Page 9 Effect of telehealth on quality of life and psychological out comes over 12 months
P. 9
BMJ 2013;346:f653 doi: 10.1136/bmj.f653 (Published 26 February 2013) Page 9 of 20
RESEARCH
intensive interventions for select clinical populations at high We thank Alan Glanz (Department of Health) and Chris Ham (The King’s
risk. Fund) for their support throughout the study; all the individual participants
The parent trial was set in the context of Whole Systems for their time and interest in the study; and all the managers and
Redesign, and the three WSD sites were selected on the basis professionals in Cornwall, Kent, and Newham in the health and social
of having achieved substantial integration of health and social services and in the participating case study organisations for their help.
care. Assuming that this integration improves outcomes, the Whole System Demonstrator evaluation team members: Stanton P
trial sought to identify any added benefit of telehealth services Newman (principal investigator), Martin Bardsley (The Nuffield Trust),
beyond those accrued from enhanced integration. In contexts James Barlow (Imperial College London), Jennifer Beecham (London
with less integrated health and social care, telehealth benefits School of Economics), Michelle Beynon (City University
may be more likely to emerge. This argument assumes that London/University College London), John Billings (The Nuffield Trust),
integrated health and social care generates ceiling or floor effects Andy Bowen (University of Manchester), Pete Bower (University of
for health related QoL, anxiety, and depressive symptoms. Manchester), Martin Cartwright (City University London/University
However, the baseline means show that our sample had similar College London), Theopisti Chrysanthaki (Imperial College London),
88
health related QoL to other comparable clinical samples with Jennifer Dixon (The Nuffield Trust), Helen Doll (University of East
scope for either improvement or deterioration (figs 4 and 5). It Anglia), Jose-Luis Fernandez (London School of Economics), Ray
is therefore unlikely that the lack of observed telehealth benefits Fitzpatrick (Oxford University), Catherine Henderson (London School
can be attributed to the integrated care context or to recruitment of Economics), Jane Hendy (Imperial College London), Shashivadan
of atypical clinical samples. P Hirani (City University London/University College London), Martin
Knapp (London School of Economics), Virginia MacNeill (Oxford
Should we expect telehealth to improve health University), Lorna Rixon (City University London/University College
related QoL or psychological outcomes? London), Anne Rogers (University of Southampton), Caroline Sanders
If telehealth delivers tailored healthcare that is acceptable to (University of Manchester), Luis A Silva (City University
London/University College London), Adam Steventon (The Nuffield
patients and facilitates more responsive interventions from Trust).
professionals, resulting in better disease control with fewer
exacerbations and admissions, we might expect corresponding Contributors: MC and SPH are joint first authors. MC, SH, LR, and MBe
improvements in health related QoL and psychological outcomes conducted preliminary analyses under HD’s supervision. MC conducted
over time. Similarly, if telehealth leads to improved self care the final analyses and drafted the manuscript. HD, PB, MBa, MK, CH,
behaviour and efficacy, we might expect increases in health AR, CS, RF, JB, SH, and SN contributed to development of the overall
related QoL and reductions in negative affect. It remains unclear WSD study protocol. SN is the principal investigator for the WSD
whether improvements in these patient reported outcomes are Evaluation. HD is the trial statistician and guarantor of statistical quality
driven primarily by objective improvements in physical health, for the WSD Evaluation. MC, SH, LR, MBe, and SN contributed to the
or by subjective improvements in perceptions of agency or planning of the questionnaire data collection; MC, SH, LR, and MBe
control. Alternatively, telehealth could reduce health related coordinated the daily implementation of the questionnaire assessment
QoL and psychological wellbeing owing to the increased burden protocol and maintained trial data. HD, SH, MC, LR, MBe, AS, and CH
of self monitoring, concerns about intrusive surveillance, a contributed to planning of the analyses. All the authors reviewed the
perceived lack of user friendliness, or the undermining of the manuscript. The evaluation team met regularly during the trial period,
traditional (face-to-face) therapeutic relationship. More research reviewed interim documents and preliminary analyses, and contributed
is required to understand the many potential beneficial and as a whole to discussions of the analytical strategy.
harmful mechanisms by which telehealth could affect patient Funding: This is an independent report commissioned and funded by
reported outcomes. However, our findings strongly suggest no the Policy Research Programme in the UK Department of Health.
net benefit from telehealth; therefore, it should not be used as Competing interests: All authors have completed the ICMJE uniform
a tool to improve health related QoL or psychological outcomes. disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support
from the Department of Health and the University College London
Future directions Hospitals and University College London; several authors have
The current findings point to other avenues of enquiry. Planned undertaken evaluative work funded by government or public agencies
subgroup analyses for chronic obstructive pulmonary disease, but these have not created competing interests; no financial relationships
diabetes, and heart failure using disease specific outcomes of with any organisations that might have an interest in the submitted work
health related QoL represent the next step in this process. in the previous three years; no other relationships or activities that could
Alternative measures of health gain (such as self care, perceived appear to have influenced the submitted work.
impact of illness, and activities of daily living) are available for Ethical approval: The study was approved by Liverpool research ethics
participants in the WSD telehealth questionnaire study and may committee (ref 08/H1005/4).
offer a different perspective on the potential effect of telehealth. Data sharing: No additional data available.
