ISSN Home Telemonitoring for Chronic Disease Management: An Economic Assessment. Par: Guy Paré Placide Poba-Nzaou Claude Sicotte

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3 ISSN Home Telemonitoring for Chronic Disease Management: An Economic Assessment Par: Guy Paré Placide Poba-Nzaou Claude Sicotte Cahier de la Chaire de recherche du Canada en technologie de l information dans le secteur de la santé N o Août 2012 Copyright HEC Montréal. Tous droits réservés pour tous pays. Toute traduction et toute reproduction sous quelque forme que ce soit sont interdites. HEC Montréal, 3000, chemin de la Côte-Sainte-Catherine, Montréal, Québec, H3T 2A7 Canada. Les textes publiés dans la série des Cahiers de la Chaire de recherche du Canada en technologie de l information dans le secteur de la santé n'engagent que la responsabilité de leurs auteurs.

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5 Guy Paré, Ph.D.* Canada Research Chair in Information Technology in Health Care HEC Montréal 3000, Côte-Ste-Catherine Road Montréal (Qc) H3T 2A7 Phone: (514) Fax: (514) Placide Poba-Nzaou, D.B.A. Assistant Professor Faculty of Management Université du Québec à Montréal Phone: (514) , ext Fax: (514) Claude Sicotte, Ph.D. Professor of Health Administration Faculty of Medicine Université de Montréal Phone: (514) Fax: (514) * Corresponding author Running title: An economic assessment of home telemonitoring All rights reserved. August Copyright HEC Montréal

6 ABSTRACT Objectives: There have been very few assessments of the economics of home telemonitoring, and the quality of evidence has often been weakened by methodological flaws. This has made it difficult to compare telehomecare with traditional home care for the chronic diseases studied. This economic analysis is an attempt to address this gap in the literature. Method: We have analyzed the consumption of health care services by 95 patients with various chronic diseases over a 21-month period, i.e. 12 months before, 4 months during home telemonitoring use, and over 5 months after withdraw of the technology. Results: Our findings indicate significant benefits to the home telemonitoring program as evidenced by large reductions in number of hospitalizations, length of average hospital stay and, to a lesser extent, number of emergency room visits. Contrary to expectations, however, the number of home visits by nurses increased both during and after the telemonitoring intervention. In terms of the financial analysis, the telehomecare program resulted in significant savings: the equivalent of over $1,557 per patient as calculated on an annualized basis. This represents a net gain of 41% as compared to traditional home care. Conclusion: While the present economic analysis led to positive results, additional assessments should be conducted to confirm the costeffectiveness of this mode of care delivery. KEYWORDS Home telemonitoring; Home telecare; Cost minimization study; Chronic disease management. ACKNOWLEDGMENTS The Ministère de la Santé et des Services sociaux du Québec is gratefully acknowledged for providing financial support for this research. Copyright HEC Montréal 1

7 INTRODUCTION Management of chronic diseases is a major problem for many health systems around the world. Due to aging populations and severe shortages of nursing and medical resources, meeting the demand for these services is becoming increasingly difficult and onerous. In such an environment, health systems are obliged to make optimal use of human resources and reorganize modes of homecare delivery. To this end, many industrialized countries have established policies to make the shift toward ambulatory care, and many authorities and organizations have strongly recommended homecare for patients with chronic diseases [e.g., 1-3]. One important success factor in such transformations is closely associated with the judicious use of information and communication technologies, which are being developed at an ever faster rate [4]. As such, telehealth is recognized as a key link in the remote delivery of health care services. Home telemonitoring is one of the main telehealth applications used in Canada [5]. Home telemonitoring is the remote transmission (by patients) and collection (by health care professionals) of physiological and biological data (such as vital signs and symptoms) and behavioral data (such as compliance with medication and activity level) for the purposes of patient monitoring, data interpretation and clinical decision making [6]. This mode of health delivery can play an important role in the provision of homecare to chronically ill patients. The technological device may serve many purposes. First, it can detect problems, generate alerts (to both the patient and the case manager) and make suggestions to patients on how to adjust their therapeutic plans. It can also reduce measurement entry and transmission errors by having medical technologies such as sphygmomanometers, blood glucose meters and spirometers transmit the electronic data. Depending on the sophistication of the device, it can provide additional benefits, such as improving patient education and empowering patients to manage their own health [7]. If necessary, the case manager can intervene directly by contacting the patient by phone or video conferencing. Health systems that adopt and disseminate home telemonitoring programs may also obtain major benefits such as less emergency room congestion [8-9] and fewer hospitalizations related to chronic illnesses [10-11]. Even though a growing number of home telemonitoring programs are already in operation particularly in North America and Europe there have been relatively few solid empirical studies on the economic issues surrounding home telemonitoring. In this context, we conducted a cost minimization study, using retrospective and prospective data, in order to assess the economic viability of a telehomecare program in Quebec, Canada. To attain our objectives, a cohort of 95 chronically ill patients was followed for over 21 months. This period included Copyright HEC Montréal 2

