Transcript Effects of e-health for Health Behavioral Changes Among

Effects of e-Health to Maintain Health Among
Older Adults with Congestive Heart Failure
(CHF):
Randomized Controlled Trial
Machiko R. Tomita, Ph.D.
Department of Rehabilitation Science
University at Buffalo
Presented at
NYSOTA Conference
Buffalo, NY
September 27-29, 2007
Funded by the National Institute of Aging
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What is e-Health?
eHealth is a method utilizing emerging
interactive technologies to address the limited
capacity of the health care system to provide
health behavior change and chronic disease
management interventions. - Health e-Technologies
Initiative
Ahern, D., Kreslake, J., Phalen J. What is eHealth: Perspectives on the
evolution of eHealth research. J. Med Internet Res 2006;8(1):e4
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What is emerging interactive technology?
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What does “the limited capacity of the health
care system” mean and why older adults?
Increase in the number of older adults: 36.3 million in
2004 (12.4%) and 55 million in 2020 (16.4%).
Administration on Aging. A profile of Older Americans 2005
Of the more than half-million licensed physicians
practicing in the US, fewer than 9,000 have met
qualifying criteria in geriatrics--which amounts to
roughly 1 geriatrician to every 4,000 older adults
presently. American Medical Directors Association, 2005
55-65 is the fastest growing segment for Internet use.
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Background
Telemedicine: health care provides to monitor
patients progress for a short period of time. –
VA, VNA,
E-health research: Type 2 Diabetes
– Limited use of e-health
– Short period
– Intervention was provided without knowledge of
behavioral change
– Identification of users
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What is CHF?
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Major Symptoms of CHF
Edema
– Legs and ankles
– Abdomen
– lung
Dyspnea
Fatigue
Depression
Weight gain
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Examples of leg/ankle edema
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Treatment for CHF
Medications to help remove fluid such as diuretics or
to make the heart work better such as beta blockers,
vasodilators, etc.
Dietary modifications, such as reducing salt , water,
and cholesterol intake
Lifestyle changes, such as smoking cessation, alcohol
intake limitation
Exercise
Health Behavior Change
Support using
e-health
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Why CHF ?
Prevalence: 5.0 million Americans (1.8%)
40-59- 2%, 60-69- 5%, 70 + -10%
New CHF cases: 550,000
Death: 300,000/year
On average, patients die within 5 years
Hospitalization rates: the leading diagnosis-related
group (DRG) among hospitalized patients older than
65 years. Approximately 30-40% of patients with
CHF are hospitalized every year. Readmission
rates:50%
Approximately 5-10% of hospital costs
Health care cost for CHF: $38.1 billion .
Source: The National Heart, Lung, and Blood Institute (NHLBI)
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Purpose of the Study
The purpose of this study was to conduct
a pilot study with a randomized controlled
trial to change CHF patients’ health
behaviors through use of e-health
providing four types of support:
Instrumental, informational, emotional,
and appraisal.
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Conceptual Model: Social Network and Social Support,
Transtheoretical Model, & Uses and Gratifications
E-health
Instrumental Support
Personal
Factors
Precontemplation contemplation
Appraisal Support
Informational
support
Preparation
Emotional Support
Action
Maintenance
Family and Friends
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Use of E-health in the Study
Informational support for knowledge
Created a public website with tailored CHF and
health activity information in a senior friendly
format with quiz. www.agingresearch.buffalo.edu
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Use of E-health in the Study
Instrumental support for monitoring health
Created a secure website for daily record of vital
signs and health activities in a short form that can be
woven into a daily routine . http://dailyhealthlog.info
–
–
–
–
–
–
BP/pulse, and weight
Medication compliance
Dietary and Alcohol intake, and Smoking
Types of and Amount of Exercise
Swelling and fatigue
Health change from the previous day
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Use of E-health in the Study
Appraisal support for assurance
Regular feedback and reinforcement of health
status from a health professional team via email and telephone.
Emotional Support
Next presenttation
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Research Questions
1. Do patients with CHF use e-health, when e-health
technology is available?
