Prof Ala Szczepura1,2
Prof Christopher James3 Workshop on prevention and detection (1-2pm)
Digital Health: design, develop, deploy, evaluate Radcliffe House Warwick,
University of Warwick
25 July 2013
1 Hon Professor, Warwick Medical School, University of Warwick, UK 2 Professor Health Technology Assessment, University of Coventry, UK 3 Institute of Digital Healthcare, University of Warwick, Coventry, UK
USEFIL Project: Evaluation of technology in healthcare
Aims:
To use "off-the-shelf" technology to develop unobtrusive, low cost support systems for older people living alone.
• Older person: to enable the individual to maintain their independence and daily activities. Provide services
more adaptable to individual needs and preferences (personalization).
• Formal/ informal carer: to provide effective means of delivering support & accessing care.
• Health funder: to extend the time older people can live independently at home, limiting public expenditure and
providing cost-effective care.
Partners: 1. Institute of Digital Healthcare & Medical School, University of Warwick, UK
2. National Center for Scientific Research "Demokritos", Athens, Greece (lead)
3. VTT Technical Research Centre of Finland, Espoo, Finland
4. Center for Computing Technologies, University of Bremen, Germany
5. Lab of Medical Informatics, Medical School, Aristotle University of Thessaloniki, Greece
6. Fraunhofer Institute for Telecommunications, Munich, Germany
7. Philips Consumer Lifestyle, Eindhoven, Netherlands
8. Maccabi Healthcare Services, Tel Aviv, Israel
USEFIL (FP7 Project)
“enables people to realize their potential for physical, mental and social well being ….and to participate in society according to their needs, desires & capacity
while providing them with adequate protection, security and care when they require assistance”
- World Health Organisation, 2002
Active Ageing….
Challenge: Active Ageing
Active Ageing
Increasing Dependency
Number of people aged 75+ projected to nearly
double by 2033 - from 4.8 to 8.7 million in England
900,000 older people with high level of physical need
in 2002, will increase by 50% in next 20 years
500,000 centenarians predicted in UK by 2066
Historically, most care for older people provided at
home with support of family
Changing family structures mean in Europe one third
of older people living at home are now alone
DH says at least 3 million people in UK with long term
conditions and/or social care needs could benefit from
use of telehealth/ telecare services
Older Person’s Care & Support Network
Older Person
at Home
Primary Care
Team
Domiciliary Care Community
Specialists
(e.g. Geriatrician,
Pharmacist)
NHS Community
Nursing Staff Informal Carer/ Relative
Quality of Life
Hospital Staff
(Inpatient care
A&E)
Need to build a USEFIL system to suit the older person living alone at home….
....not just providers of health & social care
Telecare: What way forward?
• Review of reviews: real-time telecare can improve health outcomes through enhanced
disease monitoring & better communication with health care professionals*
• Telecare demonstrator programme (Cornwall) for patients discharged home shows 20%
fall in emergency admissions & 45% fall in mortality over 1 year**
• January 2012 - NHS care service minister announces aim to develop telehealth/telecare
services to support people with long-term conditions
* Deshpande A, Khoja S, McKibbon A, Jadad AR: Real-Time (Synchronous) Telehealth in Primary Care:Systematic Review of Systematic Reviews [Technology ** Department of Health. Whole system demonstrator programme: Headline findings - December 2011. 2011 ;
Need to consider: Value for money
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
1970 1975 1980 1985 1990 1995 2000 2005
Per
Capita S
pendin
g -
PPP A
dju
sted
Growth in Total Health Expenditure Per Capita, U.S. and Selected Countries, 1970-2008
United States
Switzerland
Canada
OECD Average
Sweden
United Kingdom
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in 2008.
Care Homes Academic Research Team (CHART)
Challenges: What way forward?
Personal health portals Online engagement tool to connect patients with healthcare providers, families, social services & care givers.
Unobtrusive activity monitoring Wearable devices to unobtrusively and reliably extract cardiac and motion related features.
Home clinical monitoring for oncology patients Patients regularly monitor white blood cell count, temperature & other symptoms. Results used to inform timing of further chemotherapy or intervention
Range of technology support…….
Employment and skills in the social care sector
Improving productivity in labour intensive services whilst maintaining quality
Increasing capital-labour ratio Role for new technology
beyond “tele-care”
also
“attracting boys into girls jobs”
Improving employee skills Time for training staff & managers
improving occupation’s status
the feeding
robot
the keeping
company
robot
Hospital admission/ discharge Optimal preparation of patients & follow up at home
Personalised services Deliver appropriate level of health & social care for older person at home
Self-management Actively develop older person’s knowledge, motivation and skills
Up to 40% of acute hospital beds filled with people who shouldn’t be there, mostly elderly.
25% of emergency admissions linked to elderly patients with chronic diseases,
at an estimated excess cost of £2bn. p.a.
Key Challenges: Active Ageing
Coordination of care Across patients’ various conditions and different care givers
USEFIL Support for Older Person
Important issues for evaluation….