8 a pre phase (365 days prior to the intervention), a per phase (an average of 121 days of home telemonitoring), and a post phase (an average of 157 days of additional observation following the withdraw of the technology). To our knowledge, this is the very first study to have examined the longterm effects of telehomecare following removal of the technology. In each of the three phases we collected data on each patient s consumption of health services and calculated the costs associated with this use. BACKGROUND We consulted the MEDLINE (PubMed interface) and The Cochrane Library databases and found a total of 26 systematic reviews on the impacts of home telemonitoring. 1 Two of the reviews deal specifically with the issue of economic viability. First, Seto [12] analyzed the existing economic evidence in order to determine whether home telemonitoring of patients with congestive heart failure results in decreased costs. She analyzed data from a total of 10 different home telemonitoring studies. Nine of these studies analyzed the direct costs to the healthcare system. All of them found cost reductions from telemonitoring compared to usual care, ranging from 1.6% to 68.3%. The cost reductions were mainly associated with savings from reduced expenditures on hospitalizations and, to a lesser extent, home visits. However, these studies varied in how the telemonitoring intervention was implemented, the system defined as usual care, the items included in the economic analysis and the method for comparing costs, the duration of the study, and the sample size. The author concludes that these differences make direct comparisons of the economic analyses difficult and that future economic assessments are required for informed investment decisions. Second, Polinesa et al. [13] also reviewed the literature on the cost-effectiveness of home telehealth for chronic disease. Their review included economic assessments such as cost minimization analyses, costeffectiveness analyses, cost utility analyses and cost benefit analyses. A total of 22 empirical studies were found to be relevant for inclusion in the database, most of which were from the United States and a majority focused on patients with congestive heart failure. Half of the included studies (n=11) were concerned specifically with home telemonitoring interventions (as defined above) while the other half referred to other forms of home telehealth programs such as telephone case management and videobased nursing consultations. As in the previous review, usual care varied across the studies and the home telehealth interventions tended to be complex, often with differences in more than one facet of 1 The search was conducted on July 3, Review articles that considered multiple types of telehomecare interventions such as home teleconsultation, videoconferencing, home telemonitoring and telephone-based monitoring (e.g., Bensink et al., 2006; Bensink et al., 2007; Bowles and Baugh, 2007; Botsis and Hartvigsen, 2008; DelliFraine and Dansky, 2008) were excluded. Copyright HEC Montréal 3

9 patient management in the intervention phase of the study. Most economic studies involved an assessment of the costs associated with specific healthcare resources, including hospitalizations and emergency department visits. The authors found that in most studies (10 out of 11) home telemonitoring led reduced spending on healthcare resources. However, the overall quality of the economic studies varied considerably, and so was their relevance for decision making. Of the 24 other systematic reviews, five make no mention of the economic issues associated with telehomecare [7, 9, 14-16] and the other 19 deal only superficially with the issue of economic viability, as shown by the data summary presented in Supplementary Table 1. All the review articles published in the last five years strongly recommend that future research rigorously conduct economic assessments of home telemonitoring. In short, given the relentless growth in health care costs and the focus on quality, health care systems face the challenge of caring for a growing number of patients while minimizing costs [17]. Home telemonitoring thus represents a promising approach for achieving these objectives, as reported in most systematic reviews. However, there is still limited empirical evidence on the effects of home telemonitoring on economic viability for all chronic diseases, including congestive heart failure, which accounts for the largest number of studies (see Supplementary Table 1). This leaves managers and policymakers with little support for decision making. The present study attempts to fill this gap. METHODOLOGY Site The Jardins-Roussillon Health and Social Services Centre (hereafter called the JR Health Centre) was created in 2004 through the merger of a regional hospital, three local community health services centres as well as 11 residential and long-term care centres. The JR Health Centre covers a very large service area in south-western Montérégie, near Montreal, Canada. The JR Heatlh Centre is a multi-vocational facility responsible for maintaining and improving the health and wellbeing of the population in its health region. It serves over 192,000 people spread over an area of 1,346 km 2, making it the third largest service region in Montérégie. The JR Health Centre fulfills this responsibility by providing a wide range of continuous, high quality services of a general, specialized and highly specialized nature for health prevention as well as for curing disease in the population. To carry out its mission, the JR Health Centre counts on the cooperation and commitment of approximately 150 physicians, 213 nurse practitioners, 350 registered nurses, and 200 licensed practical nurses. Copyright HEC Montréal 4

