The National Telehealth Webinar Series Presented by The ... · Cost for 1 clinician kit ($5760) and 1 patient kit ($7200) amortized over 3 years based on 50% of usage per week $ per

The National Telehealth Webinar Series Presented by The National Network of Telehealth Resource Centers

Vice-dean, Dir., & Prof., School of Rehabilitation, Faculty of Medicine & Health Science. Université de Sherbrooke, Quebéc, Canada Research chair in-home telerehabilitation, Research Centre on Aging at CSSS –IUGS Michel. [email protected]

Assoc. Prof., Orthopedic Surgery. Faculty of Medicine & Health Science . Université de Sherbrooke, Quebéc, Canada FRQS Sr. Research Scholar, Research Centre on Aging at CSSS –IUGS & the Interdisciplinary Institute of Technological Innovation [email protected]

IN-HOME REHABILITATION AFTER KNEE JOINT REPLACEMENT SURGERY : THE EFFECTIVENESS OF

DELIVERY VIA TELEHEALTH Webinar for National Network of Telehealth Resources Centers

Patrick Boissy PhD Michel Tousignant PT, PhD

© BOISSY & TOUSIGNANT 2015 © BOISSY & TOUSIGNANT 2015

Sherbrooke The town

The universities

Bishop university

Université de Sherbrooke (3 campus)

Aging & CSSS-IUGS 3IT


The TELAGE RCT AND TEAM

Hélène Moffet, PT, PhD Michel Tousignant, PT, PhD

Sylvie Nadeau, PT, PhD Chantal Mérette, PhD

Patrick Boissy, PhD Hélène Corriveau, PT, PhD

François Marquis, MD François Cabana, MD

Pierre Ranger, MD Étienne Belzile, MD

Pascale Larochelle, MD Ronald Diementberg, MD

Funded 2009-2013

‘ Effectiveness of in-home telerehabilitation after total

knee arthropplasty: a multicentre

randomized control trial’

© BOISSY & TOUSIGNANT 2015

Overview of webinar on in-home telerehabilitation

ANSWERS TO 6 QUESTIONS �  What is it ? �  How is it done ? �  Can it be done ? �  Does it work ? �  How much does it cost ? �  Where do we go from now ?


In-Home Telerehabilitation

2007-2013 2013-


•  Rehabilitation provided through home visits is part of

the continuum of care after discharge from hospital following total knee arthroplasty (TKA).

•  As demands for rehabilitation at home are growing and becoming more difficult to meet in-home telerehabilitation is considered as an alternate service delivery method…

•  Small studies shows promises but there is a need for robust data concerning, the reliability, efficacy and the cost of dispensing in-home telerehabilitation.

Rational and objectives for TELAGE RCT

TELAGE was designed as an non-inferiority RCT to document these variables.


Design, intervention and endpoints of TELAGE RCT

•  The rehabilitation interventions (TELE, STD) included 16 sessions of about 45 minutes to one hour, supervised by a trained physical therapist.

•  The components of the intervention were: a pre- and post-exercise assessment (structured interview and observation), supervised exercises during a period of about 30 minutes (mobility, strengthening, function and balance), prescription of home exercises to perform on days without supervised sessions, and advice concerning pain control, walking aids and the return to activities


Characteristic Standard Rehabilitation

(N = 101) Telerehabilitation

(N = 104) P Value Age — yrs 67±8* 65±8 0.13

Male sex — no. (%) 56 (55) † 44 (42) 0.06 Body-mass index (BMI) — kg/m2 33±6 34±7 0.13

Comorbidity per patient— mean no. 0.2±0.1 0.2±0.1 0.15 Functional status and Quality of life

WOMAC score — % Pain 53±17 53±20 0.96

Stiffness 47±24 49±22 0.56 Function 55±18 54±20 0.60

Total 54±17 53±19 0.73 KOOS score — %

Symptoms 54±19 53±18 0.64 Pain 47±16 47±19 0.87

Activities of daily living 55±18 54±20 0.65 Sports and recreational

activitiesI 11±12 16±19 0.08

Quality of life 29±18 28±20 0.55 Range of motion — degrees

Flexion - operated knee 115±13 114±15 0.56 Extension- operated knee -6±6 -5±5 0.34 Isometric strength — Nm In flexion- operated knee At 60 degrees of flexion 53±29 49±24 0.26 At 30 degrees of flexion 61±34 56±28 0.27

In extension- operated knee At 60 degrees of flexion 108±58 103±52 0.59 At 30 degrees of flexion 73±37 70±33 0.51

Baseline characteristics of patients

•  Socio demographics and baseline values on primary clinical outcomes mesures were similar.


In-Home telerehabilitation - Can we do it ?

But

From a technology standpoint

Adapted from LeRouge (2002) Quality Attributes in Telemedicine Video Conferencing.


