Problematiche gestionali
della Telemedicina
Literature Review:
rapporto costo/beneficio
Alfredo Potena
U.O. di Fisiopatologia Respiratoria
Azienda Ospedaliera Universitaria Arcispedale S.Anna
Ferrara
Telemedicina
• L’impiego di telemedicina al fine di migliorare le prestazioni
sanitarie potrebbe rivelarsi particolarmente utile in zone ove
sia carente la disponibilità di personale medico
• Nella sanità pubblica c’è una forte richiesta di servizi di
telemedicina anche se, in molte specialità, i costi ed i
benefici rappresentano ancora oggi un’area grigia
• Tra i principali difetti della medicina occorre annoverare la
tendenza ad impiegare metodiche prima che ne sia stata
stabilita con certezza non soltanto la sua utilità, ma anche il
rapporto costo/beneficio
Perceptions of the most important benefit of
Telemedicine
S. Martin CMAJ 2001
Representative Sample of 2592 Canadians
The greatest concern was about responsibility and liability for malpractice and
errors with 87.7 % indicating that they were very or somewhat concerned
Quali risorse sono necessarie?
Quanto Costa?
Qual è il rapporto costo/efficacia?
Measure of Effectiveness
• L’Effectiveness si misura in termini di “successo della visita
o della prestazione” e l’ “utilità di queste per il paziente”
• Una visita o una prestazione hanno successo quando
permettono di conseguire una diagnosi senza bisogno di
una seconda opinione
Costi annuali (diretti & indiretti)
Effectiveness
“successo della visita o della prestazione” x
“utilità di queste per il paziente”
La telemedicina ha una sua effectiveness
basata su evidenze scientifiche?
Assessing telemedicine: a systematic
review of the literature
Risto Roine CMAJ 2001
• 1124 studies were identified, 133 full-text articles were
obtained for closer inspection, 50 were deemed to represent
assessment studies fulfilling the inclusion criteria of the review
• Thirty-four of the articles assessed at least some clinical
outcomes; the remaining 16 were mainly economic analyses
• Relatively convincing evidence of effectiveness was found only
for teleradiology, teleneurosurgery, telepsychiatry, transmission
of echocardiographic images, and the use of electronic referrals
enabling email consultations and video conferencing between
primary and secondary health care providers
• Evidence regarding the effectiveness or cost-effectiveness of
telemedicine is still limited
Systematic review of cost effectiveness
studies of telemedicine interventions
PS Whitten BMJ 2002
• A comprehensive literature search of cost related articles on
telemedicine identified more than 600 articles, but only 9%
contained any cost benefit data
• Only 4% of these articles met quality criteria justifying inclusion
in a formalised quality review, and most of these were small
scale, short term, pragmatic evaluations with few generalisable
conclusions
• There is little published evidence to confirm whether or not
telemedicine is a cost effective alternative to standard
healthcare delivery
Ricerca effettuata il 27.10.2004
Hospital at home for AECOPD
Ram The Cochrane Database of Systematic Reviews 2003
• Objectives: To evaluate the efficacy of "hospital at home"
compared to hospital inpatient care in AECOPD
• Seven studies with 754 patients were included in the review
• Studies provided data on hospital readmission and mortality
both of which were not significantly different when the two
study groups were compared
Hospital at home for AECOPD
Ram The Cochrane Database of Systematic Reviews 2003
• one in four carefully selected patients presenting to
hospital emergency departments with AECOPD can be
safely and successfully treated at home with support
from respiratory nurses
• This review found no evidence of significant differences
between "hospital at home" patients and hospital
inpatients for readmission rates and mortality at two to
three months after the initial exacerbation
• Both the patients and carers preferred "hospital at
home" schemes to inpatient care.