10 Home care services represent a major service segment for the JR Health Centre, and it has three home support services working out of its local community health services centres. The home care services programs are by definition specifically designed for coordinating and providing care and support services to people living in their natural living environments. The home is defined as the place where a person lives, temporarily or permanently, including housing for retirees, non-institutional resources, group homes, supervised apartments and long-term care facilities. The client group for home care services includes all individuals who have lost independence due to aging or who present a permanent and persistent physical disability that requires long-term care, as well as persons of any age with a limited need for physical health care, such as following surgery or palliative care. Recent statistics suggest that the number of people over the age of 65 served by the JR Health Centre will more than double between 2001 and If this is true, this client group will grow from 16,737 to 41,874 persons. This represents approximately 1,000 additional persons who are 65 years of age or older each year. In 2011, the home care service at JR Health Centre employed 16 nurse practitioners, 18 registered nurses, and 6 licensed practical nurses. Nature of the technology and intervention The telehomecare program in this study serves elderly clients suffering from a variety of chronic health problems. As for the technology used, the patients were equipped with a tactile screen and an integrated modem (from Telus Health Solutions TM ). The device came programmed with a personalized monitoring protocol that monitored various health parameters, and the nurses taught the patients how to use the device at their initial meeting. On average, a training session last about 60 minutes. Then the patients were expected to send clinical data over an Internet connection each time the data was collected. More specifically, the patient needed to complete a data entry table every day, documenting vital signs, symptoms and medication taken. The tool was designed to show the patient relationships between his or her health status and the environment, life habits and medication management, thereby empowering him or her to manage his or her illnesses by applying a therapeutic action plan. The information sent over the Internet was safely stored in a server where the case managers (the nurses) could consult it on a daily basis, remotely monitoring the patient s medical condition and compliance with the prescribed therapy. In addition, the device automatically analyzed the data transmitted by the patient as it was entered and generated an alert when the data strayed outside of predefined parameters. Like push technologies, the computer system could generate alerts to both the patient and the nurse when one of the following situations was detected: (1) the patient did not submit the completed clinical questionnaire on the specified date; (2) the patient did not comply with the Copyright HEC Montréal 5

11 medication regime or was not following the treatment plan. In such circumstances, the system intervened immediately, sending pre-programmed advice on the appropriate conduct. This advice was issued based on a personalized follow-up plan developed by the attending physician. At the same time, the case manager was automatically warned of the observed disparities and the suggestions made to the patient. This allowed the case manager to remotely monitor the patient s responses and, if necessary, intervene directly by contacting the patient by phone or informing the attending physician, who would decide on an appropriate course of action. The changes introduced through the telemonitoring system therefore consisted of: (a) how the patient entered and transmitted their clinical information; and (b) above all, the resulting effect, which allowed real-time responses of advice to the patient (intelligent functions programmed into the system) as well as delayed responses (regular remote consultations by the case manager on the status of the intervention based on the stored electronic data). In sum, the value added by telehealth in comparison to the usual homecare was at three distinct levels: (a) the close and remote monitoring of the patient s health status and behaviour; (b) the system s capacity for immediate intervention through the pre-programmed functions when discrepancies are noted in state of health or behaviour; and (c) the reinforcement of behavior produced when the system issues advice that is tailored to the patient s particular condition. Study design The research design is a pre-post cohort study. Patient selection was guided by a strict set of inclusion and exclusion criteria. First, the program was directed at patients with serious chronic illnesses requiring frequent home visits. Four main diagnoses were targeted: level 3 or higher congestive heart failure, hypertension when the patient had experienced an acute attack that was difficult to control (as identified by the physician), persons with uncontrolled diabetes, and COPD patients upon hospital discharge. Patients considered for this study had to have a regular physician, demonstrate a desire to manage their own care (with or without assistance from an informal caregiver) given their health condition, and have a working telephone line. Patients were excluded from the study if they were unable to read and understand written French or English, suffered from psychological or psychiatric disorders, presented a cognitive deficit that made them unable to participate in their own treatment, or were suffering from a visual of motor deficit that would make them unable to use the telemonitoring technology (unless their informal caregiver agreed to assume this responsibility). A total of 113 patients satisfying all the above criteria were identified by two case managers and agreed to participate in the research project (participation rate = 94%). As shown in supplementary Table 2, 18 of the recruited patients needed to be removed from the study for a variety of reasons. In view of the Copyright HEC Montréal 6

12 somewhat high attrition rate (16%), it was necessary to determine how similar the drop out group was of those who remained in the sample. As recommended by Miller and Hollist [18], we conducted a logistical regression analysis which includes demographic (age, gender, and primary diagnosis), clinical (primary diagnosis), as well as cost variables associated with the pre period (nurse home visits, emergency visits and hospitalizations). No statistically significant coefficient was found, indicating that there is no evidence of attrition bias. Table 1 presents a profile of our final sample of 95 patients. The average age was 70 years, and the women were older than the men (p<.05). Slightly more than a quarter of the sample had assistance from an informal caregiver who entered data into the telecare system. We also see that the patients with informal caregivers were older than those entering the data themselves (p<.001). The participants, who were recruited by the case managers, suffered from congestive heart failure (37%), diabetes (29%), severe pulmonary disease (24%) and hypertension (10%). Table 1. General Participant Profile (n=95) n % Gender Male 45 47% Female 50 53% Data entered by an Yes 25 26% informal caregiver No 70 74% Main diagnosis Congestive heart failure 35 37% Diabetes 28 29% COPD 23 24% Hypertension 9 10% Minimum Maximum Average SD Age Data sources The main indicators used in this study are associated with how much the patients used the health services associated with their main diagnoses, including home visits by nurses, emergency room visits and hospitalizations (including length of hospital stay). Based on these indicators, we conducted a detailed economic analysis, comparing the costs associated with managing a chronic patient (our unit of analysis) following the usual approach to home care services (the pre phase) with the costs associated with the telemonitoring approach (the per phase). The following section describes the specific methodology used in this analysis. The data on consumption of health services were extracted from the computerized medical records used at the JR Health Center and other related information systems. Furthermore, we measured the patients satisfaction with the technological device using a self- Copyright HEC Montréal 7

