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Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial

BMJ 2013; 346 doi: (Published 22 March 2013) Cite this as: BMJ 2013;346:f1035
  1. Catherine Henderson, research officer1,
  2. Martin Knapp, professor of social policy, director of personal social services research unit12,
  3. José-Luis Fernández, deputy director of personal social services research unit, principal research fellow1,
  4. Jennifer Beecham, professorial research fellow1,
  5. Shashivadan P Hirani, senior lecturer in health services research3,
  6. Martin Cartwright, research associate in health services research3,
  7. Lorna Rixon, research associate in health services research3,
  8. Michelle Beynon, research assistant in health services research3,
  9. Anne Rogers, professor of health systems implementation 4,
  10. Peter Bower, professor of health services research5,
  11. Helen Doll, senior research associate6,
  12. Ray Fitzpatrick, professor of public health and primary care7,
  13. Adam Steventon, senior research analyst8,
  14. Martin Bardsley, head of research8,
  15. Jane Hendy, senior lecturer in healthcare management9,
  16. Stanton P Newman, dean, professor, principal investigator 3
  17. for the Whole System Demonstrator evaluation team
  1. 1London School of Economics and Political Science, London WC2A 2AE, UK
  2. 2King’s College London, London, UK
  3. 3School of Health Sciences, City University London, London, UK
  4. 4University of Southampton, Southampton, UK
  5. 5University of Manchester, Manchester, UK
  6. 6University of East Anglia, Norwich, UK
  7. 7University of Oxford, Oxford, UK
  8. 8The Nuffield Trust, London, UK
  9. 9University of Surrey, Guildford, UK
  1. Correspondence to: C Henderson C.Henderson{at}
  • Accepted 16 October 2012


Objective To examine the costs and cost effectiveness of telehealth in addition to standard support and treatment, compared with standard support and treatment.

Design Economic evaluation nested in a pragmatic, cluster randomised controlled trial.

Setting Community based telehealth intervention in three local authority areas in England.

Participants 3230 people with a long term condition (heart failure, chronic obstructive pulmonary disease, or diabetes) were recruited into the Whole Systems Demonstrator telehealth trial between May 2008 and December 2009. Of participants taking part in the Whole Systems Demonstrator telehealth questionnaire study examining acceptability, effectiveness, and cost effectiveness, 845 were randomised to telehealth and 728 to usual care.

Interventions Intervention participants received a package of telehealth equipment and monitoring services for 12 months, in addition to the standard health and social care services available in their area. Controls received usual health and social care.

Main outcome measure Primary outcome for the cost effectiveness analysis was incremental cost per quality adjusted life year (QALY) gained.

Results We undertook net benefit analyses of costs and outcomes for 965 patients (534 receiving telehealth; 431 usual care). The adjusted mean difference in QALY gain between groups at 12 months was 0.012. Total health and social care costs (including direct costs of the intervention) for the three months before 12 month interview were £1390 (€1610; $2150) and £1596 for the usual care and telehealth groups, respectively. Cost effectiveness acceptability curves were generated to examine decision uncertainty in the analysis surrounding the value of the cost effectiveness threshold. The incremental cost per QALY of telehealth when added to usual care was £92 000. With this amount, the probability of cost effectiveness was low (11% at willingness to pay threshold of £30 000; >50% only if the threshold exceeded about £90 000). In sensitivity analyses, telehealth costs remained slightly (non-significantly) higher than usual care costs, even after assuming that equipment prices fell by 80% or telehealth services operated at maximum capacity. However, the most optimistic scenario (combining reduced equipment prices with maximum operating capacity) eliminated this group difference (cost effectiveness ratio £12 000 per QALY).

Conclusions The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment.

Trial registration ISRCTN43002091.


  • We thank the trial participants for their time and interest in the study; the health and social care managers and professionals in Cornwall, Kent, and Newham; the participating case study organisations for their help; Alan Glanz (Department of Health) and Chris Ham (King’s Fund) for their support throughout the study; and the reviewers for their comments and suggestions.

  • Whole System Demonstrator evaluation team members: Stanton P Newman (principal investigator), Martin Bardsley (The Nuffield Trust), James Barlow (Imperial College London), Jennifer Beecham (London School of Economics), Michelle Beynon (City University London/University College London), John Billings (The Nuffield Trust), Andy Bowen (University of Manchester), Pete Bower (University of Manchester), Martin Cartwright (City University London/University College London), Theopisti Chrysanthaki (Imperial College London), Jennifer Dixon (The Nuffield Trust), Helen Doll (University of East Anglia), Jose-Luis Fernandez (London School of Economics), Ray Fitzpatrick (Oxford University), Catherine Henderson (London School of Economics), Jane Hendy (University of Surrey), Shashivadan P Hirani (City University London/University College London), Martin Knapp (London School of Economics), Virginia MacNeill (Oxford University), Lorna Rixon (City University London/University College London), Anne Rogers (University of Southamptom), Caroline Sanders (University of Manchester), Luis A Silva (City University London/University College London), Adam Steventon (The Nuffield Trust).

  • Contributors: CH, MK, and JB contributed to the planning of economic data collection and administration. CH conducted the economic analyses under the supervision of MK and J-LF. CH, MK, and J-LF reported the analyses. HD, SPN, MK, RF, JH, PB, and AR contributed to planning the overall trial design. SPN is the principal investigator for the Whole System Demonstrator trial; HD is the guarantor of statistical quality for the trial as a whole. MK is the chief investigator for the economic evaluation. SPN, SPH, MBe, MC, and LR contributed to the planning and administration of questionnaire trial data collection. SPH, MC, MBe, LR, and AS maintained and provided data for participants. SPH, MC, MBe, LR, SPN, AS, MBa, CH, MK, and J-LF contributed to planning the analyses. All the authors reviewed the manuscript. The evaluation team met regularly during the trial period and contributed as a whole to discussions of the data under collection.

  • Funding: This is an independent report commissioned and funded by the Policy Research Programme in the Department of Health.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from the Department of Health for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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

  • Data sharing: No additional data available.

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