BackgroundTelehealth (TH) and telecare (TC) interventions are increasingly valued for supporting self-care in ageing populations; however, evaluation studies often report high rates of non-participation that are not well understood. This paper reports from a qualitative study nested within a large randomised controlled trial in the UK: the Whole System Demonstrator (WSD) project. It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial.MethodsQualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention (n = 19), or who withdrew from the intervention arm (n = 3). Participants were recruited from the four trial groups (with diabetes, chronic obstructive pulmonary disease, heart failure, or social care needs); and all came from the three trial areas (Cornwall, Kent, east London). Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home. Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes.ResultsBarriers to adoption of TH and TC associated with non-participation and withdrawal from the trial were identified within the following themes: requirements for technical competence and operation of equipment; threats to identity, independence and self-care; expectations and experiences of disruption to services. Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderstandings. Respondents’ views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping. Finally, participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued.ConclusionsThese findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake. These insights have implications for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction. It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation.
Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.Design Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat. Setting 179 general practices in three areas in England.Participants 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009. InterventionsTelehealth involved remote exchange of data between patients and healthcare professionals as part of patients' diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.Main outcome measure Proportion of patients admitted to hospital during 12 month trial period.Results Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P<0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P=0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference −0.64 days, −1.14 to −0.10, P=0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group. ConclusionsTelehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect. Trial registration number International Standard Randomised ControlledTrial Number Register ISRCTN43002091. IntroductionEfforts worldwide are dealing with the increasing prevalence of chronic disease among an ageing population. The past decade RESEARCHhas seen the growing use of telehealth as one possible approach to this problem. Telehealth involves the remote exchange of data between a patient and healthcare professionals as part of the patient's diagnosis and healthcare management. 1 2 Examples include the monitoring of blood pressure and blood glucose. Telehealth m...
This article describes a systematic review on the research into postoperative cognitive dysfunction (POCD) in noncardiac surgery to ascertain the status of the evidence and to examine the methodologies used in studies. The review demonstrated that in the early weeks after major noncardiac surgery, a significant proportion of people show POCD, with the elderly being more at risk. Minimal evidence was found that patients continue to show POCD up to 6 months and beyond. Studies on regional versus general anesthesia have not found differences in POCD. Many studies were found to be underpowered, and a number of other methodologic difficulties were identified. These include the different types of surgery in studies and variations in the number and range of neuropsychological tests used. A particular issue is the variety of definitions used to classify individuals as having POCD.
Objective To examine the costs and cost effectiveness of telehealth in addition to standard support and treatment, compared with standard support and treatment.Design Economic evaluation nested in a pragmatic, cluster randomised controlled trial.Setting Community based telehealth intervention in three local authority areas in England.Participants 3230 people with a long term condition (heart failure, chronic obstructive pulmonary disease, or diabetes) were recruited into the Whole Systems Demonstrator telehealth trial between May 2008 and December 2009. Of participants taking part in the Whole Systems Demonstrator telehealth questionnaire study examining acceptability, effectiveness, and cost effectiveness, 845 were randomised to telehealth and 728 to usual care.Interventions Intervention participants received a package of telehealth equipment and monitoring services for 12 months, in addition to the standard health and social care services available in their area. Controls received usual health and social care.Main outcome measure Primary outcome for the cost effectiveness analysis was incremental cost per quality adjusted life year (QALY) gained. ResultsWe undertook net benefit analyses of costs and outcomes for 965 patients (534 receiving telehealth; 431 usual care). The adjusted mean difference in QALY gain between groups at 12 months was 0.012. Total health and social care costs (including direct costs of the intervention) for the three months before 12 month interview were £1390 (€1610; $2150) and £1596 for the usual care and telehealth groups, respectively. Cost effectiveness acceptability curves were generated to examine decision uncertainty in the analysis surrounding the value of RESEARCHthe cost effectiveness threshold. The incremental cost per QALY of telehealth when added to usual care was £92 000. With this amount, the probability of cost effectiveness was low (11% at willingness to pay threshold of £30 000; >50% only if the threshold exceeded about £90 000). In sensitivity analyses, telehealth costs remained slightly (non-significantly) higher than usual care costs, even after assuming that equipment prices fell by 80% or telehealth services operated at maximum capacity. However, the most optimistic scenario (combining reduced equipment prices with maximum operating capacity) eliminated this group difference (cost effectiveness ratio £12 000 per QALY). ConclusionsThe QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment.Trial registration ISRCTN43002091.
This is the unspecified version of the paper.This version of the publication may differ from the final published version. Permanent repository link Abstract Objectives/HypothesesThe objectives of this study were to determine appropriate acoustic and outcome measures for the evaluation of a method of laryngeal manual therapy (LMT) used in the treatment of patients with muscle tension dysphonia (MTD). The effects of this technique was also investigated. The study was based on the hypotheses that the vertical position of the larynx in the vocal tract would lower, that the quality of the voice would normalize, and that a reduction in any vocal tract discomfort would occur following LMT. Study designThis was a small, prospective, repeated measures pilot study in which each member of the research team was 'blinded' to all other stages of the study and during which all data were anonymized until the final stage of data analysis. MethodsTen subjects presenting with MTD completed outcome measures and provided audiorecordings immediately before, immediately after and one week after LMT. The Kay CSL 4150 was used for acoustic and spectrographic measurements. A new perceptual, self-rating scale, the Vocal Tract Discomfort Scale, and a new proforma for use by the clinician for palpatory evaluation, were developed for the study. ResultsRelative average perturbation during connected speech was significantly reduced following LMT, indicating a reduction in abnormal vocal function. The severity and frequency of vocal tract discomfort was shown to have reduced following LMT. ConclusionsThis pilot study showed positive evidence for laryngeal manual therapy as a method of therapy in the treatment of hyperfunctional voice disorders. Its effects were shown to be measurable with both acoustical analysis and the Vocal Tract Discomfort scale.
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