13 administered questionnaire. The ethics committee of the health facility issued a notice of compliance for this research project. RESULTS Before presenting the results of the economic analysis, we will describe the impacts of the telehomecare program on the various health care consumption indices and present data on patient satisfaction with the technological device and the information it contained. Consumption of health care services First, the results presented in Table 2 show that the number of patients who visited an emergency room (ER) declined from 57 (the pre period) to 24 (the per period) to 10 (post period). It is important to mention that we only compiled emergency room visits related to the primary diagnosis. As expected, the patients with congestive heart failure and COPD were the ones most likely to visit an emergency room in each of these periods. In order to assess the impact of home telemonitoring on the consumption of health care services, including ER visits, the data for the post period had to be adjusted from 157 to 244 days (so the number of days before and after system deployment equals 365). After this adjustment, the total number of ER visits fell from 91 (pre) to 37 (per) to 23 (post). This suggests a 34% decrease in ER visits following deployment of the technological device (91 versus 60). This result is statistically significant at the 0.1 level (t=1.8; p=.08). Table 2. Emergency Room Visits PRE PER POST* Length of observation (average number of days) Number of patients who visited an emergency room at least once Congestive heart failure COPD Diabetes Hypertension Total Number of emergency room visits Minimum Maximum Average Standard deviation Total * adjusted for 244 days instead of 157 days to make comparisons on an annual basis. Copyright HEC Montréal 8

14 The second health care consumption index is related to hospitalizations. As in the case of emergency room visits, our analyses only took into account hospitalizations associated with the main diagnosis. The data in Table 3 reveal that the number of patients who had stayed in hospital declined from 57 (pre) to 14 (per) to 4 (post). Here again, patients with congestive heart failure and COPD were the ones most often hospitalized. The total number of hospital stays fell from 80 (pre) to 18 (per) to 9 (adjusted post). We therefore observe a 66% decrease in the number of hospitalizations during the post period compared to the pre period (80 versus 27). This result is statistically significant (t=3.8; p<.001). Lastly, the average number of days of hospitalization fell from 13.5 (pre) to 1.9 (per) to 0.6 (adjusted post). Hence, the difference in length of stay before (pre) and after (per and adjusted post) system deployment is statistically significant (t=4.6; p<.001). Table 3. Hospitalizations and Length of Stay PRE PER POST* Length of observation (average number of days) Number of patients who were hospitalized at least once Congestive heart failure COPD Diabetes Hypertension Total Number of hospital stays Minimum Maximum Average* Standard deviation Total Length of hospital stay (in days) Minimum Maximum Average Standard deviations Total 1, * Adjusted for 244 days instead of 157 days to make comparisons on an annual basis. The third health care consumption index is related to home visits by nurses. Table 4 indicates that the number of patients receiving home visits declined from 85 (pre) to 69 (per) and then went up to 73 (post). For its part, the actual number of home visits grew from 342 (pre) to 453 (per and adjusted post). Against all expectations, the number of home visits by nurses increased 32% during the per and post periods compared to the pre period. This increase, however, was not statistically significant (t=-1.6; Copyright HEC Montréal 9

15 p=.11). The total number of minutes spent providing direct care to patients increased from 9,885 (pre) to 14,049 (per + adjusted post). This increase of over 42% was statistically significant (t=-3.3; p<.005). In sum, we found that the home visits by nurses after system deployment were more frequent but shorter than during the pre period. Table 4. Home Visits by Nurses PRE PER POST* Length of observation (average number of days) Number of patients who received at least 1 home visit Number of home visits Minimum Maximum Average Standard deviation Total Time spent by nurses on home visits (in minutes) Average Standard deviation Total 9,885 6,395 7,654 * Adjusted for 244 days instead of 157 days to make comparisons on an annual basis. Patients satisfaction with the technological device We asked the 95 participants to indicate their satisfaction with the technological device after they had spent four months in the home telemonitoring program. As shown in Supplementary Table 3, the results indicate very high satisfaction among the vast majority of respondents. The results are 4 or slightly higher on a scale of 5 (where 1 = not at all and 5 = enormously) for 7 of the 8 statements in the scale (with an overall average of 4.1). Furthermore, in response to the question If you could keep the automated telemonitoring system in your home, would you continue to use it in the future?, 4 out of 5 respondents, or 80%, said that they would. Cost-minimization analysis The economic analysis strategy adopted for this study was one of cost minimization [19]. This strategy can be used to compare the costs of different interventions whose clinical results are considered similar, in order to determine which costs the least. It provides a comparative basis that, beyond calculations of costs and benefits, must be able to indicate whether the new program appears to be better than the usual model. The purpose of the analysis performed for this assessment was to confirm the extent to which telehomecare leads to cost savings. In this regard, the analysis is based on identifying costs and any Copyright HEC Montréal 10

