No Evidence for Effect of Telehealth

I’ve had a mind to review the Whole System Demonstrator cluster randomized trial for some time. To my knowledge, it is the most comprehensive telehealth study to date—but contrary to popular belief, the study shows that telehealth in its current form isn’t viable!

The study population is randomized and rather large, spans a whole year, a control group has been included to account for regression-to-the-mean errors, and the researchers have made reasonable adjustments for cofounders.

The study addresses telehealth as a possible panacea for the challenges faced by future healthcare:

Efforts worldwide are dealing with the increasing prevalence of chronic disease among an ageing population. The past decade has seen the growing use of telehealth as one possible approach to this problem. Telehealth involves the remote exchange of data between a patient and healthcare professionals as part of the patient’s diagnosis and healthcare management. Examples include the monitoring of blood pressure and blood glucose. Telehealth may help patients to better understand their health conditions by providing tools for self monitoring, encourage better self management of health problems, and alert professional support if devices signal a problem. As a consequence, telehealth promises better quality and more appropriate care for each patient, as well as more efficient use of healthcare resources by reducing the need for expensive hospital care.

The trial was conducted at three sites. Notably, the standard of care was not consistent between these sites, but they all had basic telehealth capabilities:

We included a broad class of technologies, and the study was not designed or powered to examine differences between specific devices or monitoring systems. Although sites used different protocols for allocating peripheral devices, they all used a pulse oximeter for chronic obstructive pulmonary disease, a glucometer for diabetes, and weighing scales for heart failure.

Communication with the patients either went through a telehealth unit or a TV-box set. These technologies are similar to what is currently available in Norway (1, 2, 3).

Overall, I find this study to be well prepared and executed, and I’m impressed with the sheer size of the undertaking. It is therefore interesting that the study failed to show any clinically relevant improvement in the intervention group. Unfortunately, the abstract leaves the reader with the opposite impression. I stipulate that this is due to publication bias and pressure placed on the researches by their employer.

The study seems to have one large flaw, which the researchers discuss, but are unable to account for.

After the initial increase in activity for the control group, rates of emergency admission for the two groups began to converge, although a difference in favour of the intervention group seemed to persist for the entire follow-up period.

Although they can’t explain the findings, they do present some interesting remarks (my emphasis):

Differences in hospital use were at their most marked at the start of the trial, when we observed a distinct increase in admissions for the control group. If we excluded activity from the first three months of the trial, differences in the admission proportion would not have been significant under any of the models. Therefore, this increase has implications for the interpretation.

In addition, the primary outcome of the study wasn’t significant either (my emphasis).

Among a set of patients with chronic obstructive pulmonary disease, diabetes, or heart failure, this study has shown that a smaller proportion of telehealth users than controls were admitted to hospital during a 12 month follow-up. This effect remained significant after adjusting for baseline characteristics and for a predictive risk score. However, the magnitude of the group difference in admission proportion was relatively small (10.8%, 95% confidence interval 3.7% to 18.1%), and smaller than the size that the planned study design was able to detect (17.5%), raising questions about the clinical relevance of the results.

The study failed to show a reduced mortality rate after adjusting for cofounders. Most other differences were statistically or clinically insignificant. Cost-effectiveness couldn’t be shown either.

Crude differences in notional hospital costs to commissioners of care were also not significant and were relatively small (£188 per head over 12 months), especially compared with the potentially high costs of these types of telehealth intervention.

Although telehealth has been hypothesized to be a viable method for follow-up, and prevention of chronically ill patients, no study has been able to verify this statement.

Current telehealth solutions are single purpose combinations of tailor-made hardware and software. This makes them expensive and difficult to implement. The technologies quickly become obsolete, especially as future generations will expect to be allowed to bring their own devices (i.e. smartphones). I suggest that governments and hospitals frog-leap the old telehealth technology. Instead they must invest in software-based telehealth infrastructures which utilize the increasing number of medical apps, smartphones and wearables. This will result in lower costs, quicker implementation, better compliance, and (hopefully) better results.