VA’s Challenge: Product Being Discontinued By Manufacturer
By Annette M. Boyle
PITTSBURGH—Telehealth tools are showing promise in helping save the lives of schizophrenic veterans with a high risk of suicide, but the VA is facing a setback in using them.
A product for patients with schizophrenia as well as other patients with chronic diseases has been discontinued by the manufacturer, leaving continuation or expansion of some successful programs in doubt. Last year, Bosch announced it was shutting down its U.S. subsidiary Robert Bosch Healthcare and consolidating its operations in Germany. In the process, the manufacturer closed its telehealth business, which offered the Health Buddy telehealth platform the VA used to remotely manage depression, congestive heart failure, diabetes, hypertension, post-traumatic stress disorder and other conditions. Bosch continued to support Health Buddy applications at the VA through the end of 2016.
While the VA offers other telehealth equipment and will likely replace the discontinued monitors with alternatives, Health Buddy had generally high marks among independent evaluators, patients and VA clinicians. The Commonwealth Fund cited the program as one which other healthcare organizations could replicate successfully, even in highly fragmented environments. The fund’s case study praised the VA’s algorithm that matches patients to appropriate technologies. It also noted that “[t]he home telehealth devices have been chosen for their simple user interface design and ease-of-use to ensure they can be implemented systematically among a very large number of patients and perform reliably.”
Comments on veteran discussion boards and blogs called Health Buddy “a very useful program that can be developed into a key asset for our American veterans” and reported it had fewer false positives than the phone-based telehealth systems. Some found the daily questions irritating, but others noted that when an answer indicates a veteran needs assistance, the system “lists ways for the veteran to cope or manage symptoms and will prompt him or her to call their telehealth coordinator.” Responses are also monitored by the VA healthcare facility and abnormal responses will prompt a call from a care coordinator.
The Health Buddy system has recently been tested in patients with schizophrenia following hospitalization for suicidal ideation or suicide attempts. Individuals with schizophrenia face a lifetime risk of suicide of 5%-13% and are most at risk during hospitalization and the six months following, when up to 80% of suicides in this population occur. Consequently, intensive post-discharge monitoring for at least three months is the standard of care. 1
The study’s lead author, John Kasckow, MD, PhD, of the VA Pittsburgh Health Care System Mental Illness Research Educational and Clinical Center, said the team “hypothesize that telehealth tools would likely provide greater monitoring, feelings of hope and connectivity,” compared to usual care.
The Health Buddy telehealth system appears to enhance intensive monitoring and instill hope in some veterans who use the system, according to research recently published in Psychiatry Research. The study included 25 patients at the VA Pittsburgh Health Care System who were over age 18, had landline phones and had no medical or physical issues that could preclude consistent use of the device. Participants had Hamilton Depression Rating Scale scores above 8 and scores on the Beck Scale for Suicidal Ideation that indicated either active or passive suicidal ideation.2
The researchers randomly assigned 25 patients to the telehealth experimental group, which included use of the Health Buddy system in addition to intensive care management, and 26 who received intensive care management alone. Baseline demographic, clinical characteristics and history of substance abuse were similar between the groups. The intervention group had one female participant and the control group had two.
Of those in the intervention group, five never set up the Health Buddy device for reasons including cognitive impairment, phone issues, substance dependence relapse and transportation issues that prevented continuation in the study. Four of the remaining 20 required assistance setting up the device.
The study calculated adherence rates based on the number of days participants completed questions asked by the Health Buddy divided by the number of days in the month. Highly-adherent users had adherence scores above 80% over the three months. Moderately-adherent participants had at least one month that had daily adherence rates below 80%. Overall adherence rate were 83% in Month 1, 92% in Month 2 and 89% in Month 3.
At the conclusion of the study, 14 participants provided 44 open-ended responses to a written survey. Of those, 17 responses were positive, 7 negative and 20 provided insufficient evidence one way or the other, such as “no comment.”
Among the negative comments were those that expressed a desire to be seen “not as a subject of a study to be analyzed … but as a real live man with deep psychological problems” and another that noted “when I got confronted with suicidal questions, it would make feel frustrated since the symptoms did not get better.” Depression scores improved during the study in the first patient’s case and deteriorated for the second patient over the study period.
Positive comments included “It really helped me a lot when I had bad days, it gave me hope” and “It was like talking to a doctor on a daily basis; the first month I did not think it would help but I changed my mind.” Responding veterans noted that it increased their awareness of the undesirability of taking their lives, gave them a sense of being listened to, improved their medication adherence and reduced their symptoms of anxiety and depression.
Both the Health Buddy group and those receiving intensive care management alone showed significant improvements in suicidal ideation. Mean BSS scores dropped from 9.8 to 2.44 in the telehealth group and from 10.7 to 2.88 in the control group. Patients using Health Buddy who had a lifetime history of suicide attempt had a trend for a higher remission rate at three months than those who did not use the device.
Based on the patient responses and outcomes for the telehealth intervention, “our research team would hope it would be an excellent way to augment, not replace, usual VA care for at-risk veterans with schizophrenia,” Kasckow told U.S. Medicine.
The researchers concluded that the lack of statistically significant group difference could be attributed to the intensive nature of the control condition, which included two calls from the research nurse each week and one in-person visit each week. “Patients assigned to the control condition exhibited a marked treatment effect by itself—an outcome which may have left little room for further improvement when telehealth was used as an adjunct to this treatment,” they noted. Such a high level of support for controls was included because of safety concerns given the risk of suicide in the study group, but it is substantially more intensive than most outpatient mental health settings provide.
When compared to usual care, Kasckow expects that “telehealth would involve only modest amounts of provider involvement, time and cost. We suspect it would reduce costs by reducing in patient hospitalizations in the long run,” though additional research is needed to provide a “definite answer on these health economics issues.”
Kasckow said follow-up research is planned as a multisite trial, led by Gretchen L. Haas, PhD, director of the Mental Illness Research Educational and Clinical Center at the Pittsburgh VA, which will examine all diagnostic groups at risk for suicide.
- Kasckow J, Felmet K, Zisook S. Managing suicide risk in patients with schizophrenia. CNS Drugs. 2011 Feb;25(2):129-43. doi: 10.2165/11586450-000000000-00000. Review.
- Kasckow J, Zickmund S, Gurklis J, Luther J, Fox L, Taylor M, Richmond I, Haas GL. Using telehealth to augment an intensive case monitoring program in veterans with schizophrenia and suicidal ideation: A pilot trial. Psychiatry Res. 2016 May 30;239:111-6. doi: 10.1016/j.psychres.2016.02.049.