Subgroup analysis of telehealthcare for patients with chronic obstructive pulmonary disease: the cluster-randomized Danish Telecare North Trial

Figures & data

Table 1 Overview of economic evaluation of the Danish Telecare North Trial

Perspective of analysis	Healthcare sector and social care sector
Outcomes	Total costs per QALY gained
Compared alternatives	IG: a set of telehealthcare equipment and were monitored by a community-based healthcare team (based in social care sector). Patients also received disease-specific education
	CG: usual care
Duration of study	12 months
Patients included	All patients with COPD that may benefit from telehealthcare. Fixed residence in North Denmark Region, Danish speaking, GSM coverage or phone line. No cognitive impairments. N=1,225 patients; 578 in IG and 647 in CG
Clusters	Municipality districts (social care sector), 26 clusters in total, 13 in each treatment arm. Each municipality had at least one district in both the intervention and control groups
Cost categories	Hospital admissions, outpatient visits including emergency contacts, primary-care contacts, prescribed medicine, personal care, practical help, at-home nursing care, and rehabilitation
Conclusion	Incremental QALYs was 0.0132 (rounded)
	Incremental total costs were €728 (rounded)
	ICER was €55.327 per QALY gained
	Telehealthcare is unlikely to be cost-effective

Abbreviations: QALY, quality-adjusted life-year; IG, intervention group; CG, control group; COPD, chronic obstructive pulmonary disease; GSM, global system for mobiles; ICER, incremental cost-effectiveness ratio.

Table 2 Baseline characteristics

Subgroup category	Telehealthcare	Usual care	Difference	Fisher’s exact test
	n=578	n=647	Raw	P-value
COPD severity (GOLD classification 1–4)
Mild, GOLD 1	3.98 (n=23)	4.64 (n=30)	−0.66
Moderate, GOLD 2	31.49 (n=182)	31.07 (n=201)	0.42
Severe, GOLD 3	32.18 (n=186)	30.60 (n=198)	1.58	0.937
Very severe, GOLD 4	13.84 (n=80)	13.91 (n=90)	−0.07
Missing	18.51 (n=107)	19.78 (n=128)	−1.27
Comorbidities
Coronary heart disease	32.70 (n=189)	31.84 (n=206)	0.86	0.927
Diabetes	10.21 (n=59)	9.89 (n=64)	0.32	0.962
Mental health problem	4.84 (n=28)	4.79 (n=31)	0.05	0.991
Missing	8.13 (n=47)	7.88 (n=51)	0.25
Age§
<60 years	16.78 (n=97)	14.68 (n=95)	2.10
60–69 years	34.08 (n=197)	31.68 (n=205)	2.40	0.445
70–79 years	36.33 (n=210)	40.19 (n=260)	−3.86
≥80 years	12.80 (n=74)	13.45 (n=87)	−0.65
Men§	48.27 (n=279)	43.74 (n=283)	4.53	0.063
Existing resource pattern
No resource use in social sector 12 months prior to randomization	52.25 (n=302)	57.50 (n=372)	−5.25
Resource use in social sector 12 months prior to randomization	39.62 (n=229)	36.32 (n=235)	3.30	0.136
Missing	8.13 (n=47)	6.18 (n=40)	1.95
Delivery site
Delivery site 1	8.13 (n=47)	6.18 (n=40)	1.95
Delivery site 2	16.09 (n=93)	4.33 (n=28)	11.76
Delivery site 3	10.73 (n=62)	9.58 (n=62)	1.15
Delivery site 4	5.54 (n=32)	5.10 (n=33)	0.44
Delivery site 5	6.40 (n=37)	7.88 (n=51)	−1.48	0.000
Delivery site 6	3.46 (n=20)	4.17 (n=27)	−0.71
Delivery site 7	4.50 (n=26)	4.33 (n=28)	0.17
Delivery site 8	15.40 (n=89)	6.49 (n=42)	8.91
Delivery site 9	10.55 (n=61)	10.05 n=65)	0.50
Delivery site 10	19.30 (n=111)	41.89 (n=271)	−22.59

Note: Data are presented as percentages (number of patients).

§ Variable has no missing values.

