Transcript Diapositivo 1

Mobile Systems for
Chronic Diseases
Telemonitoring:
Current Status
Introdução à Medicina 08/09
Class no.5
1
DEFINITION
Telemonitoring: collection, record and transmission of
clinical data between a patient at a distant location and a
healthcare provider via remote telecommunications. It is
provided on an outpatient basis.
(http://www.homehealthquality.org/shared/content/hhqi_campain/bpip_tm/Therapy.pdf)
2
DEFINITION
Chronic diseases: Permanent disease, which leave
residual disability, caused by nonreversible pathological
alteration. They require special training of the patient for
rehabilitation, or may be expected to require a long period of
supervision, observation or care.
Dictionary of Health Services Management, 2nd edition
3
DEFINITION
Physiological data: observable or measurable
characteristics of the ocular system, the respiratory system,
the musculoskeletal system, the nervous system or of the
blood.
(http://www.ncbi.nlm.nih.gov.sites/entrez)
4
In this new century medicine is facing a new challenge
called TELEMONITORING
Revolution in the healthcare delivery processes
Telemonitoring allows the use of electronic equipment to
observe or record physiologic processes while the patient
undergoes normal daily activities
[Mehmet R. Yuce, Peng Choong Ng, Jamil Y. Khan, Monitoring of Physiological Parameters from Multiple
Patients Using Wireless Sensor Network, April 2008, Springer Science + Business Media, LLC 2008 ]
5
A wide range of telemonitoring devices available,
nowadays, for several diseases monitoring
Chronic diseases: the most promising applications
(cardiopulmonary disease, asthma, heart failure, diabetes)
Most patients are elderly people – need to be regularly
monitored (length of their disease, nature of their health
condition, therapy)
Telemonitoring is a way of responding to new needs in home
care in an ageing population
Isolated areas do not have easy access to healthcare or
specialized medical staff
6
TELEMONITORING ALLOWS
Earlier detection of abnormal health parameters
Corrective measures to be taken before more
complications appear
Less frequent visits to healthcare facilities, shorter hospital stays
and decrease of hospital admissions
Increased patient’s quality of life
Cost-effectiveness
7
Chronic diseases telemonitoring systems allow:
•
•
•
To collect part of the diagnostic's relevant information
To gather more information with less effort
To follow the patients closely spending less time.
[Otto, C. A., Jovanov, E., and Milenkovic, E., A WBAN-based system for health monitoring at home. In 3rd IEEE/EMBS Int.
Summer School, Medical Devices and Biosensors. Sept, 20–23, 2006.]
[N. Oliver and F. F. Mangas, “HealthGear: a real-time wearable system for monitoring and analyzing physiological signals,”
Tech. Rep. MSR-TR-2005-182, Microsoft Corporation, Red-mond, Wass, USA, 2005 ]
8
A simple and not very restricted search at Pubmed ...
QUERY:(telemonitoring[All Fields] OR "telemedicine"[MeSH Terms] OR
"telemedicine"[All Fields]) AND ambulatory[All Fields]
Publications indexed by
Pubmed from 1990
- 500 articles about telemonitoring
- more than 93% of the publication's dates are
from 2000 to the present year.
9
10
MobiHealth is an healthcare project created for the development of
mobile health services and funded by the European Commission.
A patient who requires monitoring for short or long periods of time
doesn't have to stay in hospital for monitoring. With the MobiHealth
BAN the patient can be free to pursue daily life activities
www.mobihealth.org
This revels not only how recent this matter is, but also its
emerging relevance
11
Telemonitoring Status:
Despite their potential, most telemonitoring services are still
limited to the status of temporary projects without clear
prospects for wider use and proper integration into healthcare
system.
There is limited evidence of the effectiveness of telemedicine
services on a large scale. Awareness, confidence and
acceptance still need to be strengthened.
12
On which chronic diseases have
mobile telemonitoring systems been
used?
13
OBJECTIVES
Expose the scientific evidence, produced by experimental
studies, supporting the use of mobile telemonitoring systems.
Determine which chronic diseases have been targeted by
telemonitoring of physiological data.
Analyze which types of physiological data have been
monitored
and
transmitted
in
chronic
diseases
telemonitoring.
Identify on which healthcare effects scientific evidence
exists on the advantages or disadvantages of chronic
diseases telemonitoring (health improvement, system
usability, patient acceptance, etc.).
14
METHODS: Systematic Review
Keywords:
physiological, physiologic, process, phenomena,
monitor, ambulatory, outpatients, non- hospital,
telemedicine, telemonitoring, self monitoring,
supervise, telesurveillance.
