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Spinal Cord Injury/Disorder Teleconsultation Outcome Study
The purpose of this study was to compare the costs of providing specialty wound care to spinal cord injury/disorder (SCI/D) veterans by teleconsultation and traditional care. A retrospective design was used to conduct this descriptive, correlational study. A convenience sample of 76 SCI/D veterans (2 women, 74 men) met inclusion criteria from a possible 123 subjects. Variables were compared between groups using nonparametric methods (Wilcoxon rank sums and chi-square). There was no significant difference in inpatient admissions or inpatient bed days of care between the two groups. The teleconsultation group had more outpatient encounters (medians 12 vs. 4, p = .007; Wilcoxon statistic = 412.5) and longer inpatient stays (medians 81 vs. 19 days/admission, p = .05; Wilcoxon statistic = 227.0) compared to the traditional care group. There was no significant difference in inpatient cost between the two groups; however, the teleconsultation group had a significantly higher median cost per outpatient encounter ($440 vs. $141, p < .0001; Wilcoxon statistic = 469.0). Although this study only looked at costs directly associated with wound management, continued research exploring the use of teleconsultation in other areas of SCI/D specialty is needed to enhance its application.
Injury and disease processes may significantly damage the spinal cord as well as disrupt the normal transmission of electrical impulses throughout the body, contributing to major motor loss and decreased sensory function in people with spinal cord injury/disorder (SCI/D). According to the National Spinal Cord Injury Statistical Center (2009), 80% of all SCI/Ds occur in males. Approximately 6% of all spinal-cord-injured Americans are veterans, making the Department of Veteran Affairs (VA) the largest network of SCI/D care in the nation, providing a full range of health care to nearly 26,000 veterans with SCI/D, and SCI specialty care to 13,000 veterans in 2006 (Public and Intergovernmental Affairs, 2007).
Persons with SCI/D may experience neuropathic pain, alteration in skin integrity (wounds), changes in bowel and bladder function, and other disorders. Seemingly minor problems associated with SCI/D may quickly become life threatening. Realizing the special needs of veterans with SCI/D, the VA developed a system of care that specifies the comprehensive services provided to this population using a hub-and-spokes model. The hub-and-spokes model of care consists of 23 regional SCI/D centers (hubs) throughout the United States offering primary and specialty care by multidisciplinary teams, and SCI primary teams or support clinics (spokes) at local VA medical centers. The VA medical center in Cleveland, OH, is the designated hub for veterans who receive SCI/D primary care at an Ohio VA hospital.
Many veterans who require SCI/D specialty care travel long distances from their homes to Cleveland for outpatient SCI/D specialty consultation. Because of the distance often involved in traveling to the Cleveland VA hospital, an outpatient-level care visit often results in an inpatient stay that affects the quality of life of the veteran and their primary social support system. Teleconsultation allows providers to care for patients at distant locations through the use of video telecommunication. This alternative to traditional SCI/D care eliminates the long-distance travel associated with SCI/D specialty care evaluations. It also allows the veteran to be treated in an outpatient setting closer to his or her home, eliminating inpatient admissions except when it is determined that a pressure ulcer is advanced and requires aggressive treatment. In the past decade, the VA has changed its focus of care from inpatient to outpatient, with the goal of helping veterans with clinically complex conditions and those at risk for institutionalization to reside in the community as long as possible. As a result of this paradigm shift, teleconsultation services were added to improve access to care, provide education, and, ultimately, improve patient health. Although literature estimating SCI/D costs exists (French et al., 2007; Yu, Smith, Kim, Chow, & Weaver, 2008), there is no literature evaluating the cost of SCI/D wound care in veterans using teleconsultation.
Purpose and Aims
The purpose of this study was to compare the cost of providing SCI/D wound care to veterans in Ohio VAs via teleconsultation to the cost of traditional SCI/D wound care. The specific aims were to compare the two groups in terms of (a) inpatient admissions, (b) bed days of care, (c) visits in the outpatient hub and spoke centers, (d) overall cost for outpatient care, and (e) overall cost for inpatient skin/wound care.
Background and Significance
To establish the background for this study, we reviewed extant literature in three areas: (1) teleconsultation used to provide care to remote areas, (2) quality of teleconsultation transmissions for assessment diagnosis and treatment, and (3) costs associated with providing care to SCI/D veterans.
Teleconsultation in Remote Areas
Providing adequate health care to people in rural and remote areas is a long-standing health systems challenge. Consultation via teleconsultation technologies provides one way to reduce barriers associated with accessing health care when residing in rural areas.
