One Size Fits All 5/11/12

When I wrote the title for the post, I realized that it sounds like it would be about the screen size of mobile devices, both smart phones and iPads. Alas, the post is not about screen sizes, but about telehealth and connected health applications. I may still write a post about screen size, which is a very important consideration in app design and functionality, just not today.

For today, I wanted to write about a telemonitoring study I referenced in my last post. The attention-getting Mayo study found no differences in rates of readmission or ED visits between patients who received telemonitoring and those wgi received standard care with no telemonitoring. From this data, the authors concluded that telemonitoring did not help in any way. This is not exactly in line with much of the promise many see in telemonitoring.

In response to the publication and attention it generated, The Continua Health Alliance issued a statement to its members that Chris Wasden was kind enough to share in the comments of my last post. The Continua statement presents some of the limitations of the Mayo study from the authors of the study themselves. It then lists a smattering of other studies that support the use of telehealth and other connected health technologies to improve outcomes.

It is important to have a balanced perspective when it comes to evidence. The Continua cites only evidence that supports telehealth, and a recent Cochrane Review of 25 studies found telemonitoring to be effective both in terms of cost and outcomes. The new study, which was designed as a randomized controlled trial (RCT), is not the only RCT to find no difference in outcomes between telemonitoring and standard care (NEJM study).

To add some power to that, RCTs are the gold standard in study design and are considered the highest level of evidence. Also, the two RCTs I’m referencing above were published in Archives of Internal Medicine and the New England Journal of Medicine, both well-respected journals. At least one of the Continua-cited studies was also an RCT, but I’m not sure about the others because they are not linked back to the primary sources in the Continua statement.

The debate over evidence is a good one. It’s a healthy process as we learn about the efficacy of new treatment modalities, technology included. As the body of evidence surrounding telehealth — and really health technology generally — continues to grow, more answers emerge. However,  you don’t know what you don’t know, and as we collect more data, we are also coming up with more questions. In the case of this specific study, questions arise about the infrastructure needed to develop an effective connected health intervention and the population that should be targeted.

These are increasingly important considerations, but there are many, many others. When it comes to providing either sick or well care, there is no magic bullet. Also, I was under the impression that the trend in medicine and healthcare was not one-size-fits-all, but solutions tailored and personalized to the specifics of the patient and situation. Connected health technology and telehealth are great tools for improving access to care and quality of care and increasing our focus on preventative care, but they are not standalone solutions and not a standardizable healthcare delivery system.

I don’t think the studies that find no difference in outcomes and cost with telemonitoring care are edge cases that can be ignored or pushed off. If you look at the demographics and length of study for the linked studies above, the patients represent a significant portion of those who need improved care.

Let’s continue our dialogue and critical assessment of the ways that we design and implement remote care interventions. I have no doubt that telemonitoring has a significant role to play in reducing cost and improving outcomes, but I also have no doubt it doesn’t fit for every patient or every type of healthcare encounter. As long as I still get stuck behind people at the grocery store that write checks and don’t use check cards, we need another way to reach certain people. The really hard part is going to be building the flexibility and upfront identification of those people.

Travis Good is an MD/MBA involved with health IT startups. More about me.

  • Chris Wasden

    one of the key issues is to what extent the practice of medicine actually changed in a meaningful way when they applied RPM.

    One of the researchers on the Mayo study was presenting this at a recent mHealth conference and apparently it was embarrasing how little she could explain what they did and why they got such poor results. She speculated that it was because the 80 year old age group are a group that it doesn’t matter what you do you will still get the same outcome and they are all very close to expiring as well.

    She also said that maybe the lack of efficacy was that these were all Mayo patients that already had excellent care and there wasn’t much else you could do with any technology to make a difference.

    The demographic that makes the most sense for RPM related benefits are not those on death’s door, but those in the 65-80 age group where intervention, prediction, management can make a difference.

  • Smalltown CIO

    I have responded to several of these studies in the past. I am not a clinician. However, I take a slightly different view of telehealth. Even if telehealth is shown to not provide any better healthcare but is at least on par with metro-based care, isn’t that a win? The patient stays local to their home and the family is able to stay local and provide the necessary support to their loved one. Isn’t that a huge win?

  • c. gresham bayne md

    The Mayo telemonitoring multicenter trial has an interesting statistic which at p<.08 nearly approached statistical significance: telemonitoring in the chronically-ill 80 year old arm of the study nearly quadrupled the mortality rate (15/102 vice 4/102) which didn't surprise those of us who make housecalls: the multi-morbid, very old, high cost tranche of patients has trouble surviving an american hospitalization. When we kill them off with overcare, the reduced costs in the telemonitored group offset their increased costs from more ER visits and hospital days, so no economic effect was seen in the study. Just like home health, call centers and other systems with increased access to compassionate nurses on the phone (who cannot practice medicine), telemonitoring's "woodwork effect" will recruit less-sick patients introducing more care to them yet fail to show savings in the high cost patients without iin-home visits by licensed physicians or NPPs. Ten years of CMS demonstrations have consistently shown this problem. In other words, why would you want to tele daily weights for a group of patients too sick to stand on a scale? There are very few of these complex patients we cannot take care of in the home with modern point-of-care diagnostics. What we need is a study comparing proper physiologic sensors monitored (or not monitored) in a chort of housecall patients….and thank you Travis, for the continued excellent feed of very relevant topics on HisTalk!

  • Chris Wasden

    Here is a little more detail on my previous comments …

    Jennifer Pecina, one of authors of Mayo Clinic study, spoke on panel “Sustainable Home Telehealth Solutions”
    Background: 205 person study employing Guide to assess impact of telemonitoring on hospitalizations and ED visits. Study concluded that telemonitoring did not result in fewer hospitalizations or ED visits and telemonitoring group demonstrated greater mortality for unknown reasons
    Pecina did not have a strong justification for the results, but suggested several potential rationales, including:
    Study participants were Mayo patients and receive exceptional care; therefore, no additional benefits
    Patients selected from an exceedingly frail group (mean age 80.3, 60% hospitalized per year); therefore, difficult to prove benefit regardless of monitoring, increased standard care, etc.
    Potentially monitored wrong metrics. Exceedingly frail and elderly may need ADL surveillance

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