Evaluation of Pediatric Telemedicine Using Health and Economic Methods

• Main Author: Yang, Hsuan-Hui Nikki
• Format: Dissertation
• Language: English
• Published: ProQuest Dissertations & Theses 01.01.2014
• Subjects: Epidemiology; Medicine; Public health
• ISBN: 1321213352; 9781321213355

Telemedicine is defined as the exchange of medical information from one site to another using electronic communication to improve patient's health status. The applications of telemedicine include many models of care, but are frequently used in the inpatient setting, the outpatient setting, emergency departments, and home health. Novel telehealth program specific to the University of California Davis Children's Hospital (UC Davis Children's Hospital) include the use of telemedicine to connect hospitalized patients and their family and friends, and delivery of specialty consultations in emergency departments. However, there are limited data and studies that examine the impact of telemedicine in these settings, specifically how telemedicine can impact the pediatric hospitalized patient's experience, health outcomes for children seen in emergency departments, and economic outcomes of telemedicine when used to provide consultations to the emergency departments. Therefore, we evaluated the impact of telemedicine on these clinical and economic outcomes with various perspectives and analyses. First, we evaluated the impact of telemedicine on the reduction in stress experienced by hospitalized children in an urban hospital setting. University of California Davis Children's Hospital has established the Family-Link program, a videoconferencing program, to allow hospitalized children and their parents to virtually visit family members and friends using laptops, webcams, and a secure Wi-Fi connection. We examined the association of patient age, gender, length of hospitalization, and distance from children's home to the hospital with the children's level of stress through a propensity score matching model. We found that the use of Family-Link was significantly associated with a greater reduction in overall mean stress during hospitalization compared to non Family-Link users. In this cohort, the reduction in overall mean stress was 37% greater among Family-Link users than non Family-Link users. Second, we evaluated the impact of telemedicine consultations that are provided to acutely ill and injured children presenting to rural emergency departments (ED). We examined the association between patients receiving telemedicine on the appropriateness of hospital admission. In this retrospective cohort study of 138 acutely ill and injured children who presented to the rural EDs between 2003 and 2012, 74 children received telemedicine pediatric critical care consultations and 64 children received telephone pediatric critical care consultations. We further calculated and compared the overall and stratified (low and high risk for admission) observed to expected hospital admission ratios (O/E admission ratios) between the telemedicine and telephone cohorts by calculating the risk of admission using the Pediatric Risk of Admission (PRISA II) and the Revised Pediatric Emergency Assessment Tool (RePEAT). We found that the telemedicine cohort experienced a trend towards lower and more favorable overall O/E admission ratios compared to the telephone cohort. Telemedicine consultations resulted in more appropriate hospital admissions by 8.4% using PRISA II and 2.4% using RePEAT. We also found a higher rate of appropriate admissions when we stratified the patient populations into low and high risk of admission cohorts. Telemedicine consultations again resulted in more appropriate hospital admission for both PRISA II (low risk: 23.9%; high risk: 9.3%) and RePEAT (low risk: 14.7%; high risk: 19.9%) Lastly, we conducted an economic evaluation to estimate the cost, effectiveness, and return on investment (ROI) of the telemedicine program that provides consultations to acutely ill and injured children presenting to rural EDs. We conducted these analyses comparing the telemedicine model of care to telephone consultations, the current standard of care, from a health care system perspective. We found that the average cost for a telemedicine consultation was $3,238 per child/ED/year in 2009 US dollars. Telemedicine consultations resulted in 31% fewer patient transfers compared to telephone consultations, resulting in a cost reduction of $4,146 per child/ED/year. Our probabilistic CEA demonstrated that telemedicine consultations were less costly than telephone consultations in 53% of simulation iterations. The ROI was calculated to be 1.28 ($4,146/$3,238) from the base-case analysis and estimated to be 1.46 from the probabilistic analysis, suggesting a $1.46 return for each dollar invested in telemedicine. Treating ten acutely ill and injured children at each rural ED with telemedicine resulted in an annual cost-savings of $41,460 per ED. In conclusion, the findings from these studies significantly contribute to current knowledge of pediatric telemedicine in both urban and rural hospital settings. The results demonstrate that the use of telemedicine in pediatric care not only help improve pediatric patients' quality of care, but also help reduce disparities in access to specialist physicians for acutely ill and injured children in rural areas. Moreover, our study findings in economic evaluation have important implications for clinicians, health administrators, and policy makers considering implementing similar telemedicine care models for children living in rural communities. (Abstract shortened by UMI.)