Success of a teleconsultation program in rural areas is based on a progressive diffusion strategy, buy-in from the participating organization and the providers, and an understanding that the benefits are realized over an unspecified time. Gagnon, Duplantie, Fortin, and Landry (2006) studied the conditions for success of a teleconsultation program that supported medical practice in four remote areas of Quebec, Canada. By interviewing staff members, they found teleconsultation was perceived by physicians and managers as an excellent method by which second opinions and specialized services could be obtained. These staff members believed that teleconsultation (a) avoided transfers to other institutions; (b) provided better follow-up, improving continuity of care; and (c) ¨facilitated communication with peers and decreased the feeling of isolation in remote areas. The perceived limitations identified by the organizational and professional staff were anticipated changes in task and fear of replacing regional specialists.
Preprogram planning was found to be a critical factor for acceptance and efficacy of teleconsultation applications, according to Li and colleagues (2006). Li and colleagues developed a broadband teleconsultation system that supported critical care in a rural hospital in Katooma, Australia. Real-time multimedia information was transmitted over an Internet-protocol–based network to and from a large medical center in Sydney, Australia. The authors recommended establishing compatibility between the teleconsultation system and multiple media outlets to ensure high-quality diagnostic imaging and communication patterns. To enhance reliability of the system, the design must meet user needs at both the transmitting and receiving hospitals.
Other researchers have reported on the quality of care provided via teleconsultation when working with a diverse group of veterans and nonveterans with chronic healthcare conditions (Barnett et al., 2006; Debray et al., 2001; Halstead et al., 2003). Using a 2-year retrospective design, Barnett and colleagues (2006) examined the effectiveness of a home teleconsultation program for 800 veterans with diabetes. A significant reduction in diabetes-related hospitalizations was reported in the treatment group of 391 subjects. Debray and colleagues (2001) performed a pilot study with three elderly patients with wounds to investigate the feasibility of teleconsultation use for wound assessment. The teleconsultation assessment was followed by an in-person assessment. The authors reported the digital images obtained via teleconsultation provided sufficient detail to allow physicians to assess the main clinical characteristics of the wounds but they were unable to adequately assess undermining factors associated with deep wounds. When comparing teleconsultation to in-person wound assessments in 17 SCI/D veterans, Halstead and colleagues (2003) reported an 89% agreement rate for the ability to assess the wound and make appropriate treatment decisions. These findings contribute to establishing teleconsultation’s reliability in accurate wound assessment.
SCI/D Teleconsultation Costs
Wound development and subsequent management in patients with chronic conditions are costly problems that have plagued the healthcare system for decades. Secondary to the many variables that factor into the cost of treating pressure ulcers, reliable data on the cost of wound care are difficult to find. A cost minimization analysis of 233 subjects was conducted with the aim of determining the cost for prevention and treatment of pressure ulcers in two large teaching hospitals in the Netherlands. Schuurman and colleagues (2009) performed a study parallel to the Purse Value Study. The Purse Value Study was an observational prospective cohort study of 1,440 subjects that provided data on the incidence of pressure ulcers and the average number of days for care related to prevention and treatment of ulcers (Schuurman et al.). The authors of the cost-minimization analysis estimated that the annual costs associated with pressure ulcers for the Netherland’s healthcare system ranges from $27.5 million to $63.6 million (Shuurman et al.). In the United States, there were more than 500,000 reported pressure ulcer-related hospital admissions in 2006. One in twenty-five of every admission that listed “pressure ulcer” as a primary diagnosis resulted in death, with the average hospital cost for an episode of pressure ulcer treatment ranging from $10,000 to $20,000, depending on medical circumstances (Agency for Healthcare Research and Quality, 2008).
Healthcare cost estimates for people with SCI/D vary widely. According to the National SCI Statistical Center (2009), the average annual estimated healthcare cost and living expense for a person with SCI/D ranges from $236,000 to $800,000 in the first year and $16,000 to $143,000 each subsequent year. When inpatient and outpatient care were analyzed for 675 veterans (French et al., 2007), it was estimated that the annual recurring direct medical cost associated with the postacute phase of VA SCI/D specialty care in 2005 was $21,450, with a range of $16,792 to $28,334. During the 2-year study period, 233 participants had 378 discharges, accounting for $7.19 million in costs. The average outpatient care cost ranged from $7,000 to $12,000. The authors concluded that people with chronic SCI/D continue to incur substantial direct medical costs years after their initial injury, with inpatient care accounting for one-half of the cost. In fact, during the final 2 years of life, veterans with SCI/D incurred an average total cost of $61,900 in year 1 and $24,000 in year 2, with inpatient care accounting for 93% and 86%, respectively, of the total cost (Yu et al., 2008).
Convenience and economic feasibility are important factors in providing teleconsultation services. Several studies have revealed that in rural clinics, teleconsultation is less expensive than traditional care (Bynum, Irwin, Cranford, & Denny, 2003; Callahan, Malone, Estroff, & Person, 2005; Shore, Brooks, Savin, Manson, & Libby, 2007).
