9. TeleHomeCare, Ceglie Messapica, Italy

With population ageing, more people are affected by multi-morbidity (i.e. having concomitant chronic diseases, either physical or mental). Overall estimates of the prevalence of multi-morbidity across OECD countries are not available. However, country-specific studies suggest that prevalence is high and increasing (OECD, 2019[1]). A recent systematic review and meta-analysis gathering evidence from 70 community-based studies found that overall pooled prevalence of multi-morbidity was 38% in high-income countries with prevalence increasing with age (Nguyen et al., 2019[2]).

Tertiary prevention helps patient monitor and control their diseases, to reduce symptoms and complications of the disease and hospital stays, improve quality of life, and avoid re-hospitalisation. New information and communication technologies (ICT) installed at home can support patients and doctors to set up tertiary prevention projects.

TeleHomeCare (sometimes referred to as TeleMedicine) is a digital intervention designed to support home care through telemonitoring and teleconsultation for patients who suffer from chronic diseases, namely heart failure, chronic obstructive pulmonary diseases (COPD) and diabetes. TeleHomeCare was initially a pilot project developed in the hospital in Ceglie Messapica, a small town near Brindisi, the Puglia region of Italy in 2015. The intervention involves the patient, caregivers of patients, general practitioners (GPs), specialists, and nurses working in the area. The objective of TeleHomeCare is to implement an intermediate level of care that improves continuity of care from hospital to a home setting, reducing cost due to prolonged hospital stays and avoiding frequent access to emergency rooms.

The devices of the Hospital-at-Home (H@H) technology are installed at the patient’s home, allowing the patient to self-monitor diseases. These devices are composed of the H@H medical device that allow monitoring physiological parameters (detection of blood pressure, oxygen saturation, heart rate, respiratory rate) and providing oxygen therapy. It comes with the H@H e-care touchscreen device which provides video consultation, clinical parameter measurements consultation, and remote auscultation (further described in (Bonifazi et al., 2021[3])). Specifically, the devices at home record a patient’s physiological parameters and transmit, in real-time, the information to the control room located in the Community Care Centre in Ceglie Messapica as well as doctors and nurses located at the hospital. Control room operators are responsible for assisting users (i.e. patients, care givers, doctors and nurses) to resolve problems with the H@H system, and alerting GPs in case of anomalies in vital signs. The devices can, if needed, deliver oxygen therapy and endocavitary aspiration. All patient clinical parameters are centralised at the hospital, respecting privacy rules. The technology allows patients and doctors to have remote consultations via video. GPs who voluntary enrol in the programme1 agree to access the H@H system twice a day, 10 times per week, to check patients’ status. The role of specialists is to define the healthcare plan with the GP, and visit patients upon request from the GP. Nurses are in charge for visiting patients at home daily. Patients and care providers are appropriately trained to use the devices.

This section analyses TeleHomeCare against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence-base and Extent of coverage (see Box 9.1 for a high level assessment of TeleHomeCare). Further details on the OECD Framework can be found in Annex A.

The evidence of the effect of TeleHomeCare in Ceglie Messapica has not been evaluated yet. However, systematic reviews and meta-analyses collected by (Bonifazi et al., 2021[3]) provide evidence of effectiveness for telemedicine (Yun et al., 2018[4]; Faruque et al., 2017[5]; Hong and Lee, 2019[6]). This evidence is presented by type of disease in Table 9.1. Four main outcomes are summarised: mortality, healthcare resources use, quality of life, and other health outcomes. The evidence was complemented with a systematic review on telemonitoring for COPD patients (Cruz, Brooks and Marques, 2014[7]) and for patients with heart failure (Drews, Laukkanen and Nieminen, 2021[8]). Telemedicine for patients with heart failure can reduce all-cause mortality, reduce the risk of hospitalisation, and improve the quality of life of patients. In patients with COPD, telemedicine can reduce the risk of hospitalisation and emergency room (ER) admission, and reduce the number of exacerbations. In patients with diabetes, telemedicine can improve clinical measures.

Looking at telemedicine at large, evidence on cost-effectiveness of care delivered through telemedicine is context-specific and cannot be easily generalised (Oliveira Hashiguchi, 2020[9]).

In the context of TeleHomeCare in Ceglie Messapica, the intervention costs more than it saves money (Bonifazi et al., 2021[3]). The cost of the intervention was estimated at EUR 1 450 per targeted patient per year. This estimate, calculated from a regional healthcare perspective, includes costs related to GPs, nurses, control room operator, and medical device unit. On the other hand, TeleHomeCare significantly reduces the cost of outpatient clinic visits and emergency room visits, while the costs for hospitalisations and pharmaceuticals remain unchanged. The total saving is estimated at EUR 640 per patient per year. However this evaluation does not account for improved quality of life of patients, reduced waiting and travelling times, reduced workload of healthcare workers, and potential indirect cost (e.g. effect on patient’s participation in the labour force and productivity at work).

TeleHomeCare, such as self-monitoring based at home and video consultation for people with chronic diseases, can help address inequalities by reducing barriers to access, including time, distance and limited availability of services. Telemedicine services help provide care to difficult-to-reach patient groups. For instance, in Canada, where Indigenous people tend to have poorer health than non-Indigenous people, Ontario Telemedicine Network included 120 indigenous telemedicine sites and counted 9 628 indigenous patient events (OTN, 2018[10]).

However, there is a risk of digital exclusion, in particular with regards to older people, disabled people, people in remote locations as well as those on low incomes. For instance, older people who do not have knowledge or capacity to learn how to use the new technologies may not be able to use the system, and thus be excluded. To overcome this issues, patients who register for TeleHomeCare must attend training to acquire sufficient autonomy to use the device safely. The training seeks to overcome cultural limitations and poor aptitude in the use of medical devices and ICT.

While there is no study evaluating what impact TeleHomeCare has on health inequalities, the pilot experience in Ceglie Messapica identified technical difficulties implementing TeleHomeCare in areas where there was poor or no internet network coverage.

Evidence of effectiveness for the use of tele-monitoring for heart failure, Diabetes and COPD was gathered from systematic reviews and meta-analyses as described in the section on “Effectiveness”. An evaluation of the cost associated with TeleHomeCare in Ceglie Messapica was made by the Italian regional public health agency (Bonifazi et al., 2021[3]). Hence, it is not appropriate to assess the evidence-base of TeleHomeCare using the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project. Instead, this section summarises the methodology for a selection of articles cited under the section assessing the “Effectiveness” and “Efficiency” of TeleHomeCare Box 9.2.

The intervention has been initially deployed locally in the hospital of Ceglie Messapica (a small town near Brindisi, Italy), including 207 patients. The intervention has not been extended to other areas of Italy. However, similar telemonitoring programmes are in place in many countries either at the local, regional or national level (Oliveira Hashiguchi, 2020[9]), for instance, Ontario Telemedicine Network in Canada.

Policy options available to high-level policy makers (e.g. region / state / national governments) and TeleHomeCare administrators are outlined in this section and refer to each of the five best practice criteria.

Monitoring and evaluating clinical outcomes are needed to enhance the effectiveness of TeleHomeCare. Clinical outcomes associated with the use of TeleHomeCare in Ceglie Messapica have not yet been evaluated. An initial evaluation is crucial to define criteria of improvement.

Digital health products, such as TeleHomeCare devices, require patients and health professionals to be digitally health literate. Healthcare systems are growing increasingly digital as evidenced by the growing number of countries with national eHealth strategies (WHO, 2015[11]). Therefore, policy makers should promote digital health literacy so that people can apply their health knowledge/skills to digital products. TeleHomeCare has a training component for the users, however it is important to further develop this component to ensure that people are confident using telemonitoring and teleconsultation. In particular there is a need to focus on the population aged over 50 who are at greater risk of having one or multiple chronic diseases, such as heart failure, diabetes and COPD, and who are less confident using digital tools. Policy efforts should also concentrate on population groups who face barriers to accessing and utilising eHealth products, such as teleconsultation and telemonitoring, given these groups often stand to benefit most (e.g. those with a lower socio-economic status) (Oliveira Hashiguchi, 2020[9]).

Health professionals must also be digitally health literate in order to feel confident using digital products when treating patients. Among OECD countries, one-third of health workers do not feel accustomed to using digital solutions “due to gaps in knowledge and skills in data analytics” (OECD, 2019[1]). To ensure health professionals can “safely and effectively” adopt digital work tools (e.g. teleconsultation and telemonitoring), it is important they receive adequate support via training and education. For instance, GPs and specialists who are involved in the TeleHomeCare service are trained during the first two weeks by control room operators and telemedicine experts from the H@H system provider.

Future evaluations of TeleHomeCare should envisage taking a broader perspective, valuing all potentially improved outcomes. In the case of TeleHomeCare in Ceglie Messapica, it is shown that intervention costs exceed money saved (see section on “Efficiency”). However, some outcomes of the intervention could not be valued (e.g. improved quality of life of patients, reduced waiting and travelling times, reduced workload of healthcare workers, and higher work productivity of patients). Including such outcomes to future studies would provide a more holistic and therefore accurate picture of TeleHomeCare’s cost-effectiveness potential. Future studies would also benefit from taking a longitudinal perspective given interventions such as TeleHomeCare often require significant upfront fixed costs.

Efforts to enhance internet network quality and coverage can help to increase access to TeleHomeCare and improve access for population groups in remote areas. The pilot experience in Ceglie Messapica identified technical difficulties in the implementation of TeleHomeCare in areas where there was poor or absence of the Internet network coverage. Enhancing Internet network can therefore help people in underserved areas use TeleHomeCare devices.

Policies to increase access and utilisation of TeleHomeCare among disadvantaged population groups can reduce health inequalities. There is a risk of digital exclusion, in particular with regards to older people, disabled people, people in remote locations and those on low incomes. As outlined under “Enhancing effectiveness”, policy efforts should focus on building health literacy and digital health literacy among disadvantaged groups. More direct action that can be implemented by TeleHomeCare administrators include:

  • Providing training to patients on how to use the TeleHomeCare devices and providing technical support to users, especially older people, disabled people, those in remote locations and on those low incomes.

  • Collecting data that can be disaggregated by priority population groups (e.g. information on age, disabilities, education, rural location). This information can subsequently be used to amend the implementation of the intervention to suit the needs of priority populations.

Failing to address the needs of disadvantaged population groups risks widening existing health inequalities.

The impact of TeleHomeCare in Ceglie Messapica on clinical outcomes and final outcomes will be of key interest to policy makers and is therefore encouraged. To date, one study evaluated the impact of TeleHomeCare in Ceglie Messapica on health system costs, however there are no evaluations examining the impact on health outcomes, including final health outcomes (e.g. patient quality of life, work productivity of patients).

Key steps involved in undertaking an evaluation are outlined in OECD’s Guidebook on Best Practices in Public Health (OECD, 2022[12]). These steps are summarised below to assist TeleHomeCare administrators in future evaluation efforts:

  • Develop a logic model: a logic model summarises the main elements of an intervention and provides a visual overview of the relationship between inputs, activities, outputs and outcomes.

  • Select evaluation indicators: indicators for each element within the programme logic need to be specified. Example outcome indicators for TeleHomeCare may include EQ-5D (patient quality of life) and work productivity. Indicators should be SMART (specific, measurable, achievable, relevant and time-bound) and where possible be stratified to understand the intervention’s impact on inequalities (as discussed under “Enhancing efficiency”).

  • Choose a study design: process evaluations assess whether an intervention was implemented as intended whereas an outcome evaluation assesses the impact the intervention had on outcomes. Regarding the latter, it is necessary to choose a study design that is appropriate for the intervention.

  • Choose a data collection method: any evaluation of TeleHomeCare will largely rely on real-world data collected from the control room servers and devices. Additional primary sources of data may also be collected, for example, from user surveys.

  • Collect the data: data collection methods should consider logistics, consent, privacy, data security and other ethical considerations, in particular given data from TeleHomeCare contains personal and clinical information.

  • Analyse the data: it is not possible to detail all the various methods available to analyse data here, however, a first step for any intervention is to analyse descriptive statistics including a look at the pattern of missing data.

  • Follow-up action: results from the evaluation will provide useful information on how the intervention can be adapted to improve performance.

  • Disseminate results: evaluation results should be conveyed to the target audience via appropriate channels. In particular, it is important to convey “lessons learnt” and how these will be incorporated into the future design of TeleHomeCare.

To boost the uptake of TeleHomeCare throughout the national territory, it is key to ensure the devices are trusted and non-burdensome. It is also important considering the viewpoints of both patients and healthcare professionals. Patient’s data (both personal and clinical) needs to be secured. Training and technical support provided to both patients and healthcare professionals have to be promoted. The role of advanced practice nurses in remote monitoring has to be considered.

This section explores the transferability of TeleHomeCare and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publicly available data; and 3) additional considerations for policy makers interested in transferring TeleHomeCare.

TeleHomeCare in Ceglie Messapica has not yet been transferred to other areas or regions in Italy. However, similar telemonitoring programmes are in place in many countries either at the local, regional or national level (Oliveira Hashiguchi, 2020[9]), for instance, Ontario Telemedicine Network in Canada.

The ability to readily transfer TeleHomeCare, as it is implemented in Ceglie Messapica, heavily depends on whether the service uses proprietary technology.

The following section outlines the methodological framework to assess transferability and results from the assessment.

Details on the methodological framework to assess transferability can be found in Annex A.

Several indicators to assess the transferability of TeleHomeCare were identified (Table 9.2). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.

The transfer analysis shows the transferability potential of TeleHomeCare in Ceglie Messapica throughout Italy and to other countries. In Italy, there is political drive to deliver eHealth and telehealth with funding allocations, there is also legislation to protect patient data, and health professionals are comfortable using eHealth technologies according to the eHealth composite index (see the table below).

Data from other countries show high transfer potential based on population and digital health sector indicators, for example, other countries exhibit high rates of ICT development and use of home care services, further, health professional have ready access to eHealth training.

Regarding political support, 27 (out of 39 with available data) countries have a national eHealth policy, and 20 have a dedicated national telehealth policy or strategy indicating there is a mix of political will to introduce programs such as TeleHomeCare among countries.

Finally, using data to represent the economic context, most countries (i.e. 29) have special funding allocated for the eHealth policy implementation.

It is important to note though that data from publicly available datasets, alone, is not appropriate to assess the transferability of the TeleHomeCare programme in Ceglie Messapica. Countries interested in setting up a similar programme should do an analysis to identify what the needs and issues are around telemonitoring and teleconsultation, and how a national programme can address these. In addition, since similar telemonitoring programmes are already in place in many countries either at the local, regional or national level (Oliveira Hashiguchi, 2020[9]), countries should consider evaluating how to their programme compares with TeleHomeCare in Ceglie Messapica.

To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in the table above.

Countries in clusters with more positive values have the greatest transfer potential. For further details on the methodological approach used, please refer to Annex A.

Key findings from each of the clusters are below with further details in Figure 9.1 and Table 9.4:

  • Countries in cluster one have political, economic and sector specific arrangements in place to transfer TeleHomeCare. However, population uptake may be low given digital health literacy is typically below average for these countries. Italy, where TeleHomeCare currently operates, falls under this cluster indicating digital health literacy, although ideal, is not a prerequisite for this intervention.

  • Countries in cluster two have a population considered digitally health literate, in addition, these countries have political arrangements in place to support TeleHomeCare. However, prior to transferring this intervention, countries in cluster two may wish to consider introducing policies to ensure the digital health sector is ready to deliver this intervention (e.g. staff have the appropriate skills). Further, it will be important to ensure the intervention is affordable in the long run.

  • Countries in cluster three should undertake further analysis to ensure TeleHomeCare aligns with political priorities, and that the population and a digital health sector are ready to maximise TeleHomeCare’s potential.

Data from publicly available datasets is not ideal to assess the transferability of TeleHomeCare. For example, there is no publicly available information the level of public acceptability of telemonitoring and teleconsultation interventions. Therefore, Box 9.3 outlines several new indicators policy makers should consider before transferring TeleHomeCare.

The TeleHomeCare intervention assessed here, is a telemonitoring and teleconsultation programme for patients with heart failure, diabetes and COPD, implemented in Ceglie Messapica, a town near Brindisi in Italy. With TeleHomeCare, physiological parameters of the patient are recorded at home and transmitted in real-time to the control room located in the Community Care Centre in Ceglie Messapica, and to doctors and nurses located at the hospital. This programme creates an intermediate level of care that improves continuity of care from hospital to the home setting, and has the potential to reduce excessive costs caused by prolonged hospital stays and frequent access to emergency rooms.

Monitoring and evaluating clinical outcomes arising from TeleHomeCare are needed to enhance what aspects of the intervention work well and do not work well – findings from the analysis can subsequently be used to improve overall effectiveness. While the intervention was evaluated to cost more than it saves, future evaluations of TeleHomeCare should envisage taking a broader perspective by incorporating improved patient quality of life, reduced waiting and travelling times, reduced workload of healthcare workers, and higher work productivity of patients. Policy efforts should also focus on enhancing internet network coverage to enable access to the TeleHomeCare technology and improving reach to population groups with a risk of digital exclusion, in particular older people, disabled people, people in remote locations and those on low incomes.

TeleHomeCare is likely to be transferable since telemonitoring operates in many countries, either at national, regional or local level. In addition, there is political support given most countries have a national eHealth and telehealth policy or strategy. However, population readiness to use telehealth may act as a barrier for countries that are less digitally advanced.

Next steps for policy makers and funding agencies regarding TeleHomeCare are summarised in Box 9.4.

References

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Note

← 1. Voluntary enrolment by GPs may have an impact on which patients are selected to receive TeleHomeCare, thereby influencing generalisability of evaluation findings.

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