Effects of telehealth might not be uniform across all patients,
and analyses may suggest subgroups of patients for whom 1 Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: the challenges
telehealth is either particularly beneficial or harmful. 2 ahead. Lancet 2009;374:1196-208.
Office for National Statistics. The interactive population pyramid. 2011. www.
Building on existing qualitative work from the WSD 3 neighbourhood.statistics.gov.uk/HTMLDocs/dvc1/UKPyramid.html.
Spillman BC, Lubitz J. The effect of longevity on spending for acute and long-term care.
89
Evaluation and the data in web figure 2, we aim to identify N Engl J Med 2000;342:1409-15.
predictors of early removal of telehealth. Quantitative analyses 4 Robine J-M, Romieu I, Michel J. Trends in health expectancies. In: Robine J-M, Jagger
C, Mathers C, Crimmins EM, Suzman R, eds. Determining health expectancies. John
will also explore intervention participants’ and carers’ Wiley and Sons, 2003:75-104.
perceptions of telehealth over the course of the study, and ask 5 Doblhammer G, Kytir J. Compression or expansion of morbidity? Trends in healthy-life
expectancy in the elderly Austrian population between 1978 and 1998. Soc Sci Med
whether these perceptions moderate outcomes. Other research 2001;52:385-91.
questions in the WSD Evaluation are identified in the protocol 6 Rice DP. Economic implications of increased longevity in the United States. Annu Rev
paper. 18 7 Public Health 2004;25:457-73.
Department of Health. Our health, our care, our say: A new direction for community
services. 2006. www.official-documents.gov.uk/document/cm67/6737/6737.pdf.
8 McLean S, Protti D, Sheikh A. Telehealthcare for long term conditions. BMJ 2011;342:d120.
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
RESEARCH
intensive interventions for select clinical populations at high We thank Alan Glanz (Department of Health) and Chris Ham (The King’s
risk. Fund) for their support throughout the study; all the individual participants
The parent trial was set in the context of Whole Systems for their time and interest in the study; and all the managers and
Redesign, and the three WSD sites were selected on the basis professionals in Cornwall, Kent, and Newham in the health and social
of having achieved substantial integration of health and social services and in the participating case study organisations for their help.
care. Assuming that this integration improves outcomes, the Whole System Demonstrator evaluation team members: Stanton P
trial sought to identify any added benefit of telehealth services Newman (principal investigator), Martin Bardsley (The Nuffield Trust),
beyond those accrued from enhanced integration. In contexts James Barlow (Imperial College London), Jennifer Beecham (London
with less integrated health and social care, telehealth benefits School of Economics), Michelle Beynon (City University
may be more likely to emerge. This argument assumes that London/University College London), John Billings (The Nuffield Trust),
integrated health and social care generates ceiling or floor effects Andy Bowen (University of Manchester), Pete Bower (University of
for health related QoL, anxiety, and depressive symptoms. Manchester), Martin Cartwright (City University London/University
However, the baseline means show that our sample had similar College London), Theopisti Chrysanthaki (Imperial College London),
88
health related QoL to other comparable clinical samples with Jennifer Dixon (The Nuffield Trust), Helen Doll (University of East
scope for either improvement or deterioration (figs 4 and 5). It Anglia), Jose-Luis Fernandez (London School of Economics), Ray
is therefore unlikely that the lack of observed telehealth benefits Fitzpatrick (Oxford University), Catherine Henderson (London School
can be attributed to the integrated care context or to recruitment of Economics), Jane Hendy (Imperial College London), Shashivadan
of atypical clinical samples. P Hirani (City University London/University College London), Martin
Knapp (London School of Economics), Virginia MacNeill (Oxford
Should we expect telehealth to improve health University), Lorna Rixon (City University London/University College
related QoL or psychological outcomes? London), Anne Rogers (University of Southampton), Caroline Sanders
If telehealth delivers tailored healthcare that is acceptable to (University of Manchester), Luis A Silva (City University
London/University College London), Adam Steventon (The Nuffield
patients and facilitates more responsive interventions from Trust).
