Professor Stanton Newman - Whole Systems

Report
Whole System Demonstrator Trial
Evaluation of Telehealth&Telecare:
who accepts and rejects the equipment and why
Stanton P Newman,
Lorna Rixon, Shashivadan P Hirani Martin Cartwright, Michelle
Beynon, Luis Silva, AbiSelva, Caroline Sanders
School of Health Sciences
City University London
and
Manchester University
STRUCTURE OF TALK
•
Background to WSD
•
Refusals to accept Technology
•
WSD Qualitative Study of Participants and Carers
• Quantitative data of withdrawal from Telecare and
Telehealth in WSD
•
Acceptability and Withdrawal
Background to WSD
Overall Aim of WSD Evaluation
Aim: to provide a comprehensive evaluation of the
addition of telecare and telehealth to whole systems
re-design.
Project planned to assess up to 6,000 individuals and
up to 660 carers with a variety of methods and levels
of analysis.
WSD Evaluation Cluster RCT design
Group A
Group B
Group C
Group D
Social Care needs
receive usual care
(CONTROL GROUP)
Social Care needs
receive usual care
(CONTROL GROUP)
Social Care needs
receive telecare
Social Care needs
receive telecare
LTCs receive telehealth
LTCs receive telehealth
LTCs receive usual care
(CONTROL GROUP)
LTCs receive usual care
(CONTROL GROUP)
Total Numbers recruited
Target 5721
Recruited: 5831
1200
Intervention
2881
49%
1117
Control
2949
51%
1111
Control
1057
Intervention
1010
1000
775
800
760
600
Newham,
1535, 26%
Cornwall,
2228, 38%
400
200
Kent, 2067,
36%
0
Cornwall
Kent
Newham
Total Numbers recruited
1750
1625
Control
1605
Intervention
1500
1324
1276
1250
TeleCare
2600
45%
TeleHealth
3230
55%
1000
750
500
250
0
TeleHealth
TeleCare
Questionnaire Studies
Number of Participants
700
Intervention
1399
51%
Control
1367
49%
617
Control
Intervention
592
600
500
400
372
403
384
398
300
Newham,
801, 29%
Cornwall,
756, 27%
Kent, 1209,
44%
200
100
0
Cornwall
Kent
Newham
Questionnaire Studies
Number of Participants
400
Control
350
Intervention
334
300
HF
540
34%
COPD
578
37%
275
250
265
246
244
209
Diabetes
455
29%
200
150
100
50
0
COPD
Diabetes
HF
Refusals to accept Technology
Problems with recruitment
• “Our assumption that all those who were
eligible would want the technology proved
to be the biggest challenge in the
recruitment process.” (Martin Scarfe,
Project Director Newham)
http://www.wsdactionnetwork.org.uk/news/from_the_dh_pilots_update/dece
mber_2009_wsd.html
Patient refusal as a limitation on recruitment Wakefield et al 2009
Wakefield et al 2009 CHF - 35% refusal
Possible Reasons for Refusal
Concern that will lose face to face service
Invasion of Privacy
Complexity of Equipment
Suspicion of Equipment
Singapore Telehealth - refusals
Seng et al 2007
Technical Failure as a potential limitation
Wakefield et al 2009 CHF –videophone 19% failure rate
Failure to install due to technical limitations in home
WSD
Qualitative Study of Participants and
Carers
Aim and Methods
• Aim:
– to explore participant engagement with
interventions
• Methods:
– Qualitative interviews (longitudinal for 58 trial
participants, single time point for 19 declining)
– Observation (shadowing staff visits, observing kit
in use at home and monitoring centres)
Old and new practices
ID168, W, 77 yrs, COPD
Key qualitative themes from
those not wanting to trial the
equipment
• Perceptions of health, self-care and
dependency
• Views on technology and operational factors
• Expectations and experiences of changes in
service provision and use
Non-participants: Threats to health,
self-care and independence
• “I'd feel more crippled… As long as I can get out,
that's all I am worried about…sometimes we're out
shopping and might see these elderly people - we're
old; eighty four years old. We see these old people...
hobbling along, like, you know, and we're walking..”
