Evaluation of the Scottish National Telecare Development Programme Findings and implications for future research

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Evaluation of the Scottish National Telecare
Development ProgrammeFindings and implications
for future research

• Sophie Beale
• Senior Consultant, York Health Economics
  Consortium, University of York
• sjb29_at_york.ac.uk

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Overview

• What is Telecare?
• Introduction to the Telecare Development
  Programme (TDP)
• Overview of the evaluation of the TDP
• Summary of the findings
• Implications for the evaluation of telecare
• Conclusions

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Telecare Development Programme

• Telecare Development Programme (TDP) launched in
  August 2006.
• To help more people in Scotland live at home
  for longer, with safety and security, by
  promoting the use of telecare in Scotland,
  through the provision of a development fund and
  associated support
• Supported by c8M in funding
• Expected to provide a foundation for telecare to
  become an integral part of community care across
  Scotland.

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Telecare/Telehealth/Telemedicine

• There is considerable variation in the way in
  which telecare, telehealth and telemedicine are
  defined
• All involve the delivery of services via
  telecommunications and computerised systems,
  usually to individuals in their own home

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Telecare/Telehealth/Telemedicine
Tele-intervention Examples
Telecare Telecare is concerned with monitoring over time to manage the risks (which may be the concern of health and/or social care) associated with independent living. Natural gas or bottled gas detector Wearable fall detector Passive Infra Red (PIR) movement detectors Nocturnal bed monitor Opening alerts for external doors.
Telehealth Remote exchange of physiological data between a patient at home and medical staff to assist in diagnosis and monitoring Blood pressure monitoring Blood glucose monitoring Cardiac arrhythmia monitoring and Medication reminder systems
Telemedicine Use of medical information exchanged from one site to another via electronic communications Remote consultations with specialists
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Telecare Development Programme Specific
objectives

• Reduce the number of avoidable emergency
  admissions and readmissions to hospital
• Increase the speed of discharge from hospital
  once clinical need is met
• Reduce the use of care homes
• Improve the quality of life of users
• Reduce the pressure on informal carers
• Extend the range of people assisted by telecare
• Achieve efficiencies (cash releasing/time
  saving)
• Support effective procurement.

Majority of these have important economic
implications for health and social care
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Evaluation Overview

• Joint Improvement Team commissioned an evaluation
  of the TDP
• Assessment of the implementation and uptake
• Assessment of performance against the agreed
  objectives
• Provide an evidence base on the costs and
  benefits of the Programme
• Develop metrics that can become embedded in
  practice.

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Evaluation Methods

• Multiple methods explored at the outset of the
  project
• Emphasise that the TDP was an investment
  programme, not a research exercise
• Pragmatic approach
• Work with existing routine data where possible
• Minimise burden of data collection on
  partnerships
• Fit-for-purpose study, acknowledging the
  limitations.

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Evaluation Methods

• Quarterly, self-reported monitoring from
  partnerships on progress and outcomes against
  pre-specified objectives
• E.g. number of users, number of admissions
  avoided, number of delayed discharges avoided
• Surveys of users and carers to understand their
  perceptions
• Supplemented with case studies, including
  in-depth interviews with stakeholders, users and
  carers

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Findings Welcome financial headlines!

• Partnerships estimated to have saved over 11.5M
  as a result of the TDP investment
• Reduction in admissions to care homes, equating
  to over 60,000 care home days c 31 of savings
• Reduction in unplanned hospital admissions,
  equating to over 13,000 bed days c 30 of
  savings
• Improved speed of discharge, equating to over
  5,000 bed days 16 of savings
• TDP produced savings against 6 efficiency targets
  identified at the outset of the study

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Findings Impact on Users and Carers

• 60 of users reported improvements in quality of
  life
• Nearly 70 reported feeling more independent
• Over 90 reported feeling safer
• Less than 5 reported feeling lonelier as a
  result of telecare
• Nearly 75 of informal carers felt that telecare
  had reduced pressure/stress
• Facilitated greater independence for users

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Findings Organisational Policy impact

• Almost 8,000 new users of TDP funded telecare
  during 2007/08
• Predominantly older people (85 aged gt65)
• New users with dementia, learning disabilities or
  physical disabilities
• Predominantly female (62)
• Approximately half of partnerships used the
  National Framework Agreement to purchase telecare
• Some partnerships found cheaper or better
  solutions outside of the National Framework
  Agreement

