The first project we consider was launched by a non-profit organization with the goal of assisting oncology patients. The project was developed to modify the traditional perception of home care through the introduction of technological and telematic instruments at so-called “listening centres” all over the country. The listening centres provide home care services through skilled personnel who are specially trained to assist this type of patient. They allow constant monitoring of the health condition of assisted patients through data recording into a local database within each location (so that all caregivers have up-to-date information on diagnosis, medical reports, medicine prescriptions, etc.), and into a central database (for statistical purposes).
All the patients treated at the listening centres are registered in a database. Not all of them use the special telemedical devices however. The devices include:
x Videophone or video-camera enabling the patient to see his/her listening centre counterpart.
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x BP Tel for blood pressure measurement, which allows data to be transferred to the local database through a telephone connection.
x Clinic Analyser for the most frequent exams.
x Cardio Vox for teleECG.
The project’s main goal is to make the remaining life of terminally-ill patients as relaxed and peaceful as possible.
Below we estimate the costs and the economic effects of this service (i.e., tele- oncology) for patients who are undergoing palliative treatments during the final phase of cancer, analyse the costs associated with the “traditional” methods of assisting patients with similar clinical backgrounds and propose a reference framework for a successive evaluation of the benefits perceived (for instance for each single patient).
4.1. Standard tele-oncology costs
The cost analysis below for tele-oncology is useful for comparison – in the next subsection – to the other two treatment options available: day-hospital and hospitalization. The tele-oncology costs are summarized in Table 1.
Table 1.Tele-oncology costs
Cost category Cost per
patient (€) Video assistance (see Table 2 for details) 6,011
Blood pressure and heart rate measurement devices
128
Telespirometres 34
Tele-ECGs 43
Personnel costs 331
Telemonitoring devices and services
Data transmission costs 10
Total cost/patient 6,558
Video assistance represents the most advanced communication channel between the patient and the institute. However video assistance requires several devices and services:
x Maintenance and technical assistance fee for video-link equipment:
€20,454 yearly for the management of at most 4 devices for 5 patients Cost per patient: €818 yearly.
x Rental fee for video-link devices: €13,274 for the rental of at most 4 video-link devices for 5 patients. Cost per patient: €531.
x ISDN line activation. Cost per patient: €155.
x ISDN line charges: the two-month fee has been calculated proportionally to the average 65-day device use length. Cost per patient: €56.
x Throw-away injection pumps: the single cost is €47 and it has been calculated proportionally to the average number of pumps used by a
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patient (6) and to the percentage of patients who need it (70%). Cost per patient: €195.
x Video-link phone traffic: this figure has been estimated by referring to the average consumption levels registered from 1997 to 2000. The total consumption, amounting to €388, was divided by the number of days the service was used (2.449). The phone traffic cost refers only to the video-link for the monitoring of the utility perceived by each single patient. Cost per patient: €10.
Personnel cost: the calculation of this cost refers to a study carried out by the National Institute of Tumours (in Milan) about the teleassistance actually provided by doctors, social workers, registered nurses and co-ordinators to 36 patients over the three-year period. According to the simplest assumption, the personnel cost should increase in a directly proportional way vis-à-vis the number of tele-assisted patients;
the possible fixed costs are however structural costs, not differential ones. Cost per patient for three-year tele-assistance: €4,246. These costs are summarized in Table 2.
Table 2.Video assistance costs
Tele-monitoring device and service costs (equipment, installation, and services) are shown in Tables 3, 4 and 5. In addition, the personnel costs related to the telemonitoring services are estimated at €331 per patient, while the phone charges for data transmission are assumed to equal the video-link cost (i.e. €10 per patient).
Therefore the daily cost per patient is: €6,556/65 days §€101 per day. The numerator is the total cost per patient (see Table 1). The denominator is the patient’s assumed life expectancy. This is the cost of tele-oncology services only (i.e., excluding eventual pharmaceutical treatments, etc.). It is the basis for the comparative analysis in the following section.
4.2. A comparative analysis of the various options available
This section presents a comparison of the costs related to three methods of assisting terminally-ill patients: tele-oncology assistance, day-hospital assistance, and complete hospitalization. The costs of the options have been estimated based on data collected at primary oncology hospitalization treatment and research centres.
