Specialists in geriatric medicine are in short supply. Many large and medium-sized hospitals operate post-acute units for rehabilitation or extended assessment of older patients.1 These units require input from specialist geriatricians. In Australia, outside major cities, there are often no geriatricians available to support such programs.
Telemedicine, in the form of videoconferencing, provides an opportunity for specialists to interact directly with both patients and multidisciplinary teams. In a few subspecialties, mobile videoconferencing (in which the specialist interacts directly with patients, house doctors and nurses at the bedside)2,3 has been used as a substitute for “traditional” ward rounds.
The Toowoomba Base Hospital is a 200-bed general hospital located 125 km west of Brisbane. The geriatric unit is located within a 25-bed ward, which accepts patients requiring geriatric assessment, rehabilitation or other forms of post-acute care from the general hospital wards. Before the commencement of the service described here, medical oversight was provided by the same medical staff who managed the patients at their initial admission.
The geriatric unit operates as a post-acute service. Patients are identified for admission within a few days of entry to the hospital through a combination of screening and referral.4 This pre-transfer process includes an online assessment performed by a geriatrician using a web-based clinical decision support system based on the interRAI Acute Care assessment system.5,6
A shared care arrangement is used, with the initial treating medical team continuing to manage medical aspects of the patients’ care. The geriatrician provides additional diagnostic input and oversees functional and psychosocial interventions as well as discharge planning. The model is thus a variation of the Acute Care of the Elderly model described by Palmer and colleagues.7,8
Weekly rounds are conducted by videoconference (VC). The web-based clinical support system enables the remote clinician to have accurate clinical information, particularly with reference to geriatric syndromes and functional and psychosocial problems. Pathology results can be viewed online. The geriatrician is able to view all of this information at his or her office desk alongside the VC monitor (Box 1).
The apparatus is wheeled to the bedside and, after a brief introduction by the nurse on site, the conversation and examinations are led by the remote clinician (Box 2). Typically, there is a discussion with the nurse and house doctor; a review of pathology and imaging; a patient interview and clinical examination, including a gait and balance examination; a review of the medication chart; and a final discussion.
The number of patients who had consultations per week was recorded. Feasibility and sustainability of the new system were assessed by examining the use of the service, as this depended on decisions by senior medical staff to refer the patient to the service.
The level of patient satisfaction with the new system was appraised using an 11-item structured questionnaire. This was administered by a medical student immediately after each video consultation with patients who were seen during a single week in September 2008.
We conducted a service cost-minimisation analysis based on the purchase price of equipment (amortised over 3 years at a depreciation rate of 25%), operating costs for direct videoconferencing (including monthly DSL contract fees), and the salary and travel costs relating to consultations and team meetings over a period of 52 weeks. Salary costs were based on published Queensland Health award rates and included salary on-costs. Travel times and distances were recorded for each round trip made by the geriatrician (Brisbane to Toowoomba and return). Costs were compared with the recorded costs of in-person ward rounds conducted once a month with the same patient population.
At the time the videoconferencing service commenced in January 2007, four patients were seen. Patient numbers increased progressively over several months and stabilised at a pre-planned maximum of 12 patients per week after 6 months. A typical ward round comprised 2–4 new cases and 8–10 case reviews. The hospital administration’s request to expand the service to 25 patients in June 2008 was further evidence that the service was sustainable and acceptable to hospital staff. The level of patient consultations by VC has been sustained up to the present time.
Nineteen patients seen over a 1-week period in September 2008 were approached for interviews, and four declined. The mean age of the remaining 15 patients was 77 years. On average, these patients participated twice in VC ward rounds during the evaluation period.