• question of choices in the use of health care resources such as:
– what technologies to provide, when and at what level?
– how and where to provide such technologies?
– who should get the technologies?
• these are important questions for those who provide health care (e.g. clinicians), those who plan care provision or purchase care (e.g. Third Party Payers), as well as those who develop new technologies (e.g. scientists)
USEFIL Validation & Evaluation Trial
(Frail Elderly)
Technology as a facilitator for older people largely confined to home:
- Citizen-centred care
citizen empowerment
preventive care & early diagnosis/alerts
disease management
independent living for ageing society
• USEFIL Ethical Management
– to ensure all USEFIL research is carried out under best ethical guidelines
(m36)
October 2014
(m31)
May 2014
Commence Ethical
Applications
(m19)
May 2013
Decide on
distribution of
Technologies
(m14)
January 2013
USEFIL Validation and Evaluation (Pilot Trials)
- UK (frail elderly), Israel (stroke), Greece (mental health)
Ideal Scope of Evaluation
Process measures – usage, acceptability
Outcome measures - physical, psychological, social
Value for Money
7 Levels of Telecare Evaluation: Adapted from Szczepura & Kankaanpää (1996)
• Level 1: Technical : Does the telecare perform reliably and deliver
reproducible data?
• Level 2: Diagnostic accuracy: Does the data enable an accurate diagnosis to be
made of the situation?
• Level 3: Usability: Is the technology acceptable to patients & carers,
do they use it appropriately?
• Level 4: Treatment impact: Does the information provided influence selection and
delivery of treatment/ care?
• Level 5: Patient outcome: Does the technology contribute to improved health
of the person/patient?
• Level 6: Cost-effectiveness: Does use of telecare improve cost-effectiveness
of care delivery?
• Level 7: Social/organisational/ Does the technology have any social, legal, ethical
ethical/legal: or organisational implications?
Outcome indicator checklist
7 elements to address
Developing outcome indicators
Objective What are we trying to measure? 1. Why are we collecting this information? Be specific
Methodology
How to capture the data 1. What data needs to be captured
2. Who (or what) to capture the data
3. How often to capture the data
4. Is it achievable (time, resources, revenue)?
Limits Can we preset levels for:
1. Acceptable, Concern, Unacceptable, Critical
Presentation Graphic or Text
Interpretation 1. What does it mean?
2. Does it reflect on KEY quality/ outcome measures?
3. Can we compare it?
4. Can we trend it?
Limitations 1. Unintended variables
2. What does it not mean?
Action Plan 1. What will we do if it indicates acceptable outcomes?
2. What will we do if it does not?
Nonsense Metrics
[urine culture] * [glucose] * [INR]
[NUPA hr] * [Telephone minutes] X100
Just because you can calculate a
value, doesn’t mean that you should.
“Health is a state of complete physical, mental and social well being and not merely the
absence of disease or infirmity”
- World Health Organisation, 1948
Health-related quality of life - key outcome
What could USEFIL system provide?
From Perspective of Frail Older Person Living Alone:
• Increase sense of safety through unobtrusive monitoring
• Detect life-threatening situations and alert/ inform carers
• Promote socialisation and stimulate activities which
improve quality of life and reduce feelings of isolation
• Provide entertainment & educational activities leading to a
more active profile
• Enable individual to remain in own home with adequate
protection, security and care when they require assistance
(WHO Active Ageing)
UK Trial: Planned outcome measures for…
• Older Person • ICECAP-O Instrument: to measure capability for older people. The instrument contains five
attributes (attachment, role, enjoyment, security and control), each with four levels. UK index
values for ICECAP-O are available; developed for economic evaluation.
• ASCOT INT4: to capture information on social care-related quality of life (SCRQoL). Allows
current and expected SCRQoL to be estimated in community settings.
• Modified Barthel Index: to measure activities of daily living (ADL) in terms of: personal hygiene,
bathing, feeding, toilet, stair climbing, dressing, bowel/bladder control, ambulation, and chair/bed
transfer. Dependency level scores can be linked to the hours of help required per week.
Activities of Daily Living
1
Changing position
5
Bathing
4
Brushing teeth
3
Personal hygiene
2
Walking
7
Eating
6
Dressing
Importance of Informal Carers
• About 960,000 people aged 65+ provide unpaid care for a partner, family, or
others in the UK
• Carers are saving the UK economy £119 billion (2011) a year (£2.3 billion
per week). This compares to total annual NHS cost of £98.8 billion (£1.9
billion per week)
• Move to formal care = annual cost of one nursing home place is £37,880 p.a.
• The cost to carers = 68.8% of carers say that being a carer has damaged
their psychological wellbeing
• Older Person • ICECAP-O Instrument: to measure capability for older people. The instrument contains five
attributes (attachment, role, enjoyment, security and control), each with four levels.