15
METHODS: Systematic Review
D) A comprehensive literature search was conducted on
Pubmed and ISI to identify relevant published articles.
16
("physiological"[All Fields] OR "physiologic"[All Fields] OR physiologically[All
Fields] OR process[All Fields] OR phenoma[All Fields] OR phenomal[All
Fields]) AND (monitor [All Fields] OR ambulatory OR "outpatients"[MeSH
Terms] OR "outpatients"[All Fields] OR "outpatient"[All Fields] OR nonhospital[All Fields] OR "monitoring, ambulatory"[MeSH Terms]) AND
("telemedicine"[MeSH
Terms]
OR
"telemedicine"[All
Fields]
OR
telemonitoring[All Fields] OR telemonitor[All Fields] OR "self monitor"[All Fields]
OR "self monitoring"[All Fields] OR "supervise"[All Fields] OR
"telesurveillance"[AllFields]).
17
Research results
Pubmed
TOTAL
18
ISI Web of
Knowledge
502
Methods
The articles obtained were subjected to a process of critical
appraising according to its quality.
 1st. REVISION:
 Revision by title and abstract
 2 reviewers
- Articles excluded didn’t fit the inclusion/exclusion
criteria. Any articles about mobile systems for chronic
diseases telemonitoring were included.
19
Inclusion/Exclusion criteria
Inclusion criteria
(1)experimental studies which include direct data collection
from patients
(2) in humans
(3) using outdoor-usable devices and
(4) document scientific evidence of telemonitoring effects
Exclusion criteria
(1) do not include detailed description of the study, (2) are
focused on athletes telemonitoring or
(3) monitoring which does not make use of mobile systems,
(4) general reviews and
(5) conference and poster abstracts without study details.
20
Methods
2nd. REVISION:
- Extensive analysis of the full article
- 2 reviewers
- The inclusion/exclusion criteria were changed
- None of the articles excluded in the first revision would have
been included in the second revision since the new criteria is a
restriction of the previous one.
21
Inclusion/Exclusion criteria
Inclusion criteria
(1)
(2)
(3)
(4)
articles written in English,
with full text available,
regarding chronic diseases telemonitoring,
experimental studies which include direct data collection
from patients,
(5) using mobile telemonitoring systems
(6) those which document scientific evidence of telemonitoring
effects (health improvement, system usability, etc.).
Exclusion criteria
(1) do not present a detailed description of the study,
(2) describes a project of a new instrument,
(3) general reviews
22
STUDY VARIABLES:
Types of chronic disease targeted by telemonitoring
Types of physiological data monitored
Country and publication date of the article
Benefits and drawbacks (health improvement, system usability,
cost-effectiveness, etc.) mobile systems for chronic diseases
telemonitoribg can bring for the:
 clinician
 patient
 healthcare institution
23
Methods
After the data extraction:
 Check for and identify sources of heterogeneity in results
across studies
 Findings/Results of individual studies are synthesised
and subsequently statistically analysed in SPSS
24
Percentage of included, excluded articles and
those who needed a 3rd reviewer
4,02%
10,92%
85,06%
25
Graphic 1: Percentage of included, excluded articles and those who needed a 3 rd reviewer
Methods – 3rd Reviewer
 Regarding the articles subjected to a 3rd revision:
• 68,4% of the articles were included
• 31,6% were excluded
Methods – Final decision
After completing the articles revision we had:
• 7,5% of the articles included
• 92,5% of the articles excluded
26
Methods– Number of included and excluded
articles by each reviewer
27
Graphic 2: Number of included and excluded articles by each reviewer
Methods
A Chi-Square test was performed in order to check if there was
any statistically significant difference between the expected and
the actual number of excluded articles per reviewer. (p=0,668)
28
Methods – Frequency of use of each
inclusion criteria
29
Graphic 3: Frequency of use of each inclusion criteria
Methods – Frequency of use of each
exclusion criteria
30
Graphic 4: Frequency of use of each exclusion criteria
Results
Profile of Chronic Diseases Telemonitoring Studies
DIABETES
CARDIAC HYPERTENSION TOTAL
DISEASES
RESULTS
How many?
Total numbers of studies
Where?
USA
Australia
Canada
UK
Norway
When?
1996
2004
2005
2006
2007
2008
31
5
5
3
13
3
1
1
1
2
1
1
-
2
1
-
6
3
2
1
1
2
2
1
-
1
1
2
1
3
1
2
3
1
5
1
Table 1: Profile of chronic diseases telemonitoring studies
Results
Profile of Chronic Diseases Telemonitoring Studies
DIABETES
CARDIAC
DISEASES
HYPERTENSION
With whom?
Patients with cardiovascular disease
-
Adults hospitalized with heart failure.
