Access to care and benefits for cancer patients in rural and remote locations using telemedicine

Introduction: Access to specialist cancer services is a significant issue faced by residents of rural, remote, Indigenous and some regional communities in Australia. Telemedicine using videoconferencing technology has been used in many fields of the healthcare sector to address the issue of poor access. In order to provide most of the specialist cancer services closer to home for patients in Mt Isa and other rural towns in North Queensland, Australia, the medical oncology department at the Townsville Cancer Centre (TCC) embarked on establishing a teleoncology model of care (telemedicine for cancer care) in 2007. An initial hybrid teleoncology/face-to-face model was shown to be acceptable to non-Indigenous patients. The overall purpose of this study was to examine the benefits and disadvantages of teleoncology models for rural patients, health professionals and hospitals. In addition, the study sought to evaluate the model in relation to acceptance by patients and health workers. A cost comparison with face-to-face models was conducted, while the safety of remotely supervised chemotherapy and the overall impact of this model on rural service capability was also evaluated. Our evaluation was guided by the following research questions: 1. To what degree has the Townsville Teleoncology model of care improved? a. Can the model provide access to specialist medical oncology services closer to home for rural patients in North Queensland? b. What is the capacity of rural hospitals to provide medical oncology services to rural patients? 2. Are patients and rural health workers satisfied with the Townsville teleoncology model? 3. Is it safe to supervise chemotherapy administration in rural towns via the Townsville teleoncology model? 4. What is the cost comparison between the face-to-face model and the Townsville teleoncology model in relation to health systems? Methods: The project was embedded in a Continuous Quality Improvement (CQI) framework. Data for the questions relating to feasibility, safety and cost analysis were collected retrospectively from medical charts and from the oncology information management system of the TCC. Using appropriate statistical tests for comparisons, a safety analysis was performed. This was done by comparing dose intensities and toxicity profiles between rural patients and TCC patients. A cost analysis was performed by comparing the cost of establishing the service against the costs prevented by the service. A one-way sensitivity analysis was performed to study the impact of cost on savings. Patients' and health professionals' perspectives were examined by means of questionnaires and semi-structured interviews. These were analysed using iterative thematic analysis. Rural doctors and nurses were surveyed before and after the teleoncology service was implemented in order to map the service's capability in rural towns. Results: Feasibility of services Between May 2007 and May 2011, 158 patients from 18 rural towns received a total of 745 consultations. Ten of these patients were consulted urgently and treatment plans initiated locally, avoiding inter-hospital transfers. Eighteen Indigenous patients who were accompanied by more than four family members received consultative services. Eighty-three patients received a range of intravenous and oral chemotherapy regimens in Mt Isa. Oral agents were supplied in other towns through remote supervision by medical oncologists from Townsville. Timely access to care From 2007-2009, 60 new patients from Mt Isa travelled to TCC for their first consultation and their first dose of chemotherapy. Six of these patients required inter-hospital transfers and eight required urgent flights to attend outpatient clinics. Only 50% of these rural patients (n=30) were reviewed within one week of their referral, compared with 90% of the Townsville patients. In 2009, the Townsville teleoncology model mostly replaced face-to-face care in Mt Isa. Between 2009 and 2011, TCC provided cancer care to 70 new patients from Mt Isa. Of these new patients, 93% (65/70) were seen within one week of referral. All 17 patients requiring urgent reviews were seen within 24 hours of referral and were managed locally, thus eliminating the need for inpatient inter-hospital transfers. Perspectives of Indigenous patients and health professionals Eighteen patients and health professionals who participated in this study gave high ratings (more than 4) on a five point Likert scale for quality of teleoncology consultation, establishing rapport, patient preference and satisfaction with care. Health workers welcomed this model for many reasons, including educational benefits, expanding scope of practice and the ability to readily connect with specialists. Teleoncology model replacing face-to-face care Thirty-five patients participated in a qualitative study. The study identified five major themes: (i) quality of the consultation, (ii) communication and relationships, (iii) familiarity with technology and initial fears, (iv) local services and support and (v) co-ordination of services. Responses for the first four themes were largely positive. Coordination between service providers needed further improvement to facilitate the model's smooth operation. Cost-savings Six hundred and five consultations were performed for 147 patients over 56 months, at a total cost of AUD$442,276. The total cost for project establishment, equipment/maintenance and staff was AUD$36,000, AUD$143,271 and AUD$261,520, respectively. The estimated travel expense avoided was AUD$762,394, including: travel cost for patients and escorts AUD$658,760, aeromedical retrievals AUD$52,400, and specialist travel AUD$47,634. This resulted in a net saving of AUD$320,118. The cost would need to increase by 72% to negate the savings. Safety of Townsville teleoncology model Over five years, 89 patients received a total of 626 cycles of various chemotherapy regimens in Mt Isa. During the same time period, 117 patients who received a total of 799 cycles of chemotherapy at TCC were eligible to be considered in the comparison group. For most of the demographic characteristics there were no statistically significant differences between Mt Isa and TCC: mean number of cycles (5.38 vs 5.07), dose intensities, proportion of side effects (4.4% vs 9.5%) and hospital admissions (27.8% vs 35.3%) [p>0.05]. There were no toxic deaths in either group. Improvement in rural service capability The level of services provided at Mt Isa Hospital has lifted to a higher service capability level as a result of the teleoncology model of care . The number of oncology-specific medical, nursing and allied health staff has also increased. Conclusion: We were able to demonstrate the following in relation to the Townsville teleoncology model of care • It is feasible to provide comprehensive services close to home, • Patients and health professionals welcome this model, • It is safe to remotely supervise chemotherapy, and • Health systems acquire savings as a result. Other major benefits were achieved by providing timely and equitable access and improvements in service capabilities at the Mt Isa Hospital. Over five to seven years, Mt Isa has become a stand-alone rural medical oncology unit. This was due to the gradual shifting of all services from Townsville to Mt Isa, and successful lobbying for resources to adequately fund the workforce and infrastructure to sustain these services. The end result was that patients from Mt Isa could get most of their services closer to home without the need for costly long distance travel. This adds to the growing body of evidence about the feasibility and efficacy of telemedicine models of care. Since our evaluation is on a single network encompassing a large geographic area, our findings may not be applicable to networks that serve patients facing short travel distances. Impact of the findings of this thesis on service quality provided through TTN The aggregated results of the above studies have produced an improvement in the processes and resources of the TTN and continual improvement in the quality of care provided. Future directions These results should lead to development of new models of care to benefit patients from smaller rural towns. One such model is the Queensland Remote Chemotherapy Supervision (QReCS) model, which aims to provide chemotherapy services in small rural towns across the state. The concept of the model and its governance were informed by the results of the studies included in this thesis, and it is now being implemented and evaluated with funding of AUD$2.5 million from Queensland Health Innovation Fund.