(ID28, M, 84 yrs, HF,)
Non-participants: Threats to health,
self-care and independence
• “I think you feel like you're not in control of your
life… from how he explained it, you tended to have
to do your blood test every single day… I try to be a
bit more relaxed and… I just felt it, it did put a bit
more pressure on me…”
(ID31, W, 61 yrs, Diab)
Non-participants: Perceptions of technology
• “I stood at my front door the other day and I
thought, 'really, truly, this world's not for me now,
it's too complicated,' … you don't speak to
anybody, you get buttons you push and press.
I've got a mobile phone but I wouldn’t even know
how to use it.”
(ID27, W, 79, diab)
Non-participants: Perceptions of
technology
• “The older you get the more forgetful you get, it's
sometimes difficult to manage that sort of
machinery … younger people obviously are
computer wise… when you are not used to it you
need to read the manual every time.”
(Wife of ID33 M, 66yrs, COPD)
Non-participants: expectations and
experiences of services
• “They put things in your home don't they. You don't
have to go to the doctors…Too complicated for
me…I like things plain and simple. I'd sooner go over
to the doctor.”
(ID27, W, 79 yrs, diab)
Non-participants: expectations and
experiences of services
• “…we have such good contact with our district
nurses and our supporting teams around us. I
mean, I've only got to phone the hospice and
somebody will come out…we've got so many
contacts around us.”
(wife of ID134, M, 70 yrs, COPD)
Quantitative data of withdrawal from
Telecare and Telehealth in WSD
Withdrawal from using
telehealth&telecare?
Withdrawal reason
TelecareN (%)
TelehealthN (%)
Deceased
155 (5.85%)
164 (5.08%)
Physical or mental illness
24 (0.92%)
50 (1.55%)
Residential or nursing care
68 (2.62%)
13 (0.40%)
No longer wishes to be in the control group
58 (2.23%)
69 (2.14%)
19 (0.73%)
211 (6.53%)
0
6 (0.19%)
No longer wishes to be in the intervention group and
rejects the equipment after trying for a period
No longer wishes to share data
No longer wishes to participate as questionnaire is
too onerous
Moved out of area to non-participating GP practice
7 (0.27%)
8 (0.25%)
19 (0.73%)
33 (1.02%)
Absence from home or loss of contact
10 (0.38%)
12 (0.37%)
3 (0.12%)
11 (0.34%)
8 (0.31%)
15 (0.46%)
Problem with equipment (e.g. equipment broken, no
longer working, misused)
No reason given
Significant predictors of
withdrawal from Telecare
1. women less likely to withdraw
2. intervention participants less likely to withdraw
3. younger less likely to withdraw
older age categories increased the odds of
withdrawal
4. Non-white British ethnic group less likely to
withdraw
4. more co-morbid conditions greater chance of
withdrawal
Predictors of withdrawal from Telecare
Odds ratios for factors in relation to
the odds of withdrawing
Effect
Female
Male
Intervention
Control
Age 18-59
75-79
80-84
85-89
90+
White British
Non-white
Number of
comorbidities
B (S.E.)
-.369(.120)
Wald
Df
Sig.
9.497
1
.002
Change in
Odds
Lower
CI
Upper
CI
.691
.547
.874
-.409 (.117) 12.308
1
.001
.664
.528
.835
.657 (.244) 7.233
.482 (.240) 4.023
.941 (.230) 16.771
1.201 (.253) 22.558
7
1
1
1
1
.007
.045
.001
.001
1.930
1.619
2.564
3.325
1.195
1.011
1.634
2.025
3.116
2.593
4.023
5.458
-.611 (.280)
4.748
2
.029
.543
.313
.940
.106 (.038)
7.609
1
.006
1.111 1.031
1.198
Negelkerke’s adjusted R2=.063
Completed
Withdrew
trial(N/Mea
(N/Mean)
n)
1532
696
228
144
1126
1102
150
222
347
298
417
393
194
30
56
64
94
56
1755
230
325
19
1.03
1.30
Significant predictors of withdrawal
from Telehealth
1. Participants in the intervention group more likely to
withdraw
2. Older age categories increased the odds of
withdrawal
3. Non-white British ethnic group less likely to withdraw
4. More co-morbid conditions greater chance of
withdrawal
Predictors of withdrawal from TH:
Odds ratios for factors in relation to
the odds of withdrawing
Effect
B (S.E.)
