ICU Telemedicine Better at Saving Lives

Telemedicine is all the rage for policymakers looking for solutions to access issues, especially in rural and underserved communities. Implementation of telemedicine in practice has run into a number of barriers, including lack of evidence on effectiveness. The current evidence is primarily generated from single health care centers and compares pre- and post- telemedicine implementation periods, a study design with many known limitations, including lack of case-matched controls and generalizability.

A recent article published in the journal Medical Care describes a national study of intensive care unit (ICU) telemedicine that compares hospitals that had adopted a continuous monitoring ICU telemedicine program with matched controls. The authors measured changes in ICU mortality rates pre- and post-telemedicine adoption as compared to the same rates in control hospitals. Although 90-day mortality rates rose in both settings, ICU telemedicine adoption was associated with a small, but statistically significant reduction in overall 90-day mortality. The analysis showed high levels of variation in the effect of ICU telemedicine across individual hospitals, with the majority of adopters showing no change in mortality.

This study design provides a more comprehensive picture of ICU telemedicine effectiveness compared to single center studies, but also has a number of limitations, most significantly its exclusion of small hospitals, whose patients likely experience the most benefit from ICU telemedicine. Nevertheless, the results contribute to the current discourse on telemedicine best practices. Of the hospitals included, large urban hospitals with ICU telemedicine had the most favorable effect on mortality, which rebuts current Medicare policies limiting reimbursement to rural areas and federally designated health professional shortage areas .

Telemedicine can increase access to needed services for underserved communities, even in urban areas. But further research is needed to establish best practices. As telemedicine policy continues to evolve at the state and federal levels, research is critical to inform appropriate reimbursement, licensure, and clinical guidelines.

commentary by Megan Douglas

Abstract

Background: Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain. Objectives: To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals.

Research Design: We performed a multicenter retrospective case-control study using 2001–2010 Medicare claims data linked to a national survey identifying US hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 nonadopting hospitals (controls) based on size, case-mix, and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach.

Results: A total of 132 adopting case hospitals were matched to 389 similar nonadopting control hospitals. The preadoption and postadoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%,P=0.07) and control hospitals (23.5% vs. 23.7%, P<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios=0.96; 95% CI, 0.95–0.98; P<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios=1.01; interquartile range, 0.85–1.12; range, 0.45–2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions postadoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (P<0.001) and be located in urban areas (P=0.04) compared with other hospitals.

Conclusions: Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.

Kahn JM. et al. Med. Care. 2016; 54 (3): 319-325. PMID: 26765148.