Item Cost per patient (€)
Maintenance and technical assistance fee for video-link equipment
818
Rental fee for video-link devices 531
ISDN line activation 155
ISDN line charges 56
Throw-away injection pumps 195
Video-link phone traffic 10
Personnel costs 4,246
Total costs 6,011
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Table 3. Costs related to blood pressure and heart rate measurement devices
Item Parameters Per patient costs
Device at home €542
Depreciation (annual) €108
Patients/year 5
Cost/patient €21
Receiving station management software €10,618
Depreciation (annual) €2,124
Patients/year 20
Cost/patient €106
Total cost/patient €127
Box 1. Technical service characteristics and evaluation assumptions
Technical service characteristics:
x Installation of a special videoconferencing device at the patient’s house;
x Equipment management;
x Management of daily video-links (average length: 12 minutes) between central institute and patient's house, as well as constant updating of the electronic record database regarding the usefulness of the service as perceived by individual patients;
x Electronic patient record database;
x Injection of pain-relievers by means of throw-away pumps (one pump can be used for a maximum of 7 days);
x Routine medical and nursing home care;
x Possible telemonitoring of the patient’s main cardiovascular and respiratory values.
Assumptions:
x The patient’s life expectancy is 65 days (criterion for granting teleassistance to patients), same as the service delivery time length;
x Any device installed at the patient’s house can be used by 5 patients a year. This assumes full employment of all equipment
x Costs are calculated based on the assumption of offering services to a maximum of 4 patients at the same time. That is to say, 4 devices are available on a total number of 20 patients per year;
x A depreciation rate of 20% is assumed for each device;
x All installation costs are charged to the institute providing the service, either directly or on a reimbursement basis.
x the patient also requires a constant telemonitoring of both blood pressure and heart rate. For this purpose, the equipment given to the patient includes special devices (e.g. telespirometers, teleECGs, etc.).
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Table 4. Telespirometres costs
Item Parameters Per patient
costs
Spirometre (purchase cost) €858
Depreciation (annual) €172
Patients/year 5
Cost/patient €34
Table 5. Detailed costs related to tele-electrocardiograph for ECG (about 50 ECGs per year for 20 patients)
Item Parameters Per patient
costs Electrocardiograph (purchase cost) €1,550
Depreciation (annual) €310
Patients/year 20
Cost/patient €16
Subscription to medical report service €28
Cost/patient
€43
The first option considered is hospitalization. We estimate that the average daily hospitalization cost for the same patients is €465 (including the cost of clinical exams) - with an average of 40 in-hospital days - for the remaining 65 days of life (Sources:
National Institute of Tumours and European Oncology Institute). This figure includes x personnel cost directly imputable to the wards
x equipment depreciation rate
x administrative costs directly imputable to ward activities x hotel costs
x healthcare service costs.
The average total cost for hospitalization therefore totals €18,592.
Aside from hospitalization costs, the cost for medication administered to the patient at his/her own house (€646) as well as the cost for transportation to the hospital (€33) are included.
The second option is day-hospital assistance. We estimate that in 1999 the day- hospital single access cost for a patient undergoing a palliative treatment at €214, with an average number of 5 oncology patients provided with the service. The total cost borne by the medical centre therefore is €1,072. Analysis of the clinical data shows that a day-hospital patient requires on average 2.35 hospitalization days for exams, visits and special treatments. Using the average daily hospitalization cost per patient (i.e.
€465), the total hospitalization cost for this option is €1,092.
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Another cost is medication administered at the patient’s house at a daily cost of about €26 for a total of €1,618. Travel costs to and from the hospital (6.5 trips on average) are €84.
Telemedicine is the last option and it is mainly based on the tele-oncology cost analysis in the previous subsection. The total cost of tele-oncology assistance is the daily cost per patient (i.e., €101) times the number of days that the patient spends at home on average before death – for a total cost per patient of €6,200 . The clinical data show that the patient also requires on average of 3.55 days in the hospital. At the average daily hospitalization cost per patient (i.e. €465), the total hospitalization cost is to €1,650.
Added to this is medication administered at the patient’s home at the same daily cost as the previous options (€26), plus travel costs to and from the hospital (1.5 trips on average) for a total of €19.50.
Table 6 shows the full estimated costs for the three options available to patients:
telemedicine, day-hospital, and stay in hospital.
It is important to emphasize that the cost analyses of the telemedicine and day- hospital options do not take into account the opportunity cost of the time families dedicate to their sick relatives. As a consequence, with an average stay-at-home period of 62.65 days - with no external support - the day-hospital option turns out to be extremely costly. Relatives and patients face the burden of self-administered assistance both in monetary terms and terms of time. This likely imposes psychic costs - for example increased anxiety - on the people involved.
The next project we consider had a goal of paperless –that is, all-electronic - documentation, whilst at the same time meeting legal requirements for signatures. To do this, management opted for an electronic document management system which incorporates digital signature technology (as established by legislative decree DPR 28/12/2000 no. 445, art.1, paragraph 1, letter ‘ee’).
Four health care units participated in the project, one of which was the lead partner in the project. Its goal was to electronically transmit medical reports from/to a number of local health care departments and services, specifically: the diagnostic services department, various hospital departments, the social and health care districts and a selected number of general practitioners. After a successful trial period at the lead site the system was implemented at the other three health care units.
5. Blurring the line between control and social learning evaluation: Technology