The National Telehealth Webinar Series Presented by The National Network of Telehealth Resource Centers
Vice-dean, Dir., & Prof., School of Rehabilitation, Faculty of Medicine & Health Science. Université de Sherbrooke, Quebéc, Canada Research chair in-home telerehabilitation, Research Centre on Aging at CSSS –IUGS Michel. [email protected]
Assoc. Prof., Orthopedic Surgery. Faculty of Medicine & Health Science . Université de Sherbrooke, Quebéc, Canada FRQS Sr. Research Scholar, Research Centre on Aging at CSSS –IUGS & the Interdisciplinary Institute of Technological Innovation [email protected]
IN-HOME REHABILITATION AFTER KNEE JOINT REPLACEMENT SURGERY : THE EFFECTIVENESS OF
DELIVERY VIA TELEHEALTH Webinar for National Network of Telehealth Resources Centers
Patrick Boissy PhD Michel Tousignant PT, PhD
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Sherbrooke The town
The universities
Bishop university
Université de Sherbrooke (3 campus)
Aging & CSSS-IUGS 3IT
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
The TELAGE RCT AND TEAM
Hélène Moffet, PT, PhD Michel Tousignant, PT, PhD
Sylvie Nadeau, PT, PhD Chantal Mérette, PhD
Patrick Boissy, PhD Hélène Corriveau, PT, PhD
François Marquis, MD François Cabana, MD
Pierre Ranger, MD Étienne Belzile, MD
Pascale Larochelle, MD Ronald Diementberg, MD
Funded 2009-2013
‘ Effectiveness of in-home telerehabilitation after total
knee arthropplasty: a multicentre
randomized control trial’
© BOISSY & TOUSIGNANT 2015
Overview of webinar on in-home telerehabilitation
ANSWERS TO 6 QUESTIONS � What is it ? � How is it done ? � Can it be done ? � Does it work ? � How much does it cost ? � Where do we go from now ?
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
In-Home Telerehabilitation
2007-2013 2013-
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
• Rehabilitation provided through home visits is part of
the continuum of care after discharge from hospital following total knee arthroplasty (TKA).
• As demands for rehabilitation at home are growing and becoming more difficult to meet in-home telerehabilitation is considered as an alternate service delivery method…
• Small studies shows promises but there is a need for robust data concerning, the reliability, efficacy and the cost of dispensing in-home telerehabilitation.
Rational and objectives for TELAGE RCT
TELAGE was designed as an non-inferiority RCT to document these variables.
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Design, intervention and endpoints of TELAGE RCT
• The rehabilitation interventions (TELE, STD) included 16 sessions of about 45 minutes to one hour, supervised by a trained physical therapist.
• The components of the intervention were: a pre- and post-exercise assessment (structured interview and observation), supervised exercises during a period of about 30 minutes (mobility, strengthening, function and balance), prescription of home exercises to perform on days without supervised sessions, and advice concerning pain control, walking aids and the return to activities
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Characteristic Standard Rehabilitation
(N = 101) Telerehabilitation
(N = 104) P Value Age — yrs 67±8* 65±8 0.13
Male sex — no. (%) 56 (55) † 44 (42) 0.06 Body-mass index (BMI) — kg/m2 33±6 34±7 0.13
Comorbidity per patient— mean no. 0.2±0.1 0.2±0.1 0.15 Functional status and Quality of life
WOMAC score — % Pain 53±17 53±20 0.96
Stiffness 47±24 49±22 0.56 Function 55±18 54±20 0.60
Total 54±17 53±19 0.73 KOOS score — %
Symptoms 54±19 53±18 0.64 Pain 47±16 47±19 0.87
Activities of daily living 55±18 54±20 0.65 Sports and recreational
activitiesI 11±12 16±19 0.08
Quality of life 29±18 28±20 0.55 Range of motion — degrees
Flexion - operated knee 115±13 114±15 0.56 Extension- operated knee -6±6 -5±5 0.34 Isometric strength — Nm In flexion- operated knee At 60 degrees of flexion 53±29 49±24 0.26 At 30 degrees of flexion 61±34 56±28 0.27
In extension- operated knee At 60 degrees of flexion 108±58 103±52 0.59 At 30 degrees of flexion 73±37 70±33 0.51
Baseline characteristics of patients
• Socio demographics and baseline values on primary clinical outcomes mesures were similar.
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
In-Home telerehabilitation - Can we do it ?
But
From a technology standpoint
Adapted from LeRouge (2002) Quality Attributes in Telemedicine Video Conferencing.
