Managing chronic disease in rural areas is a challenge for all countries. Increased travel time and costs to reach health providers potentially decrease access and can negatively impact health status.

Telemedicine offers one solution to this ongoing challenge by reducing the effect of distance. With these thoughts in mind, researchers in Italy recently performed a study which illustrated that chronic disease could be managed effectively in rural areas using telemedicine.

The primary goal of the study was to implement a telemedicine program called TELEMACO and assess its use. TELEMACO (an acronym for a longer Italian name) offers patients access to specialists in various fields, namely cardiology, dermatology, diabetology, and pulmonology in the remote areas of of Italy in the Lombardy region.

TELEMACO resulted from a local 2004 law which called for specialized continuity of care in remote areas of Lombardy, which was experiencing a declining population like a number of rural areas in the US and throughout the world. The decline in population meant less providers and likely worse health status for people. A second goal was to create a network in the Lombardy region among providers for sharing continuity-of-care strategies for the management of chronic diseases.

The final goal of the study is an extremely important one that is often overlooked by researchers. The researchers collaborated with health authorities to gather cost data in order to assess the sustainability of the TELEMACO services. This goal determines whether the product can translate into sustainable benefits for people beyond the study population.

METHODS

Three telemedicine programs were offered through TELEMACO. The first was a home based telemedicine program for managing chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Both types of patients were well defined in the study using validated clinical assessment tools. Patients with a poor prognosis and those with cognitive impairment were excluded from the study, seemingly implying that the researchers viewed telemedicine has having limited benefit to this group of patients.

For this first program, patients were provided with educational information regarding their illness prior to discharge from a hospital. This educational intervention was important for helping the patients identify if their disease was taking a turn for the worse. They were also given portable devices to monitor their progress. CHF patients received a portable 1-lead electrocardiogram (ECG) device (Card-Guard 2206) and COPD patients received a pulse oximeter (Vitalaire, Italy) device.

After discharge, participants had scheduled calls with a nurse for six months. The required frequency of the calls is not clear from the study. Patients also called infrequently if they had problems which needed the attention of a health provider. During the calls CHF patients used a mobile phone or land line to transmit ECG. COPD patients transmitted no information. At the beginning and end of their study, patients received a clinical evaluation. They also filled out a quality of life survey and a satisfaction survey which assessed how satisfied they were with the TELEMACO project.

The second program was a second opinion service for general practitioners in rural areas of the Lombardy region. During regular visits with patients, GPs transmitted findings to specialists. The teleconsultations by the specialists took place in real time for most fields (cardiology, pulmonology, and diabetology). Teleconsultations for dermatology were performed within 30 minutes.

The third program was also a second opinion program, but for rural hospitals, focused on patients with traumatic brain injury and stroke. When these patients came to the emergency department of a rural hospital, they were evaluated and imaging (CT scan) was performed. The images were sent to the specialist’s hospital for review. Expert opinion was made available to the rural hospitals within 30 minutes.

Researchers created service centers to aid in the distribution of information between sites and provide overnight and holiday clinical support when specialists were not readily available. The service center also played a vital role in training the hospital personnel to use the telemedicine tools.

The researchers measured the effectiveness of the telemedicine program by assessing the number of people participating in the program compared to the number of people who were eligible for the program, evaluating the organization of the integrated services across the Lombardy territories, and determining if a system of reimbursement could support the program after it is implemented.

RESULTS

The planned telephone contacts of the home based programs averaged about 1 per week for both CHF and COPD patients. The diffusion of the CHF home based program was measured at 23%, which was lower than expected. The diffusion for COPD was 1.43%, which was also lower than expected. There was no change noted in the clinical parameters of participants from beginning to end indicating that their condition remained stable.

The quality of life of patients showed a marked improvement which appeared to be influenced by increased physical activity among participants as a result of the project intervention. The second opinion programs were well utilized by rural general practitioners and hospitals according to the researchers. For the hospital second opinion program, 18% of the second opinions led to hospitalizations.

Another useful result of the study is that the health authority of Lombardy decided to continue the home based telemedicine program and the second opinion program for general practitioners. The health authority estimated the cost of the home base program to be 720 euros ($953) per patient for 6 months and 18 euros ($24) for each second opinion. More than 95% of patients were satisfied with the project.

Overall, the TELEMACO project demonstrated that telemedicine can improve the chain of care for patients and that this improvement was dependent on a mixture of communication technologies. More affordable, widely available technologies – such as cheaper smartphones – and increasingly technological people in rural areas will likely make programs like TELEMACO more common and more effective in the future.