112 Patients were enrolled. The median age was eight years (4–13). 66.1% (n = 74) males and 33.9%( n = 38) were females.
Telemedicine consultations were attended by the Father, mother, siblings, uncles, and grandparents of our patients, and the Father attended the majority. 40% (n = 45) of patients belonged to the nuclear family. The median family income per year was 2 Lakh (1–4). Many patients (65%) had some prior idea about telemedicine use.
Disease-wise distribution of patients in the study was as follows. Steroid-sensitive nephrotic syndrome 30, Steroid-dependent nephrotic syndrome − 21, Steroid resistant nephrotic syndrome 10, Glomerulonephritis-11, Congenital anomalies of kidney and urinary tracts-20, Chronic Kidney Disease of Unknown cause-3, Renal Tubular acidosis-4, Urinary tract Infection without CAKUT-7, other miscellaneous diseases-6(Other six diseases were 2 of Hypercalciuria under evaluation, one each of Atypical Haemolytic Uremic Syndrome, Renal artery stenosis with hypertension, Nocturnal enuresis, and haematuria under evaluation.
).
Out of the 109 patients we could follow up with at six months, there were adverse events in only six patients. Of these, four were preceded by a telemedicine consultation. However, the adverse events did not result from a lack of in-person consult but due to poor compliance with treatment.
Figure 1 depicts the geographical distribution of the patients on a map of the state of Rajasthan in India. We calculated the distance each patient travelled for each visit. It was seen that the median distance from the residence to the hospital was 122.5 Km (30–250 km). The Average travel distance saved by a patient over six months was 743km/patient.
Our patients have saved a total travel distance of 83274 Km in the six months.
[Average 743 km per patient in the six months]. Table 3 depicts the detailed calculation of the travel distance saved.
Table 3
Calculation of distance saved
Distance traveled by individual patients from home to hospital. | N [n1,n2…….n112] | Mean = 147 km [Median = 122.5 Km (IQR:30–250] |
Distance on each round trip | 2N | |
Number of telemedicine visits of each patient in 6 months | X [ x1,x2….x112] | |
Distance travel saved by each patient in 6 months. | 2NX | Mean = 743 Km. [Median = 360 Km,(IQR:80-1012.5)] |
Total distance saved | 2NX [2n1x1 + 2n2x2 + 2n3x3...2n112x112] | 83274 km |
Table 4
Studies on cost analysis of telemedicine
Sl No | Author(Year)/Journal | Study Title | Study Population | Observation | Limitations | Conclusion |
1 | Anthony C Smith (2007)/ BMC health services research [21] | The Costs and potential savings of a Novel tele pediatric service in Queensland | n = 1499 consultations | Cost-benefit of $ 6 lakh. | Cost provided for a group of patients compared with the potential cost of visits to a tertiary center., | Telemedicine is cheaper compared to in-person visits. |
2 | Trnka P et al. (2015)/ BMC nephrology [15] | A retrospective review of telehealth services for children referred to a pediatric nephrologist | n = 168 3 months − 24 years Median of 8 years. | Cost savings with telehealth were $31,837 in 2013 (average saving of $505 per consultation). | Additional costs to the family, such as time off work, parking, fuel, and meals, were not included in this study. | Pediatric telenephrology is a practical and cost-effective tool for patient evaluation and follow-up. |
3 | Versleijen M (2015)/ Journal of Telemedicine and Telecare [17] | A telegeriatric service in a small rural hospital: A case study and cost analysis | n = 208 /geriatric patients. | There was a saving of AUD$131 per patient consultation with telegeriatric service. | There is no assessment of cost-benefit in terms of disease outcome. | Telegeriatric service offers an economically better approach to avail specialist geriatric care in rural and remote settings. |
4 | Dullet NW et al. (2017)/. Value in Health [19] | Impact of a University-Based Outpatient Telemedicine Program on Time Savings, Travel Costs, and Environmental Pollutants | 19,246 consultations in 11,281 patients | There was a savings of 5,345,602 miles. Savings of a total travel time savings of 4,708,891 minutes, almost 8.96 years Total travel cost savings of $2,882,056. Environmental benefits of emissions savings of 1969 metric tons of CO2, 50 metric tons of CO, 3.7 metric tons of NO x, and 5.5 metric tons of volatile organic compounds. | This was a retrospective study Other cost components, like saved working hours, wages, waiting time, and additional costs like parking. | Telemedicine has a positive impact on patients’ travel time, travel cost, and environmental pollutants |
5 | Snoswell C L ( 2019)/ Journal of Telemedicine and Telecare [18] | A cost- consequence analysis comparing patient travel, outreach, and telehealth clinic models for a specialist diabetes service to Indigenous people in Queensland | Not reported | In this study, while comparing the cost of attending a telemedicine consultation to the cost of travel to a metropolitan or outreach clinic, there was an economic benefit of approximately $517. | The analysis was dependent on various assumptions associated with salary, travel, and accommodation costs, which have been outlined throughout | Even Though telehealth will not be able to completely replace in-person visits, even the replacement of some of the visits gives an economic advantage for the patient. |
Thirty-four patients had telemedicine visits only during the six months. The median number of telemedicine visits was two visits/per patient (IQR: 1–4). Physical visits were required for 75 people, with a median visit of 1 physical visit/patient. Out of the physical visits, 17 were for Investigations, 9 for routine follow-up only, and 32 for both investigations and Routine follow-up. Twelve patients came with Disease worsening, and 5 for other illnesses unrelated to renal problems.
Cost Analysis
Cost Analysis was done by assessing the difference between the expenditure for an in-person/physical visit and a telemedicine consultation. All the patients had higher expenditures for physical visits. Loss of wages was also accounted for in expenses of in-person visits. Expenditure for an in-person visit was calculated as per Table 1.
Only four patients had to spend extra on the Internet for telemedicine services. Some patients had to depend on the E Mitra service for telemedicine appointments, adding to telemedicine expenses. There was a loss of work for 75 attendants. There was a loss of wages for the attendants of 47 attendants (42%). The rest had paid leaves. The median loss of wages was INR 300 (IQR: 0-500). The average loss as lost wages was INR 330.
None of the attendants had any loss of wages or any additional cost for travel to avail of the Telemedicine service. For follow-up telemedicine visits for one month, the appointment was free.27.5% (n = 30) depended on E Mitra. 45.5%( n = 46%) got it by themselves and others from the hospital during in-person visits.
The median Expenditure for Telemedicine services over six months was INR 30(IQR: 0–50).
40% had no expenditure on patients' food, and only 29% had a payment for patients' transportation. The 15%( n = 17) of Patients required to stay, out of which 10 spent on rent. Seven stayed at relatives' houses. The need for overnight stays added to the cost and affected sleep quality.
There was an average cost saving of INR − 1577/patient/visit, which amounted to INR 4200 [60 USD] over the six months study period per patient. {Median of INR 2130[30 USD](820–4390)}.
Considering all the patients, there was a total saving of INR 4, 57,900. These savings were evaluated as a percentage of their family income. Estimated: Mean savings was 4.99% of the family income [Range: 0.012%-37%], a median of 2.16% [IQR: 0.66-5, 55%] per patient over the six months. Table 2 depicts the detailed cost analysis.