In summary, findings from previous studies provide insight into lessons learned in the cost of chronic disease management while further developing the concept and practice of teleconsultation for various uses in health care. These studies were based on the use of teleconsultation to evaluate general medical conditions; however, we found no published studies comparing the cost of teleconsultation to traditional care for the provision of specialty skin/wound care in veterans with SCI/D.
A retrospective design was used to conduct this descriptive study that compared costs associated with traditional SCI/D specialty wound care to SCI/D specialty wound care via teleconsultation. Institutional review board approval was received from five Ohio VA hospitals with designated SCI/D clinics and from Robert Morris University.
A convenience sample of 76 SCI/D veterans ¨(2 women, 74 men) met inclusion criteria from a possible 123 participants identified in the VA Decision Support System (DSS) database. The inclusion criteria were veterans who lived in Ohio and received wound care for one of several qualifying ICD-9 (associated with decubitus ulcer, cellulites, osteomyelitis, or open wounds) or Current Procedural Terminology (CPT) codes (associated with excision debridement, pressure ulcers, active wound care management, or wound repairs) from an Ohio VA SCI/D clinic between July 1, 2004, and December 31, 2007. Potential participants were excluded if they resided in states other than Ohio, received wound care in clinics other than SCI/D, or received nonwound-related care from SCI/D clinics. Operational definitions can be found in Table 1.
We extracted data regarding inpatient admissions, outpatient encounters, and costs from the DSS and redacted them prior to analysis. Both inpatient and outpatient estimates are adjusted by DSS so that the estimates represent the actual national VA expenditures for that type of care (U.S. Department of Veterans Affairs Health Economics Resource Center, 2009). Healthcare costs comparing teleconsultation versus traditional SCI/D wound care for veterans were based on estimates found in the DSS, using the VA standard method of cost-effectiveness analysis program and the Statistical Analytical Software (SAS) program, version 9.1. Variables were compared between groups using categorical and nonparametric methods, Wilcoxon rank sums, chi-square, and Fisher’s exact test. Cost for care was based on an inpatient or outpatient episode of care that involved wound/skin care in an SCI/D location.
We obtained demographic data from the VA DSS database (Table 2). The typical participant on first visit was an unmarried white male in his mid-50s. A comparison of inpatient admission data showed the teleconsultation group had significantly longer lengths of stay (81 days/admission) when they were admitted compared to the traditional care group (19 days/admission; p = .05). There was no significant difference between the groups in bed days of care, but a trend toward fewer admissions among the teleconsultation group (60% with no inpatient admissions) compared to the traditional care group (41% with no inpatient admissions) was observed. However, this was not statistically significant (p = .14). Similarly, looking at outpatient encounters the teleconsultation group had significantly more outpatient encounters (12 vs. 4, p = .007) than the traditional care group (Table 3). The cost for outpatient care differed between groups, and the higher number of outpatient encounters in the teleconsultation predictably translated into significantly higher outpatient cost per patient when compared to the traditional care group, both in total and per encounter. Some patients had both inpatient and outpatient data, therefore, the sum of patients in Tables 3 and 4 exceeds the number of unique study persons. In terms of inpatient costs, there was no significant difference between the groups, but a trend toward higher inpatient costs in the teleconsultation group was observed. The ¨number of admissions was the same for both groups. Although the traditional group had a higher percentage (59%) of participants with inpatient admissions than the teleconsultation group (40%), it was not significant (Table 4).
The purpose of this study was to compare the costs of providing specialty wound care to SCI/D veterans using teleconsultation and traditional specialty care from July 1, 2004, to December 31, 2007. The demographics of our sample mirror those from other studies (Bates-Jensen, Guihan, Garber, Chin, & Burns 2009; Guihan et al., 2008), which described SCI/D veterans with recurrent pressure ulcers as non-Hispanic White males with a mean age of 56 years and a mean time of wound reoccurrence since SCI/D of 21 to 22 years postacute injury.
Inpatient Admissions and Bed ¨Days of Care
Adding teleconsultation as a treatment method has the potential to reduce the percentage of SCI/D inpatient admissions to SCI/D hubs associated with specialty consultations. Although the median number of admissions per admitted participant in both the teleconsultation and traditional groups was not different (2), the length of stay per admission was significantly higher in the teleconsultation group. However, the traditional group appeared to have a greater frequency of admissions (59%) compared with the teleconsultation group (40%), although this difference was not significant. We found that the number of bed days of care was higher for the teleconsultation group (99 vs. 46). The trend toward more admissions and shorter lengths of stay in the traditional group may support the idea that traditional SCI/D specialty care frequently results in inpatient admissions because of geographical distances.