2. Do patients with CHF gain relevant knowledge
when they use e-health technology?
3. Do patients with CHF engage in healthy behaviors
when they use e-health technology?
4. Do patients with CHF maintain their
health/function/QoL better when using e-health
technology?
5. What is the outcome of healthcare utilization?
6. What are the subjective opinions regarding e-health
use?
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Differential Expectation
Symptoms
Health care utilization
Control
Treatment
Time
Home-based
NH
Death
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Methods-Study Design
Randomized controlled repeated measures design
with the intervention duration of 18 months.
Init.
R
T
O
R
C
O
6
mo.
X
O
12
mo.
X
O
O
O
18
mo.
(X)
O
O
* This presentation is at the 12th month.
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Methods - Subjects
– Inclusion criteria: NY Heart Association
Classification of 2 or 3 and past record of
hospitalization or emergency visits due to
CHF.
– Sample size: 16 each for Treatment and
Control. Due to a higher attrition rate, 24
were recruited for the control group.
– Convenience sampling method was used to
recruit participants from 3 hospitals and 2
HMOs in WNY.
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Consort Flow Chart
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Methods - Procedures
–
–
–
–
–
Random assignment of participants.
Interview at participants’ home.
Health behavior goal set
Notification to the primary physician
Step by step patient training
For Treatment group, provision of BP monitor, pedometer,
bath scale, computer with Internet connection, desk, chair,
and lamp were provided
Computer training.
2 websites introduction.
Introduction of tailored exercise protocol.
www.agingresearch.buffalo.edu
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Methods - Procedures
– Regular feed back for their health behavior record
from a health professional team.
– E-mail and phone contact for consultation and
encouragement
– Control group, monetary compensation.
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Demographic Information
Control (n=19)
Treatment (n=13)
Age
76.4 (6.8)
74.0 (8.0)
Gender (F)
12 (63.2%)
9 (69.2%)
Race (Minority)
2 (10.5%)
3 (23.1%)
Education (High
School or less)
10 (52.6%)
10 (46.2%)
Living Status (Alone)
8 (42.1%)
7 (53.8%)
Home (Own)
8 (57.9%)
7 (53.3%)
Income (< $10000)
( - $30000)
( >$30000)
8 (42.1%)
7 (36.8%)
4 (21.1%)
8 (61.5%)
5 (38.5%)
2 (14.3%)
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Result : RQ1. Use of e-health
Use of e-health technology
– 100% of treatment people went to the publicly
available web site at least once a month. M=3.5
times/month
– 100% of treatment people recorded their health
activities in the secured website.
On average, 85% of 355 days
– Reason for nonuse was not staying home (visit
family, went to FL, a hospital or rehab facilities).
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Result: RQ 2. Knowledge Gain
Knowledge question: 20 items ( 0 – 55 )
50
45
40
Control
Treatment
35
30
25
20
Initial
6 mo.
12 mo.
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Result: RQ 3. Commitment to ExerciseBreathing
100
90
80
70
60
50
40
30
20
10
0
Control =<1/w
Control >=2-3/w
Treatment =<1/w
Treatment>=2-3/w
Baseline
6 mo.
12 mo.
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Result: RQ 3. Commitment to ExerciseWalking
100
90
80
70
60
50
40
30
20
10
0
Control =<1/w
Control >=2-3/w
Treatment =<1/w
Treatment >=2-3/w
Baseline
6 mo.
12 mo.
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Result: RQ 4. Health/Functional OutcomeBlood Pressure
150
140
130
120
110
100
90
80
70
60
50
Treatment Systolic
Contorl Systolic
Treatment Diastolic
Contorl Diastolic
Baseline
6 mo.
12 mo.
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Result: RQ 4. Health/ Functional Outcome-BMI
35
Control Male
Control Female
Treatment Male
Treatment Female
30
25
20
Initial
6 mo.
12 mo.
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Result: RQ 4. Health/Functional
Outcome- FIM Motor
82
81.5
81
80.5
Control
Treatment
80
79.5
79
78.5
Baseline
6 mo.