16 additional gains (e.g., costs avoided) obtained following implementation of a telehomecare program. It is a pre/post comparison, where the pre situation serves as a benchmark for assessing the intervention s effectiveness. The economic analysis is therefore focused on assessing the costs associated with health service consumption before and after the intervention as well as the cost of operating the home telemonitoring program. This economic analysis was performed from a health system point of view. This means that costs incurred by patients were not considered. It is our view that such costs should not change the results of the economic assessment, since the costs associated with the technology used were assumed by the health facility and both intervention types (usual home care and telehomecare) took place in the home, so that the expenses incurred by the patient should be similar. Finally, it should be noted that the calculations were made in Canadian dollars. The cost incurred for nursing was calculated by multiplying the average hourly rate under the nurses collective agreement ($41.39/hour, including employee benefits) by the total time spent in home visits (time spent with patients). The travel cost takes into account the actual time spent by nurses on the road (in transit) and the reimbursement of the mileage travelled at the rate specified in the collective agreement: 43 per kilometre. The cost of hospitalizations and emergency room visits was estimated separately for each of the 95 patients. To this end, we obtained the average hospitalization costs (daily costs) in for each of the four chronic diseases included in this study (COPD = $363.17; congestive heart failure = $383.30; diabetes = $401.42; hypertension = $391.55) and the average cost of a visit to the emergency room in 2010: $ In order to have comparative data, we adjusted all the abovementioned costs associated with the post period to a 365-day period. The cost of operating the telehomecare program came to $394 per patient (the cost incurred for nurses). This is based on the fact that 10 hours per weekday and 1 hour per day on weekends were spent in patient telemonitoring, making telephone calls and coordinating and following up on interventions in the field with road nurses and other health professionals. Finally, the costs associated with the technology were estimated using the prices negotiated with the application s supplier amortized over a three-year period. These costs include the costs associated with purchasing and installing equipment in patient homes; purchasing, hosting and maintaining a regional server; purchasing and installing the user application; purchasing and installing the application server used by the case managers; preparing clinical protocols; and professional services (including the training of nurses and technical services and 2 These data were provided by the financial services at JR Health Centre. Copyright HEC Montréal 11

17 support). The total estimate for these costs was $45,220, representing $476 per patient (n=95). Table 5 provides detailed information on the costs calculated for each of the three periods. Table 5. Economic Analysis (costs per patient) PRE PER POST* PER + POST* t p Length of observation (average number of days) Home visits by nurses Average $201 $146 $198 $ Standard deviation $428 $314 $426 $686 Total $19,114 $13,862 $18,851 $32,713 Emergency room visits Average $151 $61 $39 $ Standard deviation $183 $130 $119 $242 Total $14,316 $5,821 $3,667 $9,488 Hospitalizations Average $3,489 $726 $243 $ Standard deviation $5,692 $2,184 $652 $3,051 Total $331,410 $68,976 $23,076 $92,052 Home telemonitoring costs Average -- $ $394 Standard deviation Total -- $37, $37,430 Technology deployment and use costs Average -- $ $476 Standard deviation Total -- $45, $45,220 Total costs Average $3,840 $1,803 $480 $2, Standard deviation $5,919 $2,994 $1,197 $3,380 Total $364,840 $171,309 $45,594 $216,903 * Adjusted for 244 days instead of 157 days to make comparisons on an annual basis. The above economic analysis provided positive results. For one thing, the telehomecare program (per period) cost a total of $171,309 representing an average cost of $1,803 per patient. Considering that patients participated in the home telemonitoring program for 157 days on average, the daily cost of the intervention per patient equals $ Using annualized data, the cumulated cost of the per and post periods is $216,903 or $147,937 less than the usual home care services program (pre period). This represents savings of $1,557 per patient (t=2.4; p<.05) or a net benefit of 41% compared to the usual patient monitoring program, whose operating cost was close to $365,000. Copyright HEC Montréal 12

18 The main source of savings under telehomecare stemmed from drastic reductions to the number of hospitalizations and the average hospital stay which fell from 15.2 days (pre) to 11.1 days (per) to 6.9 days (adjusted post). The cost of hospitalizations represented 91% of the total operating costs of the usual home care services program, compared to 40% of the total operating costs of the telehomecare program (per period). Although smaller in scale, additional savings were realized through fewer emergency room visits (t=1.8; p<.10). However, total savings were offset by increased hours of nursing during home visits. Although we expected fewer hours of nursing in the home after system deployment, the data show a significant increase compared to the pre period. According to the managers of the home care services program, this increase was in large part due to the case managers lack of experience with telemonitoring. At the start of the assessment period, the nurses participating in this project had no prior experience with telehomecare. They provided prompt responses to the system s automated alerts (signaling an abnormal situation or a problem) and went to the patient s home to personally check on the patient s condition. Lastly, as expected, the savings achieved through the telehomecare program were partly reduced by the costs associated with using the technology and the cost of the time that the nurses spent running the program. These costs totalled $82,650, or 48% of the home telemonitoring program s total costs (per period). DISCUSSION As mentioned earlier, few assessments have been made of the economics of home telemonitoring, and the quality of evidence has often been weakened by methodological flaws. The main objective of this study was therefore to conduct a rigorous and exhaustive economic assessment of a home telemonitoring program recently implemented by a Quebec health care facility. More specifically, we analyzed the consumption of health services by 95 patients with a variety of chronic diseases over a period of 21 months: 12 months before, 4 months during and 5 months after deployment of the telehomecare program. Despite the inherent limitations of this evaluative approach, including the absence of a control group, the omission to measure potential effects of the intervention on clinical outcomes such as quality of life, and the absence of marginal and sensitivity analyses, we firmly believe that our results are valid for several reasons. First, the estimates of costs come from reliable sources. Second, as recommended by Drummond et al. [19], our assessment compares costs with and without home telemonitoring. Third, all Copyright HEC Montréal 13