Intervention
Control
Age 18-59
70-74
75-79
80-84
85-89
90+
White British
Non-white
Number of
comorbidities
Deprivation
deciles –
lowest thru
to highest
Wald
Df
Sig.
Change
in Odds
Lower
CI
Upper
CI
.721 (.097) 55.638
1
.000
2.057 1.702 2.487
.037 (.176)
.045
.342 (.175) 3.807
.715 (.180) 15.846
.831 (.216) 14.854
7
1
1
1
.832
.051
.000
.000
1.038
.736 1.465
1.408
.998 1.984
2.044 1.438 2.907
2.295 1.504 3.502
-.265
(.173)
.062 (.031)
2.348
1
.125
4.111
1
.043
.074 (.150)
.241
.231 (.151) 2.326
.019 (.161)
.013
.747 (.154) 23.471
Negelkerke’s adjusted R2=.081
5
1
1
1
.623
.127
.909
.000
.767
.546 1.077
Completed
trial(N/Me
an)
Withdrew
(N/Mean)
1230
1406
478
477
434
310
144
37
375
219
83
86
105
110
55
17
2018
310
497
57
1.70
2.07
543
542
501
563
476
123
111
114
93
152
1.064 1.002 1.130
1.077
.802
1.259
.936
1.019
.743
2.110 1.560
1.446
1.693
1.397
2.855
Questionnaire Studies
Number of Participants
1000
Control
845
800
728
639
TeleCare
1193
43%
600
554
TeleHealth
1573
57%
400
200
0
TeleHealth
TeleCare
Intervention
Why withdraw from using
telehealth&telecare?
Withdrawal reason
TelecareN (%)
TelehealthN (%)
Deceased
155 (5.85%)
164 (5.08%)
Physical or mental illness
24 (0.92%)
50 (1.55%)
Residential or nursing care
68 (2.62%)
13 (0.40%)
No longer wishes to be in the control group
58 (2.23%)
69 (2.14%)
19 (0.73%)
211 (6.53%)
0
6 (0.19%)
No longer wishes to be in the intervention group and
rejects the equipment after trying for a period
No longer wishes to share data
No longer wishes to participate as questionnaire is
too onerous
Moved out of area to non-participating GP practice
7 (0.27%)
8 (0.25%)
19 (0.73%)
33 (1.02%)
Absence from home or loss of contact
10 (0.38%)
12 (0.37%)
3 (0.12%)
11 (0.34%)
8 (0.31%)
15 (0.46%)
Problem with equipment (e.g. equipment broken, no
longer working, misused)
No reason given
Predictors of Rejecting the kit:
1. TH more likely to reject equipment
2. More TH kit predicts rejection of kit
3. Less TC kit predicts rejection of kit
Predictors of Rejecting the kit:
Odds ratios for factors in relation to
the odds of rejecting the equipment
Effect
B (S.E.)
Wald
Df
Sig.
Complete
Rejected
Change Lower Upper
d
Kit
in Odds
CI
CI
trial(N/M
(N/Mean)
ean)
Telehealth
2.314
(.243)
90.636
1
0.01
10.118
6.283 16.294
Telecare
Amount of
TH Kit
Amount of TC
Kit
0.722
(0.064)
-0.616
(0.074)
1230
210
1126
19
126.881
1
<0.001
2.058
1.815
2.333
1.38
2.63
70.153
1
<0.001
0.540
0.467
0.624
1.73
0.30
Acceptability and Withdrawal
Rationale for Studying Acceptability
 According to the US Institute of Medicine Guidelines for the Assessment of
Telemedicine (Field et al, 1996) “acceptability” is essentially the degree to which
patients are clinicians are satisfied with a service or willing to use it.
