Telehealth not cost-effective for heart failure care

Adding a telehealth component to standard health and social care is not a cost-effective approach for managing patients with long-term diseases such as congestive heart failure, according to results of a large, randomized controlled trial. The study was published online March 21 in BMJ.

Catherine Henderson, MSc, of the London School of Economics, and colleagues performed an economic analysis as part of the Whole System Demonstrator program, a study funded through the U.K. health department. The pragmatic, cluster randomized trial was designed to assess the role of technologies such as telemonitoring and telephone support in health and social care, and is considered the largest  telehealth study in the U.K.

The study enrolled 3,230 patients 18 years and older with one of three long-term conditions—diabetes or chronic obstructive pulmonary disease—between May 2008 and December 2009 who were randomized to usual health and social care or telehealth plus usual health and social care. Telehealth included both telemonitoring and telephone support; equipment covered a base unit and peripherals such as weight scales and blood pressure cuffs. Patients were followed for a year.

For the cost-effectiveness analysis, participants who agreed to take a study questionnaire were randomized at the practice level to either telehealth (845 patients) or usual care (728 patients). The primary outcome was incremental cost per quality life-year (QALY) gained. They used a health and social services perspective for the evaluation, calculating per-person costs to purchasers for equipment and support.

They also estimated incremental cost-effectiveness ratios (ICERs) to determine willingness to pay. In the U.K., the accepted threshold using health technology is $45,500 (£30,000). They performed sensitivity analyses as well to explore cost differences if equipment costs fell or operating capacity was maximized.

They found little differences between the two groups in adjusted net benefit at 12 months. The ICER was $139,500 (£92,000), well above the threshold. At the $45,500 threshold, the probability of cost-effectiveness was low, at 11 percent. Sensitivity analyses showed that if equipment costs dropped 80 percent, the ICER fell to $79,000 (£52,000) per QALY. Adding in operations at their highest capacity, the ICER dipped to $18,200 (£12,000) per QALY.

“However, because the difference in total costs between treatment groups was not significant even with these assumed reductions, the probability of cost effectiveness was only about 61 percent at the £30,000 threshold of willingness to pay,” they wrote.

They pointed out their results may differ from findings in the U.S. because national healthcare is free in the U.K., facilitating access to care. Better access may reduce the potential to lower costs.

Participants may have under-reported service use, they wrote, and participants who did not complete the 12-month follow-up may have had different outcomes and costs. They also acknowledged that the 12-month time frame may not have been sufficient to detect improvements in health-related quality of life.