Journal of Telemedicine and Telecare >
Volume 14, Number 8 >
Pp. 421-426
RESEARCHOriginal articles |
* Health Economics Research Group, Brunel University, Uxbridge;
Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield;
Brompton Fetal Cardiology, Royal Brompton and Harefield NHS Trust, London;
Institute of Reproductive and Developmental Biology, Imperial College, London, UK
Correspondence: Robin Dowie, Health Economics Research Group, Brunel University, Uxbridge UB8 3PH, UK (Fax: +44 1895 269 708; Email: robin.dowie{at}brunel.ac.uk)
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In the National Health Service (NHS) the major determinants of referral to a fetal cardiologist for detailed echocardiography are the local protocols of the referring hospitals that emphasize referral of women whose pregnancies are thought to be at an increased risk for congenital heart disease (CHD). While it is accepted that the risk of CHD in these women is about 3%, the majority of babies with CHD are not born to at-risk women. Thus, this protocol-driven strategy results in a referral pattern where only a small proportion of all the babies examined by fetal cardiologists have heart defects.6
Diagnostic fetal echocardiography may be undertaken in paediatric cardiology departments, isolated from obstetric services, or in tertiary fetal medicine centres. Both are sited in major city hospitals and many pregnant women make lengthy journeys to attend the regional centres. In the case of a suspected abnormality only a few days elapse between the local decision to refer and the specialist appointment, so travel arrangements have to be made quickly. For all women, there are travel costs to consider as well as incidental costs, such as child-minding and possible loss of earnings for themselves or partners.
Telemedicine offers an alternative method of delivering a fetal echocardiography service. The digitized images from obstetric ultrasound machines are suitable for electronic transmission,7 and the structures of a fetal heart can be visualized with clarity after 18 weeks gestation. Teleconsultations can be conducted either in realtime with a sonographer examining a heart while a remote specialist jointly views the images,8–10 or via the transmission of pre-recorded images (i.e. store-and-forward mode).
In London, the Royal Brompton Hospital (RBH) installed a telemedicine system in the 1990s. Paediatric telecardiology links were formed with hospitals in Greece and Portugal.11 In 2001, the RBH set up a telecardiology network with four district general hospitals (DGHs) in south-east England for the provision of specialist advice to clinicians in obstetric and paediatric departments. The local clinicians and managers decided on the precise role for this service in their hospital. An economic analysis covering all three telemedicine applications (fetal, neonatal and paediatric) showed that the telecardiology network was cost neutral when compared with conventional referral practice once patients were followed up over six months.12
In one DGH, the telemedicine system was used for fetal cardiac diagnosis alongside the existing arrangement for referring women directly to London specialist centres for fetal echocardiography. A pattern of monthly ‘virtual outreach’ clinics was established during which obstetric sonographers transmitted to a specialist, ultrasound images of fetal hearts that had been recorded when women were screened for anomalies in the second trimester of their pregnancy. The present paper describes the impact of the new service on NHS costs of antenatal care received by the women and on their personal costs. It also identifies cost-related factors that could influence the wider introduction of fetal telecardiology.
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The hospital was supplied with a videoconferencing system (model 2500, Tandberg) and connected to the ISDN network at 384 kbit/s. Training in using the telemedicine equipment was provided, as well as advanced training in fetal heart scanning. At the RBH, the existing telemedicine suite contained a videoconferencing system (model 2500, Tandberg) that was used frequently by hospital staff.
Over a 15-month period in 2001–2002, demographic details were recorded of all women referred for an assessment of their baby's heart and the women's clinical events from the time of the anomaly scan until they were delivered. The personal information included any antenatal risk factors for fetal abnormalities. The factors were of two kinds: traditional CHD risk factors (a maternal or family history of CHD; maternal dependency on insulin, anti-epilepsy or lithium therapies; or current multifetal pregnancy13); and risk factors for Down's syndrome (notably an adjusted risk based on a quadruple serum test result or a nuchal translucency measurement 
3.5 mm). Diagnostic information on fetal heart abnormalities was extracted from ultrasound and echocardiography reports. The project was approved by the appropriate ethics committees.
The referred women formed two groups for the analyses: a telemedicine-referrals group and a London group as a comparator. The telemedicine group consisted of women who, at the time of their anomaly scan, were identified for echocardiographic referral according to the obstetric department's protocol for high-risk women, and women whose fetal heart images during the anomaly scan were abnormal in some respect or were poorly visualized. The London group consisted of women who were referred for the same reasons in the five months before the telecardiology service entered regular use and those who travelled to London during the following 10 months, usually during the intervening weeks between the scheduled teleconferencing sessions. It also included women whose fetuses were strongly suspected of having a heart defect. A consultation with a fetal cardiologist was held according to the hospital protocols, usually within two working days.
