The Government’s flagship telehealth strategy has suffered another blow as the DH-commissioned review revealed the pilot cost £92,000 per quality adjusted life year, almost three times the upper limit for cost effectiveness set by NICE.
The official evaluation of the Department of Health funded Whole Systems Demonstrator pilot showed the approach had just an 11% likelihood of proving cost-effective for the NHS at this threshold, when added to standard care.
The results put the DH’s policy to roll out telehealth to three million people by 2017 in doubt, and follow a stream of negative data from other trials that showed no effect on quality of life or psychological outcomes and that telecare had no effect on service use or costs.
It also comes weeks before GPs are offered a new DES to provide remote monitoring for patients with long-term conditions.
The London School of Economics researchers had reported preliminary figures last year that showed a cost per QALY of £88,000, but have revised this to £92,000 in the final results from their cost-effectiveness evaluation published online in the BMJ today.
The analysis was based on 965 patients out of the total of 3,230 patients in the telehealth arm of the WSD trial – 534 patients who received the telehealth intervention on top of standard care and 431 control patients who received standard care only.
The results showed that telehealth was associated with a small improvement in mean QALYs gained of 0.012 at 12 months. However, the net incremental cost-effectiveness ratio (ICER) per QALY gained by adding telehealth to usual care was £92,000.
Excluding management costs reduced the incremental cost per QALY gained to £79,000, in which case the probability of cost-effectiveness at a NICE willingness to pay threshold of £30,000 went up slightly to 17%. However, the probability would only exceed 50% at thresholds above £90,000 when management costs were included, and above £79,000 when excluding management costs.
If costs of equipment were reduced by 80%, the ICER fell to £52,000 per QALY, while the total annual costs of telehealth were estimated to be slightly lower assuming a service running at full capacity.
Assuming that reducing the unit costs and operating at the higher capacity would not change outcomes, combining these two aspects meant the cost of QALY dropped to just £12,000 per QALY. However, the authors report that even on this basis the total costs would not differ significantly between groups, so the probability of cost-effectiveness is still relatively low, at 61%.
The researchers conclude: ‘A community-based, telehealth intervention is unlikely to be cost effective, based on health and social care costs and outcomes after 12 months and the willingness to pay threshold of £30,000 per QALY recommended by NICE.’
Speaking to Pulse, Professor Martin Knapp said the government’s commitment to telehealth ‘is a gamble’ but that he believes the ‘future is telehealth – it’s just we’re not there yet’.
He said the government is likely ‘taking the long view that things in the economy will get worse before they get better and telehealth is probably an affordable way for us to try to assess and meet the needs of individuals’.
However, GPC member Dr Beth McCarron-Nash questioned the wisdom of continuing to expand the commissioning of telehealth services before further evaluation.
She commented: ‘I think we have to be very careful that telehealth is not pushed as the answer to everything when on the contrary the evidence so far suggests we need to get much better at selecting the type of patients appropriate for managing in this way for it to be of real value.’
‘Best practice is to pilot and find out if something is effective – if as part of that you find it isn’t effective, the answer isn’t just to continue regardless and find out as you go along,’ she added.
Dr McCarron-Nash also warned of the potential risks of decommissioning other community services in order to fund telehealth. She said it was ‘madness’ to keep ploughing NHS money into telehealth ‘without evidence it can deliver at a time when we are facing massive cuts to frontline staff and services’.
‘We need to start questioning these political decisions – why services are being commissioned when there is no evidence that they are going to improve patient care’ said Dr McCarron-Nash.
The Department of Health maintained that its telehealth strategy would prove cost-effective. A spokesperson said: ‘This is only one part of a much wider study carried out between 2008 and 2010. The whole study showed that using telehealth reduces mortality by 45%, A&E attendances by 15% and emergency admissions by 20%.
‘This part of the study confirms that to introduce the technology in isolation, at high cost and in low numbers does not bring the cost reductions we believe are there to be made. That is why our approach, known as the 3millionlives initiative, is different. It is about bringing in telehealth at scale and will create improvements in services, care and costs.’