CSIRO NBN trial shows big savings with at-home monitoring
At-home monitoring of vital signs in older patients with chronic diseases can lead to significant savings over time in terms of MBS costs, PBS dispensing costs, costs associated with hospitalisations and average length of stay, and it can also reduce mortality rates by up to 37 per cent, new CSIRO data shows.
The data from the CSIRO's NBN-enabled telehealth project also shows that home telehealth services on an annual subscription model, including internet connection, home telehealth device and nurse wages, can be viably offered for about $2400 a year.
With annual savings of about $8000 in MBS, PBS, hospitalisation and visiting nurse costs, this represents an estimated return on investment of between two and three, the figures show.
Lead researcher Branko Celler, formerly principal scientist at the CSIRO Centre for Computational Informatics who has been heading up CSIRO's NBN Telehealth Research Group, told the Health Informatics Conference (HIC 2015) in Brisbane last week that the results will make a significant contribution to government understanding on how to nationally deploy telehealth services and how to develop cost-effective and sustainable models to fund them.
Professor Celler's team was one of the winning bidders for the NBN-enabled Telehealth Pilots Program announced in 2013. The $3 million randomised control trial recruited hundreds of patients in several states who were provided with a free internet connection and Telemedcare device, which allows for video conferencing and vital signs monitoring through peripherals including blood pressure monitors, pulse oximeters and ECGs.
The participants had an average age of 71, had one or more chronic illnesses such as congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and coronary heart disease, and had been hospitalised twice in the preceding year.
They were asked to take their measurements once a day, with a compliance rate of 68.2 per cent, and over the course of the trial about 111,000 measurements were taken, including 9000 ECGs, 20,000 blood pressure measurements and 20,000 pulse oximetries.
Healthcare costs for this cohort of patients can add up very quickly. The CSIRO trial found that over a 100-day period, patients visited the GP 5.7 times at a cost of $245; they had 0.6 visits from allied health, which cost them $30; they had 1.6 visits to specialists for a cost of $159; and they had 28 medications dispensed over the period at a cost of $959.
“The total cost of procedures and tests was $625,” Professor Celler said. “When you look at a total cost of PBS and MBS items, it's about $2029, and they spent $44.40 travelling to see the GP.”
While there is plenty of international evidence that telehealth might be able to reduce some of these costs, there has not been enough local evidence to sway the government to seriously invest in and fund in-home monitoring for chronic illness.
However, the evidence from this trial is very persuasive. It shows that costs to the MBS for chronically ill patients over the age of 71 can be reduced by about $800 or up to 31 per cent per year, PBS dispensing costs by $200 or 10 per cent per year and substantial reductions in the avoidable costs of hospitalisations and length of stay.
Reductions in mortality rates for this cohort were comparable to those from international studies such as the UK's Whole System Demonstrator, Professor Celler said.
“We compared the mortality between our test and our control patients and the calculation is that the probability of death for our test patients was 3.75 per cent and the probability of death for our control patients was 5.95 per cent,” he said.
“This means that telehealth reduced the mortality by 37 per cent against the control [group].”
In terms of hospitalisations, there was a reduction of about 0.6 to 0.7 presentations over a year, for a saving of about $3000 on average. Acute care beds can cost well over $1000 a day.
There was also a significant change in length of stay for those who did end up in hospital, Professor Celler said. “Patients that were being monitored at home and that did go to hospital spent less time in hospital by about a day, or a day and a bit. These data are statistically significant.”
He described the MBS and PBS data as “very gratifying”.
“This has never been shown before, that telehealth actually has an impact on MBS expenditure, which is all procedures, visits to GPs, visits to specialists,” he said. “It does reduce it.”
And the return on investment is likely to be between two and three, he said. The initial estimate of cost for a subscription-based telehealth model was about $12 a day, which includes $7 a day for video conferencing, messaging and a comprehensive suite of instruments, $1 a day for the internet and $4 a day for monitoring and triage.
“Telehealth, to be run professionally, had to be around $12 per day on a subscription based model,” Professor Celler said.
“However, we followed that discussion further and at the end of the trial we re-evaluated the likely costs. The cost per month for a chronically ill patient of some significant severity, we believe the monitoring, hosting and maintenance cost will be that of $150 per month. The nurse coordination, at 0.5 hours per week per patient, it is about $50 per month.
“And that means that the cost of running a telehealth service ought to be around the $2400 mark. The annual savings estimates, the savings in PBS dispensing that were shown to be $200, the savings in the MBS items of $800 … even if you consider the rate of hospitalisation to be only half per annum, for chronically ill patients that’s a saving of $3000 per year, because for chronically ill people, hospitalisation are typically around $6700 per year.
“And the reduced demand on community nursing. This is based around a saving of five per cent [full-time equivalent] per patient for a community nurse, based on the fact that a community nurse would ... have a caseload of about 10 patients, and this could be increased [using telehealth].
“So that is a total saving of about $8000 and that gives you an estimated return on investment of about three. We believe this is a fairly realistic figure, although quite preliminary still. We are doing some of the final calculations.”
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