Enrolled in health centers.
-
5
-
-
1
-
-
1
-
-
Recently implanted with CRT-D.
-
1
-
-
With symptomatic chronic heart
-
1
-
-
and left ventricular ejection.
Undergoing cardiac rehabilitation.
-
1
-
failure
Patients with Diabetes
32
3
-
Young patients and their parents.
1
-
-
-
Young patients using insulin for at
least one year.
1
-
-
-
Wide-ranging patients with type I Diabetes
1
-
-
-
Adult patients with type II Diabetes and
uncontrolled blood pressure.
-
-
1
Patients with uncontrolled hypertension
-
-
2
Results
Overview of Research Designs
DIABETES
Number of studies
Type of design, n (% within disease)
Randomized trial with control group
Randomized trial without control group
Nonrandomized trial without control group
Size of experimental group
Maximum
Minimum
Mean
Median
Size of control group, n (% within experimental group)
Maximum
Minimum
Mean
Median
Study duration
Maximum
Minimum
Mean
33
Median
CARDIAC
DISEASE
HYPERTENSION
TOTAL
5
3
13
4
2
7
5
1 (20)
1 (20)
3 (60)
1 (20)
1 (20)
3 (60)
2 (66)
200
10
55
18
750
30
236
81,5
450
20
168
33
750
10
18 (50)
18 (50)
18 (50)
18
54 (44)
54 (44)
54 (44)
54
150 (25)
10 (33)
80 (29)
80
150
10
18 months
18
months
3 days
6
18
months months
3 days 6 weeks
3,82
7,9
months months
Table 2: Overview of research designs
4
6 months
1 (33)
4 months
11,3 months
12 months
Results
Overview of Research Designs
DIABETES
34
CARDIAC HYPERTENSION TOTAL
DISEASE
5
3
13
Number of studies
Main types of data transferred
5
Heart Rate
Blood pressure
Heart electrical activity
Blood glucose
Frequency of data transmission to
health care provider
More than once a day
Once a day
A few times a week
Once a week
Once a month
Once every three months
Once every six months
5
3
1
2
-
1
3
-
4
4
2
5
3
1
1
-
2
2
-
1
1
1
1
4
2
3
1
1
1
1
Results - Frequencies of types of effects
DIABETES
CARDIAC HYPERTENSION TOTAL
DISEASE
Number of studies
5
5
3
13
Data quality
3
1
-
4
Patient condition
1
-
3
4
Patient attitudes and behaviors
2
1
3
6
Physician attitudes and behaviors
-
1
2
3
Physician facilities
-
2
3
5
Clinical efectiveness/ structural effects
4
3
3
10
Economic viability
2
4
1
7
35
Results - Frequencies of advantages and
disadvantages
Number of studies
DIABETES
CARDIAC
DISEASE
5
5
HYPERTENSION TOTAL
3
13
Advantages to:
Patient
4
3
3
10
Physician
1
3
2
6
Health care institutions
3
2
1
6
Patient
1
1
2
4
Physician
1
1
2
4
Health care institutions
-
-
-
-
Disadvantages to:
36
Results – Advantages and disadvantages for the patient
DIABETES
37
Number of studies
Patient
Advantages
- Ability to overcome the problems.
- Increased level of patients’ responsibility.
- Helps in disease self-management.
- Patients received an alert everytime the values of blood
pressure are lower or higher than the normal- Patient enthusiam and acceptance.
- System easily integrated into everyday life.
- Child independence while being monitored by their
parents.
- Allows patients with memory problems to remember to
take medication.
- Allows the introduction of healthy habits of practice of
physical exercise and alimentation in patients.
Disadvantages
- Costs.
- Difficulty in using Internet.
- Difficulty in accepting new technologies.
- No physical contact with the doctor.
- Problems of integration of other diseases.
- Problems of adaptation in the routine.
- Warns unnecessarily in situations of low levels of glucose,
HYPERTENSIO
N
3
TOTAL
5
CARDIAC
DISEASE
5
1
2
1
1
-
1
2
2
1
2
3
4
2
3
1
-
1
-
3
3
1
1
-
1
2
-
-
1
1
1
1
1
-
1
2
1
1
1
1
-
1
2
2
1
1
1
1
1
13
Results - Advantages and disadvantages for the
physician
DIABETES
Number of studies
5
CARDIAC HYPERTENSION TOTAL
DISEASE
5
3
13
Physician
Advantages
- Facilitates realtime discussions between physicians in primary and
secondary care.
- Less acute care needs when admitted.
- More accurate decision regarding the treatment of BP.
- Larger amount of information about the patient’s condition enabling
the patients’
follow-up the patient on a daily basis rather than just on the day of the
medical exam.
