Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial.
Steventon A., Bardsley M., Billings J., Dixon J., Doll H., Hirani S., Cartwright M., Rixon L., Knapp M., Henderson C., Rogers A., Fitzpatrick R., Hendy J., Newman S., Whole System Demonstrator Evaluation Team None.
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.