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Limitations

• Impact is self-reported
• Reliant on partnerships to consider the impact
  relative to no TDP grant.
• Not possible to include a control arm - difficult
  to know the counter-factual
• Not possible to attribute any incremental effect
  to TDP - some of the programmes were already
  underway
• Incentives for partnerships to overstate the
  benefits
• In addition to this, caution should be taken in
  interpreting the financial outcomes
• Some of the efficiency gains are unlikely to be
  cash-releasing

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Limitations

• Partnerships took time to implement telecare
  solutions
• Not all partnerships were able to complete all
  quarterly returns over the course of the
  evaluation
• Time-lag due to time involved in the purchase and
  implementation of telecare solutions
• Additional time lag associated with the need for
  cultural change in users and professionals
  attitudes to care
• E.g. referral triggers

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Limitations

• Impossible to quantify displacement or unintended
  consequences of telecare
• Are additional resources required in communities
  as a result of less reliance on secondary
  care/care homes?

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What can we interpret from the findings?

• Pragmatic study of telecare in use assessed
  against a wide range of outcome measures
• Beneficial impact on health and social care
  efficiencies
• More importantly, beneficial impact on user
  outcomes, such as independent living and
  perceptions of safety
• The study does not provide definitive evidence of
  the effectiveness of any specific intervention
• Too many interventions included to assess
  effectiveness in any meaningful population

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Implications for future research RCTs

• Randomised controlled trials are the most
  appropriate means of assessing the effectiveness
  of individual interventions
• Allow for identification of an attributable
  effect by controlling other influences
• However, RCTs may be of limited value in
  supporting the mainstreaming of telecare
• Effectiveness is context specific
• Heterogeneity in users and service environments
• Heterogeneity in access to interventions
• Practical difficulties in recruitment and
  randomisation
• Hawthorne effect observed in telehealth
  studies?

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Implications for future research

• A number of alternative approaches to evaluation
  were explored
• Before and after study
• Monitor users before and after the introduction
  of telecare
• Problematic in progressive conditions or where
  telecare has been provided after a sudden change
  in health state (e.g. stroke)
• Use of predictive models
• Predicts expected hospitalisations based on an
  individuals characteristics
• Methods not fully mature problematic in
  progressive illnesses and focussed primarily on
  health care
• Use of control groups
• Difficulties in selecting control group what
  should you control for?
• Is it ethical to refuse to provide telecare to a
  member of the control group?

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Implications for telecare adoption

• Widespread adoption of promising technologies
  remains limited due to the limited availability
  of high-quality evidence
• Studies tend to be commissioned by those with an
  interest in promoting telecare
• Small populations and lack of follow-up lead to
  limited generalisability of findings
• Therefore, adoption of promising technologies
  remains limited

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A model for pragmatic, evidence-based uptake of
telecare?

• A risk-sharing model may support appropriate
  adoption
• Purchasers and suppliers define reasonable
  objectives for telecare and evaluation criteria
• Promising results support further adoption
• Failure to achieve objectives explored
• Rebates in place for sub-optimal performance?

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A model for pragmatic, evidence-based uptake of
telecare?

• Risk-sharing is suited to promising technologies
  characterised by uncertainty over their
  effectiveness
• Addresses purchasers concerns about equivocal
  evidence base by providing some form of
  guarantee
• Addresses manufacturers concerns about the need
  to continuously invest in context specific trials
• Generates further evidence on the barriers and
  facilitators for implementation in practice
  settings
• Increasingly applied to pharmaceuticals
  possibly more relevant to interventions such as
  telecare
• Hard endpoints available from routinely collected
  data

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Summary Recommendations

• The Scottish TDP programme appears to have been a
  cost effective use of resources
• Acknowledge the limitations of the pragmatic
  evaluation
• Acknowledge that many of the benefits of the
  programme have yet to materialise
• The TDP evaluation provides further evidence to
  support the mainstream use of telecare, although
  the findings are equivocal
• Are RCTs the most appropriate means of supporting
  mainstreaming of telecare?
• An evidence based approach to the staged
  widespread adoption of promising telecare
  technologies might address the concerns of all
  stakeholders involved.

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Acknowledgements

• Diana SandersonAssociate Senior Consultant
• Jen KrugerProject Support Officer
• Paul Trueman
  Director
• Joint Improvement Team
• TDP partnerships