Abbreviations: COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Table 3 Average costs (€) per patient across treatment groups at 12-month follow-up for all COPD severities

Cost categories across COPD severities	Telehealthcare	Usual care	Between-group difference
	Mean (SD)	Mean (SD)	Raw mean	Standardized (%)*
Mild COPD (GOLD 1)
Hospital contacts
Admissions	768 (4879)	813 (2449)	−45.16	−1.22
Outpatient/emergency department visits	111 (291)	97 (274)	14.58	5.17
Primary-care contacts	602 (420)	725.7 (535)	−123.32	−25.01
Municipality-care contacts
Help and care at home	1174 (5128)	661 (2868)	512.96	12.82
Home nursing care	1857 (7782)	477 (1524)	1379.50	26.21
Rehabilitation§	106 (325)	17 (157)	88.90	35.85
Medicine	1025 (714)	1085.3 (726)	−60.85	−8.43
Total service costs (excluding intervention costs)	5645 (14486)	3878 (6079)	1766.58	17.22
Total costs (including intervention costs)	6280 (14464)	3878 (6079)	2401.58	23.37
Moderate COPD (GOLD 2)
Hospital contacts
Admissions	1299 (5369)	811 (2653)	488.67	11.72
Outpatient/emergency department visits	194 (450)	123 (348)	71.80	17.90
Primary-care contacts	618 (397)	616 (475)	1.93	0.44
Municipality-care contacts
Help and care at home	946 (3495)	1132 (4168)	−186.12	−4.81
Home nursing care	625 (2893)	388 (2111)	236.36	9.40
Rehabilitation§	50 (265)	24 (191)	25.56	11.14
Medicine	1312 (856)	1240 (795)	71.79	8.70
Total service costs (excluding intervention costs)	5045 (8992)	4334 (7796)	709.98	8.46
Total costs (including intervention costs)	5759 (8988)	4334 (7796)	1424.25	16.94
Severe COPD (GOLD 3)
Hospital contacts
Admissions	2686 (8818)	4116 (16371)	−1429.47	−10.73
Outpatient/emergency department visits	347 (564)	346 (583)	0.92	0.16
Primary-care contacts	602 (460)	679 (582)	−76.39	−14.46
Municipality-care contacts
Help and care at home	1990 (5654)	1968 (5934)	22.58	0.39
Home nursing care	680 (1805)	638 (2559)	42.72	1.92
Rehabilitation§	116 (462)	106 (533)	10.64	2.13
Medicine	1722 (855)	1721 (1035)	0.54	0.06
Total service costs (excluding intervention costs)	8144 (11826)	9572 (19000)	−1428.47	−8.94
Total costs (including intervention costs)	8855 (11807)	9572 (19000)	−716.92	−4.49
Very severe COPD (GOLD 4)
Hospital contacts
Admissions	6670 (21124)	4619 (12368)	2051.10	12.02
Outpatient/emergency department visits	728 (801)	527 (737)	200.35	25.88
Primary care contacts	571 (422)	518 (408)	53.01	12.76
Municipality care contacts
Help and care at home	4202 (9588)	1340 (3435)	2862.11	39.93
Home nursing care	775 (2475)	616 (1934)	158.84	7.20
Rehabilitation§	133 (422)	57 (246)	75.43	22.04
Medicine	2176 (1659)	1863 (946)	312.54	23.36
Total service costs (excluding intervention costs)	15255 (24517)	9541 (14497)	5713.38	28.52
Total costs (including intervention costs)	15941 (24506)	9541 (14497)	6399.81	31.87

Note:

* Standardized difference, difference between randomization group averages divided by the standard deviation (SD) of the total sample.

§ Imputed data.

Abbreviations: COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Figure 1 Probability of telehealthcare being cost-effective, depending on the severity of COPD (by GOLD classification).

Abbreviations: COPD, chronic obstructive pulmonary disease; QALY, quality-adjusted life-years; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Table 4 Cost-effectiveness of telehealthcare compared to usual care across COPD severities

COPD severity (GOLD classification 1–4)#	QALY	Wald test*	Total costs (€)	Wald test*	ICER	Pr(cost-effective)	Pr(cost-effective)
	Between group difference (95% CI)	P-value	Between group difference (95% CI)	P-value	(€ per QALY)	at €25,000	at €40,000
Mild, GOLD 1 (6%)	0.0281 (–0.0551; 0.1113)	0.4131	1872 (–5337; 9082)	0.3998	66,577	39%	44%
Moderate, GOLD 2 (38%)	–0.0113 (–0.0469; 0.0243)		1455 (–94; 3003)		UC dominant	35%	35%
Severe, GOLD 3 (39%)	0.0302 (–0.0075; 0.0678)		–964 (–3750; 1822)		THC dominant	68%	70%
Very severe, GOLD 4 (17%)	0.0229 (–0.0261; 0.0719)		2959 (–2087; 8005)		129,035	29%	33%

Note:

* Wald test for interaction between treatment and the subgroup variables.

