Study Suggests Implementation of Telemedicine in VA ICUs May Not Reduce Mortality Rates or Length of Hospital Stays

BACKGROUND:
Intensive care unit (ICU) telemedicine (TM) programs have been heralded as a potential solution to a number of vexing problems facing critical care, including a finite supply of intensivists, difficulty in attracting and retaining intensivists to smaller rural hospitals, and reductions in the availability of trainees in academic medical centers. Despite great promise, empirical data evaluating the impact of ICU telemedicine programs are limited. This study evaluated the impact of TM implementation on short-term (ICU and in-hospital) and longer-term (30-day) mortality rates and length of stay (LOS) within a regional network of seven Midwest VA hospitals (3 academic medical centers, 1 small urban hospital, and 3 rural hospitals). From August 2011 through February 2012, this network implemented a state-of-the-art ICU telemedicine system, which provided alerts to the TM staff when patient laboratory values were abnormal or vital signs exceeded pre-specified parameters. Study analyses included both a pre-post comparison (each ICU that received the TM system served as its own control) and comparison with concurrent control groups (e.g., VA ICUs that did not receive the ICU TM system). The cohort included 6,939 ICU admissions (6,654 Veterans), with 3,355 admissions to intervention ICUs and 3,584 admissions to control ICUs. Patient demographics and comorbid illness also were assessed.

FINDINGS:

• The implementation of an ICU telemedicine program did not reduce mortality rates or length of hospital stay at seven VA hospitals. It was not associated with a significant decline in ICU, in-hospital, or 30-day mortality rates or LOS in unadjusted or adjusted analyses.
• Unadjusted ICU mortality in the pre-TM versus post-TM periods was 2.9% vs 2.8% for the intervention ICUs, and 4.0% vs. 3.4% for the control ICUs. Unadjusted 30-day mortality during the pre-TM versus post-TM periods was 7.7% vs 7.8% for the intervention ICUs, and 12.0% vs 10.2% for the control ICUs.
• Adjusted results showed no statistically or clinically significant impact on mortality rates or LOS.
• Predicted mortality was modestly lower in the intervention ICUs than in the control ICUs during the pre-TM period (3.0% vs. 3.6%) and post-TM period (2.8% vs. 3.5%), which suggests that Veterans treated in the control ICUs were modestly sicker.

LIMITATIONS:

• The ICU mortality rate in this study was significantly lower than in studies suggesting a benefit of TM, which may have made it harder to demonstrate an impact of the TM intervention.
• The study observed between-site differences in both the adoption of the TM system and its impact, suggesting variable implementation of TM may have contributed to lack of overall effect.
• This study did not report effects of TM on other clinical outcomes, such as ventilator-acquired pneumonia, which might be improved by TM.

IMPLICATIONS:
Study investigators suggest that hospitals considering ICU telemedicine programs have modest expectations with respect to short-term patient outcomes in the first six months of implementation.

Nassar B, Vaughan-Sarrazin M, Jiang L, Reisinger H, Bonello R, and Cram P. Impact of an Intensive Care Unit Telemedicine Program on Patient Outcomes in an Integrated Health Care System. JAMA Internal Medicine. May 12, 2014;e-pub ahead of print.