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Whole System Demonstrator Trial Evaluation of T elehealth & 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 - PowerPoint PPT Presentation
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Whole System Demonstrator TrialEvaluation 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 SciencesCity University London
and Manchester University
• 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
STRUCTURE OF TALK
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
Social Care needs receive usual care
(CONTROL GROUP)
LTCs receive telehealth LTCs receive telehealth
Social Care needs receive telecare
LTCs receive usual care (CONTROL GROUP)
Social Care needs receive telecare
LTCs receive usual care(CONTROL GROUP)
Group A Group B Group C Group D
Social Care needs receive usual care
(CONTROL GROUP)
Cornwall Kent Newham0
200
400
600
800
1000
12001117
1057
775
1111
1010
760
Control InterventionControl2949
1
Intervention2881
0
Cornwall; 2228; 38%
Kent; 2067; 35%
Newham; 1535; 26%
Total Numbers recruitedTarget 5721 Recruited: 5831
TeleHealth323055%
TeleCare260045%
TeleHealth TeleCare0
250
500
750
1000
1250
1500
1750
1625
1324
1605
1276
Control Intervention
Total Numbers recruited
Cornwall; 756; 27%
Kent; 1209; 44%
Newham; 801; 29%
Control1367
0
Intervention1399
1
Cornwall Kent Newham0
100
200
300
400
500
600
700
372
592
403384
617
398
Control Intervention
Questionnaire StudiesNumber of Participants
COPD57837%
Diabetes45529%
HF54034%
COPD Diabetes HF0
50
100
150
200
250
300
350
400
244
209
275
334
246265
Control Intervention
Questionnaire StudiesNumber of Participants
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/december_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
WSDQualitative 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%)No longer wishes to be in the intervention group and rejects the equipment after trying for a period 19 (0.73%) 211 (6.53%)
No longer wishes to share data 0 6 (0.19%)No longer wishes to participate as questionnaire is too onerous 7 (0.27%) 8 (0.25%)
Moved out of area to non-participating GP practice 19 (0.73%) 33 (1.02%)Absence from home or loss of contact 10 (0.38%) 12 (0.37%)Problem with equipment (e.g. equipment broken, no longer working, misused) 3 (0.12%) 11 (0.34%)
No reason given 8 (0.31%) 15 (0.46%)
Significant predictors of withdrawal from Telecare
1. women less likely to withdraw
2. intervention participants less likely to withdraw
3. younger less likely to withdrawolder age categories increased the odds of withdrawal
4. Non-white British ethnic group less likely to withdraw
5. more co-morbid conditions greater chance of withdrawal
Effect B (S.E.) Wald Df Sig. Change in Odds
Lower CI
Upper CI
Completed trial(N/Mea
n)
Withdrew(N/Mean)
FemaleMale
-.369(.120) 9.497 1 .002 .691 .547 .874 1532696
228144
Intervention Control
-.409 (.117) 12.308 1 .001 .664 .528 .835 11261102
150222
Age 18-5975-7980-8485-8990+
.657 (.244)
.482 (.240)
.941 (.230)1.201 (.253)
7.2334.023
16.77122.558
71111
.007
.045
.001
.001
1.9301.6192.5643.325
1.1951.0111.6342.025
3.1162.5934.0235.458
347298417393194
3056649456
White BritishNon-white -.611 (.280) 4.748 2 .029 .543 .313 .940
1755230
32519
Number of co-morbidities
.106 (.038) 7.609 1 .006 1.111 1.031 1.198 1.03 1.30
Predictors of withdrawal from TelecareOdds ratios for factors in relation to
the odds of withdrawing
Negelkerke’s adjusted R2=.063
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
EffectB (S.E.) Wald Df Sig. Change
in OddsLower
CIUpper
CI
Completed trial(N/Me
an)
Withdrew(N/Mean)
Intervention Control
.721 (.097) 55.638 1 .000 2.057 1.702 2.487 1230 1406
375 219
Age 18-5970-7475-7980-8485-8990+
.037 (.176)
.342 (.175)
.715 (.180)
.831 (.216)
.0453.807
15.84614.854
7111
.832
.051
.000
.000
1.0381.4082.0442.295
.736
.9981.4381.504