- Shows when the medication has adverse effects.
- Integration of physician in the patient routine.
Disadvantages
- No longer able to contact the patient directly.
- Has to adapt its guidelines to the new technology.
38
- Availability of the physician to analyze patient data.
2
2
-
4
1
1
1
1
1
1
1
3
1
-
1
-
1
1
-
1
2
1
1
2
1
2
Results - Advantages for the hospital
Number of studies
DIABETES
CARDIAC
DISEASE
HYPERTENSI TOTAL
ON
5
5
3
13
2
-
2
4
1
-
-
1
-
1
-
1
Hospital
Advantages
- Reduction of hospitalization
- Automatically generated historical graphics
transferred to the healthcare provider, feasibility of
the system.
- Reduction of hospital overcrowding.
39
Discussion
Only articles about Diabetes, Cardiac Diseases and Hypertension were
found.
 Comparing to Paré et all, the number of included articles was
considerably smaller since our research was restricted to experimental
studies making use of mobile systems
USA is the country which has most explored the use of mobile
technology to follow up chronic patients, as well as UK, Australia, Norway
and Canada.
 The date of publication of the articles ranges between from 1996 to 2008.
 The majority of the articles were regarding Diabetes type I, revealing
the importance to closely monitor and control the levels of blood glucose on a
daily basis.
 Cardiac diseases were also frequently targeted due to its high level of
incidence and prevalence
40
Discussion
Benefits of mobile telemonitoring systems for the
patients
Telemonitoring systems enable patient’s quality of life
This kind of systems allows active participation in the process of healthcare,
more patient’s independence and responsibility,
General satisfaction and a high level of acceptance
Minimal patient intervention in the collection and transference of data,
reducing bias and subjectivity
Promotion of a healthy lifestyle with an improvement in physical exercise
practice and balanced diet as it increases patient awareness of their health
condition
Increasing of patients’ compliance with the treatment, medication and
telemonitoring which is a result of a tighter control achieved by an alarm
system warning the patient .
41
Discussion
Disadvantages of mobile telemonitoring systems for
the patients
Problems related to the usage and access to the internet namely among
elderly people since they are not used to deal with computer technology
The cost-effectiveness is quite controversial
Although it requires an initial investment in the equipment purchase, it may
compensate in the long run, since it decreases future expenditures in
healthcare services
Undesirable changes in the daily routine may happen as a result of the
permanent monitoring which leads to dependency towards the equipment
42
Discussion
Benefits of mobile telemonitoring systems for
healthcare professionals
Telemonitoring promotes the knowledge integration from the different
healthcare areas, encouraging discussion
The physician has easier access to the patient information, and can be
warned through an alarm system every time the patients’ health parameters
are not normal
Emergency situations can be detected earlier preventing the occurrence of
more serious complications
It is possible to follow closely the evolution of a patient health condition and
consequently diagnose and apply treatment at distance
43
Discussion
Disadvantages of mobile telemonitoring systems for
healthcare professionals
Less physical contact between physicians and patients
Adaptation of clinical guidelines to this new way of healthcare delivery
service
It requires availability of the physician in order to analyze the patient data
as well as ensure the maintenance of the equipment
44
Discussion
Little evidence was found on the telemonitoring effects on
the hospital and additional research is required to further
investigate and analyze the impact of chronic disease
telemonitoring in healthcare facilities
Effects of mobile telemonitoring systems on the
hospitals
Less frequent visits to the healthcare facilities, shorter hospital stays and decrease
of hospital admissions
Decrease in waiting lists associated with cost-effectiveness
The hospital can be notified in case of medical emergency
Previous professional training is needed in order to make an adequate use of this
equipment, benefiting from all its potentialities
45
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47
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Authors:
ALVES, José Pedro Figueiral Oliva Soares; CAMPOS, Marta Sofia Gomes;
DATA, Tânia Rodrigues; ESTEVES, Alexandra Sofia Moreira; FARIA, Carlos
Augusto da Silva; FERNANDES, Diana da Silva; GUEDES, Paulo Renato
Moreira; MACHADO, Marino João Pinto; MAGALHÃES, Ana Isabel Pereira;
MARQUES, Pedro Seabra; MATOS, José Pedro Rodrigues; MELO, Inês
Marisa Tribuzi de Magalhães; MOREIRA, Pedro Manuel Costa;
NASCIMENTO, João António Santos; PEREIRA, Maria Francisca Azevedo
Marques; SILVA, Ana Rita Carneiro.
Authors’ e-mail: [email protected]
Adviser: RODRIGUES, Pedro Pereira.
Class Number: 05
49