Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial

Device based monitoring in digital care and its impact on hospital service use

This systematic review examines four themes of device-based remote monitoring (DRM): technology, patient monitoring and support, integration of DRM into clinical care, and patient engagement, and their impact on hospital service use. We included randomized controlled trials (RCTs) until 2024 comparing hospital service use in DRM with usual care. Hospital service use decreased in DRM in 72% of the 116 included RCTs. Non-implantable devices were most commonly used to measure data, but showed a lower decrease in hospital service use than implanted or mobile devices (69% vs 89% and 76%). Providing 24/7 support for patients led to a decrease (81% of the studies). DRM replacing usual care, involving designated healthcare providers, and patient-performed data transmission led to a greater decrease in hospital service use. DRM has the potential to further reduce hospital service use with additional factors such as sufficient support, automated processes, and optimized care redesign.

Economic evaluations of videoconference and telephone consultations in primary care: A systematic review

INTRODUCTION

Telehealth services using videoconference and telephone modalities have been increasing exponentially in primary care since the coronavirus pandemic. The challenge now is ensuring that these services remain sustainable. This review investigates the cost-effectiveness of videoconference and telephone consultations in primary care settings, by summarizing the available published evidence.

METHODS

A systematic search of PubMed, Embase, Scopus, and CINAHL databases was used to identify articles published from January 2000 to July 2020, using keyword synonyms for telehealth, primary care, and economic evaluation. Databases were searched, and title, abstract, and full-text reviews were conducted. Article reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

Twenty articles were selected for inclusion, with 12 describing telephone triage services, seven describing telehealth substitution services, and one describing another telehealth service in primary care. These services were delivered by nurses, doctors, and allied health clinicians. Of the 20 included studies, 11 used cost analyses, five used cost-minimization analyses, and four used one or more methods, including either a cost-consequence analysis, a cost-utility analysis, or a cost-effectiveness analysis.

CONCLUSIONS

Telephone and videoconference consultations in primary care were cost-effective to the health system when deemed clinically appropriate, clinician when time was used efficiently, and when overall demand on health services was reduced. The societal benefits of telehealth consultations should be considered an important part of telehealth planning and should influence funding reform decisions for telehealth services in primary care.

Advance Planning for Technology Use in Dementia Care: Development, Design, and Feasibility of a Novel Self-administered Decision-Making Tool

BACKGROUND

Monitoring technologies are used to collect a range of information, such as one's location out of the home or movement within the home, and transmit that information to caregivers to support aging in place. Their surveilling nature, however, poses ethical dilemmas and can be experienced as intrusive to people living with Alzheimer disease (AD) and AD-related dementias. These challenges are compounded when older adults are not engaged in decision-making about how they are monitored. Dissemination of these technologies is outpacing our understanding of how to communicate their functions, risks, and benefits to families and older adults. To date, there are no tools to help families understand the functions of monitoring technologies or guide them in balancing their perceived need for ongoing surveillance and the older adult's dignity and wishes.

OBJECTIVE

We designed, developed, and piloted a communication and education tool in the form of a web application called Let's Talk Tech to support family decision-making about diverse technologies used in dementia home care. The knowledge base about how to design online interventions for people living with mild dementia is still in development, and dyadic interventions used in dementia care remain rare. We describe the intervention's motivation and development process, and the feasibility of using this self-administered web application intervention in a pilot sample of people living with mild AD and their family care partners.

METHODS

We surveyed 29 mild AD dementia care dyads living together before and after they completed the web application intervention and interviewed each dyad about their experiences with it. We report postintervention measures of feasibility (recruitment, enrollment, and retention) and acceptability (satisfaction, quality, and usability). Descriptive statistics were calculated for survey items, and thematic analysis was used with interview transcripts to illuminate participants' experiences and recommendations to improve the intervention.

RESULTS

The study enrolled 33 people living with AD and their care partners, and 29 (88%) dyads completed the study (all but one were spousal dyads). Participants were asked to complete 4 technology modules, and all completed them. The majority of participants rated the tool as having the right length (>90%), having the right amount of information (>84%), being very clearly worded (>74%), and presenting information in a balanced way (>90%). Most felt the tool was easy to use and helpful, and would likely recommend it to others.

CONCLUSIONS

This study demonstrated that our intervention to educate and facilitate conversation and documentation of preferences is preliminarily feasible and acceptable to mild AD care dyads. Effectively involving older adults in these decisions and informing care partners of their preferences could enable families to avoid conflicts or risks associated with uninformed or disempowered use and to personalize use so both members of the dyad can experience benefits.

Control Matters in Elder Care Technology:: Evidence and Direction for Designing It In

Studies find that older adults want control over how technologies are used in their care, but how it can be operationalized through design remains to be clarified. We present findings from a large survey (n=825) of a well-characterized U.S. online cohort that provides actionable evidence of the importance of designing for control over monitoring technologies. This uniquely large, age-diverse sample allows us to compare needs across age and other characteristics with insights about future users and current older adults (n=496 >64), including those concerned about their own memory loss (n=201). All five control options, which are not currently enabled, were very or extremely important to most people across age. Findings indicate that comfort with a range of care technologies is contingent on having privacy- and other control-enabling options. We discuss opportunities for design to meet these user needs that demand course correction through attentive, creative work.

Telecare Service Use in Northern Ireland: Exploratory Retrospective Cohort Study

BACKGROUND

Telecare is a health service that involves the home installation of a number of information technology support systems for individuals with complex needs, such as people with reduced mobility or disabilities and the elderly. It involves the use of sensors in patients' homes to detect events, such as smoke in the kitchen, a front door left open, or a patient fall. In Northern Ireland (NI), outputs from these sensors are monitored remotely by the telecare team, who can provide assistance as required by telephone or through the emergency services. The facilitation of such rapid responses has the aim of promoting early intervention and therefore maintaining patient well-being.

OBJECTIVE

The aims of this study were to construct a descriptive summary of the telecare program in NI and evaluate hospital-based service use by telecare patients before and after the installation of telecare equipment.

METHODS

An exploratory retrospective cohort study was conducted involving more than 2000 patients. Data analysis included the evaluation of health care use before and after the telecare service was initiated for individual participants. Individuals with data for a minimum of 6 months before and after the installation of the telecare service were included in this analysis.

RESULTS

A total of 2387 patients were enrolled in the telecare service during the observation period (February 26, 2010-February 22, 2016). The mean age was 78 years (median 81 years). More women (1623/2387, 68%) were enrolled in the service. Falls detectors were the most commonly deployed detectors in the study cohort (824/1883, 43.8% of cases). The average number of communications (calls and/or alarms) between participants and the coordinating center was the highest for patients aged ≥85 years (mean 86 calls per year). These contacts were similarly distributed by gender. The mortality rate over the study period was higher in men than women (98/770, 14.4% in men compared to 107/1617, 6.6% in women). The number of nonelective hospital admissions, emergency room visits, and outpatient clinic visits and the length of hospital stays per year were significantly higher (P<.001) after the installation of the telecare equipment than during the period before installation.

CONCLUSIONS

Despite the likely benefits of the telecare service in providing peace of mind for patients and their relatives, hospital-based health care use significantly increased after enrollment in the service. This likely reflects the increasing health care needs over time in an aging population.

Sustainable Social Care: The Potential of Mainstream “Smart” Technologies

Recent proposals for reform in England have presented widely available “smart” mainstream digital devices as a means to address some of the challenges facing adult social care and as alternatives to unsustainable analogue “telecare” systems. Drawing on 40 interviews with experts from local authorities, the care and technology sectors, and people with lived experience of social care services, we explored how mainstream technologies are being used in practice in England and critically examined their potential to contribute to policy priorities of wellbeing and sustainability. Across all expert groups interviewed, examples were cited in which the use of mainstream devices supported the economic sustainability of adult social care and/or enhanced aspects of wellbeing, moving the role of technology in care beyond monitoring and managing risks. However, when viewed through a three-dimensional conceptual lens that includes material, relational and subjective wellbeing, the use of smart devices in practice also created tensions and trade-offs between the dimensions, with implications for sustainability. The various ways mainstream devices are being used in adult social care also raised complexities related to risks, responsibilities, and inequalities and required “wraparound services”, tempering their ability to deliver cost savings. To address these issues, we suggest a person-centred approach to technology across local authorities, with investment in wraparound services and to mediate inequalities associated with the “digital divide”.

