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Table 5 Telemedicine

From: A scoping review of initiatives to reduce inappropriate or non-beneficial hospital admissions and bed days in people nearing the end of their life: much innovation, but limited supporting evidence

Author, date and journal Study design Sample and setting Research focus Relevant results Wider implications Limitations
Hex et al.; 2018; Economic analysis of care homes: New Models of Care Vanguard [36] Longitudinal cohort study. 141 care homes that had a telemedicine programme were compared with 25 control care homes in the north of England. To quantify the economic benefits generated by a telemedicine programme 1 year after implementation. Emergency department admissions decreased in the care homes using telemedicine by 4% and increased in the control homes by 7%. Of the intervention homes, nursing homes saw a 13% decrease in emergency admission and residential homes saw a 6% increase. Low intervention home usage was associated with a 17% reduction in emergency admissions, whilst high usage of homes was associated with a 10% increase. The findings were not statistically significant and can only be taken at face value. Limited control group.
Extensive data cleaning was needed to produce useable data.
The intervention was rolled out over time so there was no universal start date.
Grabowski et al.; 2014; Health Affairs [37] Prospective observational study. A chain of care homes in Massachusetts introduced telemedicine in 11 homes, covering weekday evenings and weekends. To establish whether the lack of a physician’s presence at homes out of hours might contribute to inappropriate hospitalisations and whether switching to an on-call telemedicine physician could reduce inappropriate hospital admissions. Both intervention and control groups saw a decline in hospitalisations, of 9.7 and 5.3%, respectively.
When looking at more and less engaged homes, a significant decline in hospitalisations (11.3%) was found at more engaged care homes.
The findings suggest that nursing homes fully engaged in out-of-hours telemedicine could see a reduction in hospitalisations. Small sample.
Lustbader et al.; 2017; Journal of Palliative Medicine [39] Quantitative, retrospective, comparative analysis . 82 US Medicare Shared Savings Program accountable care organisation deceased patients compared with 596 patients receiving usual care between October 2014 and March 2016. To evaluate the impact of a home-based palliative care programme within an accountable care organisation on cost and resource utilisation during the final 3 months of life. A 34% reduction in hospital admissions during the final month of life was observed in hospital-based palliative care-enrolled patients.
Hospital-based palliative care was also linked with a reduction in emergency department visits per 1000 patients compared with standard care (878 vs. 1097).
Hospital-based palliative care in an accountable care organisation is linked with significant cost savings and fewer hospital admissions. Did not test for the individual benefits or drawbacks of a 24/7 telephone line in this setting.
Hoek et al.; 2017; BMC Medicine [57] Two-armed, non-blinded randomised control trial. 74 Dutch home-dwelling palliative care cancer patients between May 2011 and January 2015. Patients were randomised to either an intervention group that received weekly teleconsultations or a control group that received standard care for 12 weeks. To determine the effects of weekly teleconsultations on hospital admissions for palliative patients (secondary objective). The was no significant difference in mean hospital admissions between the intervention and control groups (0.47 vs. 0.38, p = 0.60). Suggests that weekly teleconsultations do not reduce hospital admissions for palliative patients. Some patients eligible for the trial were not approached due to clinical considerations, which may have caused selection bias.
High attrition rate.
Bakitas el; 2015; Journal of Clinical Oncology [58] Two arm randomised study 207 patients with advanced cancer attending a National Cancer Institute Center, a Veterans Affairs Medical Centre and community outreach clinics were randomly assigned to early or late intervention. Intervention included an in-person palliative care consultation, telehealth nurse coaching sessions and monthly follow-up.
Outcomes were quality of life, symptom impact, mood, one-year survival and resource use (hospital/intensive care days, emergency room visits and death location.
Overall patient-reported outcomes were not statistically significant after enrolment or before death. Kaplan-Meier one-year survival rates were 63% in the early group and 48% in the delayed group (p = 0.038). Relative rates of early to delayed decedents’ resource use were similar for hospital days, intensive care days, emergency room visits and home deaths. Early-entry participants’ patient-reported outcomes and resource use were not statistically different; however, their survival 1 year after enrolment was improved compared with those who began 3 months later Heterogeneity and differences in unmeasured characteristics could limit practical application. Results reflect a New England population. Half of patients in the delayed group were referred for palliative care consultation ahead of time. Not all patients completed all interventions.