Variables All sites (n=97)

QC (n=27)

SHER (n=55)

MTL (n=13)

New Internet connexion (% new)

73% 76% 69% 82%

Type of Internet connexion (% cable)

84% 68% 87% 100%

Total technician time (AVG minutes, SD)

308.4 minutes (122.9)

254 minutes (90.3)

325.7 minutes (131.5)

333.0 minutes (117.9)

Number of TELE sessions performed

1433 sessions

364 sessions

831 sessions

238 sessions

Completed TELE sessions (AVG % of planned sessions, SD)

96,5 % (9.1)

94,1% (13.9)

96,4% (9.0)

91,1% (9.1)

Live time (minutes) per TELE session (AVG minutes, SD)

44.7 minutes (10.7)

45.0 minutes (14.8)

44.3 minutes (8.18)

45.9 minutes (11.1)

Dead time per TELE session (AVG minutes, SD) * includes waiting for remote site to connect

4.9 minutes (28,9)

7.3 minutes (41.1)

4.1 minutes (27,4)

4.2 minutes (13.7)

Connection interruptions per TELE session (% yes, % occurrence frequency)

21%=yes 15%=1 4%=2 2%>2

11%=yes 7%=1 3%=2 1%>2

25%=yes 17%=1 5%=2 3%> 2

24%=yes 18%=1 4%=2 2%> 2

TELE session requiring technician intervention before, during or after session (% yes, % occurrence frequency)

43% = yes 13%= 1 17%=2 13%>2

24%=yes 12%=1 12%=2 0% >2

55%=yes 18%=1 16%=2 21%>2

30%=yes 24%=1 0%=2 6%> 2

Time of technician intervention (AVG minutes, SD)

2.8 minutes (6.1)

2.1 minutes (6.7)

3.0 minutes (6.1)

2.8 minutes (5.6)

!

Reliability of service delivery and technology

•  Ressource intensive to install and de-install but excellent reliability •  Tech support presence needed but low usage


Technological impacts on clinical objectives and video mediated communications

•  Ressource intensive to install and de-install but excellent reliability •  Tech support presence needed but low usage

From a scale of 0 to 10, where 0 corresponds to “not at all” and 10 corresponds to “completely”, where you able to complete the clinical objectives of the session ?

From a scale of 0 to 10, where 0 corresponds to “impossible” and 10 corresponds to “very good”, how did you appreciate the relationship and communication with the patient during the session ?

From a scale of 0 to 10, where 0 corresponds to “very unsatisfied” and 10 corresponds to “very satisfied”, what is your evaluation of the global satisfaction of the flow of the session ?

Clinical objectives Flow of the session Relationship with patient

Scores 0-10 on question after each session

Clinical Objectives (% of total

session)

Flow of communication

(% of total session)

Relationship with the patient

(% of total session)

Score 0-5 2.5% 0.5% 1.8% Scores 6-7 5.7% 4.2% 5.6% Scores 8-9 37.2% 42.8% 41.7% Scores 10 54.6% 52.5% 51.2%

!


Patients’ impressions of risks and benefits* * French adaptation of Demeris et al. A questionnaire for the assessment of patients’ impressions of the risks and benefits of home telecare. Journal of Telemedicine and Telecare 2000; 6: 278–284

Highly positive impression before and after receiving telerehabilitation services Lowest scores on human factors questions

76 and 77%


Patient’s satisfaction of telerehabilitation*

•  High satisfaction rate (94% avg) after receving in-home telerehabilitation

* French adaptation of Yip et al. Development of the Telemedicine Satisfaction Questionnaire to evaluate patient satisfaction with telemedicine: a preliminary. Journal of Telemedicine and Telecare 2003; 9: 46–50


In-Home telerehabilitation – Does it work ?


Efficacy* of TELE vs STANDARD for TKA

In-home telerehabilitation for primary outcomes studied is as effective as STANDARD (face to face ) intervention !

In-home telerehabilitation for primary outcomes studied is as effective as STANDARD (face to face) intervention (per protocol and Intent to treat analyses)

The gain in the TELE group was evaluated as non-inferior only if the intergroup mean difference and its 95% confidence interval (one side) are less than 9% at the last follow-up (E4): H0 : µSTD-µTELE ≥ 9%; H1: µSTD-µTELE < 9%.


Same results for secondary outcomes !


Adverses events STANDARD vs TELEREHAB

Adverse events not related to intervention No differences between TELE and STANDARD intervention


How much does it cost in comparison to standard care ?


Types of economical evaluations for telehealth intervention ?

(Drummond, 1997)


No difference in "consequence" between the interventions

Economical evaluation in TELAGE RCT ?


No difference in "consequence" between the interventions

Cost Minimization

Economical evaluation in TELAGE RCT ?