"It's no good but at least I've always got it round my neck": A postphenomenological analysis of reassurance in assistive technology use by older people

The provision of reassurance is seen as a goal and benefit of the use of assistive technology (AT) in supporting people to manage their health and care needs at a distance. Conceptually, reassurance in health and care settings remains under-theorised with the benefits of experiencing reassurance through technology use assumed rather than understood. UK health and social care service goals of managing safety and risk have largely been equated with providing reassurance to users of AT and their carers. What has not been explored is how reassurance is experienced variably by users of different types of technology-enabled care. We present data from 3 case studies of different technologies in use in health and social care provision, analysed through a postphenomenology and sociomaterial lens. Our findings point to reassurance as an important facet of AT provision but the intended functions and uses of technological devices alone did not account for people's experiences of reassurance. Participant narratives referred variously to the comfort of being monitored, having their illness/wellness verified by the device, feeling reassured by the promise of help if needed, and imbuing the device with symbolic meaning (when the user associated the device with meanings and functions other than its technical capabilities). The different ways in which reassurance was experienced provides a useful way of understanding the potential tensions with AT policy goals as well as the positive meaning attributed to devices in some cases. This study reaffirms the importance of AT implementation being anchored in what matters to the user.

Telecare at a crossroads? Finding researchable questions

Purpose

This paper aims to report on a structured attempt to develop new directions for research into telecare. Current research evidence suggests that telecare in the UK is not optimally cost-effective and does not deliver better outcomes than more traditional forms of care and support. To address this problem, an analysis of expert opinion about future directions for research is provided.

Design/methodology/approach

Two electronic surveys of UK based academic experts were conducted. Participants were drawn from a range of professional disciplines, including medicine, social care, occupational therapy and social policy and identified were by their contribution in this, or allied fields. The first survey included nine questions intended to identify at least one new research question that could form the basis of a funding proposal to the Nuffield Foundation, which provided “seedcorn” funding to support this work. Ten themes were identified following thematic analysis. The second survey asked participants to prioritise three of these themes.

Findings

Key themes emerging as priority areas for future research were as follows: the role of assessment in ensuring technology deployment meets the needs of service users; ethical implications of technology and how these might be addressed in the future; and the use of end user co-production/co-creation approaches in the development of new assistive technologies and digital enabled care.

Research limitations/implications

The findings are based on academic expert opinion; perspectives of practitioners, service users and family members are unrepresented.

Practical implications

The findings of this study could contribute to development of new directions for telecare research, and future strategic funding decisions in this rapidly changing field.

Originality/value

Evidence for sub-optimal outcomes for telecare requires new thinking. The authors are not aware of any other study that offers an analysis of expert opinion of fruitful areas for new research into telecare.

The effectiveness and cost-effectiveness of assistive technology and telecare for independent living in dementia: a randomised controlled trial

Objectives

The use of assistive technology and telecare (ATT) has been promoted to manage risks associated with independent living in people with dementia but with little evidence for effectiveness.

Methods

Participants were randomly assigned to receive an ATT assessment followed by installation of all appropriate ATT devices or limited control of appropriate ATT. The primary outcomes were time to institutionalisation and cost-effectiveness. Key secondary outcomes were number of incidents involving risks to safety, burden and stress in family caregivers and quality of life.

Results

Participants were assigned to receive full ATT (248 participants) or the limited control (247 participants). After adjusting for baseline imbalance of activities of daily living score, HR for median pre-institutionalisation survival was 0.84; 95% CI, 0.63 to 1.12; P = 0.20. There were no significant differences between arms in health and social care (mean -£909; 95% CI, -£5,336 to £3,345, P = 0.678) and societal costs (mean -£3,545; 95% CI, -£13,914 to £6,581, P = 0.499). ATT group members had reduced participant-rated quality-adjusted life years (QALYs) at 104 weeks (mean − 0.105; 95% CI, −0.204 to −0.007, P = 0.037) but did not differ in QALYs derived from proxy-reported EQ-5D.

Discussion

Fidelity of the intervention was low in terms of matching ATT assessment, recommendations and installation. This, however, reflects current practice within adult social care in England.

Conclusions

Time living independently outside a care home was not significantly longer in participants who received full ATT and ATT was not cost-effective. Participants with full ATT attained fewer QALYs based on participant-reported EQ-5D than controls at 104 weeks.

Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT

BACKGROUND

Assistive technology and telecare have been promoted to manage the risks associated with independent living for people with dementia, but there is limited evidence of their effectiveness.

OBJECTIVES

This trial aimed to establish whether or not assistive technology and telecare assessments and interventions extend the time that people with dementia can continue to live independently at home and whether or not they are cost-effective. Caregiver burden, the quality of life of caregivers and of people with dementia and whether or not assistive technology and telecare reduce safety risks were also investigated.

DESIGN

This was a pragmatic, randomised controlled trial. Blinding was not undertaken as it was not feasible to do so. All consenting participants were included in an intention-to-treat analysis.

SETTING

This trial was set in 12 councils in England with adult social services responsibilities.

PARTICIPANTS

Participants were people with dementia living in the community who had an identified need that might benefit from assistive technology and telecare.

INTERVENTIONS

Participants were randomly assigned to receive either assistive technology and telecare recommended by a health or social care professional to meet their assessed needs (a full assistive technology and telecare package) or a pendant alarm, non-monitored smoke and carbon monoxide detectors and a key safe (a basic assistive technology and telecare package).

MAIN OUTCOME MEASURES

The primary outcomes were time to admission to care and cost-effectiveness. Secondary outcomes assessed caregivers using the 10-item Center for Epidemiological Studies Depression Scale, the State-Trait Anxiety Inventory 6-item scale and the Zarit Burden Interview.

RESULTS

Of 495 participants, 248 were randomised to receive full assistive technology and telecare and 247 received the limited control. Comparing the assistive technology and telecare group with the control group, the hazard ratio for institutionalisation was 0.76 (95% confidence interval 0.58 to 1.01; p = 0.054). After adjusting for an imbalance in the baseline activities of daily living score between trial arms, the hazard ratio was 0.84 (95% confidence interval 0.63 to 1.12; p = 0.20). At 104 weeks, there were no significant differences between groups in health and social care resource use costs (intervention group - control group difference: mean -£909, 95% confidence interval -£5336 to £3345) or in societal costs (intervention group - control group difference: mean -£3545; 95% confidence interval -£13,914 to £6581). At 104 weeks, based on quality-adjusted life-years derived from the participant-rated EuroQol-5 Dimensions questionnaire, the intervention group had 0.105 (95% confidence interval -0.204 to -0.007) fewer quality-adjusted life-years than the control group. The number of quality-adjusted life-years derived from the proxy-rated EuroQol-5 Dimensions questionnaire did not differ between groups. Caregiver outcomes did not differ between groups over 24 weeks.

LIMITATIONS

Compliance with the assigned trial arm was variable, as was the quality of assistive technology and telecare needs assessments. Attrition from assessments led to data loss additional to that attributable to care home admission and censoring events.

CONCLUSIONS

A full package of assistive technology and telecare did not increase the length of time that participants with dementia remained in the community, and nor did it decrease caregiver burden, depression or anxiety, relative to a basic package of assistive technology and telecare. Use of the full assistive technology and telecare package did not increase participants' health and social care or societal costs. Quality-adjusted life-years based on participants' EuroQol-5 Dimensions questionnaire responses were reduced in the intervention group compared with the control group; groups did not differ in the number of quality-adjusted life-years based on the proxy-rated EuroQol-5 Dimensions questionnaire.

FUTURE WORK

Future work could examine whether or not improved assessment that is more personalised to an individual is beneficial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN86537017.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 19. See the NIHR Journals Library website for further project information.

Placing assistive technology and telecare in everyday practices of people with dementia and their caregivers: findings from an embedded ethnography of a national dementia trial

Background

Policy makers and care providers see assistive technology and telecare as potential products to support people with dementia to live independently in their homes and communities. Previous research rarely examined how people with dementia and their caregivers actually use such technology. The study examined how and why people living with dementia and their caregivers used assistive technology and telecare in their own homes.

