An Economic Evaluation of Telemedicine to Provide Specialist Advice in Paediatric Cardiology (The TelePaed Project)
Paediatric and Fetal Cardiology
Serious congenital heart defects are usually detected in the first days following birth, although, as antenatal screening techniques improve, cardiac anomalies are increasingly being detected during pregnancy and expectant mothers may be referred to perinatal cardiologists for assessment. Older children with asymptomatic heart murmurs are likely to be referred to paediatric cardiologists for screening.
There are 15 paediatric cardiology / cardiac surgery units in the study and most hold outreach clinics in district hospitals on a monthly, bi-monthly or quarterly basis. Situations arise, however, when pregnant women with a suspected fetal heat anomaly or very ill newborn babies and children urgently travel to tertiary centres for investigation and treatment. These various clinical and resource factors make paediatric and perinatal cardiology particularly suitable for telemedicine. The technology could impact on costs (costs incurred directly by the NHS and costs incurred by patients and their families), and on patient outcomes (reduced level of morbidity, mortality, and anxiety in patients and parents). Acceptance and satisfaction with the technology by patients, parents and staff is also important in determining the future of telemedicine within the NHS.
Commissioned as part of the NHS Information and Communication Technology Research Initiative, this project examined whether, from NHS and patient perspectives, the use of telemedicine was cost-effective when compared to conventional methods for obtaining specialist advice in paediatric and fetal cardiology.
Telemedicine links were established between four district general hospitals (DGHs) in Essex and Kent and the paediatric cardiology centre at the Royal Brompton to enable district obstetricians and paediatricians obtain advice on diagnoses and management for three groups of patients:
The economic evaluation aimed to:
- Pregnant women with suspected fetal heart defects identified during routine 18-20 week ultrasound screening;
- Newborn premature and term babies suspected of having a heart problem;
- Older babies, toddlers and children with suspected heart problems.
A pragmatic study design of comparing patterns of practice in intervention and control sites was adopted using hospitals as study units. Two DGHs were `early’ users of the telemedicine service and two were `late’ users. Telemedicine equipment capable of real time transference and 'store and forward' transmissions using ISDN-6 telephone lines was installed in the DGHS to complement the outreach clinics, which continued as before. Fieldwork was conducted over 18 months:
- To identify NHS costs and indirect costs associated with both the telemedicine service and conventional referral practice;
- To assess the health-related quality of life of patients receiving telemedicine and patients not receiving telemedicine using validated health status instruments.
- To assess patient / parental satisfaction with specialist face-to-face consultations and with teleconsultations.
- A three-month phase when the telemedicine equipment was set up in the DGHs, and clinical events and resources used by patients newly assessed by the specialists were audited;
- A six-month 'intervention' phase when the telemedicine service operated in two hospitals and the audit continued. Postal surveys of expectant mothers, and mothers of infants and children were carried out to assess health-related quality of life, estimates of families' out-of-pocket expenses associated with hospital care, and opinions on the acceptability of telemedicine.
- A six-month 'service' phase when all four DGHs used the telemedicine service and the audit and postal surveys continued.
- A three-month 'follow-up' phase.
Reports and publications
Patterns in the uptake of the telemedicine services for fetal, neonatal and paediatric cardiac care differed markedly across the four DGHs, so comparative analyses between hospitals over telemedicine usage could not be performed. Instead, the research evidence for the three cardiology services (fetal, neonatal, and paediatrics) was analysed separately using modelling approaches. Four reports were prepared: one for each of the three clinical services, and a final overview.
- First Report: Paediatric Cardiology Outpatient Services - December, 2003
- Second Report: Fetal Cardiology Services - September, 2004
- Third Report: Neonatal Cardiology Services - March, 2005
- Final Report: Overview - September, 2005
Mistry H, Dowie R, Franklin RCG and Jani BR (2009) Costs of neonatal care for low birthweight babies in English hospitals. Acta Paediatrica, Vol 98, No 7, p1123-1129.
Dowie R, Mistry H, Rigby M, Young TA, Weatherburn G, Rowlinson G and Franklin RCG (2009) A paediatric telecardiology service for district hospitals in south-east England: an observational study. Archives of Disease in Childhood, Vol 94, No 4, p273-277.
Dowie R, Mistry H, Young TA, Franklin RCG and Gardiner HM (2008) Cost implications of introducing a telecardiology service to support fetal ultrasound screening. Journal of Telemedicine and Telecare, Vol 14, No 8, p421-426.
Mistry H, Dowie R, Young T and Gardiner H (2007). The costs of maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy. British Journal of Obstetrics and Gynaecology, Vol 114, No 9, p1104-1112.
Dowie R, Mistry H, Young T et al (2007) Telemedicine in pediatric and perinatal cardiology: Economic evaluation of a service in English hospitals, International Journal of Technology Assessment in Health Care, vol 23, no 1, pp 116-25
Weatherburn G, Dowie R, Mistry H, Young T (2006) An assessment of parental satisfaction with mode of delivery of specialist advice for paediatric cardiology: face-to-face versus videoconference, Journal of Telemedicine and Telecare, vol 12 (Suppl 1), pp 57-59
Collaborators and funding sources
Project team membership:
At Brunel University: Dr Robin Dowie, Hema Mistry, Tracey Young (based now in the University of Sheffield) and Dr Gwyneth Weatherburn (based at Buckinghamshire Chilterns University College).
At the Royal Brompton and Harefield Hospitals: Dr Mike Rigby, Dr Rodney Franklin, Dr Helena Gardiner and Dr Giselle Rowlinson. The project was funded by the Department of Health Policy Research Division and the Charitable Funds Committee of the Royal Brompton and Harefield Hospitals NHS Trust.