Show us the evidence for telehealth

Is “telehealth”—such as remote monitoring of pulse, blood pressure, weight, or blood oxygen—the way forward? A recent press release from the Department of Health for England would have us believe that “three million lives could be improved across England thanks to new high-tech healthcare.” This will require investment: “Over the next five years the Department of Health will work with industry, the NHS, social care and professional organisations to bring the benefits of assistive technology such as telehealth and telecare to millions of people with long term conditions.” The press release continued: “Early findings indicate that telehealth can lead to: 45% reduction in mortality; 21% reduction in emergency admissions; 24% reduction in elective admissions; 15% reduction in A&E [accident and emergency department] visits; 14% reduction in bed days; and 8% reduction in tariff costs.”1

The statements in the press release were duly reported in the mainstream and online press.2 3 What’s the evidence for the statements? Paul Burstow, care services minister, said in the press release, “The trials of telehealth and telecare have shown how people with long term conditions can live more independently, reducing the time they have to spend in hospital and improving their quality of life. The feedback I have heard from people in Cornwall today has been incredibly positive. They were absolutely clear that high-tech healthcare being used here has improved their lives for the better.” The press release also said, “Over the last three years the Department of Health has been running the world’s largest randomised control trial of telehealth and telecare—involving 6191 participants and 238 GP practices across three locations in Cornwall, Kent and Newham,” and, “Uptake in England has been slow—there are only around 5000 telehealth users and only 1.5 million pieces of telecare in use to date.”

With this criticism of the perceived lack of take up, we might want more evidence about the telehealth trials in England. In December 2011 the health department produced a three page document titled “Whole system demonstrator programme—headline findings.” It stated, “The first set of initial findings from this programme is now available. They show that, if delivered properly, telehealth can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in A&E.” However, the full trial data were not published, with the document saying that “papers will be published in due course” and also stating some relative risks that differed from those in the press release: “a 20% reduction in emergency admissions, a 14% reduction in elective admissions.”4 However, neither in this document nor in the press release were any absolute risks given, making the true effects of this intervention unclear.

The published evidence so far about telehealth is less clear cut than the press release makes out. A systematic review and meta-analysis published in 2010 showed that home telehealth (home monitoring and telephone support) for patients with chronic obstructive pulmonary disease did reduce length of stay in hospital but also resulted in a greater death rate in comparison with usual care.5 A Cochrane review concluded that telehealth may improve clinical outcomes in patients with severe asthma but that further trials are needed on cost effectiveness.6 The Trans-European Network home care management system study reported in 2005 that nurse telephone support or telemonitoring could reduce the death rate among patients who had heart failure and were at high risk of recurrent admission and death. In the usual care group 33% had died, compared with 20% in the nurse support group and 22% in the telemonitoring group.7 This was not a clear victory for telehealth but for increased contact, which could have been provided by any nurse, not just through telehealth technology. A Cochrane review published in 2010 showed that telemonitoring of patients with chronic heart failure could reduce all cause mortality at one year from 15.4% to 10.4%, in comparison with usual care.8

Why did the health department not publish full results along with a statement of its intentions? A department spokesman told the BMJ, “We know that telehealth will bring great benefits to patients and that’s why we want to take action as soon as we can. We have seen the results of the whole system demonstrator programme, which our Three Million Lives campaign is based on.” This certainty has not been seen in the peer reviewed press, and the National Institute for Health and Clinical Excellence has not assessed the cost effectiveness of the interventions.

The healthcare think tank the King’s Fund is currently publicising the International Congress on Telehealth and Telecare 2012, at which many study results will be available, promises Nick Goodwin, the fund’s senior fellow in health policy, writing in a King’s Fund blog.9 He also said, while recounting the same figures given in the health department press release, that “these impressive results will surpass the expectations of many in the private sector who have found the UK telehealth market (particularly in England) a tough nut to crack,” and, “now that telehealth has a stronger evidence base and the support of the Department of Health, we have created the most receptive environment for it yet.”9 But without access to the full data, never mind absolute rather than relative risks, how can we possibly know? The private sector is poised to play. But without evidence this becomes a public relations stunt, not a cost effective practice.