Background: Health services internationally are exploring the potential of telehealth to support the
management of the growing number of people with long-term conditions (LTCs).
Aim: To develop, implement and evaluate new care programmes for patients with LTCs, focusing on
two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk.
Methods
Development: We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for
LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal
survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the
development and evaluation of the Healthlines Service for patients with LTCs.
Implementation: The Healthlines Service consisted of regular telephone calls to participants from health
information advisors, supporting them to make behaviour change and to use tailored online resources.
Advisors sought to optimise participants’ medication and to improve adherence.
Evaluation: The Healthlines Service was evaluated with linked pragmatic randomised controlled trials
comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic
evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices
in three areas of England. The primary outcome was response to treatment and the secondary outcomes
included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication
adherence, perceptions of support, access to health care and satisfaction with treatment.
Trial results
Depression trial: In total, 609 participants were randomised and the retention rate was 86%. Response
to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after
4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270)
[odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5; p = 0.02]. Anxiety also improved. Intervention
participants reported better access to health support, greater satisfaction with treatment and small
improvements in self-management, but not improved medication adherence.
CVD risk trial: In total, 641 participants were randomised and the retention rate was 91%. Response to
treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention
group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect
(odds ratio 1.3, 95% CI 1.0 to 1.9; p = 0.08). The intervention was associated with small improvements in
blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to
adhere to medication, reported better access to health support and greater satisfaction with treatment,
but few improvements in self-management.
The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained,
but not for depression. The intervention was implemented largely as planned, although initial delays and
later disruption to delivery because of the closure of NHS Direct may have adversely affected participant
engagement.
Conclusion: The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided.
This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra
cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth
programmes for LTCs.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)