Health service and women's costs
Detailed resource use information was collected for each woman from the anomaly scan until delivery. Unit costs in pounds sterling (£1 
1.3 US$ 2.0) for the resource items were obtained from hospital finance departments in Gillingham and specialist centres in London. The items covered ultrasound scans, antenatal and outpatient review consultations, and prenatal inpatient admissions. The unit cost for an outpatient or antenatal clinic attendance included nursing supervision and clerical staff time, consumables and equipment, overheads and capital charges. The status of the clinician (midwife or doctor) who examined each woman at each attendance was recorded separately. The mean durations of the consultations were estimated to allow the time of these clinicians to be costed and the staff cost was added to the unit cost in the analysis. The cost for an ultrasound examination incorporated the sonographer's time as well as consumables, an administrative cost, overheads and capital charges. Originally, the costs applied to the 2001–2002 financial year, but for the present paper they were inflated to 2005–2006 prices (Table 1).14 When deriving the fetal telemedicine system cost, an annual equivalent cost covering the equipment, the installation of the ISDN lines and 17.5% tax (VAT) was calculated, with an expected lifetime for the equipment of 5 years15 and an annual discount rate of 3.5%.16 The monthly invoices from the telephone company provided details of the ISDN line rental and call charges. A mean component cost per telemedicine patient was then derived (Table 2).
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After attributing unit costs to the clinical events recorded for all women (Table 1), a mean cost per woman was estimated for telemedicine referrals and London referrals for each of three time periods: the events relating to the specialist consultation; antenatal care over 14 days inclusive of the specialist consultation; and antenatal care spanning the second and third trimesters until delivery. These follow-up periods were adopted for the evaluation of all three applications of the telecardiology service in the district hospitals.12 The short-term period covered emergency events arising from the specialist assessment (such as a termination of pregnancy following prenatal diagnosis). Fourteen days duration was selected to minimize the weighting effect on a patient's costs of any complications associated with an emergency event. The longer-term period covering the women's care until delivery had also been used in a companion paper from this project on the costs of NHS maternity care for women with high-risk and low-risk pregnancies.13
As the patient total costs were skewed, a simulation technique known as bootstrapping19 was used, taking 5000 iterations of the data, to calculate 95% confidence intervals around the mean costs. Statistical analyses were conducted using the software Stata version 1020 and S-PLUS.21
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Antenatal costs of the referral services
A telemedicine assessment was significantly more costly than an examination in London (bootstrapped mean costs per referral of £206 versus £74, P < 0.001) (Table 4). This was a predictable result since the mean cost per woman of the telemedicine service in its first year of operation was £158 (Table 2). However, there was no significant difference in the antenatal mean costs for the two cohorts in each follow-up period. Six women had a late termination of pregnancy; two in the telemedicine group (4%) and four among the directly referred women (17%). These procedures were assigned a unit cost of £858, and this outcome for the pregnancies of four London-referred women contributed to the higher mean cost for the London cohort within the 14-day period. Among all the referred women, 25 were under treatment for diabetes or epilepsy; 21 in the telemedicine group (40%) and four (17%) in the directly-referred group (chi-square test, P = 0.041). A separate analysis of the study's pregnancy data-set found that the antenatal care for women with underlying medical conditions was significantly more expensive than antenatal care for singleton women in general.13 Thus the differing risk profiles of the telemedicine and London cohorts would account for the higher mean cost for the telemedicine women for the extended period until delivery.
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Details of travel arrangements when attending Gillingham hospital were included in 23 questionnaires from women whose anomaly scans were video-recorded for a telemedicine assessment and 98 questionnaires from women managed locally. The mean travel costs for the two groups in 2005–2006 prices were similar: £5.49 (SD 5.03) for telemedicine referrals and £7.01 (SD 5.51) for local care. Six women were seen in London and their mean travel cost of £37.33 (SD 12.06) was significantly greater (F test, P < 0.001). Twenty-one (17%) of the Gillingham hospital attenders reported a loss of income or an expenditure on babysitting, bringing their total mean cost to £59.96 (SD 45.53).
A sensitivity analysis was used to examine the effect on the initial specialist assessment when personal travel costs of the referred women were added to the NHS resource costs. (Multiple imputation22 was performed to estimate the costs of women who had not been surveyed.) The bootstrapped mean cost for the telemedicine group remained significantly greater than the mean cost for the London group: £213 (SD 13) versus £108 (SD 27), t-test, P < 0.001. Sharing the telemedicine system with other users was the scenario with the greatest potential for moderating the cost of a teleconsultation.12,15 So, as the Gillingham telecardiology service was also used in the neonatal unit, the NHS resource costs for 52 women and nine babies seen by telemedicine were compared with the costs for 24 women and eight babies who travelled to London. The telemedicine initial assessment cost was significantly less than the London assessment: £335 (SD 396) versus £1131 (SD 2708), t-test, P = 0.027. This was due to the high cost of neonatal ambulance transfers. However, at 14 days and six months, the alternative referral services were cost neutral: the six-month mean costs were £5303 (SD 14,176) for the telemedicine group and £6650 (SD 11,500) for the London group, t-test, P = 0.65).
