Triangulation analysis of tele-palliative care implementation in a rural community area in Japan.

We conducted a comprehensive evaluation of tele-palliative care by triangulation method. This consisted of qualitative analyses of 2 patients and then performing quantitative analysis of a simulated model for tele-palliative care based on that experience. Semistructured interviews with 2 patients were conducted for qualitative analysis. The recorded conversations were analyzed using traditional categorization and coding techniques, looking for patterns and themes both within and across the interviews. A state-transition process was modeled using a Markov model to compare the costs for three different options for patients requiring palliative care: admission to the palliative care unit, home care only (8 physician visits), and tele-palliative care. The cost data were mainly derived from the reimbursement scale of the Japanese Health Insurance System. Sensitivity analysis was used to assess the influence of particular conditions or costs. The qualitative assessment identified some positive concepts, such as "expectation," "convenience," "reliance," and "communication." In the cost analysis, the reference case yielded the annual costs as follows: (1) costs for admission to the palliative care unit were 1,137,000 dollars; (2) costs for home care were 521,000 dollars; and (3) costs for telepalliative care were 478,000 dollars. One-way sensitivity analyses showed that home care was the most cost-saving strategy if the care was continued for more than 4 months or the number of physician visits during tele-palliative care could be reduced to less than 6 physician visits per month. The important issues in reducing the cost of tele-palliative care were (1) having adequate patient numbers, (2) reducing the number of physicians' visits, and (3) offsetting the costs of telemedicine against cost savings to the system to sustain the program. In addition, the qualitative analysis demonstrated patients positive views of tele-palliative care.