Prof Ala Szczepura1,2

Prof Christopher James3 Workshop on prevention and detection (1-2pm)

Digital Health: design, develop, deploy, evaluate Radcliffe House Warwick,

University of Warwick

25 July 2013

1 Hon Professor, Warwick Medical School, University of Warwick, UK 2 Professor Health Technology Assessment, University of Coventry, UK 3 Institute of Digital Healthcare, University of Warwick, Coventry, UK

USEFIL Project: Evaluation of technology in healthcare

Aims:

To use "off-the-shelf" technology to develop unobtrusive, low cost support systems for older people living alone.

• Older person: to enable the individual to maintain their independence and daily activities. Provide services

more adaptable to individual needs and preferences (personalization).

• Formal/ informal carer: to provide effective means of delivering support & accessing care.

• Health funder: to extend the time older people can live independently at home, limiting public expenditure and

providing cost-effective care.

Partners: 1. Institute of Digital Healthcare & Medical School, University of Warwick, UK

2. National Center for Scientific Research "Demokritos", Athens, Greece (lead)

3. VTT Technical Research Centre of Finland, Espoo, Finland

4. Center for Computing Technologies, University of Bremen, Germany

5. Lab of Medical Informatics, Medical School, Aristotle University of Thessaloniki, Greece

6. Fraunhofer Institute for Telecommunications, Munich, Germany

7. Philips Consumer Lifestyle, Eindhoven, Netherlands

8. Maccabi Healthcare Services, Tel Aviv, Israel

USEFIL (FP7 Project)

“enables people to realize their potential for physical, mental and social well being ….and to participate in society according to their needs, desires & capacity

while providing them with adequate protection, security and care when they require assistance”

- World Health Organisation, 2002

Active Ageing….

Challenge: Active Ageing

Active Ageing

Increasing Dependency

Number of people aged 75+ projected to nearly

double by 2033 - from 4.8 to 8.7 million in England

900,000 older people with high level of physical need

in 2002, will increase by 50% in next 20 years

500,000 centenarians predicted in UK by 2066

Historically, most care for older people provided at

home with support of family

Changing family structures mean in Europe one third

of older people living at home are now alone

DH says at least 3 million people in UK with long term

conditions and/or social care needs could benefit from

use of telehealth/ telecare services

Older Person’s Care & Support Network

Older Person

at Home

Primary Care

Team

Domiciliary Care Community

Specialists

(e.g. Geriatrician,

Pharmacist)

NHS Community

Nursing Staff Informal Carer/ Relative

Quality of Life

Hospital Staff

(Inpatient care

A&E)

Need to build a USEFIL system to suit the older person living alone at home….

....not just providers of health & social care

Telecare: What way forward?

• Review of reviews: real-time telecare can improve health outcomes through enhanced

disease monitoring & better communication with health care professionals*

• Telecare demonstrator programme (Cornwall) for patients discharged home shows 20%

fall in emergency admissions & 45% fall in mortality over 1 year**

• January 2012 - NHS care service minister announces aim to develop telehealth/telecare

services to support people with long-term conditions

* Deshpande A, Khoja S, McKibbon A, Jadad AR: Real-Time (Synchronous) Telehealth in Primary Care:Systematic Review of Systematic Reviews [Technology ** Department of Health. Whole system demonstrator programme: Headline findings - December 2011. 2011 ;

Need to consider: Value for money

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

1970 1975 1980 1985 1990 1995 2000 2005

Per

Capita S

pendin

g -

PPP A

dju

sted

Growth in Total Health Expenditure Per Capita, U.S. and Selected Countries, 1970-2008

United States

Switzerland

Canada

OECD Average

Sweden

United Kingdom

Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-en (Accessed on 14 February 2011). Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are PPP adjusted. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in 2008.

Care Homes Academic Research Team (CHART)

Challenges: What way forward?

Personal health portals Online engagement tool to connect patients with healthcare providers, families, social services & care givers.

Unobtrusive activity monitoring Wearable devices to unobtrusively and reliably extract cardiac and motion related features.

Home clinical monitoring for oncology patients Patients regularly monitor white blood cell count, temperature & other symptoms. Results used to inform timing of further chemotherapy or intervention

Range of technology support…….

Employment and skills in the social care sector

Improving productivity in labour intensive services whilst maintaining quality

Increasing capital-labour ratio Role for new technology

beyond “tele-care”

also

“attracting boys into girls jobs”

Improving employee skills Time for training staff & managers

improving occupation’s status

the feeding

robot

the keeping

company

robot

Hospital admission/ discharge Optimal preparation of patients & follow up at home

Personalised services Deliver appropriate level of health & social care for older person at home

Self-management Actively develop older person’s knowledge, motivation and skills

Up to 40% of acute hospital beds filled with people who shouldn’t be there, mostly elderly.

25% of emergency admissions linked to elderly patients with chronic diseases,

at an estimated excess cost of £2bn. p.a.

Key Challenges: Active Ageing

Coordination of care Across patients’ various conditions and different care givers

USEFIL Support for Older Person

Important issues for evaluation….