19 resources (human and technology) associated with the intervention program were identified and measured. Last, our assessment is based on a relatively long period of observation, that is, 21 months. Basically, our study reveals that the telehomecare program implemented at the JR Health Center resulted in significant savings, i.e. $1,557 per patient on an annualized basis, representing a net gain of 41%. As mentioned above, these savings were mainly due to a significant reduction in the number of hospitalizations and ER visits as well as shorter hospital stays, supporting the findings of previous studies [e.g., 20-22]. Importantly, we observed that these effects were more significant for heart failure and COPD patients. This finding, which also supports conclusions of prior systematic reviews [e.g., 10, 15, 17, 27], has major implications for policy makers and health care managers who must establish priorities in terms of chronic disease management programs and select patients who participate in these interventions. Lastly, the operating costs of the home telemonitoring program and the costs associated with the technology represented 38% of the home telemonitoring program s total costs. As an additional remark, case managers were asked to take note of each emergency room visit during the telehomecare period that may have been avoided due to an early intervention made possible by the technological device. In order to do so, they applied specific decision rules based on a set of clinical criteria. For example, for COPD the signs of exacerbation are increased shortness of breath, abundant secretions, changes in the color of secretions (yellow or greenish) and fever. An early intervention by the case manager would generally take the form of an adjustment to the patient s medication and advice for improved breathing. When the patient s health status improved following such an intervention, allowing him or her to continue living at home, this was recorded as an avoided emergency room visit. As another example, signs of exacerbation in diabetic hypoglycemia are: stomach ache, frequent urination, drowsiness, fatigue and intense thirst. In such cases, an early intervention by a case manager usually consists of adjusting the patient s medication or diet and giving other professional advice. Maintaining blood glucose levels between 4 and 7 mmol/l and attenuating signs and symptoms can result in avoidance of an emergency room visit. All in all, 75 emergency room visits were prevented over the 4-month period. These avoided visits involved 35 patients, most of whom were being treated for congestive heart failure or diabetes. CONCLUSION In conclusion, despite the positive and significant results found in this cost minimization study, future research will nevertheless be needed to confirm the cost effectiveness of home telemonitoring programs. We concur with Polinesa et al. [13] that in order to support informed decision making, these assessments will need to be conducted in a rigorous manner and take into account not only Copyright HEC Montréal 14

20 economic parameters, but also the improvements brought to the quality of care and clinical outcomes. Copyright HEC Montréal 15

21 REFERENCES [1] World Health Organization (2008). Home care in Europe. Document retrieved on June 29, 2012 from: data/assets/pdf_ file/0005/96467/ E91884.pdf. [2] Quebec Health & Social Services Ministry (2003). Chez soi : le premier choix. La politique de soutien à domicile. Document retrieved on June 29, 2012 from: [3] Canadian Home Care Association (2012). Home is best TM : developing an integrated primary and home & community care system. Document retrieved on June 29, 2012 from: [4] Canada Health Infoway (2011). Toward critical mass: moving from availability to adoption (title of annual report). Document retrieved on June 29, 2012 from: annual-reports. [5] Canada Health Infoway (2011). Telehealth benefits and adoption: connecting people and providers across Canada. Document retrieved on June 29, 2012 from: [6] Roine R, Ohinmaa A, & Hailey D. (2001). Assessing telemedicine: a systematic review of the literature. Canadian Medical Association Journal, 165(6), [7] Paré, G., Moqadem, K., Pineau, G. & St-Hilaire, C. (2010). Clinical effectiveness of home telemonitoring programs in the context of diabetes, asthma, heart failure and hypertension: a systematic review. Journal of Medical Internet Research, 12(2), e21. [8] Dang, S., Dimmick, S. & Kelkar, G. (2009). Evaluating the evidence base for the use of home telehealth remote monitoring in elderly with heart failure. Telemedicine and e-health, 15(8), [9] Polinesa, J., Tran, K., Cimon, K., Hutton, B., McGill, S. & Palmer, K. (2009). Home telehealth for diabetes management: a systematic review and meta-analysis. Diabetes, Obesity and Metabolism, 11, [10] Maric, B., Kaan, A., Ignaszewski, A. & Lear, S.A. (2009). A systematic review of telemonitoring technologies in heart failure. European Journal of Heart Failure, 11, [11] Clarke, M., Shah, A. & Sharma, U. (2011). Systematic review of studies on telemonitoring of patients with congestive heart failure: a meta-analysis. Journal of Telemedicine and Telecare, 17, [12] Seto, E. (2008). Cost comparison between telemonitoring and usual care of heart failure: a systematic review. Telemedicine and e-health, 14(7), [13] Polinesa, J., Coyle, D., Coyle, K. & McGill, S. (2009). Home telehealth for chronic disease management: a systematic review and an analysis of economic evaluations. International Journal of Technology Assessment in Health Care, 25(3), [14] Klersy, C., De Silvestri, A., Gabutti, G. et al. (2009). A meta-analysis of remote monitoring of heart failure patients. Journal of the American College of Cardiology, 54(18), [15] Polinesa, J., Tran, K., Cimon, K., Hutton, B., McGill, S. Palmer, K. & Scott, R.E. (2010). Home telemonitoring for congestive heart failure: a systematic review and meta-analysis. Journal of Telemedicine and Telecare, 16, Copyright HEC Montréal 16