Methods

This study used an ethnographic design embedded within the NIHR-funded Assistive Technology and Telecare to maintain Independent Living At home for people with dementia (ATTILA) randomised controlled trial. We collected 208 h of observational data on situated practices of ten people with dementia and their ten caregivers. We used this data to construct extended cases to explain how technologies supported people with dementia in home and community settings.

Results

We identified three themes: placing technology in care, which illustrates how people with dementia and caregivers ‘fit’ technology into their homes and routines; replacing care with technology, which shows how caregivers replaced normal care practices with ones mediated through technologies; and technology displacing care and everyday life, which highlights how technologies disrupted the everyday lives of people with dementia.

Discussion

This study exemplifies unintended and unanticipated consequences for assistive technology and telecare uptake in ‘real world’ community-based dementia care. It underlines the need to identify and map the context of technological provision over time within the changing lives of people with dementia and their caregivers.

Effectiveness of Digital Technologies to Support Nursing Care: Results of a Scoping Review

BACKGROUND

The field of digital technologies being developed or applied to support nursing care is extensive. The aim of this scoping review is to provide an overview on technologies for which results on positive or negative effects on persons in need of care, caregivers or care institutions are available and to appraise the reliability of these results.

METHODS

A scoping review design has been used to identify studies focussing on the effectiveness of digital technologies in nursing care for persons in need of care, caregivers or care institutions. The screening process included 19,510 scientific publications from 9 databases.

RESULTS

A total of 123 single studies and 31 reviews were subjected to the analysis. The included technologies comprise nursing and health information technologies, such as assistive devices, information and communication technologies, sensors and robotics. The results show that there are many studies that demonstrate positive effects, but the level of evidence is mostly low and study sizes are often small. Hardly any technology has been researched intensively enough to produce conclusive results. Studies on a high level of evidence (RCTs) lack for most technological areas. Heterogeneous results in some areas indicate that effects may depend strongly on the mode and specific context into which the technologies are introduced.

CONCLUSION

Due to the limited evidence on effectiveness of digital technologies in nursing care, it is not surprising that care institutions are reluctant to put innovative technologies into practice. The scoping review indicates technology areas that should be subject to future research with higher quality studies. Research on outpatient, informal and cross-sectoral care should be intensified to further exploit the potential of digital technologies with a view to improving independence of care-recipients and unburdening formal and informal carers.

Mobile Health Monitoring of Cardiac Status

Cardiovascular diseases (CVDs) are responsible for more deaths than any other cause, with coronary heart disease and stroke accounting for two-thirds of those deaths. Morbidity and mortality due to CVD are largely preventable, through either primary prevention of disease or secondary prevention of cardiac events. Monitoring cardiac status in healthy and diseased cardiovascular systems has the potential to dramatically reduce cardiac illness and injury. Smart technology in concert with mobile health platforms is creating an environment where timely prevention of and response to cardiac events are becoming a reality.

Technology and social care in a digital world: challenges and opportunities in the UK

Purpose

Technology enabled care (TEC) equipment has been a part of adult social care (ASC) in most areas of the UK for decades. More recently, commissioners have been exploring mainstream technologies’ potential to support older people living in the community. The purpose of this paper is to examine the challenges and opportunities presented by the growing application of mainstream technologies in ASC against the backdrop of the planned UK-wide switchover from analogue to digital telecommunications by 2025.

Design/methodology/approach

This general review uses research evidence, literature, industry standards and policy documents to address the challenges presented by the UK’s digital switchover and the potential role of mainstream technologies such as “smart speakers” in ASC.

Findings

The use of digital TEC and mainstream devices in ASC brings challenges related to access to reliable internet connections in parts of the UK; the need to update TEC safety standards; the ethics, privacy and data security measures that ensure digital products and services safeguard the interests of users; and evidence and commissioning practice.

Originality/value

This general review explores emerging areas of policy and research related to the planned UK digital switchover and the use of mainstream technologies in ASC. It offers a conceptual approach and suggests ways forward for research, regulatory and commissioning agendas.

Perceptions About Technologies That Help Community-Dwelling Older Adults Remain at Home: Qualitative Study

Background

The population of Europe is aging rapidly. Most community-dwelling older adults (CDOAs) want to remain in their homes, particularly those experiencing functional decline. Politicians and academics repeatedly praise technological instruments for being the preferred solution for helping older adults with deteriorating health to remain at home.

Objective

This study aimed to understand the perceptions of CDOAs and their informal caregivers (ICs) and professional caregivers (PCs) about technologies that can help keep older adults at home.

Methods

This qualitative study used personal interviews, focus groups, and photo-elicitation interviews to better understand the perceptions of a convenience sample of 68 CDOAs, 21 ICs, and 32 PCs.

Results

A fraction of CDOAs did not perceive technological instruments to be a very useful means of helping them remain at home. However, the ICs and PCs were more positive. The CDOAs preferred and were more willing to adopt technologies related to their mobility and safety and those that would help slow down their cognitive decline. The ICs preferred technological aids that assist in the activities of daily living as well as safety-related technologies for detecting falls and helping to locate disoriented older adults. The PCs preferred integrated communication and information systems to improve collaboration between all stakeholders, housing equipped with technologies to manage complex care, high-performance ancillary equipment to transfer people with reduced mobility, and surveillance systems to ensure safety at home.

Conclusions

Although our study reports that CDOAs have limited interest in innovative technologies to help them remain at home, their technological skills will undoubtedly improve in the future, as will those of ICs and PCs. Technological tools will play an increasingly important role in home health care.

Why do evaluations of integrated care not produce the results we expect?

A number of evaluations of models of integrated care have not produced the expected result of reduced hospital admissions, and in some cases have even found people receiving integrated care services using hospitals more than matched controls. We tested three hypotheses for these surprising results with a group of 50 integrated care experts in a seminar: (1) problems with the model; (2) problems of implementation; and (3) problems of evaluation. Our group of experts did not rule out any of these hypotheses and came up with some advice as to manage these issues. For example, model designers should rigorously test the underlying logic; commissioners should seek out advice from experts and patients/professionals; and evaluators should choose outcomes wisely, use mixed methods approaches, and provide regular feedback loops to implementation sites. Evaluating integrated care is a skilled task that requires multiple approaches in terms of the design and implementation of the models. National research funders or other appropriate bodies might consider developing an advisory service to provide support to local systems planning evaluations.

Factors influencing the implementation of self-management solutions in healthcare: an interview study with NHS managers

Background/aims

Research focusing on the perspectives of healthcare managers, who are often key in devising strategies for the implementation of self-management solutions, is limited. This study aimed to investigate the barriers to the implementation of technology-based self-management solutions in an NHS organisation and how this affects project delivery.

Methods

Semi-structured interviews were held with 15 NHS employees in various managerial roles from one organisation. As initial findings suggested that managers were not fully aware of how to approach the different stages of project delivery, a second analysis was conducted to explore their approaches and insights at various stages of a self-management project.

Findings

Participants were highly knowledgeable about key decision-making processes in the initial phases of a project, but clearly struggled during the organisation and implementation phases.

Conclusions

To support the successful implementation of projects, managers should focus more on unpacking the later stages of project delivery and addressing the contextual factors that influence them.

Will applications on smartphones allow a generalization of telemedicine?

Background

Telemedicine is one of the healthcare sectors that has developed the most in recent years. Currently, telemedicine is mostly used for patients who have difficulty attending medical consultations because of where they live (teleconsultation) or for specialist referrals when no specialist of a given discipline is locally available (telexpertise). However, the use of specific equipment (with dedicated cameras, screens, and computers) and the need for institutional infrastructure made the deployment and use of these systems expensive and rigid. Although many telemedicine systems have been tested, most have not generally gone beyond local projects.

Our hypothesis is that the use of smartphones will allow health care providers to overcome some of the limitations that we have exposed, thus allowing the generalization of telemedicine.

Main body

This paper addresses the problem of telemedicine applications, the market of which is growing fast. Their development may completely transform the organization of healthcare systems, change the way patients are managed and revolutionize prevention. This new organization should facilitate the lives of both patients and doctors.

