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Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial

BMJ 2012; 344 doi: (Published 21 June 2012) Cite this as: BMJ 2012;344:e3874
  1. Adam Steventon, senior research analyst1,
  2. Martin Bardsley, head of research1,
  3. John Billings, associate professor of health policy and public service2,
  4. Jennifer Dixon, director1,
  5. Helen Doll, senior research associate3,
  6. Shashi Hirani, senior lecturer in health psychology4,
  7. Martin Cartwright, research associate4,
  8. Lorna Rixon, research associate 4,
  9. Martin Knapp, professor of social policy; director of personal social services research unit; professor of health economics67,
  10. Catherine Henderson, research officer6,
  11. Anne Rogers, professor of the sociology of health care8,
  12. Ray Fitzpatrick, professor of public health and primary care 5,
  13. Jane Hendy, senior lecturer in healthcare management and policy 9,
  14. Stanton Newman, professor in health psychology and dean of school of health sciences (principal investigator)4
  15. for the Whole System Demonstrator Evaluation Team
  1. 1The Nuffield Trust, London W1G 7LP, UK
  2. 2New York University, New York, NY, USA
  3. 3University of East Anglia, Norwich, UK
  4. 4School of Health Sciences, City University London, London
  5. 5University of Oxford, Oxford, UK
  6. 6London School of Economics and Political Science, London
  7. 7King’s College London, London
  8. 8University of Manchester, Manchester, UK
  9. 9University of Surrey, Guildford, UK
  1. Correspondence to: A Steventon adam.steventon{at}


Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.

Design Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat.

Setting 179 general practices in three areas in England.

Participants 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009.

Interventions Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients’ diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.

Main outcome measure Proportion of patients admitted to hospital during 12 month trial period.

Results Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P<0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P=0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference −0.64 days, −1.14 to −0.10, P=0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group.

Conclusions Telehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect.

Trial registration number International Standard Randomised Controlled Trial Number Register ISRCTN43002091.


  • We thank all the study participants; staff from the three sites; Bupa Health Dialog for managing the remote collection of primary care data and providing predictive modelling analytic data files; and Theo Georghiou and Ian Blunt for assistance with classifying statistics data for hospital episodes and applying unit costs.

  • Contributors: AS led the collection of administrative datasets, analysis, and manuscript drafting. MB, JD, and JB took part in the original design of this element of the work and contributed to the analysis. Additionally, HD, SH, MK, AR, RF, JH, and SN were involved in the development of the study protocol for the overall project. SN was principal investigator of the Whole System Demonstrator trial and HD was statistical adviser and guarantor of the statistical robustness of the overall project. MC, SH, and LR co-ordinated the daily implementation of the trial protocol and maintained trial participants’ data. CH provided input to the analysis. All authors reviewed the manuscript. The Whole System Demonstrator Evaluation Team contributed to periodic discussions of the data collected for this study during team meetings, and commented on interim documents produced during the study.

  • Funding: The study was funded by the Department of Health in England. The Department of Health reviewed the protocol for the study and provided project manager support for the implementation of telehealth. The University College London Hospitals and University College London were the Whole System Demonstrator study sponsors. Their role as sponsors was to ensure that the study was conducted in accordance with the Research Governance Framework for Health and Social Care (2nd ed, April 2005) and to confirm that arrangements were in place for the initiation, management, monitoring, and financing of the trial.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: support from the Department of Health and the University College London Hospitals and University College London; several authors have undertaken evaluative work funded by government or public agencies but these have not created competing interests; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was approved by Liverpool research ethics committee (reference 08/H1005/4).

  • Data sharing: no additional data available.

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