1.4651.9842.9073.502
478 477 434 310 144 37
83 86 105 110 55 17
White BritishNon-white
-.265 (.173)
2.348 1 .125 .767 .546 1.0772018 310
497 57
Number of co-morbidities
.062 (.031) 4.111 1 .043 1.064 1.002 1.1301.70 2.07
Deprivation deciles – lowest thru to highest
.074 (.150)
.231 (.151)
.019 (.161)
.747 (.154)
.2412.326
.01323.471
5111
.623
.127
.909
.000
1.0771.2591.0192.110
.802
.936
.7431.560
1.4461.6931.3972.855
543542501563476
12311111493
152
Predictors of withdrawal from TH:Odds ratios for factors in relation to
the odds of withdrawing
Negelkerke’s adjusted R2=.081
TeleHealth157357%
TeleCare119343%
TeleHealth TeleCare0
200
400
600
800
1000
728
639
845
554
Control Intervention
Questionnaire StudiesNumber of Participants
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%)No longer wishes to be in the intervention group and rejects the equipment after trying for a period 19 (0.73%) 211 (6.53%)
No longer wishes to share data 0 6 (0.19%)No longer wishes to participate as questionnaire is too onerous 7 (0.27%) 8 (0.25%)
Moved out of area to non-participating GP practice 19 (0.73%) 33 (1.02%)Absence from home or loss of contact 10 (0.38%) 12 (0.37%)Problem with equipment (e.g. equipment broken, no longer working, misused) 3 (0.12%) 11 (0.34%)
No reason given 8 (0.31%) 15 (0.46%)
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
Effect B (S.E.) Wald Df Sig. Change in Odds
Lower CI
Upper CI
Completed
trial(N/Mean)
Rejected Kit
(N/Mean)
Telehealth 2.314 (.243) 90.636 1 0.01 10.118 6.283 16.294 1230 210
Telecare 1126 19
Amount of TH Kit
0.722 (0.064) 126.881 1 <0.001 2.058 1.815 2.333 1.38 2.63
Amount of TC Kit
-0.616 (0.074) 70.153 1 <0.001 0.540 0.467 0.624 1.73 0.30
Predictors of Rejecting the kit:Odds ratios for factors in relation to the odds of rejecting the equipment
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.
WSD QuestionnairesCognitive measures
SCB-SES Self-care Behaviours Self Efficacy Scale - examines individuals confidence in performing self-care behaviours
Generalised SES Generalised Self Efficacy Scale - assesses optimistic self-beliefs 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 Scale
Measures the degree that illness/problems interferes with 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
copd - 215 diabetes- 95 heart failure- 168
cornwall - 169 kent -218 newham - 91
mean age = 70.92 years (9.93)
pulse oximeter glucometer weight scales
mean experience with kit = 126 days (23.9)
average items of kit = 2.71 (0.61)
478 TH participants receiving telehealth kit for minimum 90 days- WSD
female - 182 male - 296
Sub-Scale Scores
Enhanced Care Increased Accessibility
Privacy & Discomfort
Care Personnel Concerns Kit as substitution Satisfaction
mean=4.80, SD=1.03 mean=4.13, SD=1.33 mean=1.94, SD=1.01
mean=2.43 SD =1.17 mean=3.35 SD =1.21 mean= 5.29 SD =0.93
enhanced care increased accessibility privacy/discomfort care personnel concerns kit as substitution satisfaction
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
* p < 0.05
* p < 0.05
strongly agree
strongly disagree
mildly agree
moderately disagree
moderately agree
mildly disagree
6
1
4
2
5
3
4.858 4.164a,b 1.833a 2.346 3.434 5.3674.743 4.382a 2.150b 2.498 3.112 5.1374.752 3.949b 1.966a,b 2.496 3.385 5.266
Sub-Scale differences by long term condition
enhanced care increased accessibility privacy/discomfort care personnel concerns kit as substitution satisfaction
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
** p < 0.001
p > 0.05 ** p < 0.001
** p < 0.001
** p < 0.001
** p < 0.001
strongly agree
strongly disagree
mildly agree
moderately disagree
moderately agree
mildly disagree
6
1
4
2
5
3
Predictive validity of acceptability: SUTAQ sub-scale differences in rejecters of kit
and completers
4.872 4.219 1.877 2.390 3.407 5.3603.740 2.917 2.767 2.811 2.544 4.411
Thank you