Time (minutes) Distance (Km)

Travel Treatment

Time (minutes)

Time (minutes) Distance (Km)

Time (minutes)

Installation /desinstallaton

After each intervention

Costing data collection


CLINICAL COSTS TELE VISIT

Description Duration

Professional Cost Duration x hourly wagea


Direct

time

Contact with the participant

Hours # Hours x $ per hour # Hours x $ per hour

Indirect

time

Planning the session Hours # Hours x $ per hour # Hours x $ per hour

Follow-up with orthopedic surgeon


Writing the report and follow-up notes

Hours # Hours x $ per hour

# Hours x $ per hour

Travel Hours # Hours x $ per hour Km x $0.40

Clinical equipment amortization

$/ 16 tx $ per treatment $ per treatment

Clinical costs breakdown


CLINICAL COSTS TELE VISIT

Description Duration



Direct

time

Contact with the participant


Indirect

time

Planning the session Hours # Hours x $ per hour # Hours x $ per hour

Follow-up with orthopedic surgeon


Writing the report and follow-up notes

Hours # Hours x $ per hour

# Hours x $ per hour

Travel Hours # Hours x $ per hour Km x $0.40

Clinical equipment amortization

$/ 16 tx $ per treatment $ per treatment

Clicial costs breakdown


TECHNOLOGY COSTS

TELE VISIT

Un/Installation of technology Travel time x $ hour b and km x $0.40/km

-

Internet costs (high speed): Cost for 2 months / 16 sessions

$ per intervention -

Technical equipment amortization: Cost for 1 clinician kit ($5760) and 1 patient kit ($7200) amortized over 3 years based on 50% of usage per week

$ per intervention -

Technical problems

Technician Hours x $ hour -

Physiotherapist Hours x $ hour -

Costs breakdown per participant


Costs of telerehabilitation and home visits


Costs of telerehabilitation and home visits


Costs differential between telerehabilitation and home visits


Home Visits Telerehabilitation

Costs breakdown per treatment


Home Visits Telerehabilitation

Costs breakdown per treatment


What we have learned form TELAGE RCT ? We must decrease the reluctance of clinicians toward TELE

Training (brief) to use the platform Training to think different… «being creative» in delivering treatment & exercises

Technology support (minimal) is essential If a problem arise = being able to reach a technician «right now» !!

Contact with Internet Service Provider is essential Time between discharge from hospital and beginning treatment may be minimal = we must have «special access» to connect the home to internet without delay

To begin a new project in clinical setting… is not easy Contact and support of direction and staff of IT department of the health care center is crucial Strong commitment from stakeholders (administration) is crucial to implement TELE because we must «gently push» on the culture of change of the clinicians and managers J


On-going projects in telerehabilitation

Tai Chi for with post-CVA patients

Rehabilitation for COPD patients

Rehabilitation for COPD patients


Wrap up & conclusions •  In home telecare services for physical rehabilitation can be

delivered reliably and that this mode of delivery is well accepted by clinicians and patients.

•  The evidences of non-inferiority compared to face to face interventions for post TKA rehabilitation support its use clinically and make a good argument to evaluate this mode of service delivery for more patient populations and conditions.

•  Cost analyses results for post TKA rehabilitation suggest that depending on the intensity of the services provided and the distance between the provider and the patient, significant saving can be achieve…

•  As the performance and prices of the technological infrastructure and equipment need to support in-home telerehabilitation are constantly improving cost of service delivery will go down.

It’s time for program evaluation and pragmatic trials on in-home telerehabilitation…


36

Acknowledgements & Questions

Michel Tousignant, PT, PhD [email protected] Tel: (819) 780 -2220 ext. 45628 (CDRV) Tel: (819) 821-8000 ext. 65717 (3IT) Skype: patrickboissy

•  The Telage team members •  The clinicians and patients who participated •  Research personnel at research centre on aging Funding:

Patrick Boissy Ph.D. [email protected] Tel: (819) 780 -2220 ext. 45628 (CDRV) Tel: (819) 821-8000 ext. 65717 (3IT) Skype: patrickboissy

Research chair on telerehabilitation

Telage RCT

PBOISSY Research Scholar

The National Telehealth Resource Center Webinar Series

3rd Thursday of every month Next Webinar:

Topic: Telehealth Security & Breaches: What Last Year’s Problems Tell Us About Future Threats Presenter: Garret Spargo, National Telehealth Technology Assessment Resource Center Date: Thursday, February 19, 2015 Times: 9:00AM HST, 10:00AM AKST, 11:00AM PST, 12:00PM MST, 1:00PM CST, 2:00PM EST

Your opinion of this webinar is valuable to us. Please participate in this brief perception survey: http://www.surveymonkey.com/s/NationalTRCWebinarSeries

TRC activity is supported by grants from the Office for the Advancement of Telehealth, Office of Health Information Technology, Health Resources and Services Administration, DHHS

Documents

The National Telehealth Webinar Series Presented by The ... · Cost for 1 clinician kit ($5760) and 1 patient kit ($7200) amortized over 3 years based on 50% of usage per week $ per