22 [16] Polinesa, J., Tran, K., Cimon, K., Hutton, B., McGill, S. Palmer, K. & Scott, R.E. (2010). Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. Journal of Telemedicine and Telecare, 16, [17] Paré, G., Jaana, M. & Sicotte, C. (2007). Systematic review of home telemonitoring for chronic diseases: the evidence base. Journal of the American Medical Informatics Association, 14(3), [18] Miller, R.B. & Hollist, C.S. (2007). Attrition bias. In Encyclopedia of Measurement and Statistics (ed. N. Salkind), pp Thousand Oaks: Sage Reference. [19] Drummond M.F., O Brien B., Stoddart G.L. & Torrance, G.W. (1997). Methods for the economic evaluation of health care programmes. Second edition, Oxford Medical Publications. [20] Johnson, B., Wheeler, L. Deuser, J. & Sousa, K.H. (2000). Outcomes of the Kaiser Permanente telehome health research project. Archives of Family Medicine, 9 (Part 1), [21] Jerant, A.F., Azari, R. & Nesbitt, T.S. (2001). Reducing the cost of frequent hospital admissions for congestive heart failure. Medical Care, 39(11), [22] Lehmann, C.A., Mintz, N. & Giacini, J.M. (2006). Impact of telehealth on healthcare utilization by congestive heart failure patients. Disease Management & Health Outcomes, 14, [23] Louis, A.A., Turner, T., Gretton, M., Baksh, A. & Cleland, J.G.F. (2003). A systematic review of telemonitoring for the management of heart failure. The European Journal of Heart Failure, 5, [24] Martinez, A., Everss, E., Rojo-Alvarez, J.L. et al. (2006). A systematic review of the literature on home monitoring for patients with heart failure. Journal of Telemedicine and Telecare, 12, [25] Clark, R.A., Inglis, S.C., McAlister, F.A., Cleland, J.G.F. & Stewart. S. (2007). Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. British Medical Journal, 334, [26] Chaudry, S.I., Phillips, C.O., Stewart, S.S. et al. (2007). Telemonitoring for patients with chronic heart failure: a systematic review. Journal of Cardiac Failure, 13(1), [27] Inglis, S.C., Clark, R.A., McAlister, F.A., Stewart, S. & Cleland, J.G.F. (2011). Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: Abridged Cochrane Review. European Journal of Heart Failure, 13, [28] Giamouzis, G., Mastrogiannis, D., Koutrakis, K. et al. (2012). Telemonitoring in chronic heart failure: a systematic review. Cardiology Research and Practice, article ID , 7 pages. [29] Jaana, M., Paré, G. & Sicotte, C. (2007). Hypertension home telemonitoring: Current evidence and recommendations for future studies. Disease Management and Health Outcomes, 15(1), [30] AbuDagga, A., Resnick, H.E. & Alwan, M. (2010). Impact of blood pressure telemonitoring on hypertension outcomes: a literature review. Telemedicine and e-health, 16(7), [31] Omboni, S. & Guarda, A. (2011). Impact of home blood pressure telemonitoring and blood pressure control: a meta-analysis of randomized controlled studies. American Journal of Hypertension. 24(9), Copyright HEC Montréal 17

23 [32] Cox, N.S., Alison, J.A., Tshepo, R. & Holland, A.E. (2012). Telehealth in cystic fibrosis: a systematic review. Journal of Telemedicine and Telecare, 18, [33] Jaana, M., Paré, G. & Sicotte, C. (2009). Home telemonitoring for respiratory conditions: A systematic review. The American Journal of Managed Care, 15(5), [34] Bolton, C.E., Waters, C.S., Peirce, S & Elwyn, G. (2011). Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD. Journal of Evaluation in Clinical Practice, 17, [35] Barlow, J., Singh, D., Bayer, S. & Curry, R. (2007). A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions. Journal of Telemedicine and Telecare, 13, [36] Farmer, A., Gibson, O.J. & Neil, A. (2005). A systematic review of telemedicine interventions to support blood glucose self-monitoring in diabetes. Diabetes, 22, [37] Jaana, M. & Paré, G. (2007). Home telemonitoring of patients with diabetes: A systematic assessment of observed effects. Journal of Evaluation in Clinical Practice, 13(2), Copyright HEC Montréal 18

