CSIRO study shows massive return on investment for at-home telemonitoring
The final report from a CSIRO-led trial into home monitoring of vital signs of elderly patients with chronic disease has found that billions could be saved in healthcare expenditure from both the primary care and hospital sectors with a modest investment in home telemonitoring equipment, risk stratification tools and remote monitoring by telehealth nurses in new roles of clinical care coordinators.
The report, Home Monitoring of Chronic Disease for Aged Care, gathers evidence from one of the trials conducted under the $20 million telehealth pilots program, run by the Department of Health between 2012 and 2014 and originally designed to test the benefits to the healthcare system of the National Broadband Network (NBN).
Early results from the study proved promising, showing for the first time in Australia that home monitoring with a telehealth device could reduce costs to the federal government through the MBS and PBS and to state governments through avoidable admissions to hospital and reductions in length of stay.
There would also be savings for district nursing services and local health districts in better targeted nurse visits, and the early results also showed that home telemonitoring could also improve actual health outcomes, including a reduction in mortality rates of up to 37 per cent.
Savings in the range of several thousand dollars per person per annum were expected and a return on investment was calculated at between two and three. Those results were based on a calculation of the cost of a day in hospital of about $1000.
However, a full analysis of the project, in which a more realistic cost of a hospital stay of $2050 per day is used, has shown that with an annual expenditure of $2760 per person, huge savings of between $16,383 and $19,263 per annum are possible, predominantly in fewer admissions to hospital and length of stay. This is a massive return on investment of between 4.9 and 6.0.
CSIRO's modelling shows that telemonitoring by a clinical care coordinator authorised to make interventions can result in:
- 46.3% reduction in the rate of MBS expenditure
- 25.5% reduction in the rate of PBS expenditure
- 53.2% reduction in the rate of admission to hospital
- 75.7% reduction in the rate of length of stay
- > 40% reduction in mortality
- > 60% user adherence to measurement protocols
- > 50% user adherence to questionnaire administration
- > 83% user acceptance and use of telemonitoring technology
- > 89% of clinicians would recommend telemonitoring services to other patients.
For project director Branko Celler, the results are very gratifying after many years of research into telehealth. “This was a really complicated project,” Professor Celler said.” It was very ambitious in that we had six different sites in five different states and territories, we had a lot of delays due to the original government .requirement that we only connect patients to the NBN.
“We also had to deal with seven different ethics committees … and the numbers [of test patients] were a bit smaller than we wanted but the results are pretty robust.”
Professor Celler, who has now left the CSIRO and is working part-time as a research professor at the University of NSW and part-time in a research director's role with the company behind the device used in the trial, Telemedcare, said the study showed that rather than complicated care coordination or integrated care projects, in-home tele-monitoring was a simple and effective model that could save the health system billions every year.
“At home tele-monitoring is actually very simple. You have a competent clinician, well-trained, in charge of reviewing the questionnaire and vital signs data from a patient, who has the authority to coordinate the care, and you can get the sorts of results shown in our report.”
The study was initially run over six sites around the country, with a trial run in Canberra in association with the Canberra Hospital and ACT Health; in Queensland, through Townsville Mackay Medicare Local (TMML); in Victoria, through the Grampians Rural Health Alliance and Djerriwarrh Health Services; in Tasmania, in association with Tasmanian Health Organisation – North and Launceston Hospital; and two sites in western Sydney that eventually merged into one: Nepean Blue Mountains Medicare Local and Anglican Retirement Villages (ARV), both in Penrith.
The aim was to demonstrate how telehealth services for chronic disease management in the community could be deployed nationally in Australia in a range of hospital and community settings with differing models of care, and to develop advanced data analytics tools that can stratify a patient's condition on a daily basis to automatically identify exacerbations or trends, allowing for early interventions to avoid a hospital admission.
The trial involved a test group and a control group, with test patients provided with a telehealth device from Telemedcare that included video conferencing capabilities as well as vital signs devices such as blood pressure cuffs and ECGs. They were also given questionnaires and were assigned a nurse who remotely monitored their vital signs and used a simple risk stratification schema that enabled them to see significant changes in their readings. The control group received normal care, delivered primarily by GPs and community nurses.
As the researchers write, part of the study’s remit was to investigate the introduction of a new role for nurses as clinical care coordinators using telehealth.
“The role of the CCC was to monitor each participant’s vital signs and liaise with GPs, specialists and community nurses who may be caring for the participant,” they write. “A project officer (PO) was also allocated to each site and fully funded by the project to manage operational activities for the study and thereby separating patient care from study operations.”
While Professor Celler has a long-standing involvement in Telemedcare (TMC) going back to its early development by the University of NSW, the company's device was chosen as part of a comprehensive technology assessment conducted at arm's length from the study team.
