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Invited Commentary
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May 28, 2012

Another Sobering Result for Home Telehealth—and Where We Might Go NextComment on “A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits”

Author Affiliations

Author Affiliations: Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine (Drs Wilson and Cram), and Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center (Dr Cram), Iowa City.

Arch Intern Med. 2012;172(10):779-780. doi:10.1001/archinternmed.2012.685

Rapid advances in technology combined with increasing demand for interventions that can “bend the cost curve” have stoked widespread interest in telehealth technologies. Telehealth has been broadly defined as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration.”1 In this issue of the Archives, Takahashi et al2 report on the results of a rigorous randomized controlled trial of telemonitoring in older adults at high risk for hospitalization. They found that in-home monitoring of biometrics (eg, blood pressure and weight) and symptoms failed to reduce hospital readmissions or the need for emergency department (ED) visits compared with usual care.

The results of this study are important and sobering and warrant careful consideration. It might be tempting to discount the lack of benefit of the telehealth intervention for any number of reasons. For example, it might be possible that the lack of effect in the telehealth intervention compared with usual care was a consequence of the fact that usual care was already outstanding because the comparator group was already receiving care from a top-tier integrated delivery system (Mayo Clinic, Rochester, Minnesota). Alternatively, it is possible that telehealth is not beneficial among the (presumed) highly educated and affluent residents of Olmsted County, Minnesota, because such patients already are highly activated and engaged in their own health care at baseline.

We would caution against such discounting of this study and its negative findings. In contrast, we would argue that this study joins a growing body of literature suggesting that home telehealth does not reduce readmissions or ED visits.3 Most, but not all, of these studies have focused on patients with congestive heart failure, which adds to the importance of the study by Takahashi et al.2 In a 2010 study in The New England Journal of Medicine, Chaudhry et al4 found that telemonitoring failed to reduce mortality or hospital readmission for patients with congestive heart failure. A 2011 study published in Circulation by Koehler and colleagues5 reached similar conclusions. Studies6,7 focusing on other applications of telehealth (eg, disease management and tele–intensive care unit monitoring) have demonstrated similarly negative and mixed results.

The somewhat underwhelming results aside, the accumulating evidence should not necessarily be taken as a blanket indictment of a potentially useful technology. In particular, it is likely that telehealth may be effective at influencing the right outcomes in the right context.8

We begin by briefly discussing contextual factors that may influence telehealth program effectiveness. It seems logical that the effectiveness of telehealth programs would be mediated by an array of patient, physician, and larger health system factors, as well as by factors related to the details of the implementation of the telehealth program. For example, it seems probable that not all patients are equally likely to benefit from home telehealth monitoring. Yet, at the present time, there is little empirical research to guide us as to which patients we should encourage to sign up for telehealth monitoring. Similarly, there are certain key details related to how a telehealth program is organized, what technology is used, which staff should be hired, and how they are trained that would influence telehealth effectiveness. For example, if the objective was to reduce hospital admissions and ED visits, one could envision training telehealth team nurses to manage patients at home unless a patient's medical condition necessitated clinic or hospital evaluation. Alternatively, one could envision the same program training the telehealth nurses to instruct patients to go to the ED immediately at the earliest symptoms. It seems almost certain that these subtle differences in strategy and training of telehealth providers would have major influences on study results, but these sorts of details are often difficult to describe adequately within the constraints of published articles.9,10

It is also important to think about the metrics used to evaluate telehealth programs. The study by Takahashi et al2 focused specifically on ED visits and inpatient hospitalizations as the relevant outcomes and did not examine an array of other outcomes, including health care spending, outpatient clinic visits, or patient satisfaction, quality of life, or anxiety. In actuality, there is a growing array of studies whose results suggest that home telehealth may help in many of these areas. In a related article, Pecina et al11 reported on the qualitative portion of this topic and found that patients rated home telemonitoring favorably. Gellis et al12 recently reported that home telehealth monitoring had statistically and clinically significant effects on patient satisfaction, depression, and health-related quality of life in a group of older adults with congestive heart failure or chronic obstructive pulmonary disease.

In conclusion, Takahashi et al2 provide further evidence that home telehealth programs do not reduce ED visits or hospital readmissions, this time among a fairly generalizable population of vulnerable older adults. We believe there are 2 principal lessons to be drawn from this well-performed study. First, we need a better understanding of the critical patient, physician, health system, and telehealth program factors that predict success and that would allow us to target these interventions to patients who are most likely to see benefit. Second, there should be careful thought given to the appropriate outcomes that telehealth programs aim to effect. While awaiting the answers to these questions, we would advise payers and physicians to move slowly in implementing telehealth programs on a wide scale.

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Article Information

Correspondence: Dr Cram, Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Dr, 6GH SE, Room 611, Iowa City, IA 52240 (peter-cram@uiowa.edu).

Published Online: April 16, 2012. doi:10.1001/archinternmed.2012.685

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant R01 HL085347 from the National Heart, Lung and Blood Institute and by grant R01 AG 33035 from the National Institute on Aging (Dr Cram).

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

References
1.
Health Resources and Services Administration, US Department of Health and Human Services.  Telehealth. http://www.hrsa.gov/ruralhealth/about/telehealth. Accessed February 13, 2012
2.
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3.
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9.
Takahashi PY, Hanson GJ, Pecina JL,  et al.  A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study. BMC Health Serv Res. 2010;10:e255. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939600/?tool=pubmed. Accessed February 13, 2012
10.
Chaudhry SI, Barton B, Mattera J, Spertus J, Krumholz HM. Randomized trial of Telemonitoring to Improve Heart Failure Outcomes (Tele-HF): study design.  J Card Fail. 2007;13(9):709-714PubMedArticle
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