Re: Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial
We read with interest the recent report of the whole system demonstrator randomised controlled trial (WSD)[1]. This was a much needed study of the impact of an increasingly frequent intervention which until now has been deployed with relatively little evidence of efficacy. The headline reduction of an approximate halving of mortality within the intervention group is both impressive and surprising. This is mirrored by the reduction in hospital admissions of 5.3%. Figure 2 reveals this apparent intervention-related reduction in admissions is in fact an early increase in admissions in the control group when compared to baseline. As inferred by the authors this may be due to an increase in anxiety-related requests for admission as a consequence of the denial of telehealth in the control group. It is known that hospital admission can be associated with an increase in subsequent mortality[2, 3]. In particular, in patients with COPD (the largest group included in the trial) the recent Cochrane review comparing hospital at home with inpatient care suggested that the risk ratio for death is 0.65 in those managed at home[4]. Hospital admission appears to be bad for your health!
If hospital admission is the main reason for the greater mortality seen in the WSD control group then this should occur irrespective of the original inclusion diagnosis. We challenge the authors to present the relative risk of admission and death in their three diagnostic categories. If there is no difference then whilst the WSD demonstrates a significant impact on admissions, whether this is due to the intervention, or the unfulfilled expectation of telehealth, is a moot point.
1. Steventon et al, Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ, 2012. 344.
2. Shepperd, S.D., H. Angus, RM. Illiffe, S. Kaira, L Ricauda, NA. WIlson, AD., Hospital at home admission avoidance. Cochrane review, 2010.
3. Bell, C.R., MD,Mortality of patients admitted to hospital on weekends as compared with weekdays. New England Journal of Medicine, 2001. 345(9): p. 663-8.
4. Jeppesen E, B.K., Vist GE, Wedzicha JA, Wright JJ, Greenstone M, Walters JAE, Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane review, 2012.
Rapid Response:
Re: Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial
We read with interest the recent report of the whole system demonstrator randomised controlled trial (WSD)[1]. This was a much needed study of the impact of an increasingly frequent intervention which until now has been deployed with relatively little evidence of efficacy. The headline reduction of an approximate halving of mortality within the intervention group is both impressive and surprising. This is mirrored by the reduction in hospital admissions of 5.3%. Figure 2 reveals this apparent intervention-related reduction in admissions is in fact an early increase in admissions in the control group when compared to baseline. As inferred by the authors this may be due to an increase in anxiety-related requests for admission as a consequence of the denial of telehealth in the control group. It is known that hospital admission can be associated with an increase in subsequent mortality[2, 3]. In particular, in patients with COPD (the largest group included in the trial) the recent Cochrane review comparing hospital at home with inpatient care suggested that the risk ratio for death is 0.65 in those managed at home[4]. Hospital admission appears to be bad for your health!
If hospital admission is the main reason for the greater mortality seen in the WSD control group then this should occur irrespective of the original inclusion diagnosis. We challenge the authors to present the relative risk of admission and death in their three diagnostic categories. If there is no difference then whilst the WSD demonstrates a significant impact on admissions, whether this is due to the intervention, or the unfulfilled expectation of telehealth, is a moot point.
1. Steventon et al, Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ, 2012. 344.
2. Shepperd, S.D., H. Angus, RM. Illiffe, S. Kaira, L Ricauda, NA. WIlson, AD., Hospital at home admission avoidance. Cochrane review, 2010.
3. Bell, C.R., MD,Mortality of patients admitted to hospital on weekends as compared with weekdays. New England Journal of Medicine, 2001. 345(9): p. 663-8.
4. Jeppesen E, B.K., Vist GE, Wedzicha JA, Wright JJ, Greenstone M, Walters JAE, Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane review, 2012.
Competing interests: No competing interests