The device had to be capable of:
- Vital sign monitoring – ECG, heart rate, spirometry, non-invasive blood pressure, oxygen saturation, body weight and body temperature, and optional glucometry
- Interactive features such as participant/clinician video conferencing and messaging features, support for scheduling and the delivery of clinical and study specific questionnaires to participants. It also had to be easy to use by participants and clinicians with multi-language support
- Comply with TGA and preferably also European CE Mark and US FDA regulations, as well as with Health Information Exchange (HIE) and HL7 standards and service-oriented architecture (SOA) for web services
- Clinical decision support capabilities such as the ability to export de-identified raw data signals from the system for research and analysis, and have an expert system for daily patient risk profiling
- Demonstrated experience and participation in telehealth clinical trials and research projects in Australia, along with Australian-based software and hardware R&D capability and capacity to support the research requirements of the CSIRO.
In addition to scheduled times, patients could take their vital signs at any time and a full suite of clinical questionnaires was also available, scheduled and administered by the CCCs. The TMC clinical monitoring unit also permits secure messaging and video conferencing between patients and their care coordinators.
Trial sites were originally selected based on location and demographic profile but also on the area's early participation in the roll out of fibre-to-the-premises (FTTP) NBN. This was relaxed to any kind of broadband provision following the election of the new Coalition government in September 2013.
Patients had to be over 50, have good cognitive capacity but one or more complex illnesses such as COPD, coronary artery disease, congestive heart failure, diabetes or asthma, and have been admitted to hospital more than twice in the last 12 months or more than four times in the previous five years due to that condition.
A series of questionnaires were taken on entry and exit to the study as well as periodically through the study, including demographic information such as gender, age, weight and height (BMI), occupation, marital status, income, computer skills, social media and NBN connectivity; behavioural information such alcohol intake, tobacco smoking, fruit and vegetable consumption, meat and fish, fibre, fat and salt intake; physical activity measures; psychosocial functioning, quality of life and medication adherence.
The study used a range of other software for the researchers, including the OpenClinical open sources clinical trial software and portal. Patient data was obtained from multiple sources and integrated into a single unified database linked via a unique OpenClinica ID (OCID). A data model was also developed which provided the template for data analysis by linking outcomes and objectives to specific data variables and identifying the data sources.
The trial set out to recruit 25 test patients and 50 matched controls in each of the six sites selected, but ended up enrolling 287 in total, 114 for the test group and 173 for the control. Analysis was carried out on total MBS and PBS expenditure such as number and cost of GP visits, number and cost of visits to specialists and number and cost of tests and procedures prescribed, as well as number of admissions to hospital and length of stay.
The patients' views
Surveys showed that all test patients were satisfied with using the monitoring device and found instructions easy to understand, with few finding it was cumbersome or complex.
“[The majority] of participants found the TMC easy to use (87.5%) and felt confident in using it (85.7%) despite 32.1% of them reporting that there were occasions of frustration,” the researchers write. “In terms of compatibility, majority of participants found that using the monitoring device could be incorporated in their daily routine (80.4%), fits in with their daily life (71.4%) and the way they would like to manage their health (76.8%).”
They also reported that they liked their experience with their telehealth nurses, but only 12.2 per cent reported that their GPs reviewed the telemonitoring results during patients’ visits and only 34.7 per cent agreed that telemonitoring improved their communications with GPs.
Compliance with the measurement protocols was generally high and patients filled out their questionnaires regularly, which the researchers say is a considerable achievement given the demanding schedule of measurements and questionnaires.
A lot of this comes down to their nurse, the researchers write. “A strong correlation was found between the level of involvement of the CCCs and patient compliance. The higher the CCC engagement with the patient and the monitoring of patient data, the higher was the level of compliance from the patient. Clinical care coordinators generally viewed every patient’s record daily and tracked time spent on each patient using the CSIRO web portal.
The Telemedcare Clinician Portal allowed authorised clinicians to view and edit patient data if necessary, and also provided a number of facilities for setting flags which would indicate that patient’s measurements exceeded individual bounds.
Analysis of the effect of telemonitoring on patient expenditure on MBS and PBS items showed that there was a significant reduction in both following the start of telemonitoring.
There was a 46.3 per cent drop in the rate of MBS expenditure in the year following the start of intervention, representing a saving of $611 over that year, with savings generally greater for patients with cardiac conditions ($804) and those managed in community settings ($648). Savings were least for patients with chronic respiratory conditions ($409).
Savings were primarily made through modest falls in the number and cost of GP visits and significant falls in the number and costs of specialist visits and procedures carried out. Pathology costs began to fall only in the last two months of the trial.
In terms of the PBS, patients had on average six or seven scripts filled per month, with overall expenditure on PBS items of $2984 per annum. The study found an overall 25.5 per cent drop in the rate of PBS expenditure in the year following the start of intervention, representing a saving of $354 over that year.
In terms of hospital admissions, based on their rate of admission at the start of intervention of 2.55 admissions per annum, test patients were predicted to have 3.09 admissions per annum one year after the intervention. However, their rate of admission fell to 1.45, a reduction of more than 53 per cent. This represents a reduction of between 0.67 and 1.0 admissions per year.
The analysis also showed a significant fall in length of stay following the telemonitoring intervention. Test patients at the start had length of stays of approximately 19.8 days, which after one year were projected to increase to 24.6 days. However, this was reduced to only 6.0 days per annum after one year of the intervention, a reduction of almost 76 per cent. This is significant considering the cost of a hospital bed per day is estimated to be about $2051.