In this paper, we examine why telemedicine has failed for years to take its rightful place in many European healthcare systems although there was a real need. By developing the example of France, this article analyses the reasons most commonly put forth: the administrative and legal difficulties, and the lack of funding. We argue that the real reason telemedicine struggled to find its place was because the technology was not close enough to the patient.

Conclusion

Finally, we explain how the development of smartphones and their current ubiquitousness should allow the generalization of telemedicine in France and on a global scale.

Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review

Background

Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain.

Objective

This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care.

Methods

A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis.

Results

This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes.

Conclusions

E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.

Effectiveness of assistive technology in improving the safety of people with dementia: a systematic review and meta-analysis

Objectives: Assistive technology (AT) may enable people with dementia to live safely at home for longer, preventing care home admission. This systematic review assesses the effectiveness of AT in improving the safety of people with dementia living in the domestic setting, by searching for randomised controlled trials, non-randomised controlled trials and controlled before-after studies which compared safety AT with treatment as usual. Measures of safety include care home admission; risky behaviours, accidents and falls at home; and numbers of deaths. The review updates the safety aspect of Fleming and Sum's 2014 systematic review. Method: Seven bibliographic databases, the Social Care Institute for Excellence website and the Alzheimer's Society website were searched for published and unpublished literature between 2011-2016. Search terms related to AT, dementia and older people. Common outcomes were meta-analysed. Results: Three randomised controlled trials were identified, including 245 people with dementia. No significant differences were found between intervention and control groups in care home admission (risk ratio 0.85 95% CI [0.37, 1.97]; Z = 0.37; p = 0.71). The probability of a fall occurring was 50% lower in the intervention group (risk ratio 0.50 95% CI [0.32, 0.78]; Z = 3.03; p = 0.002). One included study found that a home safety package containing AT significantly reduced risky behaviour and accidents (F(45) = 4.504, p < 0.001). Limitations include the few studies found and the inclusion of studies in English only. Conclusion: AT's effectiveness in decreasing care home admission is inconclusive. However, the AT items and packages tested improved safety through reducing falls risk, accidents and other risky behaviour.

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

Gender and socioeconomic inequalities in the implementation of the Basque programme for multimorbid patients

Background

The aim of our study was to increase awareness of the relevance of the implemented programmes to inequity of access and inequality of health by analyzing the impact of a patient-centred strategy for multimorbid patients.

Methods

This retrospective study compared the 2014 multimorbid patient group (intervention group) with its 2012 analogue (control group), before the Department of Health of the Basque Country launched the strategy for managing disease chronicity. Inequalities in healthcare access were represented by differences in the inclusion of patients in the programme and in contacts with primary care (PC) services by gender and socioeconomic status (measured by deprivation index by census track). Likewise, differences in hospital care represented inequalities in health outcomes. Generalized linear models were used to analyze relationships among variables. A propensity score by a genetic matching approach was used to minimize possible selection bias.

Results

At baseline, women had less probability of being eligible for the programme. No clear patterns were seen in resource consumption in PC. The probability of hospitalization was higher for men and increased according to socioeconomic status. The implementation of the programme yielded more contacts with PC services in all groups and a reduction in hospitalizations, especially among men and the most socioeconomically deprived patients.

Conclusion

The patient-centred, integrated-care intervention launched by the Department of Health of the Basque Country might have reduced some gender and socioeconomic inequalities in health outcomes, as it avoided more hospitalizations in subgroups that presented with more episodes of decompensation in the reference year.

Marketing of surveillance technology in three ageing countries

Purpose

The purpose of this paper is to review marketing materials of surveillance products for people with dementia and their carers in three ageing countries, as part of a dementia-technology media analysis.

Design/methodology/approach

An online environmental scan was conducted using search terms for surveillance technologies (STs) and dementia through a Google search focussed on the UK, Sweden and the Netherlands. Data were extracted on the products’ and websites’ marketing messages from consumer and marketer perspectives.

Findings

Information was gathered for 382 product websites, of which 242 met eligibility criteria. The majority of products come from the UK. In the UK and Sweden, the companies behind the websites appeared to be mainly “cottage industries” which focus on selling ST. In contrast, sellers in the Netherlands included a more balanced mixture of small, medium and large companies. In all three countries, the website messaging focussed on the need to manage safety concerns, without considering privacy or consent.

Social implications

Contrary to the perception of future dependence on technology, the ST sector seems to be a niche market. The media messages, equating people with dementia with animals and children, are at odds with initiatives that strive for dignity and dementia friendliness.

Originality/value

No previous study is known to have explored media messages from websites that market ST for people with dementia.

Methods to evaluate perspectives of safety, independence, activity, and participation in older persons using welfare technology. A systematic review

Purpose: To conduct a systematic review of existing methods to evaluate the individual aspects of welfare technology from the perspectives of independence, safety, activity, and participation. Furthermore, the study aimed to describe outcomes that have been the focus of previous research to evaluate individual aspects of welfare technology in older persons living in ordinary housing. Materials and methods: A systematic literature review in PubMed, CINAHL Plus, PsycINFO, Scopus, and Web of Science. Studies selected were those that explored the use of assistive and welfare technology devices from older persons' perspectives, and which considered the concepts of independence, safety, activity and participation, and quality of life. Results: A broad spectrum of instruments was applied in the studies. For independence, three questionnaires were used in the identified studies. For safety, one instrument was used in two versions. To study activity and participation as well as quality of life, several scales were used. Additionally, several studies included qualitative approaches for evaluation, such as interviews, or posed one or more questions regarding the effects of welfare technology. Conclusions: The integration of digital assistive and welfare technology should be based on the needs of older persons, and those needs must be assessed using reliable and relevant instruments. The heterogeneity of the target group, i.e., older persons, together with the fact that assessments must give consideration to identifying goals, obstacles, and risks as well as users' preferences, implies a person-centred approach.Implications for rehabilitationThe integration of digital assistive and welfare technology should be based on older persons' needs, and those needs must be assessed using reliable and relevant instruments.The heterogeneity of the target group, i.e. older persons, together with the fact that assessments must give consideration to identifying goals, obstacles and risks as well as users' preferences, implies a person-centred approach.The ideal would be one coherent model that explores the use of digital assistive and welfare technology from the individual, economic as well as organisational dimensions. This would cover the different needs and expectations of various stakeholders, including economic and organisational, but also the needs of the older person.

A Scoping Review of the Quality and the Design of Evaluations of Mobile Health, Telehealth, Smart Pump and Monitoring Technologies Performed in a Pharmacy-Related Setting

Background: There is currently a need for high quality evaluations of new mobile health, telehealth, smart pump and monitoring technologies undertaken in a pharmacy-related setting. We aim to evaluate the use of these monitoring technologies performed in this setting. Methods: A systematic searching of English articles that examined the quality and the design of technologies conducted in pharmacy-related facilities was performed using the following databases: MEDLINE and Cumulative index to Nursing and Allied Health Literature (CINAHL) to identify original studies examining the quality and the design of technologies and published in peer-reviewed journals. Extraction of articles and quality assessment of included articles were performed independently by two authors. Quality scores over 75% are classed as being acceptable using a "relatively conservative" quality benchmark. Scores over 55% are included using a "relatively liberal" cut-off point. Results: Screening resulted in the selection of 40 formal evaluations. A substantial number of studies (32, 80.00%) were performed in the United States, quantitative in approach (33, 82.50%) and retrospective cohort (24, 60.00%) in study design. The most common pharmacy-related settings were: 22 primary care (55.00%); 10 hospital pharmacy (25.00%); 7 community pharmacy (17.50%); one primary care and hospital pharmacy (2.50%). The majority of the evaluations (33, 82.50%) reported clinical outcomes, six (15.00%) measured clinical and economic outcomes, and one (2.50%) economic only. Twelve (30.00%) quantitative studies and no qualitative study met objective criteria for "relatively conservative" quality. Using a lower "relatively liberal" benchmark, 27 quantitative (81.82%) and four qualitative (57.41%) studies met the lower quality criterion. Conclusion: Worldwide, few evaluations of mobile health, telehealth, smart pump and monitoring technologies in pharmacy-related setting have been published.Their quality is often below the standard necessary for inclusion in a systematic review mainly due to inadequate study design.

