People are increasingly living with long-term health conditions. Management of these conditions is expensive, and their increased prevalence challenges health system sustainability and current service models. Can alternative models of care meet the needs of patients with long-term conditions at an acceptable cost?
One growing area of healthcare that could serve as a replacement or adjunct to traditional care models is telehealth, which is the remote provision of healthcare by a variety of communication tools. Telehealth advocates argue that the wider use of technology and a greater reliance on self-management in supporting patients with long-term conditions may produce the same or better health outcomes, but at a lower cost, than traditional care modalities. Is this optimism justified, and might telehealth be good value for the NHS?
Recent work, funded by the National Institute for Health Research (NIHR) and led by the Centre for Academic Primary Care’s (CAPC’s) Professor Chris Salisbury, addressed this question. This work designed and evaluated, in two linked randomised controlled trials (RCTs), a telehealth intervention for patients with two exemplar long-term conditions: depression, and cardiovascular disease (CVD) risk.
In each trial, patients randomised to the intervention were contacted regularly over a 12-month period by a trained health advisor who discussed ways of improving their lifestyle, offered advice about condition-specific resources and supportive online material, and facilitated improved medication management.
To assess the value of the telehealth intervention, a CAPC-led team conducted three economic evaluations of the intervention. Two within-trial economic evaluations were conducted alongside each RCT to establish if the interventions represented good value for money at the end of 12-month follow-up. In addition to the within-trial evaluations, the long-term consequences of changes in CVD risk associated with the intervention were assessed in a decision analytic model that simulated the effects of the intervention over the remaining lifetime of trial participants. In all studies, value was measured as a function of the ratio of incremental costs of the telehealth intervention to incremental changes in quality-adjusted life years.
The trials of this complex intervention produced complex results. Patients with depression reported high levels of satisfaction and acceptability of the intervention and, on average, their depression improved more than those in the control group, who received usual care. However, only a small gain in quality-adjusted life years was observed for the intervention group, which meant that telehealth was not cost-effective using conventional criteria.
There was a modest improvement in overall CVD risk for patients randomised to the intervention. Quality of life improved more than for those receiving usual care and the intervention was cost-effective. The modelling showed that the enduring effect of the intervention was the key to reducing CVD risk over the long term: the longer the effect the stronger the evidence of good value for money.
Overall, the evidence from this programme of work does not offer a simple “value story”. The intervention did not reduce costs relative to usual care within the period of trial follow up, and the value of the increased costs observed was within conventional cost-effectiveness criteria for the CVD trial only. Important considerations for healthcare funders and commissioners weighing the case for telehealth deployments include the nature and duration of behavioural changes associated with a telehealth programme, and the changing capacities and costs of telehealth technologies.
The economic evaluations have been published and are available to download:
- Cost-effectiveness for depression
- Cost-effectiveness for CVD risk
- Long-term cost-effectiveness for CVD risk