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Variables All sites (n=97)
QC (n=27)
SHER (n=55)
MTL (n=13)
New Internet connexion (% new)
73% 76% 69% 82%
Type of Internet connexion (% cable)
84% 68% 87% 100%
Total technician time (AVG minutes, SD)
308.4 minutes (122.9)
254 minutes (90.3)
325.7 minutes (131.5)
333.0 minutes (117.9)
Number of TELE sessions performed
1433 sessions
364 sessions
831 sessions
238 sessions
Completed TELE sessions (AVG % of planned sessions, SD)
96,5 % (9.1)
94,1% (13.9)
96,4% (9.0)
91,1% (9.1)
Live time (minutes) per TELE session (AVG minutes, SD)
44.7 minutes (10.7)
45.0 minutes (14.8)
44.3 minutes (8.18)
45.9 minutes (11.1)
Dead time per TELE session (AVG minutes, SD) * includes waiting for remote site to connect
4.9 minutes (28,9)
7.3 minutes (41.1)
4.1 minutes (27,4)
4.2 minutes (13.7)
Connection interruptions per TELE session (% yes, % occurrence frequency)
21%=yes 15%=1 4%=2 2%>2
11%=yes 7%=1 3%=2 1%>2
25%=yes 17%=1 5%=2 3%> 2
24%=yes 18%=1 4%=2 2%> 2
TELE session requiring technician intervention before, during or after session (% yes, % occurrence frequency)
43% = yes 13%= 1 17%=2 13%>2
24%=yes 12%=1 12%=2 0% >2
55%=yes 18%=1 16%=2 21%>2
30%=yes 24%=1 0%=2 6%> 2
Time of technician intervention (AVG minutes, SD)
2.8 minutes (6.1)
2.1 minutes (6.7)
3.0 minutes (6.1)
2.8 minutes (5.6)
!
Reliability of service delivery and technology
• Ressource intensive to install and de-install but excellent reliability • Tech support presence needed but low usage
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Technological impacts on clinical objectives and video mediated communications
• Ressource intensive to install and de-install but excellent reliability • Tech support presence needed but low usage
From a scale of 0 to 10, where 0 corresponds to “not at all” and 10 corresponds to “completely”, where you able to complete the clinical objectives of the session ?
From a scale of 0 to 10, where 0 corresponds to “impossible” and 10 corresponds to “very good”, how did you appreciate the relationship and communication with the patient during the session ?
From a scale of 0 to 10, where 0 corresponds to “very unsatisfied” and 10 corresponds to “very satisfied”, what is your evaluation of the global satisfaction of the flow of the session ?
Clinical objectives Flow of the session Relationship with patient
Scores 0-10 on question after each session
Clinical Objectives (% of total
session)
Flow of communication
(% of total session)
Relationship with the patient
(% of total session)
Score 0-5 2.5% 0.5% 1.8% Scores 6-7 5.7% 4.2% 5.6% Scores 8-9 37.2% 42.8% 41.7% Scores 10 54.6% 52.5% 51.2%
!
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Patients’ impressions of risks and benefits* * French adaptation of Demeris et al. A questionnaire for the assessment of patients’ impressions of the risks and benefits of home telecare. Journal of Telemedicine and Telecare 2000; 6: 278–284
Highly positive impression before and after receiving telerehabilitation services Lowest scores on human factors questions
76 and 77%
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Patient’s satisfaction of telerehabilitation*
• High satisfaction rate (94% avg) after receving in-home telerehabilitation
* French adaptation of Yip et al. Development of the Telemedicine Satisfaction Questionnaire to evaluate patient satisfaction with telemedicine: a preliminary. Journal of Telemedicine and Telecare 2003; 9: 46–50
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
In-Home telerehabilitation – Does it work ?
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Efficacy* of TELE vs STANDARD for TKA
In-home telerehabilitation for primary outcomes studied is as effective as STANDARD (face to face ) intervention !
In-home telerehabilitation for primary outcomes studied is as effective as STANDARD (face to face) intervention (per protocol and Intent to treat analyses)
The gain in the TELE group was evaluated as non-inferior only if the intergroup mean difference and its 95% confidence interval (one side) are less than 9% at the last follow-up (E4): H0 : µSTD-µTELE ≥ 9%; H1: µSTD-µTELE < 9%.
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Same results for secondary outcomes !
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Adverses events STANDARD vs TELEREHAB
Adverse events not related to intervention No differences between TELE and STANDARD intervention
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
How much does it cost in comparison to standard care ?
© BOISSY & TOUSIGNANT 2015
Types of economical evaluations for telehealth intervention ?
(Drummond, 1997)
© BOISSY & TOUSIGNANT 2015
No difference in "consequence" between the interventions
Economical evaluation in TELAGE RCT ?
© BOISSY & TOUSIGNANT 2015
No difference in "consequence" between the interventions
Cost Minimization
Economical evaluation in TELAGE RCT ?
