Long-term impact of home telehealth service on preventable hospitalization use

1. Long-term impact of home telehealth service on preventable hospitalization use Huanguang “Charlie” Jia, PhD Research Health Scientist VA RORC REAP North Florida/South Georgia VHS Gainesville, Florida

2. Co-authors • Ho-Chih Chuang, MS • Samuel S. Wu, PhD • Xinping Wang, PhD • Brad N. Doebbeling, MD • Neale R. Chumbler, PhD

3. Acknowledgement • This work was funded by the Community Care Coordination Service at VA VISN 8 through the Rehabilitation Outcomes Research Center (RORC REAP) at N. Florida/S. Georgia VHS, Gainesville, FL. • The views expressed in this report are those of the authors and do not necessarily represent the views of Department of Veterans Affairs.

4. Background: ACSC & Preventable Hospitalization • Hospitalizations for ACSCs may be prevented if timely and appropriate ambulatory care were accessible. • Barriers to accessibility include provider unavailability, costs, health insurance absence. • Improved access at community level would lower ACSC hospitalization. References: 1) Weissman JS, et al. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA. 1992;268:2388-2394 2) Bindman AB, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274:305-311 3) Culler SD, et al . Factors related to potentially preventable hospitalizations among the elderly. Med Care. 1998;36:804-817 4) Friedman B, Basu J. The rate and cost of hospital readmissions for preventable conditions. Med Care Res Rev. 2004;61:225-240 5) Basu J, et al. Primary care, HMO enrollment, and hospitalization for ACSCs. Med Care. 2002;40:1260-1269

5. Background: Home Telehealth • Application of modern telecommunications. • Link patients to out-of-home sources of care information, education, or service. • Medical benefit: early detect problems, frequently monitor conditions, increase access, improve care plan compliance. • Home telehealth reduces inpatient & ER use within short-term. References: 1) Koch S. Home telehealth--current state and future trends. Int J Med Inform. 2006;75:565-576 2) Hailey D, et al. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare. 2002;8 (Supplement 1):1-30 3) Barnett TE, et al. The effectiveness of a care coordination home telehealth program.. Am J Manag Care. 2006;12:467-474 4) Chumbler NR, et al. Evaluation of a home-telehealth program for veterans with diabetes. Eval Health Prof. 2005;28:464-478

6. Objective • To test 4-year effect of a VA patient-centered, care coordination/home telehealth (CCHT) program on potentially preventable hospitalization use by veteran patients diagnosed with diabetes mellitus.

7. Study Design • Retrospective, matched treatment and control study design. • Treatment group (n=387): DM patients, enrolled in the CCHT program at 4 VAMCs. • Control group (n=387): DM patients in the 4 VAMCs matched by a propensity score. References: 1) Barnett TE, et al. The effectiveness of a care coordination home telehealth program for veterans with diabetes mellitus: A 2-year follow-up. Am J Manag Care. 2006;12:467-474 2) D'Agostino RB, Jr. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17:2265-2281

8. VA CCHT Program • Transition from hospital-based care to patient-centered and ambulatory care. • Care coordination by nurse practitioner. • Disease monitoring using supportive home telemonitoring technology. • Each enrollee has a messaging device installed at home using basic land-line telephone service. • Daily basis: patients answer scripted questions from the messaging device about their diabetes symptoms and health status. • Care coordinators monitor the patients’ daily updates from the devices.

9. CCHT enrollment criteria • Diagnosed with DM. • ≥1-time VA hospitalizations or ≥1-time VA ER visits in 12 months prior to enrollment. • Non-institutionalized. • A telephone land-line at home.

10. Dependent Variable • Semi-annual P.H. count by patient. • AHRQ defined 12 ACSCs and ICD-9 codes applied. • VA automated inpatient databases. References: 1) AHRQ. Guide to prevention quality indicators: Hospital admission for ACSCs. March 12, 2007; Version 3.1 2) AHRQ. Prevention quality indicators: Technical specifications. March 12, 2007; Version 3.1

11. Independent & Covariates • Treatment/CCHT enrollee: yes, no. • Baseline: age, gender, marital status, race, VA care priority, and study sites. • Pre-enrollment: 6-month comorbidity score, 12-month inpatient and outpatient use. • Post-enrollment: 4-year survival time in days.

12. Statistical Analysis • Descriptive statistics. • Multicollinearity diagnostics. • A GLIMMIX to estimate the impact of the CCHT program on P.H. use over a period of 4 years, adjusting for patient characteristics and time.

13. Table 1.1. Baseline characteristics (No sig. difference observed)

14. Table 1.2. Pre- & Post-baseline Characteristics †p value <0.05; ‡p value <0.01;

15. Table 2. Freq of 4-year P.H. ACSCs occurrences by group P.H. conditions/ACSCs Diabetes long-term complications L. extremity amput. in DM pts Diabetes short-term complication Diabetes uncontrolled Bacterial pneumonia Angina Congestive heart failure Urinary infection C. obstructive pulmonary disease Dehydration Hypertension Adult asthma Ctrl 121 55 28 15 34 19 67 31 14 9 5 2 Tx 42 29 7 4 22 8 84 33 31 11 3 1

16. Table 3. Results from a GLIMMIX (dependent var=P.H. count)

17. Main Results • The linear mixed results suggest that the CCHT enrollees were less likely to be admitted for a P.H. (RR 0.36, p<0.05). • The difference reduced as time progressed during the 4-year follow-up.

18. Limitations • A single geographic region. • VA healthcare system enrollees. • Patients with DM, a diagnosis associated with high rates of morbidity, mortality, and resource use.

19. Conclusions • The VA CCHT program for diabetes patients reduced preventable hospitalizations overtime. • It may reduce healthcare cost.