Telehealth, or telemedicine, is the use of telecommunications and information technology to provide health care when distance separates participants. A number of studies have shown that home telehealth interventions can improve clinical outcomes for conditions common among SCI patients, such as pressure ulcers (Phillips et al. 2001) and diabetes (Joseph 2006; Barnett et al. 2007). Little is known, however, about the costs and potential savings associated with the use of telehealth for persons with SCI.
VA has developed a network of major SCI rehabilitation sites ("hubs") and has identified smaller VA facilities in the same VISNs ("spokes") that can consult with the major facilities on SCI care. To support this effort, VA has provided a significant amount of telehealth equipment to hub and spoke sites. What is lacking is explicit guidance on when to use it. Clinicians have been left to implement telehealth in an uncoordinated fashion without understanding when its use is optimal in terms of clinical outcomes, access to care, or cost.
Telehealth consultation between hospitals could improve patient well-being while saving VA money and increasing access to expert care. In one common situation, a veteran with SCI presents at a smaller VA hospital with an apparent pressure ulcer. The clinicians see few SCI patients and feel they need consultation with an SCI specialist. The patient is then transported in a specialized ambulance to the nearest hub site, a trip that often takes several hours and may require an overnight inpatient stay if the return trip cannot be made during normal hours. If a telehealth connection were available between facilities, the consultation could occur without transporting the patient. The patient would receive an SCI expert evaluation and would be spared considerable inconvenience and discomfort. VA could save thousands of dollars, and depending on his/her copayment status the patient may save money as well.
This study has two primary objectives:
1) To determine the costs and outcomes for the patient and VA in each clinical scenario.
2) To develop a probabilistic decision model for each scenario that shows the clinical and cost implications of using telehealth under each scenario under a range of reasonable assumptions.
The study addresses two high-priority HSR&D research topics: healthcare informatics, and care for complex, chronic conditions. It will make several contributions to VHA research and health care. Addressing the primary objectives will assist managers and clinicians in proving optimal SCI care. The study will benefit VA researchers proposing new studies through the data collected on telehealth costs and outcomes. Finally, it will promote increased collaboration between health services researchers and rehabilitation/SCI clinicians at the Palo Alto VA.
1. Clinical scenarios
Three content experts, Drs. Creasey, Kiratli, and Hill, will develop clinical scenarios. Each will have 2-4 options for treatment, the first representing typical care and outcomes without telehealth, and the remaining representing alternative care and outcomes with telehealth.
Probabilities of developing ulcers will come from their expertise, from published literature on SCI patients, and on analysis of VA utilization data. We will estimate costs for VA (including community nursing home stays), for patients, and for patients' caregivers.
Costs associated with VA care will be extracted from the VA Decision Support System (DSS) National Data Extracts (NDEs). We will use a second set of utilization data, the Outpatient Care File (OPC) and the Patient Treatment File (PTF), to assist in locating relevant encounters, and then will find the costs of those encounters in DSS NDEs. VA-funded care for home-based health care and for care at certain non-VA facilities, such as rehabilitation hospitals and community nursing homes, can be found in the Fee Basis program files.
Dr. Smith, Ms. Ananth, and the RA will determine costs and Dr. Cronkite will contribute her expertise to planned statistical analyses. Using MS Excel we will develop decision models that show how the various telemedicine options can affect costs. We will then carry out sensitivity analyses, varying the parameters singly and jointly through reasonable ranges. The result will be estimated cost ranges for each treatment option within the three scenarios and comparisons of costs across the treatment options. Our decision modeling will follow the methods presented in publications from two earlier VA telehealth studies.
[May 28, 2009 update]
1. Clinical Scenarios
Hill developed the scenarios. Smith and Hill estimated probabilities for the elements of them with additional input from a Palo Alto SCI nurse.
Smith calculated costs for each element of the scenarios.
3. Cost-outcomes analysis
Although still preliminary, our analyses indicate that telehealth interventions could be cost-saving under certain conditions, and that overall the telehealth options seem to have relatively minor impact on costs.
The exact outcome in each of the three scenarios depends in part on assumptions about healing rates of pressure ulcers. This is a thorny issue because telehealth can have opposing effects: it can increase the likelihood of detection relative to usual care, but relative to in-person visits (the optimal care) it is less effective at allowing accurate staging.
The Veterans Health Administration has invested heavily in telehealth under the broader notion of 'care coordination.' An important question for VA stations is how moving toward more telehealth will affect their budgets. Based on our preliminary analyses it appears that telehealth care for pressure ulcers among veterans with SCI could be implemented without a substantial increase in costs.
- Smith MW, Hill ML, Hopkins KL, Kiratli BJ, Cronkite RC. A modeled analysis of telehealth methods for treating pressure ulcers after spinal cord injury. International journal of telemedicine and applications. 2012 Aug 28; 2012:729492.
- Hill ML, Cronkite RC, Ota DT, Yao EC, Kiratli BJ. Validation of home telehealth for pressure ulcer assessment: a study in patients with spinal cord injury. Journal of telemedicine and telecare. 2009 Jan 1; 15(4):196-202.
- Cronkite RC, Hill ML, Hopkins KL, Kiratli BJ. A Modeled Cost Analysis of Telehealth Methods for Treating Pressure Ulcers after Spinal Cord Injury. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.
- Smith MS, Hill M, Kiratli J, Hopkins K, Cronkite RC. A Modeled Analysis of Telehealth Methods for Treating Pressure Ulcers after Spinal Cord Injury. Paper presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 5; Portland, ME.
- Smith MW, An L, Fu S, Nugent S, Nelson DB, Joseph AM. Cost-effectiveness of a telehealth intervention for smoking cessation. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN.
- Hill ML, Cronkite RC, Yao EC, Ota DT, Bacon SA, Henderson PT, Kiratli JB. Validation of Home Telehealth for Diagnosis and Assessment of Pressure Ulcers in Patients with Spinal Cord Injury. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
- Schaefer JA, Cronkite RC, Hu K. Continuity of Care Practices: Impact on Inpatient/Residential Substance Use Disorder Patients' Engagement in Continuing Care and Abstinence. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.