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From the perspective of a district hospital, the most important telecommunications factor is the annual volume of use. The expected lifetime for the telemedicine equipment was five years,15 so the mean patient cost was based on the first year of the equipment's use plus the ISDN line rental and call charges for the same period. When the expense of the videoconferencing equipment in Gillingham was shared among the 52 women and nine babies, the adjusted mean cost (in 2005–2006 prices) for the service in the first year was reduced to £135 per patient. Senior ultrasonographers discussed pre-recorded videoed images of fetal hearts with the fetal cardiologists, spending five minutes on each case. If the women had been referred directly to the London clinics, as new patients they would have been booked for a 45-minute appointment to allow time for counselling should an abnormality be detected.
The magnitude of the financial savings to women who avoided travelling to London was determined primarily by the distances of the hospitals from their homes. The average return journey to the London clinics was 145 km compared with 21 km to the local hospital.
By assessing comprehensively the antenatal care received by the surveyed women during the second and third trimesters of their pregnancy, we observed how a teleconsultation was a relatively modest cost component of the total package of care provided by the NHS. Moreover, the telemedicine referral service was cost neutral in the extended period until delivery. Analyses of the study's data-sets showed that the total antenatal mean cost for a cohort of women could be markedly affected by costs associated with their pre-existing or pregnancy-related medical conditions.13 Thus, in the telemedicine group, almost 80% of the 52 women had CHD risk factors, such as diabetes, epilepsy or a family history of CHD, and 19 (37%) experienced a prenatal admission to hospital at a cost of £241 per bed-day.
Since the study, the fetal telecardiology service in Gillingham has continued to use the same videoconferencing system. During 2006, eight telemedicine sessions of 45–60 min duration were held and the videos of 84 women were assessed. Eleven of these women were followed up by London specialists and the hearts of four babies proved to be abnormal. Maternal obesity can impede visualization of the fetal heart during an anomaly scan. More than half the fetal cardiac images transmitted were from women with a body mass index above 30 but were of sufficient quality to distinguish abnormal cases. The ultrasound department remained committed to the telemedicine service because of its educational value for training staff in addition to its clinical effectiveness. Counselling is currently undertaken face to face in London as it is felt that this is better for achieving mutual understanding between the specialist and parents when major decisions, such as a termination of a pregnancy, are made, and specialist fetal cardiac liaison nurses are available to provide parental support. (It is also relevant that fetal images from specialist echocardiography machines are of a higher quality than images from obstetric ultrasound machines.) In the longer term, however, it may become acceptable to counsel parents during teleconferences, especially for more straightforward CHD lesions.
Only a small proportion of the 75 paediatric cardiology consultants in England are also specialists in fetal cardiology, so if their workloads are to be kept in check, a change of practice is needed to reduce the amount of time spent by them on the great majority of high-risk women whose fetuses are normal. The number of women with fetal cardiac risk factors in the UK is likely to increase as more and more survivors of CHD (both males as potential fathers, and females) reach adulthood, and the incidence of type 2 diabetes continues to rise.25 As maternal obesity becomes more prevalent, a subpopulation with poor fetal heart imaging is likely to contribute to the workload.
New challenges to the existing workload of fetal cardiologists will arise as standards of antenatal screening in maternity services rise,26 particularly as visualization of outflow tracts of the fetal heart is increasingly performed during second trimester anomaly scans.1 Higher detection rates of equivocal and unequivocal cardiac anomalies by obstetric sonographers will, in turn, lead to appropriately higher rates of referral for perinatal echocardiography. Nuchal translucency screening in the first trimester is already available in one-quarter of English hospital trusts2 in accordance with recently issued national guidelines.27 This will substantially increase the number of women requiring an early and more complex fetal cardiac scan performed by a specialist, given the independent higher risk of CHD despite a normal karyotype.
In conclusion, the present study demonstrates the potential for fetal telecardiology to support the few perinatal cardiologists in the UK in providing timely specialist consultations for women with frank or suspected fetal abnormalities. Setting up networks between specialist units and referring district hospitals for the transmission of pre-recorded video or digitally-stored ultrasound images, where up to 12 patients can be discussed in hour-long videoconference sessions, is likely to be an efficient and economic way of providing support and training to local obstetric screening programmes and will avoid unnecessary referral to tertiary centres.
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