Cost-effectiveness of interventions to reduce the thrombolytic delay for acute myocardial infarction

New Concepts and Technological Resources in Patient Education and Asthma Self-Management

Asthma is a chronic disease that is associated with significant morbidity and mortality. In general, the use of technology resources or electronic health (e-health) has been shown to have beneficial effects on patients with asthma. E-health can impact a broad section of patients and can be cost-effective and associated with high patient satisfaction. E-health may enable remote delivery of care, as well as timely access to health care, which are some of the common challenges faced by patients with asthma. Web-based asthma self-management systems have been found to improve quality of life, self-reported asthma symptoms, lung function, reduction in asthma symptoms/exacerbations, and self-reported adherence for adults. Social media is commonly being used as a platform to disseminate information on asthma to increase public awareness. It can facilitate asthma self-management in a patient friendly manner and has shown to improve asthma control test scores as well as self-esteem. Text massages reminders can increase awareness regarding asthma treatment and control, thus potentially can improve adherence to medications and asthma outcome. Mobile health applications can support asthma self-management, improve a patient's quality of life, promote medication adherence, and potentially reduce the overall costs for asthma care. Inhaler trackers have shown to be beneficial to asthma outcome in various populations by improving adherence to asthma medications. Barriers such as physician financial reimbursement as well as licensing for rendering tele-healthcare services are important concerns. Other limitations of using technology resources in health care are related to liability, professionalism, and ethical issues such as breach of patient confidentiality and privacy. Additionally, there may be less face-to-face interaction and care of the patient when e-health is used.

Telemedicine: A systematic review of economic evaluations

Background: Telemedicine is an expanded term in health information technology that comprises procedures for transmitting medical information electronically to improve patients’ health status. The objective of this research is to evaluate the cost-effectiveness of telemedicine interventions in various specialty areas.

Methods: The Cochrane Library and Centre for Review and Dissemination were searched up to February 2013 using Mesh. Studies that compared any kind of telemedicine with any other routine care technique and used cost per health utility unit’s outcomes were included.

Results: Twenty-one articles were included. According to the included studies, it seems that using telemedicine in cardiology can be effective and cost-effective enough but pre-hospital telemedicine diagnostics program are likely to have little impact on acute myocardial infarction fatality. In pulmonary, telemedicine can be a cost-effective strategy for delivering outpatient pulmonary care to rural populations which have limited access to specialized services, but telemedicine is not cost- effective in asthma and airways cancer. In ophthalmology, especially in the diagnosis of diabetic retinopathy, the use of telemedicine is a cost-effective tool. In dermatology, telemedicine is not cost-effective enough in comparison of conventional cares. In other fields such as physical activity and diet, eating disorder, tele-ICU, psychotherapy for depression and telemedicine on ships, telemedicine can be used as a cost-effective tool for treatments or cares.

Conclusion: Most of the included studies confirmed that telemedicine is cost-effective for applying in major medical fields such as cardiology; but in dermatology, papers could not confirm the positive capability of telemedicine.

Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? A preliminary cost analysis

BACKGROUND

Telemedicine has been shown to improve quality of health-care delivery in several fields of medicine; its cost-effectiveness, however, is still a matter of debate.

HYPOTHESIS

Pre-hospital telemedicine electrocardiogram triage for regional public emergency medical service may reduce costs.

METHODS

An economic evaluation (cost analysis) was performed from the perspective of regional health-care system. Patients enrolled in the study and considered for cost analysis were those who called the local emergency medical service (EMS; dialing 1-1-8) during 2012 and underwent prehospital field triage with a telemedicine electrocardiogram (ECG) in the case of suspected acute cardiac disease (acute coronary syndrome, arrhythmia). The prehospital ECGs were read by a remote cardiologist, available 24/7. Cost savings associated with this method were calculated by subtracting the cost of prehospital triage with telemedicine support from the cost of conventional emergency department triage (ECG and consultation by a cardiologist).

RESULTS

During 2012, the regional EMS performed 109 750 ECGs by telemedicine support. The associated total cost for the regional health-care system was €1 833 333, with a €16.70 cost per single ECG/consultation. Given the cost of similar conventional emergency department treatment from a regional rate list of €24.80 to €55.20, the savings was €8.10 to €38.40 per ECG/consultation (total savings, €891 759.50 to €4 219 379.50). The cost for ruling out an acute cardiac disease was €25.30; for a prehospital diagnosis of cardiovascular disease, €49.20. With 629 prehospital diagnoses of ST-elevation myocardial infarction and reported reductions in mortality thanks to prehospital diagnosis deduced from prior studies, 69 lives per year presumably could be saved, with a cost per quality-adjusted life year gained of €1927, €990/€ - 2508 after correction for potential savings.

CONCLUSIONS

Prehospital EMS triage with telemedicine ECG in patients with suspected acute cardiac disease may reduce health-care costs.