The mean consultation time per patient was 15.3 minutes (95% CI, 13.6–16.9 minutes) for consultations conducted by VC and 13.7 minutes (95% CI, 11.5–15.9 minutes) for in-person consultations. New patients required a mean of 19.7 (95% CI, 17.0–22.4) and 19.0 (95% CI, 15.2–22.8) minutes for VC and in-person consultations, respectively. The mean time per patient spent in meetings was 4.8 minutes (95% CI, 4.2–5.4 minutes) for VC team meetings and 5.5 minutes (95% CI, 4.3–6.7 minutes) for in-person team meetings. Thus, a typical ward round of 12 patients required 140–200 minutes in both formats, and the team meeting required 50–80 minutes.
Travel by road to and from the hospital was about 200 minutes for the round trip. Therefore, including travel time, ward rounds and team meetings, in-person consultations with patients required a total weekly time allocation of around 8.5 hours, while the VC approach required 5.0 hours when breaks and disruptions were included. This resulted in a time difference of 3.5 hours, largely attributable to travel time. Cost analyses for VC ward rounds compared with in-person ward rounds are shown in Box 3.
The results of a sensitivity analysis of the effect of “low” and “high” input costs on the cost difference between VC and in-person consultations are summarised in Box 4.
The effects of varying the travel distance and cost per kilometre travelled, while holding all other aspects of the model constant, are summarised in Box 5. At the cost per kilometre identified in the base case ($2.75/km), videoconferencing (at a level of 5 hours per week) becomes cost-saving when the round trip is 125 km or longer. At a low-estimate cost of $1.25/km, videoconferencing becomes cost-saving if the total distance travelled for each visit exceeds 275 km. At a high-estimate cost of $4.25/km, videoconferencing becomes cost-saving when the total distance travelled each week is 81 km or more.
To our knowledge, the model of service delivery described here is unique in geriatric medical practice. Reviews in the literature suggest that patient acceptance of telemedicine is generally high,9,10 but no previous studies in a geriatric population have been reported. As the prevalence of cognitive, visual and communication deficits in this population is high, it is important to specifically verify acceptance. Our study indicated a high level of patient acceptance.
The videoconferencing model limits the ability to perform a “hands on” clinical examination. Although there is evidence that cognitive assessment and neurological examination can be performed reliably by VC,11 the geriatrician is reliant on the judgement of others for examinations requiring palpation and auscultation. The potential loss of accuracy in these areas of assessment in geriatric practice requires further research. Nevertheless, in many communities, a telemedicine service will be the only viable means of having access to the expertise of a geriatrician. Thus, the key research question is whether a telemedicine-delivered service is better than no service.
Our study demonstrates that a geriatrician can provide major input into the operations of a remote geriatric unit, using a combination of online clinical information and videoconferencing. The service is sustainable, well accepted by patients and staff, and less expensive than in-person consultations if the geriatrician’s total weekly travel time exceeds 72 minutes — a remarkably short time. This service model has the potential for widespread application wherever geriatric specialists are in short supply and the requisite technical infrastructure is available.
3 Cost comparison (in dollars per annum) between ward rounds conducted by videoconference (VC) and in person in the geriatric unit at Toowoomba Base Hospital
Abstract
Objective: To evaluate the acceptance and cost of a ward-based geriatric consultation service delivered via a mobile videoconferencing system.
Design and setting: Prospective observational study conducted in the geriatric unit of Toowoomba Base Hospital, Queensland, comparing a specialist consultation service delivered by videoconference (VC) with a “traditional” in-person service. The VC system was established in January 2007 and evaluated over an 18-month period. Patient satisfaction with the service was assessed by questionnaire during a 1-week period in September 2008.
Main outcome measures: Hospital acceptance of the service; patient satisfaction with the service; comparative cost of providing in-person and VC-mediated consultations.
Results: Uptake of the service increased progressively throughout the study period. Patient acceptance levels were high. The cost of video consultations for a 12-patient ward round and case conference was less than the cost of in-person consultations if the total road distance travelled by the specialist (Brisbane to Toowoomba and back) was 125 km or longer.
Conclusion: Consultations via VC are an acceptable alternative to in-person consultations, and are less expensive than in-person consultations for even modest distances travelled by the clinician.