The cost-effectiveness of technology transfer using telemedicine

K JOHNSTON 2 C KENNEDY 1 I MURDOCH 1 P TAYLOR 0 C COOK 3 0 Centre for Health Informatics and Multiprofessional Education, University College London , UK 1 Institute of Ophthalmology , London, UK 2 Health Economics Research Centre, University of Oxford , UK 3 Eye Clinic, Edendale Hospital , Edendale, KwaZulu-Natal, South Africa The high burden of disease in developing countries often makes it difficult for health systems in these countries to attain the same level of specialist skills as industrialized countries. Technology transfer is one way to improve specialist skills whilst at the same time reducing the burden of disease. This paper describes the use of teleophthalmology, a form of telemedicine, as a mode of technology transfer between the United Kingdom and South Africa. As the burden of eye disease in South Africa is high, the country cannot afford the level of ophthalmic specialization achieved in the UK. The paper estimates the cost-effectiveness of the technology transfer project in terms of a cost per Disability Adjusted Life Year (DALY) averted. We found the technology transfer project to be cost-effective in reducing the burden of eye disease, and that practitioners in South Africa also learned novel procedures that could help future patients and improve cost-effectiveness. Technology transfer using telemedicine is a cost-effective method that richer countries can employ to aid capacity building in the health care systems of poorer countries. Introduction All health services require a skilled workforce in order to deliver effective health care, but it is often difficult for health systems in developing countries to attain the same level of specialist skills as industrialized countries. This arises because the high level of disease burden in poorer countries compounds the problem of sustaining adequate health care systems from their limited resources. Yet there has been only a limited response by the international community to the high disease burdens in developing countries, and investment by richer countries in poorer countries has been inadequate (Sachs 2001). One way that richer countries could support the health care systems of poorer countries is by assisting in building the scientific capacity in those countries (Harris and Tanner 2000). Health technology transfer is one method of building capacity: specialist skills are imparted to local practitioners who can then provide benefits that will improve the health of the local population (Donald 1999). One mode of technology transfer, as yet unevaluated, is to use telemedicine as a form of communication and learning between practitioners in richer and poorer countries. This paper describes the use of teleophthalmology as a mode of technology transfer between the United Kingdom (UK) and South Africa. The burden of eye disease in South Africa is high, with blindness approximately five times higher than it is in the UK. As a result, there is a high demand for ophthalmic services in South Africa; yet the country cannot afford the level of ophthalmic specialization achieved in the UK. The aim of the paper is to report the costs and benefits to patients and practitioners associated with the technology transfer project. Model of technology transfer The conceptual framework of technology transfer used is based on that developed by Bozeman (2000). This framework identifies the following as key components of technology transfer: the transfer agent, transfer media, transfer object and transfer recipient. The transfer agent was Moorfields Eye Hospital, London, UK. The hospital has approximately 70 inpatient beds (including hostel beds) and serves the local community and patients around the UK as a tertiary service, providing a full spectrum of ophthalmic subspecialties including glaucoma, adnexal, strabismus, corneas and vitreo-retinal. Around 18 000 operations are performed annually, with approximately 250 000 outpatient attendances per year. Ophthalmologists at Moorfields Eye Hospital provided specialist advice as part of the technology transfer project. These included ophthalmologists-in-training and consultant ophthalmologists who all have expertise in treating diseases of the cornea, retina and anterior segment, as well as glaucoma, oculoplastics, neuro-ophthalmology, uveitis and ocular motility. The transfer medium was teleophthalmology, the practice of eye medicine at a distance. Videoconferencing was used in conjunction with the transmission of slit-lamp images of the eye. Videoconferencing facilities were installed at Moorfields hospital in London and at the recipient hospital in South Africa. A slit lamp and a hand-held camera were also purchased for the recipient hospital in South Africa. The transfer object was specialist advice on clinical management. Videoconferencing sessions were held every week, lasting between 12 hours, with three to four cases discussed. Specialist advice was provided on patient diagnosis, management and treatment. Responsibility for clinical decision-making following the consultation remained with the practitioner in South Africa. The transfer recipients were patients and ophthalmologists at Edendale Hospital, a district hospital near Pietermaritzberg, the provincial capital of KwaZulu-Natal in South Africa. Patients attending the hospital are primarily of Zulu origin. The hospital has 1225 inpatient beds, of which 38 are based in the eye department. The hospital also has an outpatient eye clinic that treats a high number of patients, around 15 000, per year. The types of cases presenting at the eye clinic are largely anterior segment, external eye disease and multiple pathology. An expert in telemedicine from the UK trained the local practitioners in the use of the teleophthalmology equipment. The technology transfer project ran for 12 months and an evaluation was conducted alongside the project. Evaluation Design Evaluations of technology transfer projects are rare (Bozeman 2000) and consequently there is a lack of literature on evaluation methods. An estimate of the benefits of the technology transfer is required, however, in order to determine whether the benefits justify the costs. Even in the field of telemedicine, there is no general agreement as to how to evaluate its costs and benefits (Hailey et al. 1999). Particular methodological issues include how to estimate costs averted as a result of telemedicine and the role of patientbased outcome measures (McIntosh and Cairns 1997). Furthermore, a recent systematic review found there to be no good evidence that telemedicine is cost-effective (Whitten et al. 2003). This arises because studies erroneously draw conclusions about cost-effectiveness based solely on evidence of apparent costs savings (Whitten et al. 2003). There are no economic evaluations of teleophthalmology, although there is one costing analysis (Lamminen et al. 2001), and there are no evaluations of the role of telemedicine in developing countries ( (...truncated)