 They further assert that: In the evaluation of any Telemedicine Project the
following areas must be assessed:
1. “quality” referring to the degree to which the services increases the
chances of desired health outcomes
2. “access” referring to patients receiving the right care at the right time
3. “cost” referring to the economical value of resource use associated with
the accomplishment of the defined objectives
4. “acceptability” as defined above.
Cognitive measures
SCB-SES
WSD Questionnaires
Self-care Behaviours Self Efficacy Scale - examines
individuals confidence in performing self-care behaviours
Generalised SES Generalised Self Efficacy Scale - assesses optimistic selfbeliefs to cope with a variety of difficult demands in life
SUTAQ
Service User Technology Acceptability Questionnaire –
technology users beliefs and perceptions of the equipment
(e.g. impact of kit on communication, concerns with
confidentiality, anxiety using kit)
Illness Strain
Index
Measure of strain related to having a chronic illness –
(revision of CGSI for cared for individual)
Impact of Illness Measures the degree that illness/problems interferes with
Scale
key roles and responsibilities in daily living
Subjective
Norms
Measures the individual’s estimate of the social pressure to
perform or not perform the target behaviour
Sample Characteristics
478 TH participants receiving telehealth kit for minimum 90 days- WSD
copd - 215
diabetes- 95
heart failure- 168
pulse oximeter
glucometer
weight scales
female - 182
cornwall - 169
male - 296
kent -218
mean age = 70.92 years (9.93)
mean experience with kit = 126 days (23.9)
average items of kit = 2.71 (0.61)
newham - 91
Sub-Scale Scores
Enhanced Care
Increased Accessibility
Privacy & Discomfort
mean=4.80, SD=1.03
mean=4.13, SD=1.33
mean=1.94, SD=1.01
Care Personnel Concerns
Kit as substitution
Satisfaction
mean=2.43 SD =1.17
mean=3.35 SD =1.21
mean= 5.29 SD =0.93
Sub-Scale differences by
long term condition
2.5
strongly agree
6
2.0
1.5
moderately agree
5
1.0
0.5
mildly agree
4
* p < 0.05
0.0
* p < 0.05
-0.5
mildly disagree
3
-1.0
-1.5
moderately disagree
2
-2.0
-2.5
strongly disagree
1
-3.0
enhanced care
COPD
Diabetes
Heart Failure
1.358
4.858
1.243
4.743
1.252
4.752
increased
accessibility
0.664 a,b
4.164
0.882 a
4.382
b
0.449
3.949
privacy/disco
mfort
-1.667 a
1.833
-1.350 b
2.150
a,b
-1.534
1.966
care personnel
concerns
-1.154
2.346
-1.002
2.498
-1.004
2.496
kit as
substitution
-0.066
3.434
-0.388
3.112
-0.115
3.385
satisfaction
1.867
5.367
1.637
5.137
1.766
5.266
Predictive validity of acceptability:
SUTAQ sub-scale differences in rejecters of kit
and completers
strongly agree
2.5 6
2.0
1.5 5
moderately agree
** p < 0.001
1.0
0.5 4
** p < 0.001
p > 0.05
mildly agree
** p < 0.001
0.0
-0.5 3
** p < 0.001
** p < 0.001
mildly disagree
-1.0
-1.5 2
moderately disagree
-2.0
-2.5 1
strongly disagree
-3.0
enhanced care
Completed
Rejected Kit
1.3720
4.872
.2400
3.740
increased
accessibility
privacy/discomfort
care personnel
concerns
kit as substitution
.7192
4.219
-.5833
2.917
-1.6232
1.877
-.7333
2.767
-1.1103
2.390
-.6889
2.811
-.0926
3.407
-.9556
2.544
satisfaction
1.8599
5.360
.9111
4.411
Thank you
[email protected]

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