Personalisation, customisation and bricolage: how people with dementia and their families make assistive technology work for them

Assistive technologies (ATs) are being ‘mainstreamed’ within dementia care, where they are promoted as enabling people with dementia to age in place alongside delivering greater efficiencies in care. AT provision focuses upon standardised solutions, with little known about how ATs are used by people with dementia and their carers within everyday practice. This paper explores how people with dementia and carers use technologies in order to manage care. Findings are reported from qualitative semi-structured interviews with 13 people with dementia and 26 family carers. Readily available household technologies were used in conjunction with and instead of AT to address diverse needs, replicating AT functions when doing so. Successful technology use was characterised by ‘bricolage’ or the non-conventional use of tools or methods to address local needs. Carers drove AT use by engaging creatively with both assistive and everyday technologies, however, carers were not routinely supported in their creative engagements with technology by statutory health or social care services, making bricolage a potentially frustrating and wasteful process. Bricolage provides a useful framework to understand how technologies are used in the everyday practice of dementia care, and how technology use can be supported within care. Rather than implementing standardised AT solutions, AT services and AT design in future should focus on how technologies can support more personalised, adaptive forms of care.

What is the patient acceptability of real time 1:1 videoconferencing in an orthopaedics setting? A systematic review

BACKGROUND

Real time 1:1 videoconferencing (VC) has the potential to play an important role in the management of orthopaedic pathologies. Despite positive reporting of telemedicine studies uptake in clinical practice remains low. Acceptability to patients is an important element of system take-up in telemedicine and a focus towards qualitative methodology may explore the underlying reasons behind its acceptability. In this paper we have systematically reviewed qualitative studies that include evidence about patient responses to VC services in an orthopaedic setting.

OBJECTIVES

To determine whether real time 1:1 videoconferencing is acceptable to patients in an orthopaedic setting.

DATA SOURCES

MEDLINE, AMED, PsychINFO, CINAHL, SCOPUS, Cochrane Database, Evidence Search and Open Grey were searched with forwards and backwards reference screening of eligible papers.

ELIGIBILITY CRITERIA

Qualitative studies exploring the acceptability of VC in an orthopaedic setting were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were appraised using the CASP tool. A Directed Content Framework Analysis was conducted using Normalisation Process Theory.

RESULTS

Four studies were included for review. The themes for the four studies did not overlap and did not report clinician acceptability of VC. The Directed Content Analysis of these papers using Normalisation Process Theory highlighted factors which contribute towards its acceptability.

CONCLUSIONS

All studies concluded that the use of VC was acceptable. Further qualitative research exploring both patient and clinician acceptability is required utilising a theoretical framework to allow for repeatability and generalisability. Systematic Review Registration Number: PROSPERO CRD42015024944.

The use of assistive technology in shoulder exercise rehabilitation - a qualitative study of acceptability within a pilot project

Background

Painful shoulders pose a substantial socioeconomic burden accounting for 2.4% of all primary care consultations in the UK. There is a strong evidence to indicate that the majority of this shoulder pain can be managed successfully with exercise based treatments and that common surgical procedures provide no extra benefit. Patient adherence and engagement is cited as an important factor in gaining positive outcomes.

The MUJO System has been designed to help target the rehabilitation of the rotator cuff muscles which are commonly recommended for the management of shoulder pain. The purpose of this qualitative study was to evaluate the acceptability of the MUJO System amongst clinicians and patients.

Methods

A qualitative study was undertaken to look at the usability of the MUJO System both from clinicians’ and patients’ perspectives. Patients with shoulder problems were identified by an experienced physiotherapist using the study eligibility criteria. and invited to participate. Semi-structured interviews were performed with patients and clinicians to explore factors surrounding its acceptability and feasibility of use. The study was designed using Normalisation Process Theory as a theoretical basis for the inquiry.

Results

Seven physiotherapists and ten patients were interviewed in the study. The Internal and External Devices were seen as having the potential to rehabilitate the rotator cuff however it posed limitations towards more functional based exercises. Patients and clinicians found the visual feedback from the Patient App enhanced the rehabilitation experience. The Internal and External Devices were acceptable to all for rehabilitation providing the devices were available for use by the patients in the community.

Conclusion

Patients and clinicians found the MUJO System acceptable as a modality to perform shoulder exercises. For the MUJO System to be taken up as a routine part of clinical practice patients need to be able to access the devices in the community. For the MUJO System to be taken up in clinical practice it needs to be workable within the context of the treatment pathway and not interfere with standard processes.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2042-6) contains supplementary material, which is available to authorized users.

Providing telecare for older adults: understanding the care navigators’ experience

Purpose

The provision of telecare for older adults in England is increasingly being facilitated by care navigators in the non-statutory sector. The purpose of this paper is to explore the experiences of care navigators when assessing older adults for telecare and to understand what contextual and organisational factors impact on their practice.

Design/methodology/approach

A purposeful sample of care navigators and telecare installers was selected. Care navigators were recruited from five non-statutory organisations. In order to provide an insight into telecare provision by this sector, telecare installers were also recruited. Semi-structured interviews were conducted with 11 participants covering: role, training, assessment, reviews, installation, suitability, impact, aims, outcomes, and organisational structure. Interview data were analysed using the framework approach.

Findings

Five main themes emerged from the analysis: responsiveness, autonomy, knowledge exchange, evolving practice, and sustaining performance.

Research limitations/implications

This study included a small sample, and was only based in one local authority, focusing on the experience of care navigators in only one sector.

Practical implications

The findings suggest that strategic placement of care navigators could support the demand for telecare assessment to facilitate discharges from hospital. This study highlights the perception of home assessment as a gold standard of practice for care navigators. In order to develop a more sustainable model for care navigators’ capacity to work within hospital teams and provide home assessments needs further consideration.

Originality/value

This study is one of the first to explore the role of the care navigator and their involvement in the provision of telecare for older adults.

Care relationships at stake? Home healthcare professionals' experiences with digital medicine dispensers - a qualitative study

BACKGROUND

Although digital technologies can mitigate the burdens of home healthcare services caused by an ageing population that lives at home longer with complex health problems, research on the impacts and consequences of digitalised remote communication between patients and caregivers is lacking. The present study explores how home healthcare professionals had experienced the introduction of digital medicine dispensers and their influence on patient-caregiver relationships.

METHODS

The multi-case study comprised semi-structured interviews with 21 healthcare professionals whose home healthcare service involved using the digital medicine dispensers. The constant comparative method was used for data analyses.

RESULTS

Altogether, interviewed healthcare professionals reported three main technology-related impacts upon their patient-caregiver relationships. First, national and local pressure to increase efficiency had troubled their relationships with patients who suspected that municipalities have sought to lower costs by reducing and digitalising services. Participants reported having to consider such worries when introducing technologies into their services. Second, participants reported a shift towards empowering patients. Digital technology can empower patients who value their independence, whereas safety is more important for other patients. Healthcare professionals needed to ensure that replacing care tasks with technology implies safe and improved care. Third, the safety and quality of digital healthcare services continues to depend upon surveillance and control mechanisms that compensate for less face-to-face monitoring. Participants did not consider the possibility that surveillance exposes information about patients' everyday lives to be problematic, but to constitute opportunities for adjusting services to meet patients' needs.

CONCLUSIONS

Technologies such as digital medicine dispensers can improve the efficiency of healthcare services and enhance patients' independence when introduced in a way that empowers patients as well as safeguards trust and service quality. Conversely, the patient-caregiver relationship can suffer if the technology does not meet patients' needs and fails to offer safe and trustworthy services. Upon introducing technology, home healthcare professionals therefore need to carefully consider the benefits and possible disadvantages of the technology. Ethical implications for both individuals and societies need to be further discussed.

Impact of At-Home Telemonitoring on Health Services Expenditure and Hospital Admissions in Patients With Chronic Conditions: Before and After Control Intervention Analysis

BACKGROUND

Telemonitoring is becoming increasingly important for the management of patients with chronic conditions, especially in countries with large distances such as Australia. However, despite large national investments in health information technology, little policy work has been undertaken in Australia in deploying telehealth in the home as a solution to the increasing demands and costs of managing chronic disease.

OBJECTIVE

The objective of this trial was to evaluate the impact of introducing at-home telemonitoring to patients living with chronic conditions on health care expenditure, number of admissions to hospital, and length of stay (LOS).

