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An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Programme Grants for Applied Research, No. 5.1

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Author Information
Southampton (UK): NIHR Journals Library; .

Headline

Two linked telehealth trials found small benefits with increased costs and raised questions about the most appropriate methods for future development and evaluation of telehealth.

Abstract

Background:

Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term conditions (LTCs).

Aim:

To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk.

Methods

Development:

We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the development and evaluation of the Healthlines Service for patients with LTCs.

Implementation:

The Healthlines Service consisted of regular telephone calls to participants from health information advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence.

Evaluation:

The Healthlines Service was evaluated with linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. The primary outcome was response to treatment and the secondary outcomes included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication adherence, perceptions of support, access to health care and satisfaction with treatment.

Trial results

Depression trial:

In total, 609 participants were randomised and the retention rate was 86%. Response to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after 4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270) [odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5; p = 0.02]. Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence.

CVD risk trial:

In total, 641 participants were randomised and the retention rate was 91%. Response to treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect (odds ratio 1.3, 95% CI 1.0 to 1.9; p = 0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management.

The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression. The intervention was implemented largely as planned, although initial delays and later disruption to delivery because of the closure of NHS Direct may have adversely affected participant engagement.

Conclusion:

The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth programmes for LTCs.

Trial registration:

Current Controlled Trials ISRCTN14172341 (depression trial) and ISRCTN27508731 (CVD risk trial).

Funding:

The National Institute for Health Research Programme Grants for Applied Research programme.

Contents

About the Series

Programme Grants for Applied Research
ISSN (Print): 2050-4322
ISSN (Electronic): 2050-4330

Article history

The research reported in this issue of the journal was funded by PGfAR as project number RP-PG-0108-10011. The contractual start date was in November 2009. The final report began editorial review in June 2015 and was accepted for publication in March 2016. As the funder, the PGfAR programme agreed the research questions and study designs in advance with the investigators. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The PGfAR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

Chris Salisbury is a member of the National Institute for Health Research (NIHR) Health Services and Delivery Research Board and the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West. He also had an honorary consultant contract with NHS Direct, the NHS trust that hosted this research, in order for him to act as principal investigator. Glyn Lewis is a member of the NIHR Efficacy and Mechanism Evaluation Board and Jon Nicholl is a member of the NIHR Clinical Trials Unit Standing Advisory Committee. Catherine Pope is a member of the NIHR CLAHRC Wessex, which is a partnership between Wessex NHS organisations and partners and the University of Southampton and is part of the NIHR.

Last reviewed: June 2015; Accepted: March 2016.

Copyright © Queen’s Printer and Controller of HMSO 2017. This work was produced by Salisbury et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK409363PMID: 28121092DOI: 10.3310/pgfar05010

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