12 mo.
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Result: RQ 4. Health/Functional
Outcome- IADL Total
14
12
10
8
Control
Treatment
6
4
2
0
Baseline
6 mo.
12 mo.
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Result: RQ 4. Health/Functional OutcomeCHF Symptoms
30
25
Dyspnea Control
20
Dyspnea Treatment
15
Yale Task Control
10
Yale Task
Treatment
5
0
Baseline
6 mo.
12 mo.
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Result: RQ 6. Quality of Life
220
210
200
190
180
Control
Treatment
Initial
6 mo.
12 mo.
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Result: RQ 5. Healthcare UtilizationEmergency Room Visits
0.6
0.5
0.4
ER-OhterControl
ER-Other Treatment
ER-CHF Control
ER-CHF Treatment
0.3
0.2
0.1
0
6 mo.
12 mo.
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Result: RQ 5. Healthcare UtilizationHospital Stay
6
5
4
HS-Other Control
HS-Other Treatment
HS-CHF Control
HS-CHF Treatment
3
2
1
0
6 mo.
12 mo.
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Result: RQ 5. Healthcare UtilizationNursing Home Stay
18
16
14
12
NH-Other Control
NH-Other Treatment
NH-CHF Control
NH-CHF Treatment
10
8
6
4
2
0
6 mo.
12 mo.
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Result: RQ 5. Healthcare Use and Living Status
In the
study
Died
NH
AL
QuitCHF
Other
C (24)
19
2
2
0
1
0
T (16)
13
1
0
1
0
1
In the Lost
Lost
Study due to due to
CHF other
reason
C (24) 19
5
0
T (16) 13
0
3
Above
Cramer’s V = .356 (p=.409)
Left
Cramer’s V= .443, (P=.020)
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Result: RQ 6. Evaluation of e-health
How much did you learn about healthy behaviors?
A lot 84.6%
Some 15.4%
How satisfied are you with the program?
Very much 84.6% Somewhat 15.4%
How is your CHF condition compared with one year ago?
Better 92.3%
Same 7.7%
How helpful was it for you to do the exercises?
Helpful 92.3% Not much 7.7%
How confident are you in dealing with CHF due to the program?
Confident 100%
Do you recommend this program to your friend with CHF?
Yes 100%
Which part did you like most?
Monitoring myself for increased awareness (4) Improved health (3)
Support/people (3) Exercise (2) Computer use (1) Website (1)
Which part did you dislike most?
Exercise when I don’t feel like doing (1) Entering data of exercise part (1)
None (11)
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Summary and Conclusion
Successful
– Health behavior change occurred and was sustained due to
patients’ heightened awareness of their own health
behaviors and confidence in managing illness.
Reasons
– Interventions were guided by theories and implemented
strategically in every step.
Contribution
– The social network and social support theory was extend to
technology use
– E-health can be effective among older adults, if feedback is
available from a health care professional.
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Acknowledgement
Bruce J. Naughton , MD
Bin-Min Tsai, MS, OTR
Jim Peron
Kathy Stanton, RN, MSN
Nadine Fisher, Ed.D
Neeraj Kumar, PT, MS
Greg Wilding, Ph.D.
Kay Sackett, RS, Ed.D
Michael Noe, MD
Aki Tomita, BS
Mike Schlicht, MS
Michael Sciortino, JD
Kaleida Health
Niagara Memorial Hospital
Blue Cross/Blue Shield, Univera
PCI, Clear Ahead
Full Circle
Dept. of Family Medicine
Dept. of Rehab. Science
Center for Assistive Technology
Aging & Technology Research
Dept of Rehab. Science
Dept of Rehab. Science
Dept of Biostatistics
School of Nursing
Dept. of Social Preventative Medicine
Dept. of Computer Engineering at UIUC
SPHHP (IT Support)
SPHHP (Web-master)
(Patient recruitment)
(Patient recruitment)
(Both, Patient recruitment,)
Web Server Maintenance, HIPPA-website
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