Summary
Introduction
The SECT(A&E) project (Standards, Effectiveness and Costs of Telemedicine in Accident and Emergency) set out to comprehensively evaluate the role of telemedicine within the Accident and Emergency (A&E) environment. The introduction of this new technique allows peripheral and minor injuries units to be supported from a central A&E department, providing specialist expertise at a local level, reducing the need for patients to travel long distances, and potentially changing the staffing requirements at these remote sites. The formal evaluation of information and communications technologies is a central government and NHS priority, and is of particular relevance to the current A&E modernisation programme.
Objectives
This project, funded by a grant from the Department of Health under the Information and Communications Technology Initiative (ICT/312), followed a clear sequence of events in three stages:
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Stage One
Stage one took the form of a series of laboratory-based assessments concentrating on still radiographic images (X-rays) and still digital images (clinical photographs) at the stages of image acquisition, compression and display, but also paying attention to transmission modes and times since A&E consultation requires real-time consultation, and therefore rapid image transfer.
It was found that image file size declined with reductions in resolution and increases in compression, as expected, but the ratio of maximum to minimum file size did not fall uniformly as the level of compression increased.
For both X-rays and still images the minimum technical standard comprises images containing at least 250,000 pixels (e.g. an image resolution of 563x438 pixels), compressed at up to JPG 50 (or GIF for colour images) and displayed on a high-resolution computer monitor. The average file size of such images is 16.69 kB for digital images and 8.91 kB for X-rays, facilitating rapid real-time transfer over ISDN, or even an analogue modem.
Stage Two
Minor injuries telemedicine was evaluated through a prospective, randomised and blinded study. Recruited patients were assessed by an A&E specialist via a telemedicine link, and in person by a second on-site A&E specialist and also by a general practitioner (GP) wherever possible, allowing two or three independent treatment plans to be drawn up. These were compared with a gold standard established subsequently to identify potential discrepancies, which were then submitted to an independent expert panel for assessment. Each patient was randomly assigned to follow one of the two or three treatment plans and reviewed 7 days later to assess a range of outcomes related to safety, clinical effectiveness and process of care.
The calculated sample size of 600 patients was achieved, and baseline characteristics were similar across all three randomisation groups. The mean duration of a telemedicine consultation (6.0 min.) was almost twice as long as an onsite A&E (3.1 min.) or GP consultation (3.4 min.) (p<0.0001 in both cases). Telemedicine and onsite A&E consultations resulted in very similar rates of X-ray (59.2 vs. 60.5%), but significantly more patients were given a follow up appointment following telemedicine (35.8% vs. 27.5%: p<0.0001). No consultation modality was clearly better or worse than any other, and the clinical outcomes measured at 7 days showed no statistically significant differences between randomisation groups.
Stage Three
Because the clinical data demonstrated near equivalence between the three approaches a cost minimisation analysis was undertaken. Costs to the National Health Service and patients and their families over the seven days following randomisation were identified, valued and compared. An extensive sensitivity analysis was also carried out.
The mean cost to the National Health Service for telemedicine patients over the seven days following their initial attendance was £78.14, whilst that for face-to-face consultation with an onsite A&E specialist was £48.03, and with a general practitioner (routine care) was £57.02. In relation to costs incurred by the patients and their families the respective figures were £58.37, £41.88 and £32.05. Under all the assumptions used in the sensitivity analysis, telemedicine remained the most costly of the three options for both the National Health Service and the patients and their families, although the decision between the specialist registrar and the general practitioner reversed across the analyses. We were therefore unable to demonstrate a premise under which telemedicine would save money for the National Health Service and/or patients and their families.
Conclusion
Whilst a relatively low cost system is capable of delivering satisfactory clinical results, there are several potential problems that may be overlooked by enthusiasts. Many of these will not be influenced by further technological advances, and must be addressed in other ways: some problems are inherent to telemedicine itself, but most are related to service delivery and organisation. It is important that decision-makers are not overly distracted by technical concerns but focus on the managerial and economic issues that underpin telemedicine as a change in the way that care is delivered.
This research has demonstrated that minor injuries telemedicine enjoys an acceptable safety profile, with overall clinical outcomes similar to conventional practice. However except in rare circumstances telemedicine is more expensive than conventional alternatives, and there are a number of important process issues that must be adequately addressed if this new technique is to develop and succeed. Further research is required to establish the role of telemedicine in the treatment of illness and more serious injury.