# QALYs and total costs were not simultaneously controlled for baseline FEV1%. All results are imputed.

Abbreviations: QALY, quality-adjusted life-years; COPD, chronic obstructive pulmonary disease; UC, usual care; THC, telehealthcare; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICER, incremental cost-effectiveness ratio; Pr, probability.

Table 5 Cost-effectiveness of telehealthcare compared to usual care in subgroups

Subgroup category	QALY	Wald test*	Total costs (€)	Wald test*	ICER	Pr(cost-effective)	Pr(cost-effective)
	Between group difference (95% CI)	P-value	Between group difference (95% CI)	P-value	(€ per QALY)	at €25,000	at €40,000
Comorbidities
Coronary heart disease
No (65%)	0.0168 (–0.0059; 0.0394)	0.636	445 (–1604; 2493)	0.566	26,527	49%	57%
Yes (35%)	0.0068 (–0.0315; 0.0451)		1290 (–650; 3229)		189,373	28%	31%
Diabetes
No (89%)	0.0112 (–0.0116; 0.3402)	0.577	309 (–1340; 1957)	0.182	27,573	49%	56%
Yes (11%)	0.0294 (–0.0312; 0.090)		4731 (–1085; 10547)		160,728	8%	12%
Mental health problem
No (95%)	0.0130 (–0.0094; 0.0354)	0.911	772 (–770; 2314)	0.815	59,378	29%	39%
Yes (5%)	0.0178 (–0.0627; 0.0983)		38 (–5837; 5913)		2,135	55%	58%
Gender
Female (54%)	0.0052 (–0.0172; 0.0276)	0.347	407 (–1471; 2286)	0.573	77,890	39%	42%
Male (46%)	0.0225 (–0.0108; 0.0557)		1122 (–888; 3132)		49,917	44%	55%
Age##
<60 years (16%)	0.0046 (–0.0403; 0.0495)	0.692	–560 (–2972; 1851)	0.707	THC dominant	69%	68%
60–69 years (33%)	0.0009 (–0.0322; 0.0340)		1622 (–1170; 4415)		1,764,487	22%	25%
70–79 years (38%)	0.01607 (–0.0211; 0.0532)		528 (–1848; 2903)		32,845	47%	51%
≥80 years (13%)	0.0489 (–0.0202; 0.1180)		484 (–2117; 3085)		9,900	62%	71%
Patients with previous resource use in social sector
No resource use in social sector 12 months prior to randomization (64%)	0.0180 (–0.0054; 0.0414)	0.894	1396 (290; 2503)	0.228	77,622	7%	18%
Resource use in social sector 12 months prior to randomization (36%)	0.0143 (–0.0322; 0.0607)		–1205 (–5144; 2734)		THC dominant	89%	89%
Delivery site
Delivery site 1 (7%)	0.0675 (0.0357; 0.0993)	0.102	3952 (2952; 4952)	0.000	58,520	0%	6%
Delivery site 2 (10%)	–0.0033 (–0.0311; 0.0245)		3375 (1870; 4881)		UC dominant	1%	3%
Delivery site 3 (10%)	0.0033 (–0.0712; 0.0779)		–12 (–2344; 2319)		THC dominant	55%	56%
Delivery site 4 (5%)	0.0397 (0.0061; 0.0732)		–290 (–1026; 446)		THC dominant	90%	93%
Delivery site 5 (7%)	–0.0007 (–0.0322; 0.0308)		–981 (–2985; 1023)		1,389,780	71%	70%
Delivery site 6 (4%)	0.0308 (–0.0117; 0.0733)		–9138 (–12087; –6188)		THC dominant	100%	100%
Delivery site 7 (4%)	0.0193 (–0.0171; 0.0557)		262 (–248; 772)		13,549	58%	64%
Delivery site 8 (11%)	0.0383 (–0.0027; 0.0792)		–2545 (–2848; –2242)		THC dominant	100%	100%
Delivery site 9 (10%)	0.0160 (–0.0032; 0.0353)		416 (72; 759)		25,921	51%	59%
Delivery site 10 (32%)	0.0028 (–0.0379; 0.0435)		1062 (94; 2029)		376,794	19%	26%

Note:

* Wald test for interaction between treatment and the subgroup variable.

## QALYs and total costs were not simultaneously controlled for age. All results are imputed.

Abbreviations: QALY, quality adjusted life year; COPD, chronic obstructive pulmonary disease; UC, usual care; THC, telehealthcare; GOLD, Global Initiative for Chronic Obstructive Lung Disease; ICER, incremental cost-effectiveness ratio; Pr, probability.