Telemonitoring also had an effect on mortality, with a reduction of 41.3 per cent based on the aged specific death rate. Patient self-reported measures were also promising, with improvements in anxiety and depression measures, and quality of life, although these were not statistically significant. However, patients almost universally expressed strong support for the service and reported better understanding and self-management of their chronic conditions.
The cost of delivering the telemonitoring service in terms of the nursing workforce is about $6.22 per patient per day, with a CCC costing approximately $100,000 per annum including overheads, the researchers say.
A single nurse working full time could probably manage 68 patients, although the researchers say improved procedures and processes as well as increased efficiency and the use of predictive analytics tools to automatically risk stratify patients would bring the monitoring cost per patient per day to approximately $4.00/day. This would allow a single nurse to monitor about 100 patients.
The cost of a typical telemonitoring system based on a tablet with three Bluetooth measurement devices is approximately $1324 or $35 a month over four years. Taking into account internet costs, web services hosting and nurse coordination, they estimate the annual cost would be $2760 per person per annum.
The end result is that with an investment of $2760 per person, savings in terms of MBS and PBS costs, reduced length of stay and reduced demand on community nurses could be as high as $19,263 per person. This represents a return on investment of 5.98. Without the involvement of a community nurse, it drops to 4.9.
The study team faced a lot of difficulties, Professor Celler said, including the slow and limited roll-out of the NBN, the study being limited to the NBN rather than more available options, difficulties with some of the data provided by the DHS, changes of government and the closure of some the Medicare Locals.
A lack of GP involvement was one of the more disappointing aspects, he said. GPs were required to provide consent for the participation of their patients and they were given the opportunity of viewing their patient's data, either directly on screen or to receive PDF reports by email, fax or the post.
Only 16 per cent chose to have the option of viewing their patient’s records online and obtaining their consent could take months, the researchers report. CCCs also frequently reported difficulties in making contact with the patient’s GP when exacerbation of their patient’s chronic condition was becoming evident.
However, the researchers say that notwithstanding these difficulties, project has provided a large amount of valuable data on the effect of telemonitoring services at five different locations each with a different model of care for the management of chronic disease in the community.
Overall, the researchers say the evidence shows that the return on investment of a telemonitoring initiative on a national scale would be in the order of five to one by reducing demand on hospital inpatient and outpatient services, reduced visits to GPs, reduced visits from community nurses and an overall reduced demand on increasingly scarce clinical resources.
Over 500,000 Australians aged over 65 would be good candidates for at-home telemonitoring. If rolled out nationally, they estimate it would cost about $2 billion to set up the number of telemonitoring centres required. However, savings in the order of $3 billion per annum could be achieved simply by reducing hospital admissions by one episode each person each year.
“Additional savings would also be made from a far more efficient use of existing clinical resources including a 2-3 fold increase in case load for each community nurse and a reduction in patient visits to their GP,” they say.
However, getting something moving on a national scale is going to be difficult, Professor Celler said, despite the outstanding results.
“What we said in the report was that there is a distance between those that pay and those that benefit. This has been a big problem forever. Clearly, the biggest savings are in hospital admissions and from that perspective the states would benefit th emost. However, the states say that at home tele-monitoring is primary care and the commonwealth should pay for it.
“The compromise we've reached is to suggest that the best organisations to manage the care coordination role would be the primary health networks which at the end of the day are the agents of the federal government operating at a state level. If a PHN then takes on this crucial role, not only will the local health district benefit, but any other service provider that wants to use telehealth could avail themselves of the care coordinator that the PHN would provide.”
Two of the Medicare Locals involved in the trial were shut down afterwards so were unable to continue with their telehealth services, although the ARV site in NSW agreed to extend its telemonitoring service to a total number of 40.
Djerriwarrh Health Services in Victoria has continued its telemonitoring service, funded through internal cost efficiencies, but it is also seeking state government funding to continue. ACT Health intends to expand its existing telehealth service.
In Queensland, the Medicare Local that was involved in the trial, Townsville-Mackay Medicare Local, did not win the contract to become the PHN. That team instead has set up as a not-for-profit provider called Northern Australia Primary Health.
Its CEO, Julie Scheuber, who worked closely with Professor Celler and his team during the trial, has since spoken to the Townsville Hospital and Health Service and together they have developed a proposal to roll out telemonitoring in the region. This has been submitted to the state government for funding under the Queensland Health Innovation Fund. They will know if they are successful at the end of June, Professor Celler said, and this proposal has the potential to provide the template for similar models to be deployed in all 31 PHNs, he said.
The study has been released to all partner organisations and is expected to be publicly released by the CSIRO shortly.
The project was funded by the federal government NBN telehealth pilot program to the tune of $3.05 million with the CSIRO contributing an additional $750,000 in personnel costs and an additional $344,000 to ensure that the project could be extended to the end of 2014. Telemedcare, Samsung, iiNet and the clinical service providers contributed over $1.3 million in in-kind support.
Professor Celler 's team included Marlien Varnfield, Rajiv Jayasena, Ross Sparks, Jane Li, Surya Nepal, Julian Jang-Jaccard and Simon McBride.
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