Adam Steventon: Evaluating the Whole System Demonstrator trial

1. © Nuffield TrustJune 22, 2012
Adam Steventon: Evaluating the Whole
System Demonstrator trial
Authors:
Adam Steventon, Martin Bardsley
Nuffield Trust

2. © Nuffield Trust
What is telehealth?
“the remote exchange of data between a patient
and health care professionals as part of the
diagnosis and management of health care
conditions”
Telehealth devices enable items such as blood
glucose level and weight to be measured by the
patient and transmitted to health care professionals
working remotely.
ImageisthecopyrightofTunstallGroupLtd
© Nuffield Trust

3. © Nuffield Trust
Three whole system demonstrators
• The poorest county in England, with a
dispersed rural population
• Population of >500,000
• 46% of the population live in settlements of
<3,000 people
• 99.1% White British
• 10.3% of the population are aged 65+;
7.2% 75+ and 2.6% 85+
• 21% of the population report a limiting
long-term illness
CORNWALL
• One of the most deprived areas in the UK
• Population of 270,442 - GP registered
population of 300,000
• Population increasing at a higher rate than
the London average
• 2nd most diverse population in the UK -
>68% black and minority ethnic (BME) >140
first languages
• 8.5% of the population are aged 65+
• 17.3% of the population have a limiting long-
term illness
• Highest death rate from stroke and COPD
• Highest diabetes rate in the UK
• 2nd highest CHD rate in London
NEWHAM
• Combination of rural and urban populations
• Population of 1.37m (excluding Medway
Unitary Authority). Two areas already piloting
telehealth: Ashford/Shepway (population:
211,100) and Dartford/Gravesham/Swanley
(population: 210,00)
• 3.5% BME
• 17.3% of the population are aged 65+
8.4% 75+ and 2.2% 85+
• Within the target population, individuals
report having an average of 1.6 of the three
target conditions of heart failure, COPD,
diabetes
KENT

4. © Nuffield Trust
Trial design

5. © Nuffield Trust
Long-term conditions of intervention participants

6. © Nuffield Trust
Multi-dimensional evaluation
Theme 1
(Nuffield Trust)
Impact of service
use and
associated costs
for the NHS and
social services
All 3,000 people
Theme 2
(City & Oxford)
Participant
reported
outcomes
Subset of people
plus their
informal carers
Theme 3
(LSE)
Costs and cost-
effectiveness
Subset of people
Theme 4
(Manchester
& Oxford)
Experiences of
service users,
informal carers
and
professionals
Qualitative
interviews
Theme 5
(Imperial)
Organisational
factors and
sustainable
adoption and
integration
Qualitative
interviews

7. Information flows for this analysis

8. © Nuffield Trust
Predictive risk scores

9. © Nuffield Trust
Crude (unadjusted) trends in emergency hospital admissions

10. © Nuffield Trust
Primary measure: Proportion of patients admitted
to hospital in twelve months of trial
Control Intervention Absolute
difference
Relative
difference
Proportion of patients
admitted to hospital in 12
months (%)
48.2 42.9 -5.2 -10.8
Endpoint Interpretation Model Estimate [95%
confidence
interval]
p value
Admission proportion Odds ratio
Unadjusted
0.82
[0.70 to 0.97] 0.017
Adjusted
0.82
[0.69 to 0.98] 0.026
Combined Model
adjusted
0.82
[0.69 to 0.96] 0.016

11. © Nuffield Trust
Differences in secondary measures
Control Intervention Absolute
difference
Relative
difference
Mortality (%) 8.3 4.6 -3.7 -44.5%
Emergency admissions per head 0.68 0.54 -0.14 -20.6%
Elective admissions per head 0.49 0.42 -0.07 -14.3%
Outpatient attendances per head 4.68 4.76 0.08 1.7%
Accident and Emergency visits per head 0.75 0.64 -0.11 -14.7%
Bed days per head 5.68 4.87 -0.81 -14.3%
Tariff costs (£) 2,448 2,260 188 -7.7%
= statistically significantKey:

12. © Nuffield Trust
Key findings
• Compared to controls, a smaller proportion of intervention patients were
admitted to hospital.
• Intervention patients had fewer emergency admissions, deaths and hospital
bed days.
• Tariff hospital costs £188 per head lower in intervention group – but this did not
reach statistical significance. (Cost of intervention not included in these
figures).
• Some reasons for caution:
• Theoretical possibility of differences in characteristics of intervention and
control patients
• Differences in emergency hospital admissions were from a low base
• Increases in emergency admissions for controls

13. © Nuffield Trust
Multi-dimensional evaluation
Theme 1
(Nuffield Trust)
Impact of service
use and
associated costs
for the NHS and
social services
All 3,000 people
Theme 2
(City & Oxford)
Participant
reported
outcomes
Subset of people
plus their
informal carers
Theme 3
(LSE)
Costs and cost-
effectiveness
Subset of people
Theme 4
(Manchester
& Oxford)
Experiences of
service users,
informal carers
and
professionals
Qualitative
interviews
Theme 5
(Imperial)
Organisational
factors and
sustainable
adoption and
integration
Qualitative
interviews

14. © Nuffield TrustJune 22, 2012
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© Nuffield Trust
adam.steventon@nuffieldtrust.org.uk