Long-term impact of home telehealth service on preventable hospitalization use

Huanguang “Charlie” Jia, PhD Research Health Scientist VA RORC REAP North Florida/South Georgia VHS Gainesville, Florida

Co-authors

     Ho-Chih Chuang, MS Samuel S. Wu, PhD Xinping Wang, PhD Brad N. Doebbeling, MD Neale R. Chumbler, PhD

Acknowledgement

  This work was funded by the Community Care Coordination Service at VA VISN 8 through the Rehabilitation Outcomes Research Center (RORC REAP) at N. Florida/S. Georgia VHS, Gainesville, FL.

The views expressed in this report are those of the authors and do not necessarily represent the views of Department of Veterans Affairs.

Background: ACSC & Preventable Hospitalization

   Hospitalizations for ACSCs may be prevented if timely and appropriate ambulatory care were accessible.

Barriers to accessibility include provider unavailability, costs, health insurance absence.

Improved access at community level would lower ACSC hospitalization.

References: 1) Weissman JS, et al. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland.

JAMA

. 1992;268:2388-2394 2) Bindman AB, et al. Preventable hospitalizations and access to health care.

JAMA

. 1995;274:305-311 3) Culler SD, et al . Factors related to potentially preventable hospitalizations among the elderly.

Med Care

. 1998;36:804-817 4) Friedman B, Basu J. The rate and cost of hospital readmissions for preventable conditions.

Med Care Res Rev

. 2004;61:225-240 5) Basu J, et al. Primary care, HMO enrollment, and hospitalization for ACSCs.

Med Care

. 2002;40:1260-1269

Background: Home Telehealth

    Application of modern telecommunications.

Link patients to out-of-home sources of care information, education, or service.

Medical benefit: early detect problems, frequently monitor conditions, increase access, improve care plan compliance. Home telehealth reduces inpatient & ER use within short-term.

References: 1) Koch S. Home telehealth--current state and future trends. Int J Med Inform. 2006;75:565-576 2) Hailey D, et al. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare. 2002;8 (Supplement 1):1-30 3) Barnett TE, et al. The effectiveness of a care coordination home telehealth program.. Am J Manag Care. 2006;12:467-474 4) Chumbler NR, et al. Evaluation of a home-telehealth program for veterans with diabetes. Eval Health Prof. 2005;28:464-478

Objective

 To test 4-year effect of a VA patient centered, care coordination/home telehealth (CCHT) program on potentially preventable hospitalization use by veteran patients diagnosed with diabetes mellitus.

Study Design

   Retrospective, matched treatment and control study design. Treatment group (n=387): DM patients, enrolled in the CCHT program at 4 VAMCs.

Control group (n=387): DM patients in the 4 VAMCs matched by a propensity score. References: 1) Barnett TE, et al. The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow up. Am J Manag Care. 2006;12:467-474 2) D'Agostino RB, Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17:2265-2281

VA CCHT Program

      Transition from hospital-based care to patient centered and ambulatory care.

Care coordination by nurse practitioner.

Disease monitoring using supportive home telemonitoring technology. Each enrollee has a messaging device installed at home using basic land-line telephone service. Daily basis: patients answer scripted questions from the messaging device about their diabetes symptoms and health status.

Care coordinators monitor the patients’ daily updates from the devices.

CCHT enrollment criteria

    Diagnosed with DM.

≥1-time VA hospitalizations or ≥1-time VA ER visits in 12 months prior to enrollment.

Non-institutionalized.

A telephone land-line at home.

Dependent Variable

   Semi-annual P.H. count by patient.

AHRQ defined 12 ACSCs and ICD-9 codes applied.

VA automated inpatient databases.

References: 1) AHRQ. Guide to prevention quality indicators: Hospital admission for ACSCs. March 12, 2007; Version 3.1

2) AHRQ. Prevention quality indicators: Technical specifications. March 12, 2007; Version 3.1

Independent & Covariates

    Treatment/CCHT enrollee: yes, no.

