King’s Fund. March 2011The cost-effectiveness of telecare and telehealth Martin Knapp, Catherine Henderson, Ariane Buescher, Jose-Luis Fernandez o London School of Economics and Political Science o Institute of Psychiatry at King’s College London o NIHR School for Social Care Research
Structureo Contexto Systematic review of economic evidenceo Lessons from the reviewo WSD
Contexto Ageing - growing needso Rising aspirationso Public sector resource constraintso Private resources also under pressureo Even tougher to coordinate across sectors and systems …o … and to move beyond very short time horizons
Systematic reviewo Telehealth and telecare interventionso Searched sstematic reviews, meta-analyses and individual studieso All designs: RCTs, cohorts, quasi- experimentso English language, 2000-2011o Economic dimensions, e.g. service use, costs, cost-effectivenesso 27 systematic reviews foundo Paper currently being prepared for publication (if we have something to add to existing reviews)
Reviews of economics evidenceBensink M, Hailey D. et al. (2006) A systematic review of successes and failures in home telehealth: preliminary results. J Telemed Telecare; 12: 8-16 [TH]Bergmo, T. (2009) Can economic evaluation in telemedicine be trusted? A systematic review of the literature. Cost effectiveness and resource allocation; 7:18 [TM]Davalos M., French M et al. (2009) Economic evaluation . J Telemed Telecare; General consensus the evidence 15(10):933-948 [TH]Jennett P, Hall L (2003) The socio-economic impact of telehealth: A systematic review. base is methodologically weak … Journal of Telemedicine and Telecare; 9(6): 311-320. [TH]Kairy, D., P. Lehoux, et al.(2009) A systematic review of clinical outcomes, clinical … and so it is hard to draw clear process, healthcare utilization and costs associated with telerehabilitation. Disability and Rehabilitation; 31(6): 427-447. [TR] conclusions from available studies.Polisena J, Tran K et al. (2009b). Home telehealth for chronic disease management: A systematic review and an analysis of economic evaluations. International Journal of What areas of weakness? Technology Assessment in Health Care; 25(3): 339-349. [TH]Rojas, S., Gagnon, M. P. (2008) A systematic review of the key indicators for assessing telehomecare cost-effectiveness. Telemedicine and e-Health; 14(9): 896-904 [TC]Seto, E. (2008) Cost comparison between telemonitoring and usual care of heart failure: a systematic review. Telemedicine and e-Health; 14(7): 679-686 [TH]Wade, V. A., J. Karnon, et al. (2010) A systematic review of economic analyses of telehealth services using real time video communication. BMC Health Services Research; 10:1-13 [TH]
Lessons from the review: equityA. Forgetting equity Much emphasis on 3 Es: - economy (what goes into providing a service) People with long-term needs/conditions are - efficiency (level of output relative to input) disproportionately in the lower socioeconomic - effectiveness (the groups … impact on outcomes) … which makes the Very little on the 4th E: distributional issue - equity especially important. Distribution of burdens and outcomes (linked closely to needs)
Lessons from the review: outputsA. Forgetting equity Budget reports measure spending (=costs)B. Outputs (alone) Activity stats and PIsThis is especially measure ‘busy-ness’pertinent if costs are and people supportedfound to increase; (=outputs)or if evaluations are But the primary concerntoo short term; or if of health and social care(narrow) ‘efficiency’ is impact on individuals’is the dominant health, quality of life,sentiment wellbeing = outcomes
Lessons from the review: silosA. Forgetting equity Budget cuts could encourage narrow self-B. Outputs (alone) interest.C. Silos But many service users and families have wide- A ‘whole systems’ ranging needs … approach is needed … and hence they use a And research needs to range of supports examine evidence from and services. different perspectives (agency, individual, Evidence often fails to societal …) mirror this multi-agency / budget reality
Lessons from the review: horizonsA. Forgetting equity Effective interventions could head off long-B. Outputs (alone) term problems + costs.C. Silos Hard-pressed decision-D. Short-termism makers and researchers focus on short-term But consequences of TC (TH too?) could be most pronounced in long- term Explore longer-term simulation modelling?
Lessons from the review: averagesA. Forgetting equity Research reports averages (costs,B. Outputs (alone) outcomes).C. Silos But who is this ‘averageD. Short-termism user or patient’ ?E. The average user Need to understand individual variations in outcomes and costs… For whom is this intervention effective and cost-effective?
Lessons from the review: samples Research often limitedA. Forgetting equity by samples that are tooB. Outputs (alone) small to pick up significant differences.C. Silos There is a general issueD. Short-termism of statistical power, butE. The average user it is a particular issue inF. Small samples cost-effectiveness studies.
Lessons from the review: ‘good’ costsA. Forgetting equity Costs are seen as bad – saving money is a goodB. Outputs (alone) thing.C. Silos But many people withD. Short-termism long-term needs are under-supported, soE. The average user interventions thatF. Small samples identify unmet needs could increase costs.G. Good/bad costs This could be good. To check we must look at cost-effectiveness
Lessons from the review: comparatorsA. Forgetting equity Evidence almost alwaysB. Outputs (alone) needs to be seen in context – needs toC. Silos include a comparator.D. Short-termism There are still studiesE. The average user that examine impacts of one intervention in theF. Small samples absence of a controlG. Good/bad costs group.H. Roman Emperor
Lessons from the review: locationA. Forgetting equity Most evidence comesB. Outputs (alone) from North America – where health and careC. Silos systems are veryD. Short-termism different from here; also prices different.E. The average user Outcome results mightF. Small samples transfer more readilyG. Good/bad costs than cost or cost- effectiveness results.H. Roman Emperor Need to set findings inI. Transportability context of local systems
Lessons from the review: interestsA. Forgetting equity Of course, interested parties will commissionB. Outputs (alone) research:C. Silos • manufacturersD. Short-termism • governmentsE. The average user • lobbying groups etcF. Small samples Need to be aware of theG. good/bad costs funding source whenH. Roman Emperor judging the quality of evidenceI. TransportabilityJ. Interest groups
WSD: economic questionsi. What are the costs of the TH/TC interventions themselves?ii. What are the levels of service use (and their associated costs) for TH/TC users?iii. Are individual, area, other characteristics associated with service use and cost variations?iv. Is TH/TC cost-effective? I.e. how do the costs and outcomes compare? Are the outcomes of TH/TC worth the costs?v. And for whom is TH/TC (most) cost-effective?vi. What are the marginal productivities of support and treatment services for TH/TC users?