Participant reported

outcomes

Subset of people plus their

informal carers

Theme 3

(LSE)

Costs and cost- effectiveness

Subset of people

Theme 4

(Manchester & Oxford)

Experiences of service users, informal carers

and professionals

Qualitative interviews

Theme 5 (Imperial)

Organisational factors and sustainable

adoption and integration

Qualitative interviews

© Nuffield Trust June 22, 2012

www.nuffieldtrust.org.uk

Sign-up for our newsletter: www.nuffieldtrust.org.uk/newsletter

Follow us on Twitter: http://twitter.com/NuffieldTrust

© Nuffield Trust

adam.steventon@nuffieldtrust.org.uk