Baseline: age, gender, marital status, race, VA care priority, and study sites.

Pre-enrollment: 6-month comorbidity score, 12-month inpatient and outpatient use.

Post-enrollment: 4-year survival time in days.

Statistical Analysis

   Descriptive statistics.

Multicollinearity diagnostics.

A GLIMMIX to estimate the impact of the CCHT program on P.H. use over a period of 4 years, adjusting for patient characteristics and time.

Table 1.1. Baseline characteristics

(No sig. difference observed) Characteristics Age Male Being married White Hispanic High VA priority Site A Site B Site C Site D Study cohort (N=774) 67.6 (10.1) 98.3% 61.9% 39.4% 49.2% 97.9% 14.6% 14.5% 46.3% 24.7% Tx (n=387) 68.0 (9.2) 98.7% 64.3% 40.1% 48.8% 98.2% 15.3% 15.0% 46.1% 23.8% Ctrl (n=387) 67.2 (10.9) 97.9% 59.4% 38.8% 49.6% 97.7% 14.0% 14.0% 46.5% 25.6%

Table 1.2. Pre- & Post baseline Characteristics

Characteristics Pre-enrollment: Crude death rate † Survival days ‡ Study cohort (N=774) 6-m comorb score 12-m inpt. care use 12-m outpt. visit ‡ 4-year post-enrollment: 26.5(21.6) P.H. counts † 0.2(0.5) 0.8(1.3) 0.8(1.6) 22.9% 1314(330) † p value <0.05; ‡ p value <0.01; Tx (n=387) 0.3 (0.6) 0.7 (1.2) 30.3 (21.7) 0.7 (1.3) 19.4% 1349(266) Ctrl (n=387) 0.2 (0.5) 0.8 (1.5) 22.6 (20.8) 1.0 (1.9) 26.4% 1278(380)

Table 2. Freq of 4-year P.H. ACSCs occurrences by group

P.H. conditions/ACSCs

Diabetes long-term complications L. extremity amput. in DM pts Diabetes short-term complication Diabetes uncontrolled Bacterial pneumonia Angina Congestive heart failure Urinary infection C. obstructive pulmonary disease Dehydration Hypertension Adult asthma

Ctrl

121 55 28 15 34 19 67 31 14 9 5 2

Tx

42 29 7 4 22 8 84 33 31 11 3 1

Table 3. Results from a GLIMMIX

(dependent var=P.H. count) Characteristics Treatment: yes vs. no Time Treatment x time Age Male: yes vs. no Married: yes vs. no White: yes vs. no VHA priority high: yes vs. no 6-m prior comorbid score 12-m prior inpatient use 12-m prior outpatient visit Site A vs. C Site B vs. C Site D vs. C Relative Risk (95% CI) 0.36 (0.21-0.61) 0.88 (0.82-0.94) 1.15 (1.04-1.27) 1.02 (1.00-1.04) 1.35 (0.37-4.85) 0.54 (0.38-0.77) 0.64 (0.38-1.08) 0.87 (0.26-2.95) 1.54 (1.13-2.10) 1.57 (1.40-1.76) 1.01 (1.01-1.02) 0.97 (0.48-1.94) 1.68 (0.97-2.89) 1.50 (0.83-2.73) P value 0.0002

0.0002

0.0047

0.0217

0.6489

0.0006

0.0949

0.8284

0.0060

<.0001

0.0006

0.9255

0.0630

0.1818

Main Results

 

The linear mixed results suggest that the CCHT enrollees were less likely to be admitted for a P.H. (RR 0.36, p<0.05). The difference reduced as time progressed during the 4-year follow-up.

Limitations

   A single geographic region. VA healthcare system enrollees.

Patients with DM, a diagnosis associated with high rates of morbidity, mortality, and resource use.

Conclusions

  The VA CCHT program for diabetes patients reduced preventable hospitalizations overtime.

It may reduce healthcare cost.