© BOISSY & TOUSIGNANT 2015
Time (minutes) Distance (Km)
Travel Treatment
Time (minutes)
Time (minutes) Distance (Km)
Time (minutes)
Installation /desinstallaton
After each intervention
Costing data collection
© BOISSY & TOUSIGNANT 2015
CLINICAL COSTS TELE VISIT
Description Duration
Professional Cost Duration x hourly wagea
Professional Cost Duration x hourly wagea
Direct
time
Contact with the participant
Hours # Hours x $ per hour # Hours x $ per hour
Indirect
time
Planning the session Hours # Hours x $ per hour # Hours x $ per hour
Follow-up with orthopedic surgeon
Hours # Hours x $ per hour # Hours x $ per hour
Writing the report and follow-up notes
Hours # Hours x $ per hour
# Hours x $ per hour
Travel Hours # Hours x $ per hour Km x $0.40
Clinical equipment amortization
$/ 16 tx $ per treatment $ per treatment
Clinical costs breakdown
© BOISSY & TOUSIGNANT 2015
CLINICAL COSTS TELE VISIT
Description Duration
Professional Cost Duration x hourly wagea
Professional Cost Duration x hourly wagea
Direct
time
Contact with the participant
Hours # Hours x $ per hour # Hours x $ per hour
Indirect
time
Planning the session Hours # Hours x $ per hour # Hours x $ per hour
Follow-up with orthopedic surgeon
Hours # Hours x $ per hour # Hours x $ per hour
Writing the report and follow-up notes
Hours # Hours x $ per hour
# Hours x $ per hour
Travel Hours # Hours x $ per hour Km x $0.40
Clinical equipment amortization
$/ 16 tx $ per treatment $ per treatment
Clicial costs breakdown
© BOISSY & TOUSIGNANT 2015
TECHNOLOGY COSTS
TELE VISIT
Un/Installation of technology Travel time x $ hour b and km x $0.40/km
-
Internet costs (high speed): Cost for 2 months / 16 sessions
$ per intervention -
Technical equipment amortization: Cost for 1 clinician kit ($5760) and 1 patient kit ($7200) amortized over 3 years based on 50% of usage per week
$ per intervention -
Technical problems
Technician Hours x $ hour -
Physiotherapist Hours x $ hour -
Costs breakdown per participant
© BOISSY & TOUSIGNANT 2015
Costs of telerehabilitation and home visits
© BOISSY & TOUSIGNANT 2015
Costs of telerehabilitation and home visits
© BOISSY & TOUSIGNANT 2015
Costs differential between telerehabilitation and home visits
© BOISSY & TOUSIGNANT 2015
Home Visits Telerehabilitation
Costs breakdown per treatment
© BOISSY & TOUSIGNANT 2015
Home Visits Telerehabilitation
Costs breakdown per treatment
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
What we have learned form TELAGE RCT ? We must decrease the reluctance of clinicians toward TELE
Training (brief) to use the platform Training to think different… «being creative» in delivering treatment & exercises
Technology support (minimal) is essential If a problem arise = being able to reach a technician «right now» !!
Contact with Internet Service Provider is essential Time between discharge from hospital and beginning treatment may be minimal = we must have «special access» to connect the home to internet without delay
To begin a new project in clinical setting… is not easy Contact and support of direction and staff of IT department of the health care center is crucial Strong commitment from stakeholders (administration) is crucial to implement TELE because we must «gently push» on the culture of change of the clinicians and managers J
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
On-going projects in telerehabilitation
Tai Chi for with post-CVA patients
Rehabilitation for COPD patients
Rehabilitation for COPD patients
© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015
Wrap up & conclusions • In home telecare services for physical rehabilitation can be
delivered reliably and that this mode of delivery is well accepted by clinicians and patients.
• The evidences of non-inferiority compared to face to face interventions for post TKA rehabilitation support its use clinically and make a good argument to evaluate this mode of service delivery for more patient populations and conditions.
• Cost analyses results for post TKA rehabilitation suggest that depending on the intensity of the services provided and the distance between the provider and the patient, significant saving can be achieve…
• As the performance and prices of the technological infrastructure and equipment need to support in-home telerehabilitation are constantly improving cost of service delivery will go down.
It’s time for program evaluation and pragmatic trials on in-home telerehabilitation…
© BOISSY & TOUSIGNANT 2015
36
Acknowledgements & Questions
Michel Tousignant, PT, PhD [email protected] Tel: (819) 780 -2220 ext. 45628 (CDRV) Tel: (819) 821-8000 ext. 65717 (3IT) Skype: patrickboissy
• The Telage team members • The clinicians and patients who participated • Research personnel at research centre on aging Funding:
Patrick Boissy Ph.D. [email protected] Tel: (819) 780 -2220 ext. 45628 (CDRV) Tel: (819) 821-8000 ext. 65717 (3IT) Skype: patrickboissy
Research chair on telerehabilitation
Telage RCT
PBOISSY Research Scholar
The National Telehealth Resource Center Webinar Series
3rd Thursday of every month Next Webinar:
Topic: Telehealth Security & Breaches: What Last Year’s Problems Tell Us About Future Threats Presenter: Garret Spargo, National Telehealth Technology Assessment Resource Center Date: Thursday, February 19, 2015 Times: 9:00AM HST, 10:00AM AKST, 11:00AM PST, 12:00PM MST, 1:00PM CST, 2:00PM EST
Your opinion of this webinar is valuable to us. Please participate in this brief perception survey: http://www.surveymonkey.com/s/NationalTRCWebinarSeries
TRC activity is supported by grants from the Office for the Advancement of Telehealth, Office of Health Information Technology, Health Resources and Services Administration, DHHS
Top Related