• ASCOT INT4: to capture information on social care-related quality of life (SCRQoL), and allows
current and expected SCRQoL to be estimated in community settings;
• Modified Barthel Index: to measure activities of daily living (ADL) in terms of: personal hygiene,
bathing, feeding, toilet, stair climbing, dressing, bowel/bladder control, ambulation, and chair/bed
transfer. Dependency level scores can be linked to the hours of help required per week.
• Informal Carer • Adult Carer Quality of Life (AC-QoL) questionnaire: simple instrument that measures quality
of life in eight separate domains: support for caring; caring choice; caring stress; money matters;
personal growth; sense of value; ability to care; and carer satisfaction. Can be used before and
after an intervention in order to evaluate whether the intervention has had an effect.
• Carer Experience Scale (CES): a profile measure of the caring experience for use in economic
evaluation; the CES focuses on 'care-related quality of life' rather than health-related quality of
life, comprising attributes that are pertinent to unpaid carers.
UK Trial: Planned outcome measures for…
What could USEFIL system provide?
From Perspective of Professional:
• Provide a means to help detect early signs of health
deterioration or transition to a pathological state
• Provide a number of decision-support tools in order to
reinforce diagnosis
• Deliver personalised suggestions and analysis regarding
the most suitable actions
• Create a health/social care profile that can help maintain
someone in their own home
Benefit from use of telehealth/ telecare
services…
So I said...
"How long can our
mother remain safely
at home Doctor?"
and he said...
“One to two months
probably ..
But 1 - 2 years if I can
prescribe a USEFIL
support system!”
Prevention/delay in care home or hospital admission • Average cost of nursing home care ca. £700 per week.
• NHS hospital bed costs ca. £2,100 per week.
• Older people occupy >60% of NHS hospital beds
• 5% of inpatients account for 43% of overall UK hospital inpatient days
• The Commons Public Accounts Committee has estimated that ‘bed blocking’
costs the NHS £170m every year.
• Average cost of USEFIL system ca. £2-£3,000?
Challenge: Reducing drug errors
In England there are:
• 77,000 hospital admissions p.a. linked to adverse drug reactions (ADRs)
• 59% of all cases involve older people (aged 60+ years)
• ADR numbers have increased by 45% over 8 year period
Care home residents at increased risk due to:
• age-related changes in body’s response to drugs
• multiple medication (polypharmacy)
• 28% of care homes still failing to meet minimum standard for medication management
in 2010
• dementia may limit resident’s role in monitoring own drug administration
• most care home staff are not clinically trained (i.e. social care staff)
• medication rounds occupy ca. one-third of nursing time in nursing homes
Internet
Pharmacy Plus maintains
the residents file and their
drugs using CAPA
All information is copied over
to the Central PCS Server via
the Internet. New information
is passed back to PCS
Drug administrations
and stock movemenets
are recorded on PCS Manager can view every
administration via Internet
The system is then Docked
Proactive Care System (PCS) Components
• UK pharmacy-managed, point-of-care, bar-code medication management system
developed by Pharmacy Plus Ltd over 4 years with residential and nursing home staff
What did we find?
• Analysed 188,249 drug administrations
24/7 over 3 months in 345 residents (13 homes)
• Residents averaged 8.9 different
medications each
• Survey prior to system introduction showed
social care staff more aware of potential
for medication errors than nurses
• When system alerted staff to potential error,
level of non-compliance was <1 per 1,000
(i.e. virtually all administration errors
avoided)
Main Conclusions • With support of the system, staff were able
to avert 2,289 errors over 12 weeks
• Cumulative risk of a resident being exposed
to one or more error over 12 week period
was 88% in RHs and 98% in NHs
• Risk of exposure to a more serious
error (e.g. attempt to give medication to
wrong person) was 52% over 3 months
• Error rates were lower for social care staff
in residential homes than for nurses in
nursing homes (p<0.01)
• Social care staff in nursing homes could
give medication using system & free up
valuable nurse time for other clinical tasks
Better Health, Safer Care but .....
at what Cost?
• As well as improved patient safety and quality of care, use of new technology
also appears to be cost saving:
► technology cost per annum to care home is
£1,800 (including 2 hand held devices)
► potential savings to nursing home from staff
substitution: if care staff replace nurses, annual saving ~ £15,330
► reduction in hospital admissions linked to adverse drug reactions
could lead to - £4,250 p.a. (saving) per 70 bed care home for NHS
► after accounting for system savings (reduced drug waste & improved
stock control) & advice provided online (e.g. drug switching,
inappropriate prescribing etc) net saving per care home could be
- £38,199 p.a. (saving)
Continuing Tensions in Long-Term Care
of Older People
Citizen / Patient Care Home Resident
Time – Age – Disease State & Complexity
Innovation,
Training /CPD, Research Evidence
Needs, Direct Costs
& Regulation
THANKYOU
Contacts
• Ala Szczepura (health technology assessment)
Email: [email protected]
• Debbie Biggerstaff (psychologist)
Email: [email protected]
• Josh Elliott (research assistant) Email: [email protected]
Top Related