24 Supplementary Table 1. Empirical Evidence on the Cost-effectiveness of Home Telemonitoring Systematic review # of studies Main conclusions regarding economic evaluations Heart Failure Louis et al. [23] 24 Only five of the twenty-four studies assessed the cost benefit of telemonitoring. (p.588). [ ] In conclusion, telemonitoring might have an important role as part of a strategy for the delivery of effective health care for patients with heart failure but more evidence of efficacy is required before its widespread adoption can be recommended. Furthermore, analysis of existing studies and new large multicenter, randomized controlled trials are necessary to evaluate the potential benefits and cost-effectiveness of this evolving intervention. (p.589) Martinez et al. [24] 42 Nine out of the 42 studies assessed the economic impacts of home telemonitoring. The details of the cost calculations were not always described. The authors conclude that home telemonitoring produces significant hospital cost reductions, but the results are strongly dependent on the specific national health model. (p.239). Clark et al. [25] 5 None of the five studies assessed its impacts on healthcare costs. Chaudry et al. [26] 2 Although preliminary results suggest this approach [telemonitoring] may have value in improving outcomes, such strategies will have to be evaluated for cost-effectiveness. (p.62) Dang et al. [8] 9 The results are not strong and consistent with regard to impact on quality and cost. Data are scarce regarding effectiveness, even though there are suggestions that this population may benefit from telemonitoring. There are even fewer rigorous cost-effectiveness analyses and there are no available data on long-term effectiveness and sustainability of such programs. (p.794) Maric et al. [10] 56 Despite a large number of studies, this research is still in its infancy and larger, randomized trials are needed to thoroughly test efficacy. Accordingly, future research should focus [on] the feasibility and cost effectiveness of system wide implementation. (p.516) Inglis et al. [27] 13 Three of the 13 home telemonitoring studies provided details on cost of the intervention or cost reductions associated with the intervention or cost effectiveness. All three studies reported reductions in healthcare costs. Clarke et al. [11] 13 Six studies mentioned a cost-analysis of a telemonitoring intervention versus usual care but provided no breakdown about how the overall cost was estimated. Four of these concluded that costs were reduced in the intervention group, and two studies found no significant difference between the two groups. (p.12) Giamouzis et al. [28] 12 Three studies investigated the cost of hospitalization calculated per patient. One study found statistically significant cost reduction in the telemonitoring group compared to the usual care group. In the second study, there was a 12% reduction in the telemonitoring group (statistically non significant). In contrast, the third study reported increased costs associated with the telemonitoring group (statistically non significant). Hypertension Jaana et al. [29] 14 Little information was available on the cost effectiveness of hypertension telemonitoring and its economic viability. Three studies reported the cost of the intervention/system per patient over a specific time period. (p.27). Only one study presented a detailed costeffectiveness analysis. On this basis, the authors conclude that we know little about the economic viability of this patient management approach. Copyright HEC Montréal 19

25 Systematic review # of studies Main conclusions regarding economic evaluations Hypertension (cont d) AbuDagga et al. [30] Omboni and Guarda [31] 15 Few studies included economic measures of the impact of telemonitoring, such as healthcare utilization and cost. [ ] The few cost measures used were simple, such as the direct cost of the technology per person. (p. 836) 12 We were unable to examine two additional important issues related to home blood pressure telemonitoring, namely its impact on patient s quality of life and the ratio between the clinical benefits and costs of telemedicine. Unfortunately, such information was available from only a couple of studies. (p. 996) Cystic fibrosis Cox et al. [32] 8 None of the included studies considered the cost-benefits of telehealth [which is an area] where research is needed. (p.78) Pulmonary diseases Jaana et al. [33] 23 Except for 3 studies, no detailed cost analysis was performed to estimate the actual savings associated with the use of this approach. To advocate the use of home telemonitoring as a patient management approach and to incorporate it into practice, it is critical to have evidence indicating its economic viability and benefits. (p.319) Bolton et al. [34] 6 Future trials involving telemonitoring for COPD need to have improved designs and more attention to [ ] and economic analyses. (p.1221) Multiple chronic conditions Paré et al. [17] 65 Last, evidence on the economic viability of telemonitoring as a patient management approach was scarce across all four categories of chronic illnesses. Among the studies examining patients with pulmonary conditions, only one presented a detailed and comprehensive cost minimization analysis of the telemonitoring program in question. There was no empirical evidence presented in diabetes, cardiac, and hypertension telemonitoring projects that could allow firm conclusions regarding the cost of this patient management approach and its economic viability as compared to usual patient care. (p.273) Barlow et al. [35] 34 Based on the evidence reviewed, the most effective telecare interventions appear to be automated vital signs monitoring (for reducing health service use) and telephone follow-up by nurses. The cost-effectiveness of these interventions was less certain. (p.172) Diabetes Farmer et al. [36] 26 Two RCTs looked at the clinician costs and tow at patient costs. (p.1377) Jaana and Paré [37] 17 No cost-benefit and cost-effectiveness analyses were reported. Copyright HEC Montréal 20