professionals, resulting in better disease control with fewer
exacerbations and admissions, we might expect corresponding Contributors: MC and SPH are joint first authors. MC, SH, LR, and MBe
improvements in health related QoL and psychological outcomes conducted preliminary analyses under HD’s supervision. MC conducted
over time. Similarly, if telehealth leads to improved self care the final analyses and drafted the manuscript. HD, PB, MBa, MK, CH,
behaviour and efficacy, we might expect increases in health AR, CS, RF, JB, SH, and SN contributed to development of the overall
related QoL and reductions in negative affect. It remains unclear WSD study protocol. SN is the principal investigator for the WSD
whether improvements in these patient reported outcomes are Evaluation. HD is the trial statistician and guarantor of statistical quality
driven primarily by objective improvements in physical health, for the WSD Evaluation. MC, SH, LR, MBe, and SN contributed to the
or by subjective improvements in perceptions of agency or planning of the questionnaire data collection; MC, SH, LR, and MBe
control. Alternatively, telehealth could reduce health related coordinated the daily implementation of the questionnaire assessment
QoL and psychological wellbeing owing to the increased burden protocol and maintained trial data. HD, SH, MC, LR, MBe, AS, and CH
of self monitoring, concerns about intrusive surveillance, a contributed to planning of the analyses. All the authors reviewed the
perceived lack of user friendliness, or the undermining of the manuscript. The evaluation team met regularly during the trial period,
traditional (face-to-face) therapeutic relationship. More research reviewed interim documents and preliminary analyses, and contributed
is required to understand the many potential beneficial and as a whole to discussions of the analytical strategy.
harmful mechanisms by which telehealth could affect patient Funding: This is an independent report commissioned and funded by
reported outcomes. However, our findings strongly suggest no the Policy Research Programme in the UK Department of Health.
net benefit from telehealth; therefore, it should not be used as Competing interests: All authors have completed the ICMJE uniform
a tool to improve health related QoL or psychological outcomes. disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support
from the Department of Health and the University College London
Future directions Hospitals and University College London; several authors have
The current findings point to other avenues of enquiry. Planned undertaken evaluative work funded by government or public agencies
subgroup analyses for chronic obstructive pulmonary disease, but these have not created competing interests; no financial relationships
diabetes, and heart failure using disease specific outcomes of with any organisations that might have an interest in the submitted work
health related QoL represent the next step in this process. in the previous three years; no other relationships or activities that could
Alternative measures of health gain (such as self care, perceived appear to have influenced the submitted work.
impact of illness, and activities of daily living) are available for Ethical approval: The study was approved by Liverpool research ethics
participants in the WSD telehealth questionnaire study and may committee (ref 08/H1005/4).
offer a different perspective on the potential effect of telehealth. Data sharing: No additional data available.
Effects of telehealth might not be uniform across all patients,
and analyses may suggest subgroups of patients for whom 1 Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: the challenges
telehealth is either particularly beneficial or harmful. 2 ahead. Lancet 2009;374:1196-208.
Office for National Statistics. The interactive population pyramid. 2011. www.
Building on existing qualitative work from the WSD 3 neighbourhood.statistics.gov.uk/HTMLDocs/dvc1/UKPyramid.html.
Spillman BC, Lubitz J. The effect of longevity on spending for acute and long-term care.
89
Evaluation and the data in web figure 2, we aim to identify N Engl J Med 2000;342:1409-15.
predictors of early removal of telehealth. Quantitative analyses 4 Robine J-M, Romieu I, Michel J. Trends in health expectancies. In: Robine J-M, Jagger
C, Mathers C, Crimmins EM, Suzman R, eds. Determining health expectancies. John
will also explore intervention participants’ and carers’ Wiley and Sons, 2003:75-104.
perceptions of telehealth over the course of the study, and ask 5 Doblhammer G, Kytir J. Compression or expansion of morbidity? Trends in healthy-life
expectancy in the elderly Austrian population between 1978 and 1998. Soc Sci Med
whether these perceptions moderate outcomes. Other research 2001;52:385-91.
questions in the WSD Evaluation are identified in the protocol 6 Rice DP. Economic implications of increased longevity in the United States. Annu Rev
paper. 18 7 Public Health 2004;25:457-73.
Department of Health. Our health, our care, our say: A new direction for community
services. 2006. www.official-documents.gov.uk/document/cm67/6737/6737.pdf.
8 McLean S, Protti D, Sheikh A. Telehealthcare for long term conditions. BMJ 2011;342:d120.
No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe
