Telehealth did not improve quality of life, anxiety and depressive symptoms in patients with diabetes

A stethoscope on a keyboard

As pressure increases on an over-burdened healthcare system, focusing on self-care has potential. Advances in technology have improved many aspects of healthcare: now its uses may be harnessed to reduce utilisation of health services by those with long term conditions. “Telehealth” is an assistive technology that allows individuals to exchange information with their healthcare professional remotely. Ideally this would facilitate diagnosis, monitoring and management of long-term conditions. 

In February 2013, the British Medical Journal published a study funded by the Policy Research Programme in the UK Department of Health that focused on the Whole Systems Demonstrator (WSD) Evaluation telehealth questionnaire study.  It aimed to see if a home-based telehealth system could improve Health-related quality of life (HRQoL), anxiety and depressive symptoms over a 12 month period.

Methods

This paper reports on the WSD telehealth questionnaire study, which is part of a wider cluster randomised control trial of telehealth. This large scale trial compared telehealth to usual care and was conducted between May 2008 and December 2009. Participants were recruited from three diverse regions of England (Cornwall, Kent, and Newham).

Eligible patients were diagnosed with chronic obstructive pulmonary disease (COPD), diabetes or heart failure, as confirmed by a local clinician or hospital consultant.

The intervention focused on monitoring vital signs, symptoms and the self-management of behaviour. Data was collected at baseline, 4 months and 12 months.

Across 154 sites, 1573 participants provided questionnaire data at baseline. Over two thirds completed the questionnaires at 2 time points, with 45.1% assessed at all 3 time-points.  The main outcomes of the study were assessed by self-report measures. These included:

  • Generic HRQoL (SF-12 and the EQ-5D)
  • Anxiety (6 item Brief State-Trait Anxiety Inventory)
  • Depressive symptoms (10 item Centre for Epidemiological Studies Depression Scale).

Results

Here’s what they found:

  • Participants receiving telehealth as part of the WSD trial were more likely than those receiving usual care to participate in the questionnaire study, and were more likely to provide data at both follow-up assessments.
  • Differences between treatment groups were small and non-significant for all outcomes.
  • The differences between trial arms (telehealth vs. usual care) failed to meet the cut-off for minimal clinically important differences for any outcome at either 4 or 12 months
  • No adverse events or side effects related to any of the telehealth devices were reported in the intervention group throughout the trial.

Conclusions

The authors concluded:

Second generation, home-based telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only. Telehealth did not improve quality of life, anxiety, or depressive symptoms for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months. The findings suggest that concerns about potentially deleterious effect of telehealth are unfounded for most patients.

Commentary

Missing the target

Using non-specific scales across these highly dissimilar conditions is bound to miss out on the particular needs of a certain individual.

The findings were robust even when factors such as drop-out and adherence to the trial protocol were considered.  However, the intervention did not significantly improve well-being. This might raise concerns about the utility of telehealth interventions.

However, Brownsell (2009) highlighted the difficulties associated with calculating the “success” of such programs. It is often unclear what success implies. “Success” could incorporate improved health, well being, empowerment, access to more information, cost-savings, reduced hospital utilisation, quality of life or satisfaction with the programme.

This study focused on one aspect of success, whereby other parts of the WSD Evaluation have suggested that telehealth may be promising in some domains of healthcare. Is telehealth worth the investment? Right now, the answer is unclear.

Perhaps the telehealth system is not a ‘one-size-fits all’ model, with demographic factors at baseline playing a pivotal role in the impact of the intervention. Those who might benefit most from the intervention may be those who have lower levels of education or higher levels of deprivation … and in this study such individuals were less likely to participate.

Analysing three different conditions in one study could be mixing apples and oranges. While telehealth might suit some, it may not fit equally well with the lifestyle that goes with all long-term conditions. HRQoL was assessed using generic rather than condition-specific scales. Using non-specific scales across these highly dissimilar conditions is bound to miss out on the particular needs of a certain individual. Combining generic and specific with self-report and objective measures may result in a clearer picture of what changes occurred for whom.

As research begins to catch up with technological advances, telehealth may yet prove its worth. It certainly seems intuitive that it could maybe work for at least some of the people, some of the time. So what’s needed?

Research could help us understand the beneficial and harmful mechanisms by which telehealth could affect patient reported outcomes. There is certainly hope for tailored remote healthcare. However, some people might always prefer to seek out a healthcare professional whereas others will always seize the chance to avoid the clinic at all costs. Some medical conditions might suit the telehealth framework more than others. Before we can ask what telehealth might offer, we should look first at its context, in particular WHOM it might work for and how successful interventions will be quantified. This paper provokes thought while highlighting that there are many questions that remain unanswered.

References

Cartwright, M., Hirani, S.P., Rixon, L., Beynon, M., Doll, H., Bower,P., Bardsley, M., Steventon, A., Knapp ,M,. Henderson , C., Rogers , A., Sanders , C., Fitzpatrick R.,  Barlow,J.,  Newman, S.P. Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial. British Medical Journal 2013, doi: 10.1136/bmj.f653

Brownsell, Simon (2009) Measuring the ‘success’ of telehealth interventions. Journal of Assistive Technologies, 3 (4). pp. 12-20