Likewise, the longer inpatient stays and increased bed days of care among patients in the teleconsultation group may be related to that group being admitted to the SCI/D hub only after the wound had advanced to stage III or IV. Noel, Vogel, Erdos, Cornwall, and Levin (2004) have reported that bed days of care and unscheduled urgent visits decreased significantly (p ≤ .01) when home teleconsultation was added to nurse case management for elderly patients with complex comorbidities. These findings suggested that teleconsultation added to traditional healthcare methods works synergistically to ¨reduce healthcare resource use, encourage compliance with treatment protocol, and stabilize chronic disease. In contrast, our findings show a higher resource use for wound management among the teleconsultation group.
Number of Outpatient Encounters
The teleconsultation group had a significantly higher number of outpatient encounters (12 vs. 4, p = .007)), with a higher percentage (70%) of patients having an outpatient encounter compared to the traditional group (52%). This may be a result of the frequent visits associated with outpatient wound treatment. To adequately monitor the healing of wounds, patients are usually assessed every 2–4 weeks. Waiting for an appointment at the hub site can be delayed for a number of reasons. Receiving care at the primary VA using teleconsultation allows the patient to receive specialty care at the time of need without long-distance traveling or delay in services.
Total Cost for Inpatient and ¨Outpatient Care
Unlike reported findings (Rees & Bashshur, 2007) that total inpatient cost were considerably lower in a teleconsultation group of chronically ill individuals with chronic wounds compared to a nonteleconsultation group, we found a higher total cost in the teleconsultation group. Higher total costs per patient in the teleconsultation group for an inpatient stay correlates with the longer lengths of stay. The higher total cost for outpatient care correlates inversely with the higher number of outpatient encounters. In this study, the total inpatient cost ($139,473) was incurred over 3.5 years; comparatively, this is about half the cost of providing end-of-life care in SCI/D veterans (Yu et al., 2008).
The increased number of admissions among the traditional care group, though not significant, is noteworthy. Wound care is only one aspect of SCI/D specialty care that veterans receive during their lifetime. The cost of wound care as indicated by the results of this study can be relatively expensive. Although this study only looked at costs associated with teleconsultation and traditional care in SCI/D wound management, other areas of SCI/D care that may be enhanced by teleconsultation include bladder and erectile dysfunction management, functional electrical stimulation evaluations for extremities, vocational rehabilitation research studies, and discharge planning. The decision to support VA SCI/D centers in the purchase of teleconsultation equipment is a demonstration of the support of the teleconsultation mission to appropriately use cost-effective health information and telecommunication technologies to provide the right care in the right place at the right time. Opportunities for additional research with wounds and other SCI/D comorbidities broaden as teleconsultation is integrated into the VA SCI/D hub-and-spokes system nationally.
The limiting factors in this study included using a gender-biased, purposive sample that was selected from a database that is highly dependent upon human input. The study was gender biased because there were only two women in the study, although the number of female veterans entering the VA healthcare system mirrors the increased number of females entering the armed services and fighting alongside their male comrades, and the injuries they present with do not discriminate by gender. The purposive sample is another limiting factor of this study. The sample may not be representative of VA facilities in all states; therefore, the results cannot be generalized beyond our setting. The inability to standardize the treatment protocol adds to the limitations of this study.
We retrieved data from existing information in the DSS system. Altough the DSS is used for research, it contains workload data. Workload data are dependent on human input that lends itself to user error when recording data. Encounter information from which the diagnosis is drawn is provider-dependent and based on the provider’s assessment and familiarity with the VA records system. In addition, data are dependent on the accuracy of the documentation structure (Relative Value Unit [RVU]) and labor mapping at each local site. Although each site is required to keep information current, it is possible that ¨mapping and RVU changes may not be entered into the DSS system in a timely manner.
Recommendations for Research
This study adds another piece to the puzzle of wound care costs associated with the use of teleconsultation with Ohio SCI/D veterans. The high cost we found to be associated with higher outpatient encounters and the lower frequency of inpatient admissions among the teleconsultation group emphasizes the need for a more comprehensive study on the cost of wound care management in the SCI/D veteran. We recommend conducting a prospective study that includes (a) more detailed demographics of the sample, including injury type, disease, and level; (b) pressure ulcer history, including stage, location, ulcer history, and treatment history; (c) a more detailed examination of cost, including travel cost and lost time from work due to inpatient stays; and (d) a patient and provider satisfaction survey that evaluates the decision whether to use teleconsultation. We believe that including these variables in a study will help address the complex issues in the cost of SCI/D wound care.
About the Authors
Sadie Young-Hughes, DNP MSN RN, is a nurse practitioner at Cincinnati Veterans Affairs Medical Center, Spinal Cord Injury/Disorder Clinic, in Cincinnati, OH. Please address correspondence to her at firstname.lastname@example.org.
Loretta A. Simbartl, MS, is a statistician at Cincinnati Veterans Affairs Medical Center, Medical Service in Cincinnati, OH.
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