METHODS

A before and after control intervention analysis model was adopted whereby at each location patients were selected from a list of eligible patients living with a range of chronic conditions. Each test patient was case matched with at least one control patient. Test patients were supplied with a telehealth vital signs monitor and were remotely managed by a trained clinical care coordinator, while control patients continued to receive usual care. A total of 100 test patients and 137 control patients were analyzed. Primary health care benefits provided to Australian patients were investigated for the trial cohort. Time series data were analyzed using linear regression and analysis of covariance for a period of 3 years before the intervention and 1 year after.

RESULTS

There were no significant differences between test and control patients at baseline. Test patients were monitored for an average of 276 days with 75% of patients monitored for more than 6 months. Test patients 1 year after the start of their intervention showed a 46.3% reduction in rate of predicted medical expenditure, a 25.5% reduction in the rate of predicted pharmaceutical expenditure, a 53.2% reduction in the rate of predicted unscheduled admission to hospital, a 67.9% reduction in the predicted rate of LOS when admitted to hospital, and a reduction in mortality of between 41.3% and 44.5% relative to control patients. Control patients did not demonstrate any significant change in their predicted trajectory for any of the above variables.

CONCLUSIONS

At-home telemonitoring of chronically ill patients showed a statistically robust positive impact increasing over time on health care expenditure, number of admissions to hospital, and LOS as well as a reduction in mortality.

TRIAL REGISTRATION

Retrospectively registered with the Australian and New Zealand Clinical Trial Registry ACTRN12613000635763; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364030 (Archived by WebCite at http://www.webcitation.org/6sxqjkJHW).

Integrating and safeguarding care: The potential role of health information technologies

The increasing burden of chronic diseases is one of the greatest challenges healthcare systems globally are facing. Across the world, compelling demands can be found for a fundamental shift in the organisation of health and social care to meet the needs of chronic patients. Integrated care has gathered momentum to overcome fragmentation of care in order to create care systems which are demand-driven, client-centred and cost-conscious. Health information technology – often referred to as eHealth – is usually considered to be an essential building brick of integrated care. Moreover, health information technology is said to hold potential for improving patient safety in chronic care settings. The current perspective paper explores the role of health information technology in integrating and safeguarding care. We argue that health information technology – which supports integrated care – may create optimal conditions to improve patient safety, but only when well-implemented, state-of-the-art technologies are used.

Understanding heart failure; explaining telehealth - a hermeneutic systematic review

BACKGROUND

Enthusiasts for telehealth extol its potential for supporting heart failure management. But randomised trials have been slow to recruit and produced conflicting findings; real-world roll-out has been slow. We sought to inform policy by making sense of a complex literature on heart failure and its remote management.

METHODS

Through database searching and citation tracking, we identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta-analyses and 8 qualitative reviews); six mega-trials and over 60 additional relevant empirical studies and commentaries. We synthesised these using Boell's hermeneutic methodology for systematic review, which emphasises the quest for understanding.

RESULTS

Heart failure is a complex and serious condition with frequent co-morbidity and diverse manifestations including severe tiredness. Patients are often frightened, bewildered, socially isolated and variably able to self-manage. Remote monitoring technologies are many and varied; they create new forms of knowledge and new possibilities for care but require fundamental changes to clinical roles and service models and place substantial burdens on patients, carers and staff. The policy innovation of remote biomarker monitoring enabling timely adjustment of medication, mediated by "activated" patients, is based on a modernist vision of efficient, rational, technology-mediated and guideline-driven ("cold") care. It contrasts with relationship-based ("warm") care valued by some clinicians and by patients who are older, sicker and less technically savvy. Limited uptake of telehealth can be analysed in terms of key tensions: between tidy, "textbook" heart failure and the reality of multiple comorbidities; between basic and intensive telehealth; between activated, well-supported patients and vulnerable, unsupported ones; between "cold" and "warm" telehealth; and between fixed and agile care programmes.

CONCLUSION

The limited adoption of telehealth for heart failure has complex clinical, professional and institutional causes, which are unlikely to be elucidated by adding more randomised trials of technology-on versus technology-off to an already-crowded literature. An alternative approach is proposed, based on naturalistic study designs, application of social and organisational theory, and co-design of new service models based on socio-technical principles. Conventional systematic reviews (whose goal is synthesising data) can be usefully supplemented by hermeneutic reviews (whose goal is deepening understanding).

Telehealthcare for patients suffering from chronic obstructive pulmonary disease: effects on health-related quality of life: results from the Danish 'TeleCare North' cluster-randomised trial

OBJECTIVE

To assess the effect of telehealthcare compared with usual practice in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

A cluster-randomised trial with 26 municipal districts that were randomly assigned either to an intervention group whose members received telehealthcare in addition to usual practice or to a control group whose members received usual practice only (13 districts in each arm).

SETTING

Twenty-six municipal districts in the North Denmark Region of Denmark.

PARTICIPANTS

Patients who fulfilled the Global Initiative for COPD guidelines and one of the following criteria: COPD Assessment Test score ≥10; or Medical Research Dyspnoea Council Scale ≥3; or Modified Medical Research Dyspnoea Council Scale ≥2; or ≥2 exacerbations during the past 12 months.

MAIN OUTCOME MEASURES

Health-related quality of life (HRQoL) assessed by the physical component summary (PCS) and mental component summary (MCS) scores of the Short Form 36-Item Health Survey, Version 2. Data were collected at baseline and at 12 month follow-up and analysed according to the intention-to-treat principle with complete cases, n=574 (258 interventions; 316 controls) and imputed data, n=1225 (578 interventions, 647 controls) using multilevel modelling.

RESULTS

In the intention-to-treat analysis (n=1225), the raw mean difference in PCS from baseline to 12 month follow-up was -2.6 (SD 12.4) in the telehealthcare group and -2.8 (SD 11.9) in the usual practice group. The raw mean difference in MCS scores in the same period was -4.7 (SD 16.5) and -5.3 (SD 15.5) for telehealthcare and usual practice, respectively. The adjusted mean difference in PCS and MCS between groups at 12 months was 0.1 (95% CI -1.4 to 1.7) and 0.4 (95% CI -1.7 to 2.4), respectively.

CONCLUSIONS

The overall sample and all subgroups demonstrated no statistically significant differences in HRQoL between telehealthcare and usual practice.

TRIAL REGISTRATION NUMBER

NCT01984840; Results.

Home monitoring of breathing rate in people with chronic obstructive pulmonary disease: observational study of feasibility, acceptability, and change after exacerbation

Telehealth programs to promote early identification and timely self-management of acute exacerbations of chronic obstructive pulmonary diseases (AECOPDs) have yielded disappointing results, in part, because parameters monitored (symptoms, pulse oximetry, and spirometry) are weak predictors of exacerbations.

PREDOMOS study, impact of a social intervention program for socially isolated elderly cancer patients: study protocol for a randomized controlled trial

Background

Cancer incidence and social isolation increase along with advanced age, and social isolation potentiates the relative risk of death by cancer. Once spotted, social isolation can be averted with the intervention of a multidisciplinary team. Techniques of automation and remote assistance have already demonstrated their positive impact on falls prevention and quality of life (QoL), though little is known about their impact on socially isolated elderly patients supported for cancer.

The primary objective of the PREDOMOS study is to evaluate the impact of establishing a Program of Social intervention associated with techniques of Domotic and Remote assistance (PS-DR) on the improvement of QoL of elderly isolated patients, treated for locally advanced or metastatic cancer. The secondary objectives include treatment failure, tolerance, survival, and autonomy.

Methods/design

This trial is a multicenter, prospective, randomized, placebo-controlled, open-label, two-parallel group study. The setting is 10 French oncogeriatric centers. Inclusion criteria are patients aged at least 70 years with a social isolation risk and a histological diagnosis of cancer, locally advanced or metastatic disease. The groups are (1) the control group, receiving usual care; (2) the experimental group, receiving usual care associating with monthly social assistance, domotic, and remote assistance. Participants are randomized in a 1:1 allocation ratio. Evaluation times involve inclusion (randomization) and follow-up (12 months). The primary endpoint is QoL at 3 months (via European Organization for Research and Treatment of Cancer (EORTC) QLQ C30); secondary endpoints are social isolation, time to treatment failure, toxicity, dose response-intensity, survival, autonomy, and QoL at 6 months. For the sample size, 320 individuals are required to obtain 90% power to detect a 10-point difference (standard deviation 25) in QoL score between the two groups (20% loss to follow-up patients expected).

