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Systematic review of cost effectiveness studies of telemedicine interventions

BMJ 2002; 324 doi: (Published 15 June 2002) Cite this as: BMJ 2002;324:1434

Rapid Response:

Lack of evidence for effectiveness differs from evidence of lack of effectiveness

We very much appreciate Scufflam’s thoughtful contribution to the
debate generated by our paper. He is, of course, correct to emphasize the
potential value of telemedicine in improving access to specialist
healthcare services in isolated locations. The use of telemedicine in
such locations provides one potentially valuable method of enhancing
accessibility to such services. However, such issues were beyond the
scope of our review. In undertaking our review we did not attempt to
introduce new evidence on the cost-effectiveness of telemedicine but
simply to act as a mirror reflecting the quality and quantity of evidence
that was already in existence. From a personal perspective I have little
doubt that in certain locations and for certain specialties telemedicine
may be able to provide a cost effective method of improving both the cost-
effectiveness and accessibility of health care provision within the NHS.
Unfortunately, this is a personal view and it not reflected in the weight
of evidence currently available in the literature. In interpreting the
results of our review it is crucial to acknowledge that lack of evidence
for the cost-effectiveness of telemedicine is not equivalent to evidence
of lack of cost-effectiveness of telemedicine. Our review simply
identified the former without seeking to make any contribution towards the
debate concerning the latter.

We would, however, take slight exception to one of the points raised
by Scufflam. The use of cost minimisation analysis is only a ‘conservative
approach’ if the benefits arising from telemedicine consultations are at
least as good and preferably better than traditional (i.e. face to face)
methods of consultation. Our argument with such an approach is that such
superiority cannot simply be assumed but must be based on a high quality
evidence base.

One of the major weaknesses of the evidence base was its inability to
identify circumstances where telemedicine was and wasn’t cost-effective.
Perhaps more than in any other area of new technology the cost-
effectiveness of any telemedicine service is very much location specific.
This is not to say that results obtained in one location (the Highlands of
Scotland) cannot be generalised to other locations (the centre of
Liverpool) but that such generalisation must be undertaken with the utmost
care. Specifically an impact model should be developed to distinguish
between elements that contribute to the success of a telemedicine service
that are generalisable (e.g. technological factors) from those that are
location specific (e.g. geographical and environmental factors). All too
often the success of a telemedicine service evaluated in inaccessible
locations were automatically assumed to be generalisable elsewhere without
testing this assumption. Our review presents a challenge to the
telemedicine research community to strengthen their analyses by
identifying the extent to which results obtained in one research location
are likely to be replicable elsewhere.

Our review presents an early overview of the quality of research
currently available in the field of telemedicine. The review is timely
given the growing interest in this branch of medicine. The review
presents a challenge to the telemedicine research community to strengthen
their analyses. Should they do this we would welcome the opportunity to
revisit our review in the future hopefully to reflect the improved quality
of evidence generated in response to this challenge. The authors of the
review are, in general, persuaded of the potential value of telemedicine.
Our role in undertaking the review, however, was not to be ‘for’ or
‘against’ the telemedicine but simply to reflect the realities of the
current evidence base available. It is our hope that in doing so we have
indicated some of the areas in which the quality of this evidence base can
be improved.

Competing interests: No competing interests

04 July 2002
Alan R Haycox
Senior Lecturer - Health Economics
Frances S Mair, Senior Lecturer, Department of Primary Care
University of Liverpool, L69 3GE