• question of choices in the use of health care resources such as:

– what technologies to provide, when and at what level?

– how and where to provide such technologies?

– who should get the technologies?

• these are important questions for those who provide health care (e.g. clinicians), those who plan care provision or purchase care (e.g. Third Party Payers), as well as those who develop new technologies (e.g. scientists)

USEFIL Validation & Evaluation Trial

(Frail Elderly)

Technology as a facilitator for older people largely confined to home:

- Citizen-centred care

citizen empowerment

preventive care & early diagnosis/alerts

disease management

independent living for ageing society

• USEFIL Ethical Management

– to ensure all USEFIL research is carried out under best ethical guidelines

(m36)

October 2014

(m31)

May 2014

Commence Ethical

Applications

(m19)

May 2013

Decide on

distribution of

Technologies

(m14)

January 2013

USEFIL Validation and Evaluation (Pilot Trials)

- UK (frail elderly), Israel (stroke), Greece (mental health)

Ideal Scope of Evaluation

Process measures – usage, acceptability

Outcome measures - physical, psychological, social

Value for Money

7 Levels of Telecare Evaluation: Adapted from Szczepura & Kankaanpää (1996)

• Level 1: Technical : Does the telecare perform reliably and deliver

reproducible data?

• Level 2: Diagnostic accuracy: Does the data enable an accurate diagnosis to be

made of the situation?

• Level 3: Usability: Is the technology acceptable to patients & carers,

do they use it appropriately?

• Level 4: Treatment impact: Does the information provided influence selection and

delivery of treatment/ care?

• Level 5: Patient outcome: Does the technology contribute to improved health

of the person/patient?

• Level 6: Cost-effectiveness: Does use of telecare improve cost-effectiveness

of care delivery?

• Level 7: Social/organisational/ Does the technology have any social, legal, ethical

ethical/legal: or organisational implications?

Outcome indicator checklist

7 elements to address

Developing outcome indicators

Objective What are we trying to measure? 1. Why are we collecting this information? Be specific

Methodology

How to capture the data 1. What data needs to be captured

2. Who (or what) to capture the data

3. How often to capture the data

4. Is it achievable (time, resources, revenue)?

Limits Can we preset levels for:

1. Acceptable, Concern, Unacceptable, Critical

Presentation Graphic or Text

Interpretation 1. What does it mean?

2. Does it reflect on KEY quality/ outcome measures?

3. Can we compare it?

4. Can we trend it?

Limitations 1. Unintended variables

2. What does it not mean?

Action Plan 1. What will we do if it indicates acceptable outcomes?

2. What will we do if it does not?

Nonsense Metrics

[urine culture] * [glucose] * [INR]

[NUPA hr] * [Telephone minutes] X100

Just because you can calculate a

value, doesn’t mean that you should.

“Health is a state of complete physical, mental and social well being and not merely the

absence of disease or infirmity”

- World Health Organisation, 1948

Health-related quality of life - key outcome

What could USEFIL system provide?

From Perspective of Frail Older Person Living Alone:

• Increase sense of safety through unobtrusive monitoring

• Detect life-threatening situations and alert/ inform carers

• Promote socialisation and stimulate activities which

improve quality of life and reduce feelings of isolation

• Provide entertainment & educational activities leading to a

more active profile

• Enable individual to remain in own home with adequate

protection, security and care when they require assistance

(WHO Active Ageing)

UK Trial: Planned outcome measures for…

• Older Person • ICECAP-O Instrument: to measure capability for older people. The instrument contains five

attributes (attachment, role, enjoyment, security and control), each with four levels. UK index

values for ICECAP-O are available; developed for economic evaluation.

• ASCOT INT4: to capture information on social care-related quality of life (SCRQoL). Allows

current and expected SCRQoL to be estimated in community settings.

• Modified Barthel Index: to measure activities of daily living (ADL) in terms of: personal hygiene,

bathing, feeding, toilet, stair climbing, dressing, bowel/bladder control, ambulation, and chair/bed

transfer. Dependency level scores can be linked to the hours of help required per week.

Activities of Daily Living

1

Changing position

5

Bathing

4

Brushing teeth

3

Personal hygiene

2

Walking

7

Eating

6

Dressing

Importance of Informal Carers

• About 960,000 people aged 65+ provide unpaid care for a partner, family, or

others in the UK

• Carers are saving the UK economy £119 billion (2011) a year (£2.3 billion

per week). This compares to total annual NHS cost of £98.8 billion (£1.9

billion per week)

• Move to formal care = annual cost of one nursing home place is £37,880 p.a.

• The cost to carers = 68.8% of carers say that being a carer has damaged

their psychological wellbeing

• Older Person • ICECAP-O Instrument: to measure capability for older people. The instrument contains five

attributes (attachment, role, enjoyment, security and control), each with four levels.