Discussion

The randomized controlled design is the most appropriate design to demonstrate the efficacy of a new experimental strategy (Evidence-Based Medicine Working Group classification). National and international recommendations could be updated based on the findings of this study.

Trial registration

ClinicalTrials.gov, NCT02829762. Registered on 29 June 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1894-7) contains supplementary material, which is available to authorized users.

Telecare - where, when, why and for whom does it work? A realist evaluation of a Norwegian project

Introduction

Evaluations of telecare demonstrate disparate results, which are of little help for understanding what the users need from further policy and development. This study aims to provide a more nuanced approach to telecare evaluations.

Methods

Realist evaluation is used to scrutinize what it is about telecare that works for whom, why, how and in which circumstances. Sequential interviews were conducted with telecare users and relatives at pre- and post-implementation stages.

Result

Some users experienced the intended effects from telecare, such as increased feeling of safety, whereas others did not. Various contextual elements influenced how people reasoned about the resources provided by telecare and affected the individual outcomes.

Discussion

The desire to remain in own home appeared to be a major driving force in accepting telecare. Users had surprisingly high tolerance to side effects of telecare, which might indicate that much was at stake. Some users disapproved of having telecare due to contextual reasons; however, readjustments proved successful to some.

Conclusion

This study illuminates how and why telecare works differently in different situations, and thus leads to different outcomes. When telecare is correctly adjusted to match the user's needs, abilities and contexts it enables them to feel safe and remain in their own homes.

Making Telecare desirable rather than a last resort

Despite reported benefits of Telecare use for older adults, uptake of Telecare in the United Kingdom remains relatively low. Non-users of Telecare are an under-researched group in the Telecare field. We conducted 22 qualitative individual semi-structured interviews to explore the views and opinions of current non-users of Telecare regarding barriers and facilitators to its use, and explored considerations which may precede their decision to accept, or reject, Telecare. Framework analysis identified a number of themes which influence the outcome and timing of this decision, including peace of mind (for the individual and their family), the strength and composition of an individual's support network, the impact of changing personal and health circumstances, and lack of communication about Telecare (e.g.advertising). A cost–benefit decision process appears to take place for the potential user, whereby the benefit of peace of mind is weighed against perceived ‘costs’ of using Telecare. Telecare is often perceived as a last resort rather than a preventative measure. A number of barriers to Telecare use need to be addressed if individuals are to make fully informed decisions regarding their Telecare use, and to begin using Telecare at a time when it could provide them with optimal benefit. Although the study was set in England, the findings may be relevant for other countries where Telecare is used.

Evaluating the Economic Impact of Smart Care Platforms: Qualitative and Quantitative Results of a Case Study

Background

In response to the increasing pressure of the societal challenge because of a graying society, a gulf of new Information and Communication Technology (ICT) supported care services (eCare) can now be noticed. Their common goal is to increase the quality of care while decreasing its costs. Smart Care Platforms (SCPs), installed in the homes of care-dependent people, foster the interoperability of these services and offer a set of eCare services that are complementary on one platform. These eCare services could not only result in more quality care for care receivers, but they also offer opportunities to care providers to optimize their processes.

Objective

The objective of the study was to identify and describe the expected added values and impacts of integrating SCPs in current home care delivery processes for all actors. In addition, the potential economic impact of SCP deployment is quantified from the perspective of home care organizations.

Methods

Semistructured and informal interviews and focus groups and cocreation workshops with service providers, managers of home care organizations, and formal and informal care providers led to the identification of added values of SCP integration. In a second step, process breakdown analyses of home care provisioning allowed defining the operational impact for home care organization. Impacts on 2 different process steps of providing home care were quantified. After modeling the investment, an economic evaluation compared the business as usual (BAU) scenario versus the integrated SCP scenario.

Results

The added value of SCP integration for all actors involved in home care was identified. Most impacts were qualitative such as increase in peace of mind, better quality of care, strengthened involvement in care provisioning, and more transparent care communication. For home care organizations, integrating SCPs could lead to a decrease of 38% of the current annual expenses for two administrative process steps namely, care rescheduling and the billing for care provisioning.

Conclusions

Although integrating SCP in home care processes could affect both the quality of life of the care receiver and informal care giver, only scarce and weak evidence was found that supports this assumption. In contrast, there exists evidence that indicates the lack of the impact on quality of life of the care receiver while it increases the cost of care provisioning. However, our cost-benefit quantification model shows that integrating SCPs in home care provisioning could lead to a considerable decrease of costs for care administrative tasks. Because of this cost decreasing impact, we believe that the integration of SCPs will be driven by home care organizations instead of the care receivers themselves.

Effect of Telehealth Interventions on Hospitalization Indicators: A Systematic Review

BACKGROUND

Telehealth has been defined as the remote delivery of healthcare services using information and communication technology. Where resource-limited health systems face challenges caused by the increasing burden of chronic diseases and an aging global population, telehealth has been advocated as a solution for changing and improving the paradigm of healthcare delivery to cope with these issues. The aim of this systematic review is to investigate the effect of telehealth interventions on two indicators: hospitalization rate and length of stay.

MATERIALS AND METHODS

The reviewers searched the PubMed, ScienceDirect, and Springer electronic databases from January 2005 to November 2013. A search strategy was developed using a combination of the following search keywords: impact, effect, telehealth, telemedicine, telecare, hospitalization, length of stay, and resource utilization. Both randomized controlled trials and observational studies were included in the review. To be included in the review, articles had to be written in English. The results of study were compiled, reviewed, and analyzed on the basis of the review aims.

RESULTS

This systematic review examined 22 existing studies with a total population of 19,086 patients. The effect of telehealth on all-cause hospitalization was statistically significant in 40 percent of the related studies, whereas it was not statistically significant in 60 percent. Similarly, the effect of telehealth on the all-cause length of stay was statistically significant in 36 percent of the studies and nonsignificant in 64 percent.

CONCLUSION

Considering the fact that hospitalization rate and length of stay can be confounded by factors other than telehealth intervention, studies examining the effect of the intervention on these indicators must take into account all other factors influencing them. Otherwise any judgment on the effect of telehealth on these indicators cannot be valid.

Economic evaluation of integrated new technologies for health and social care: Suggestions for policy makers, users and evaluators

With an ageing population there is a move towards the use of assisted living technologies (ALTs) to provide social care and health care services, and to improve service processes. These technologies are at the forefront of the integration of health and social care. However, economic evaluations of ALTs, and indeed economic evaluations of any interventions providing both health benefits and benefits beyond health are complex. This paper considers the challenges faced by evaluators and presents a method of economic evaluation for use with interventions where traditional methods may not be suitable for informing funders and decision makers. We propose a method, combining economic evaluation techniques, that can accommodate health outcomes and outcomes beyond health through the use of a common numeraire. Such economic evaluations can benefit both the public and private sector, firstly by ensuring the efficient allocation of resources. And secondly, by providing information for individuals who, in the market for ALTs, face consumption decisions that are infrequent and for which there may be no other sources of information. We consider these issues in the welfarist, extra-welfarist and capabilities frameworks, which we link to attributes in an individual production model. This approach allows for the valuation of the health component of any such intervention and the valuation of key social care attributes and processes. Finally, we present a set of considerations for evaluators highlighting the key issues that need to be considered in this type of economic evaluation.

Mixed methods for telehealth research

Mixed methods research is important to health services research because the integrated qualitative and quantitative investigation can give a more comprehensive understanding of complex interventions such as telehealth than can a single-method study. Further, mixed methods research is applicable to translational research and program evaluation. Study designs relevant to telehealth research are described and supported by examples. Quality assessment tools, frameworks to assist in the reporting and review of mixed methods research, and related methodologies are also discussed.