Telemedicine versus face to face patient
care: effects on professional practice and
health care outcomes
R Currell The Cochrane Database of Systematic Reviews 2000
• Establishing systems for patient care using telecommunications technologies is feasible, but there is little evidence of
clinical benefits
• The studies provided variable and inconclusive results for
other outcomes such as psychological measures, and no
analysable data about the cost effectiveness of telemedicine
systems
• The review demonstrates the need for further research and
the fact that it is feasible to carry out randomised trials of
telemedicine applications
• Policy makers should be cautious about recommending
increased use and investment in unevaluated technologies
Cost Effectiveness of Telemedicine for the
Delivery of Outpatient Pulmonary Care to a
Z. Agha Telemedicine J and E-Health 2002
Rural Population
Case series: 65 patients (99 visits)
AIM: to compare the cost/effectiveness
of providing outpatient telemedicine
pulmonary consultations with
alternative treatment methods
1200
1000
800
600
Cost effectiveness of telemedicine is related
400
to three major factors:
1) cost sharing, i.e., adequate patient volume200
and sharing of telemedicine infrastructure
0
amongst various clinical users;
2) effectiveness of telemedicine in terms of
patient utility and successful clinical
consultations;
3) indirect cost savings accrued by
decreasing cost of patients' lost productivity
$ per Patient/Year
Telemedicine
Routine Care
On-site care
Telecare of patients with COPD
M. Pfeifer Med Klin 2004
Regular transmissions of lung function values insure a close
contact of COPD or asthma patients to specialized
institutions without impairing or ignoring medical home care
Whether it will be possible to react more quickly to disease
changes by telemetric means or whether other treatment
advantages will result remains yet to be seen
Results, so far, are encouraging in such a way that the use of
telemedical means in chronically ill patients will be further
evaluated
A feasibility study of remote monitoring of
asthmatic patients
Steel J. Telemed Telecare2002
• Multi Center Study – Aim: to assess a remote monitoring
system for asthmatics to use in their own homes
following discharges after acute exacerbation
• Patients: 84 invited to participate
33 monitored for two weeks
• Patient compliance with monitoring was 80%
compliance with transmitting the results using a
modem was 52%
A feasibility study of remote monitoring of
asthmatic patients
Steel J. Telemed Telecare2002
• time spent teaching patients for measurements was 16 min
• time spent providing asthma education was
39 min
• 96 % of pts found the equipment easy or very easy to use
• 92% of pts said they would use the equipment again
• medical intervention occurred in 48% of patients
THE USE OF REMOTE MONITORING COULD BE IMPORTANT IN REDUCING
ASTHMA MORBIDITY AND IMPROVING
TREATMENT OUTCOMES
Telemedicine for multidisciplinary lung
cancer meetings
A.G. Davison J Telemed Telecare 2004
Lung cancer cases should be reviewed prospectively by a lung cancer
multidisciplinary team (MDT) and a thoracic surgeon should be readily
available to liaise with the MDT
Over a one-year period, 28 MDT meetings were held at a district general
hospital in Southend, at which 62 patients were presented to a tertiary
cardiothoracic centre in London, 80 km away, via ISDN videoconferencing at
384 kbit/s
The annual resection rate increased by 30% following the introduction of the
telemedicine MDTmeetings, and the mean time from first being seen in the
clinic to surgery was reduced from 69 to 54 days
We estimate that the telemedicine meetings saved over three working weeks of
thoracic surgical time during the year.
R Roine CMAJ 2001
PS Whitten BMJ 2002
Z. Agha Pulmonary Dis 2002
Steel 2002 (Asthma)
Currell Cochrane Rev 2000
Pfeifer 2004 (COPD)
Davison 2004 (Cancer)
BPCO
I.R.
Asma
Neoplasie
Conclusioni
La telemedicina applicata alla
Pneumologia può essere C/E
E’ necessario programmare studi
clinici (RCT) che lo dimostrino
BPCO con IRC, Asma Bronchiale,
Neoplasie polmonari sono le
patologie su cui concentrare gli studi
E’ auspicabile lo sviluppo di joint
venture tra AIPO Industria della
Telemedicina ed associazioni dei
pazienti per realizzare i progetti di
studio