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      Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial

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          Abstract

          Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.

          Design Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat.

          Setting 179 general practices in three areas in England.

          Participants 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009.

          Interventions Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients’ diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.

          Main outcome measure Proportion of patients admitted to hospital during 12 month trial period.

          Results Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P<0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P=0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference −0.64 days, −1.14 to −0.10, P=0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group.

          Conclusions Telehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect.

          Trial registration number International Standard Randomised Controlled Trial Number Register ISRCTN43002091.

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          Most cited references31

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          How should cost data in pragmatic randomised trials be analysed?

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            What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings.

            Nearly half a century ago, telemedicine was disregarded for being an unwieldy, unreliable, and unaffordable technology. Rapidly evolving telecommunications and information technologies have provided a solid foundation for telemedicine as a feasible, dependable, and useful technology. Practitioners from a variety of medical specialties have claimed success in their telemedicine pursuits. Gradually, this new modality of healthcare delivery is finding its way into the mainstream medicine. As a multidisciplinary, dynamic, and continually evolving tool in medicine, researchers and users have developed various definitions for telemedicine. The meaning of telemedicine encapsulated in these definitions varies with the context in which the term was applied. An analysis of these definitions can play an important role in improving understanding about telemedicine. In this paper we present an extensive literature review that produced 104 peer-reviewed definitions of telemedicine. These definitions have been analyzed to highlight the context in which the term has been defined. The paper also suggests a definition of modern telemedicine. The authors suggest that telemedicine is a branch of e-health that uses communications networks for delivery of healthcare services and medical education from one geographical location to another. It is deployed to overcome issues like uneven distribution and shortage of infrastructural and human resources. We expect that this study will enhance the level of understanding and meaning of telemedicine among stakeholders, new entrants, and researchers, eventually enabling a better quality of life.
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              Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention.

              Self-management interventions improve various outcomes for many chronic diseases. The definite place of self-management in the care of chronic obstructive pulmonary disease (COPD) has not been established. We evaluated the effect of a continuum of self-management, specific to COPD, on the use of hospital services and health status among patients with moderate to severe disease. A multicenter, randomized clinical trial was carried out in 7 hospitals from February 1998 to July 1999. All patients had advanced COPD with at least 1 hospitalization for exacerbation in the previous year. Patients were assigned to a self-management program or to usual care. The intervention consisted of a comprehensive patient education program administered through weekly visits by trained health professionals over a 2-month period with monthly telephone follow-up. Over 12 months, data were collected regarding the primary outcome and number of hospitalizations; secondary outcomes included emergency visits and patient health status. Hospital admissions for exacerbation of COPD were reduced by 39.8% in the intervention group compared with the usual care group (P =.01), and admissions for other health problems were reduced by 57.1% (P =.01). Emergency department visits were reduced by 41.0% (P =.02) and unscheduled physician visits by 58.9% (P =.003). Greater improvements in the impact subscale and total quality-of-life scores were observed in the intervention group at 4 months, although some of the benefits were maintained only for the impact score at 12 months. A continuum of self-management for COPD patients provided by a trained health professional can significantly reduce the utilization of health care services and improve health status. This approach of care can be implemented within normal practice.
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                Author and article information

                Contributors
                Role: senior research analyst
                Role: head of research
                Role: associate professor of health policy and public service
                Role: director
                Role: senior research associate
                Role: senior lecturer in health psychology
                Role: research associate
                Role: research associate
                Role: professor of social policy; director of personal social services research unit; professor of health economics
                Role: research officer
                Role: professor of the sociology of health care
                Role: professor of public health and primary care
                Role: senior lecturer in healthcare management and policy
                Role: professor in health psychology and dean of school of health sciences (principal investigator)
                Journal
                BMJ
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1756-1833
                2012
                2012
                21 June 2012
                : 344
                : e3874
                Affiliations
                [1 ]The Nuffield Trust, London W1G 7LP, UK
                [2 ]New York University, New York, NY, USA
                [3 ]University of East Anglia, Norwich, UK
                [4 ]School of Health Sciences, City University London, London
                [5 ]University of Oxford, Oxford, UK
                [6 ]London School of Economics and Political Science, London
                [7 ]King’s College London, London
                [8 ]University of Manchester, Manchester, UK
                [9 ]University of Surrey, Guildford, UK
                Author notes
                Correspondence to: A Steventon adam.steventon@ 123456nuffieldtrust.org.uk
                Article
                stea002866
                10.1136/bmj.e3874
                3381047
                22723612
                da098586-9e14-44d8-b764-26172539f957
                © Steventon et al 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                Categories
                Research
                1778
                Epidemiologic Studies
                UK

                Medicine
                Medicine

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