• ASCOT INT4: to capture information on social care-related quality of life (SCRQoL), and allows

current and expected SCRQoL to be estimated in community settings;

• Modified Barthel Index: to measure activities of daily living (ADL) in terms of: personal hygiene,

bathing, feeding, toilet, stair climbing, dressing, bowel/bladder control, ambulation, and chair/bed

transfer. Dependency level scores can be linked to the hours of help required per week.

• Informal Carer • Adult Carer Quality of Life (AC-QoL) questionnaire: simple instrument that measures quality

of life in eight separate domains: support for caring; caring choice; caring stress; money matters;

personal growth; sense of value; ability to care; and carer satisfaction. Can be used before and

after an intervention in order to evaluate whether the intervention has had an effect.

• Carer Experience Scale (CES): a profile measure of the caring experience for use in economic

evaluation; the CES focuses on 'care-related quality of life' rather than health-related quality of

life, comprising attributes that are pertinent to unpaid carers.

UK Trial: Planned outcome measures for…

What could USEFIL system provide?

From Perspective of Professional:

• Provide a means to help detect early signs of health

deterioration or transition to a pathological state

• Provide a number of decision-support tools in order to

reinforce diagnosis

• Deliver personalised suggestions and analysis regarding

the most suitable actions

• Create a health/social care profile that can help maintain

someone in their own home

Benefit from use of telehealth/ telecare

services…

So I said...

"How long can our

mother remain safely

at home Doctor?"

and he said...

“One to two months

probably ..

But 1 - 2 years if I can

prescribe a USEFIL

support system!”

Prevention/delay in care home or hospital admission • Average cost of nursing home care ca. £700 per week.

• NHS hospital bed costs ca. £2,100 per week.

• Older people occupy >60% of NHS hospital beds

• 5% of inpatients account for 43% of overall UK hospital inpatient days

• The Commons Public Accounts Committee has estimated that ‘bed blocking’

costs the NHS £170m every year.

• Average cost of USEFIL system ca. £2-£3,000?

Challenge: Reducing drug errors

In England there are:

• 77,000 hospital admissions p.a. linked to adverse drug reactions (ADRs)

• 59% of all cases involve older people (aged 60+ years)

• ADR numbers have increased by 45% over 8 year period

Care home residents at increased risk due to:

• age-related changes in body’s response to drugs

• multiple medication (polypharmacy)

• 28% of care homes still failing to meet minimum standard for medication management

in 2010

• dementia may limit resident’s role in monitoring own drug administration

• most care home staff are not clinically trained (i.e. social care staff)

• medication rounds occupy ca. one-third of nursing time in nursing homes

Internet

Pharmacy Plus maintains

the residents file and their

drugs using CAPA

All information is copied over

to the Central PCS Server via

the Internet. New information

is passed back to PCS

Drug administrations

and stock movemenets

are recorded on PCS Manager can view every

administration via Internet

The system is then Docked

Proactive Care System (PCS) Components

• UK pharmacy-managed, point-of-care, bar-code medication management system

developed by Pharmacy Plus Ltd over 4 years with residential and nursing home staff

What did we find?

• Analysed 188,249 drug administrations

24/7 over 3 months in 345 residents (13 homes)

• Residents averaged 8.9 different

medications each

• Survey prior to system introduction showed

social care staff more aware of potential

for medication errors than nurses

• When system alerted staff to potential error,

level of non-compliance was <1 per 1,000

(i.e. virtually all administration errors

avoided)

Main Conclusions • With support of the system, staff were able

to avert 2,289 errors over 12 weeks

• Cumulative risk of a resident being exposed

to one or more error over 12 week period

was 88% in RHs and 98% in NHs

• Risk of exposure to a more serious

error (e.g. attempt to give medication to

wrong person) was 52% over 3 months

• Error rates were lower for social care staff

in residential homes than for nurses in

nursing homes (p<0.01)

• Social care staff in nursing homes could

give medication using system & free up

valuable nurse time for other clinical tasks

Better Health, Safer Care but .....

at what Cost?

• As well as improved patient safety and quality of care, use of new technology

also appears to be cost saving:

► technology cost per annum to care home is

£1,800 (including 2 hand held devices)

► potential savings to nursing home from staff

substitution: if care staff replace nurses, annual saving ~ £15,330

► reduction in hospital admissions linked to adverse drug reactions

could lead to - £4,250 p.a. (saving) per 70 bed care home for NHS

► after accounting for system savings (reduced drug waste & improved

stock control) & advice provided online (e.g. drug switching,

inappropriate prescribing etc) net saving per care home could be

- £38,199 p.a. (saving)

Continuing Tensions in Long-Term Care

of Older People

Citizen / Patient Care Home Resident

Time – Age – Disease State & Complexity

Innovation,

Training /CPD, Research Evidence

Needs, Direct Costs

& Regulation

THANKYOU

Contacts

• Ala Szczepura (health technology assessment)

Email: ala.szczepura@warwick.ac.uk

• Debbie Biggerstaff (psychologist)

Email: D.L.Biggerstaff@warwick.ac.uk

• Josh Elliott (research assistant) Email: Joshua.Elliott@warwick.ac.uk