An evidence based approach to the use of telehealth in long-term health conditions: Development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Background

Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term health conditions (LTCs).

Aim

To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk.

Methods

Development: We synthesised quantitative and qualitative evidence on effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Findings are included in the full report. Based on these studies we developed a conceptual model (‘TECH’) as a framework for development and evaluation of the Healthlines Service for patients with LTCs.

Implementation: The Healthlines Service comprised regular telephone calls from Health Information Advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence.

Evaluation: Design: Linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care versus usual care alone, with nested process and economic evaluations. Participants: Adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. Primary outcome: Response to treatment. Secondary outcomes included: anxiety (depression trial); individual risk factors (CVD risk trial); efficiency; self-management skills; medication adherence; perceptions of support, access to healthcare, and satisfaction with treatment.

Trial results

Depression trial: 609 participants; 86% retention rate. Response to treatment (PHQ-9 reduction ≥ 5 points and score < 10 after four months) was higher in the intervention group (27% (68/255)) than the control group (19% (50/270)); odds ratio=1.7 (95% confidence interval 1.1, 2.5; p=0.02). Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence. CVD risk trial: 641 participants; 91% retention rate. Response to treatment (maintenance/reduction in QRISK2 after 12 months) was higher in the intervention group (50% (148/295)) than in the control group (43% (124/291)), which does not exclude a null effect: odds ratio 1.3 (95% CI 1.0, 1.9; p=0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management.The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression.The intervention was implemented largely as planned, although initial delays and later disruption to delivery due to closure of NHS Direct may have adversely affected participant engagement.

Conclusion

The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This Service was cost-effective for CVD risk, but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on implementation of comprehensive telehealth programmes for LTCs.