How to Measure Costs and Benefits of eHealth Interventions: An Overview of Methods and Frameworks

Information on the costs and benefits of eHealth interventions is needed, not only to document value for money and to support decision making in the field, but also to form the basis for developing business models and to facilitate payment systems to support large-scale services. In the absence of solid evidence of its effects, key decision makers may doubt the effectiveness, which, in turn, limits investment in, and the long-term integration of, eHealth services. However, it is not realistic to conduct economic evaluations of all eHealth applications and services in all situations, so we need to be able to generalize from those we do conduct. This implies that we have to select the most appropriate methodology and data collection strategy in order to increase the transferability across evaluations. This paper aims to contribute to the understanding of how to apply economic evaluation methodology in the eHealth field. It provides a brief overview of basic health economics principles and frameworks and discusses some methodological issues and challenges in conducting cost-effectiveness analysis of eHealth interventions. Issues regarding the identification, measurement, and valuation of costs and benefits are outlined. Furthermore, this work describes the established techniques of combining costs and benefits, presents the decision rules for identifying the preferred option, and outlines approaches to data collection strategies. Issues related to transferability and complexity are also discussed.

Experiences of front-line health professionals in the delivery of telehealth: a qualitative study

BACKGROUND

Telehealth is an emerging field of clinical practice but current UK health policy has not taken account of the perceptions of front-line healthcare professionals expected to implement it.

AIM

To investigate telehealth care for people with long-term conditions from the perspective of the front-line health professional.

DESIGN AND SETTING

A qualitative study in three sites within the UK (Kent, Cornwall, and the London Borough of Newham) and embedded in the Whole Systems Demonstrator evaluation, a large cluster randomised controlled trial of telehealth and telecare for patients with long-term and complex conditions.

METHOD

Semi-structured qualitative interviews with 32 front-line health professionals (13 community matrons, 10 telehealth monitoring nurses and 9 GPs) involved in the delivery of telehealth. Data were analysed using a modified grounded theory approach.

RESULTS

Mixed views were expressed by front-line professionals, which seem to reflect their levels of engagement. It was broadly welcomed by nursing staff as long as it supplemented rather than substituted their role in traditional patient care. GPs held mixed views; some gave a cautious welcome but most saw telehealth as increasing their work burden and potentially undermining their professional autonomy.

CONCLUSION

Health care professionals will need to develop a shared understanding of patient self-management through telehealth. This may require a renegotiation of their roles and responsibilities.

Making sense of the shadows: priorities for creating a learning healthcare system based on routinely collected data

Socrates described a group of people chained up inside a cave, who mistook shadows of objects on a wall for reality. This allegory comes to mind when considering 'routinely collected data'-the massive data sets, generated as part of the routine operation of the modern healthcare service. There is keen interest in routine data and the seemingly comprehensive view of healthcare they offer, and we outline a number of examples in which they were used successfully, including the Birmingham OwnHealth study, in which routine data were used with matched control groups to assess the effect of telephone health coaching on hospital utilisation.Routine data differ from data collected primarily for the purposes of research, and this means that analysts cannot assume that they provide the full or accurate clinical picture, let alone a full description of the health of the population. We show that major methodological challenges in using routine data arise from the difficulty of understanding the gap between patient and their 'data shadow'. Strategies to overcome this challenge include more extensive data linkage, developing analytical methods and collecting more data on a routine basis, including from the patient while away from the clinic. In addition, creating a learning health system will require greater alignment between the analysis and the decisions that will be taken; between analysts and people interested in quality improvement; and between the analysis undertaken and public attitudes regarding appropriate use of data.

The everyday use of assistive technology by people with dementia and their family carers: a qualitative study

Background

Assistive Technology (AT) has been suggested as a means by which people with dementia can be helped to live independently, while also leading to greater efficiencies in care. However little is known about how AT is being used by people with dementia and their carers in their daily routines. This paper reports on a qualitative study exploring the everyday use of AT by people with dementia and their families.

Methods

The research employed a qualitative methodology. Semi structured interviews took place with 39 participants, 13 people with dementia and 26 carers. Key themes were identified using thematic analysis and the constant comparative method.

Results

Three categories of AT use in everyday settings were identified; formal AT, accessed via social care services, ‘off the shelf AT’ purchased privately, and ‘do it yourself’ AT, everyday household products adapted by families to fulfil individual need in the absence of specific devices. Access to AT was driven by carers, with the majority of benefits being experienced by carers. Barriers to use included perceptions about AT cost; dilemmas about the best time to use AT; and a lack of information and support from formal health and social care services about how to access AT, where to source it and when and how it can be used.

Conclusions

It has been argued that the ‘mixed economy’ landscape, with private AT provision supplementing state provision of AT, is a key feature for the mainstreaming of AT services. Our data suggests that such a mixed economy is indeed taking place, with more participants using ‘off the shelf’ and ‘DIY’ AT purchased privately rather than via health and social care services. However this system has largely arisen due to an inability of formal care services to meet client needs. Such findings therefore raise questions about just who AT in its current provision is working for and whether a mixed market approach is the most appropriate provider model. Everyday technologies play an important role in supporting families with dementia to continue caring; further research is needed however to determine the most effective and person-centred models for future AT provision.

Efficacy of a Physician-Led Multiparametric Telemonitoring System in Very Old Adults with Heart Failure

OBJECTIVES

To evaluate the effect of an innovative model integrating telemonitoring of vital parameters and telephone support on 6-month survival and hospital admissions of elderly adults with heart failure (HF).

DESIGN

Parallel-arm, randomized trial.

SETTING

Geriatric acute care ward and outpatient clinic at Policlinico Campus Biomedico (Rome, Italy).

PARTICIPANTS

Individuals with HF aged 65 and older (mean age 80) randomly assigned to intervention (n = 50) or control (n = 46). Participants had an average ejection fraction of 46%.

INTERVENTION

Telemonitoring system (receives and communicates oxygen saturation, heart rate, and blood pressure readings) and office-hours telephonic support provided by a geriatrician.

MEASUREMENTS

Combination of all-cause death and hospital admissions.

RESULTS

The two groups were similar with the exception of the prevalence of women and of disability (both more common in the control group). Three patients for each group were lost to follow-up (final analyzed sample size: 90). Incidence of the main outcome was 42% in the control group and 21% in the intervention group (relative risk = 0.51, 95% confidence interval (CI) = 0.26-0.98). The results were unchanged after taking into account the setting of enrollment, sex, and disability (hazard ratio = 0.42, 95% CI = 0.19-0.94).

CONCLUSION

Telemonitoring of elderly people with HF is feasible and reduces the risk of death and hospitalization. Further studies are needed to confirm these findings and evaluate the cost-efficacy of the service.

Telecare for diabetes, CHF or COPD: effect on quality of life, hospital use and costs. A randomised controlled trial and qualitative evaluation

OBJECTIVES

To assess the effect of telecare on health related quality of life, self-care, hospital use, costs and the experiences of patients, informal carers and health care professionals.

METHODS

Patients were randomly assigned either to usual care or to additionally entering their data into a commercially-available electronic device that uploaded data once a day to a nurse-led monitoring station. Patients had congestive heart failure (Site A), chronic obstructive pulmonary disease (Site B), or any long-term condition, mostly diabetes (Site C). Site C contributed only intervention patients - they considered a usual care option to be unethical. The study took place in New Zealand between September 2010 and February 2012, and lasted 3 to 6 months for each patient. The primary outcome was health-related quality of life (SF36). Data on experiences were collected by individual and group interviews and by questionnaire.

RESULTS

There were 171 patients (98 intervention, 73 control). Quality of life, self-efficacy and disease-specific measures did not change significantly, while anxiety and depression both decreased significantly with the intervention. Hospital admissions, days in hospital, emergency department visits, outpatient visits and costs did not differ significantly between the groups. Patients at all sites were universally positive. Many felt safer and more cared-for, and said that they and their family had learned more about managing their condition. Staff could all see potential benefits of telecare, and, after some initial technical problems, many staff felt that telecare enabled them to effectively monitor more patients.

CONCLUSIONS

Strongly positive patient and staff experiences and attitudes complement and contrast with small or non-significant quantitative changes. Telecare led to patients and families taking a more active role in self-management. It is likely that subgroups of patients benefitted in ways that were not measured or visible within the quantitative data, especially feelings of safety and being cared-for.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12610000269033.