Approaches to economic evaluation in telemedicine

External validity or generalizability is a major challenge in the economic evaluation of telemedicine. There are two possible ways of increasing generalizability: the first is to use a pragmatic trial design so it better reflects normal patient caseload and everyday practice. The second is to use existing data from the literature and decision modelling to estimate the expected costs and outcomes of different alternatives. The first will increase generalizability to other patients than those in the trial and the second will increase generalizability from place to place. The objective and role of the evaluation will decide the most appropriate evaluation approach. Pragmatic trials should be used in studies where the objective is to provide measurements of costs and outcomes for a specific group of patients in a particular setting. This approach is highly relevant in telemedicine evaluations where the objective is to support local investments strategies and reimbursement systems. Decision modelling provides an overall structure for a decision problem and a formal analysis of the implications of different decisions. Modelling can simulate a trial or mimic a current system or a system that decision makers would like to use. Modelling is a useful approach when decisions need to be made about whether to invest in telemedicine within a broader context.

Can economic evaluation in telemedicine be trusted? A systematic review of the literature

BACKGROUND

Telemedicine has been advocated as an effective means to provide health care services over a distance. Systematic information on costs and consequences has been called for to support decision-making in this field. This paper provides a review of the quality, validity and generalisability of economic evaluations in telemedicine.

METHODS

A systematic literature search in all relevant databases was conducted and forms the basis for addressing these issues. Only articles published in peer-reviewed journals and written in English in the period from 1990 to 2007 were analysed. The literature search identified 33 economic evaluations where both costs (resource use) and outcomes (non-resource consequences) were measured.

RESULTS

This review shows that economic evaluations in telemedicine are highly diverse in terms of both the study context and the methods applied. The articles covered several medical specialities ranging from cardiology and dermatology to psychiatry. The studies analysed telemedicine in home care, and in primary and secondary care settings using a variety of different technologies including videoconferencing, still-images and monitoring (store-and-forward telemedicine). Most studies used multiple outcome measures and analysed the effects using disaggregated cost-consequence frameworks. Objectives, study design, and choice of comparators were mostly well reported. The majority of the studies lacked information on perspective and costing method, few used general statistics and sensitivity analysis to assess validity, and even fewer used marginal analysis.

CONCLUSION

As this paper demonstrates, the majority of the economic evaluations reviewed were not in accordance with standard evaluation techniques. Further research is needed to explore the reasons for this and to address how economic evaluation in telemedicine best can take advantage of local constraints and at the same time produce valid and generalisable results.

Neighborhood income, health insurance, and prehospital delay for myocardial infarction: the atherosclerosis risk in communities study

BACKGROUND

Outcomes following an acute myocardial infarction (AMI) are generally more favorable if prehospital delay time is minimized.

METHODS

We examined the association of neighborhood household income (nINC) and health insurance status with prehospital delay among a weighted sample of 9700 men and women with a validated, definite, or probable AMI in the Atherosclerosis Risk in Communities (ARIC) community surveillance study (1993-2002). Weighted multinomial regression with generalized estimation equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) and to account for the clustering of patients within census tracts.

RESULTS

Low nINC was associated with a higher odds of long vs short delay (OR, 1.46; 95% CI, 1.09-1.96) and medium vs short delay (OR, 1.43; 95% CI, 1.12-1.81) compared with high nINC in a model including age, sex, race, diabetes, hypertension, presence of chest pain, arrival at the hospital via emergency medical service, distance from residence to hospital, study community, and year of AMI event. Meanwhile, compared with patients with prepaid insurance or prepaid plus Medicare, patients with Medicaid were more likely to have a long vs short delay (OR, 1.87; 95% CI, 1.10-3.19) and a medium vs short delay (OR, 1.76; 95% CI, 1.13-2.74).

CONCLUSIONS

Both low nINC and being a Medicaid recipient are associated with longer prehospital delay. Reducing socioeconomic and insurance disparities in prehospital delay is critical because excess delay time may hinder effective care for AMI.

When analyses are invalidated by erroneous assumptions

In a recent publication in the “International Journal of Technology Assessment in Health Care” (7), Kildemoes and Kristiansen claim to address “Cost-effectiveness of interventions to reduce the thrombolytic delay for acute myocardial infarction.” Their study is based on a “Master of Public Health Assessment” thesis published by Kildemoes in the year 2001 (6). Three years ago, the author was informed that several of her assumptions were incorrect. In this letter, we will address six of the erroneous assumptions made by Kildemoes and Kristiansen.

Response to an optimistic viewpoint

We appreciate the interests in our work and observe that we agree that earlier thrombolysis for AMI can reduce the AMI case fatality. The question is how much and at what price. There are no data available to directly address this issue, and we developed a simulation model to quantify costs and health consequences of less thrombolytic delay by using public awareness campaigns, telemedicine, or a combination of the two. Inevitably, such a model needs to be based on several uncertain parameter values. We performed a range of sensitivity analyses so readers of the analysis could see the effect of replacing our base case values with others that the reader might consider more appropriate. Due to space restrictions, we had to omit a table with sensitivity analyses that would have addressed several of the concerns Terkelsen and coworkers have.