A systematic review of economic analyses of telehealth services using real time video communication

“Pare [20] summarised a number of reviews of home care for chronic disease, and reported that very few detailed economic analyses had been done, leading to no confirmation of economic viability.”

“It is a subset of e-health, which encompasses all uses of ICT in health, including electronic records and decision support systems, however telehealth is particularly characterised by the geographical separation of patient and provider[4].”

“Also in line with earlier reviews [11,23], there was great variability in methodology and outcome measures.”

“Jennet reviewed the broader socio-economic impacts of telehealth in 2003 [ 12 ] and combining cost, cost-effectiveness and health system utilisation measures into one category, concluded that there was evidence of benefit of at least fair to good quality in paediatrics, geriatrics, home care, radiology, mental health…”

“Each found lower costs and reductions in patient mortality when the telehealth service was operating; additionally Breslow[49] reported shorter hospital stays, and Rosenfeld reported lower complications[50].”

“Rosenfeld 2000[50] Specialist on-call Intensive Care B&A CCA 80 Computer, Not specified Health service Less More”

“Ruskin[51] found that telepsychiatry was more expensive if the psychiatrist needed to travel less than 22 miles to an outlying clinic.”

“The field was originally known as telemedicine, but was later broadened to telehealth[3], although these terms continue to be used interchangeably.”

“Jerant 2001 [37] Home care Cardiology RCT CCA 67 Not specified PSTN Health service Less More”

“Quality assessment using Chiou’s criteria[24] gave similar results to those of Bergmo’s recent review of economic analyses in telehealth[23].”

“Although two of these studies[45,48] reported that they used both urban and rural settings, the distances concerned were of the order of 10 to 20 kms, so they have been classified as local care.”

“Finkelstein 2006[38] Home care Nursing RCT CCA 67 TV, PSTN Health service Less More”

“Two reviews of telepsychiatry concluded that cost-effectiveness could not be demonstrated because the volume of consulting was too low[15,16], while another found conflicting results of both increased and decreased costs[17].”

“Those studies in which the only health outcomes reported were patient satisfaction ratings were also excluded because telehealth studies report almost uniformly high patient satisfaction, which is likely to be a positive bias due to social desirability and acquiescence [69].”

“Two reviews of telepsychiatry concluded that cost-effectiveness could not be demonstrated because the volume of consulting was too low[15,16], while another found conflicting results of both increased and decreased costs[17].”

“Hailey’s review[13] of the benefits of telemedicine in 2004 rated 25 health economic analyses, using Drummond’s criteria[14], finding 13 studies met 5 or more criteria and were rated as fair to good.”

“Two reviews of telepsychiatry concluded that cost-effectiveness could not be demonstrated because the volume of consulting was too low[15,16], while another found conflicting results of both increased and decreased costs[17].”

“Duchesne 2008[57] Rural inpatient Emerg med B&A CCA 34 VC, T1 line Health service Less More”

“Although two of these studies[ 45 ,48] reported that they used both urban and rural settings, the distances concerned were of the order of 10 to 20 kms, so they have been classified as local care.”

“However, in regard to heart failure, Martinez concluded that home monitoring reduced costs of hospital admissions[ 21 ], and Seto reported initial costs, but substantial long term cost savings[22].”

“The studies that delivered home care via real time video produced cost savings; an interesting finding because reviews of tele-homecare have mainly used telephone and/or telemonitoring[20,22, 70 ].”

“This approach resulted in the exclusion of some wellconducted cost analyses[65-68].”

“Bergmo TS: Can economic evaluation in telemedicine be trusted?”

“Six of the cost-minimisation studies relied on citations of previous work for health outcomes data; in five of these the authors cited their own work in the same clinical settings[25-29], and one study cited a very similar setting[30], therefore these citations were taken as valid evidence of equivalence.”

“All studies showed similar patient outcomes and increased costs for the health services[45-47].”

“Modai 2006 [72] Rural outpatient Psychiatry ProspCC CCA 45 Not specified, ISDN Health service More Same”

“Three reviews published in 2000 covered the early economic analyses of telehealth[ 7-9 ], and each reported that the studies were methodologically flawed; lacking appropriate outcome measures, consistency and clarity.”

“Three of the studies in this group had low quality ratings, of 25 or less, for their economic analysis; two were small scale feasibility projects[42,43]), and the third included an economic analysis as part of a larger study[44].”

“Oakley 2000 [74] Rural outpatient Dermatology RCT CCA 15 Computer, ISDN Patient Less Same”

“Crow SJ, Mitchell JE, Crosby RD, Swanson SA, Wonderlich S, Lancanster K: The cost effectiveness of cognitive behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face.”

“Tulu[ 5 ] categorises telehealth according to its purpose, such as clinical, educational or administrative; its healthcare discipline area; the environmental setting; the type of communication infrastructure used; and the delivery modality.”

“Three reviews published in 2000 covered the early economic analyses of telehealth[7-9], and each reported that the studies were methodologically flawed; lacking appropriate outcome measures, consistency and clarity.”

“Three reviews published in 2000 covered the early economic analyses of telehealth[ 7-9 ], and each reported that the studies were methodologically flawed; lacking appropriate outcome measures, consistency and clarity.”

“For example Cusack[6]modelled cost savings of $4.3 billion a year if telehealth were implemented to facilitate consultations between healthcare providers in the USA, and this is without considering savings associated with the provision of care direct to the patient.”

“However, tele-home care can lead to additional use of health workforce if the telehealth visits are added on to, rather than substituting for, existing services[41].”

“This approach resulted in the exclusion of some wellconducted cost analyses[65-68].”

“Sable C, Roca T, Gold J, Gutierrez A, Gulotta E, Culpepper W: Live transmission of neonatal echocardiograms from underserved areas: accuracy, patient care, and cost.”

“A review of the use of telehealth in intensive care units found two clinical trials which showed cost savings[ 19 ].”

“For example it has been noted[71] that a visiting paediatric cardiology service was less than monthly, whereas a teleconsultation could be arranged within two days, and that telehealth reduced the time for an ENT consultation from four months to four to six weeks[52].”

“Kunkler[60] reported that halving the technology cost would reduce their breakeven point from 40 to 20 multidisciplinary meetings per year, although Noble[61] and Ohinmaa[33] found that reducing the annual equipment cost had no impact on the overall cost outcomes.”

“Persaud DD, Jreige S, Skedgel C, Finley J, Sargeant J, Hanlon N: An incremental cost analysis of telehealth in Nova Scotia from a societal perspective.”

“Ehlers 2008 [76] Rural inpatient Neurology EcModel CUA 65 Computer, Not specified Societal Less (HS more) More Wade et al.”

“The studies in this review do not reflect the recent advances in connectivity produced by widespread rollout of fast broadband or Digital Services Lines (DSL) with only one recent study utilising DSL[31].”

“Meilonen[63] commented that differences in telecommunications costs made telehealth cost-saving in some countries and uneconomical in others, and Shore[29] found that telehealth changed from being more costly in 2003 to less costly in 2005, due to reductions in ISDN line charges.”

“Wong HT, Poon WS, Jacobs P, Goh KY, Leung CH, Lau FL, Kwok S, Ng S, Chow L: The comparative impact of video consultation on emergency neurosurgical referrals.”

“Chan 2000 [58] Residential care Dermatology DiagAcc CCA 32 VC, ISDN Health service Less Less(3)”

“For example it has been noted[71] that a visiting paediatric cardiology service was less than monthly, whereas a teleconsultation could be arranged within two days, and that telehealth reduced the time for an ENT consultation from four months to four to six weeks[52].”

“[ 56 ] Rural inpatient Paediatric Cardiol DiagAcc CEA 63 VC, ISDN Health service More More”

“This approach resulted in the exclusion of some wellconducted cost analyses[65-68].”

“Brebner[18] reviewed telehealth provision of accident and emergency support to primary care, and found seven studies with economic data, all indicating cost-effectiveness, however he concluded that the case was far from proven.”

“Both of the latter studies were of outpatient services to rural areas; one found that more investigations were ordered in a telehealth neurology clinic[ 36 ], and the other delivered treatment of bulimia nervosa by videoconferencing, which was clinically effective, but less so than in-person treatment[35].”

“This has been reported for primary care management of ENT problems[52], colposcopy [62], and skin conditions[59].”

“Smith 2002 [42] Home care Nursing(CPAP) DiagAcc CMA 25 Custom, PSTN Health service Less Same”

“This approach resulted in the exclusion of some wellconducted cost analyses[65-68].”

“Telehealth became a separate field of study from the 1970’s[1], and innovation increased from the 1990’s, due to the development of new technologies such as cellular phones and the internet[2].”

“Rendina 1997 [75] Rural inpatient Paediatric Cardiol B&A CBA 56 VC, T1 line Health service Less Same”

“Noble SM, Coast J, Benger JR: A cost-consequences analysis of minor injuries telemedicine.”

“In addition to increased efficiency and accessibility, a recently published review examined the economic value of clinical telehealth and found that the delivery of home care health services by Web-based video consultations was also cost-effective [33].”

“▸ Combinations of the above—for example, a systematic review of the cost-effectiveness of ‘telehealth’ that included both home-based and telemedicine services, which showed that both the efficacy and costs of such services varied considerably across studies.(90) The contribution of these technologies to healthcare has…”