Transcript Mid-range Cardiology System - 08-10 Octobre 2009, Paris (France)

Disease management and telephone monitoring
Assistance Publique
Hôpitaux de Paris
Plan
CNCF 8-10 octobre 2009
saint
antoine
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Plan
• Disease Management dans l’insuffisance
cardiaque
• Disease Management dans la maladie
coronaire
• Avantages et limites des formes de Disease
Management
• Conclusion
CNCF 8-10 octobre 2009
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2008
Heart failure management programmes
Class of recommendation I, level of evidence A
-Heart failure management programmes are recommended for patients with
HF recently hospitalized and for other high-risk patients.
-It is recommended that HF management programmes include the following
components shown (Table). Adequate education is essential. Remote
management is an emerging field within the broader context of HF
management programmes.
-Telephone support is a form of remote management that can be provided
through scheduled calls from a HF nurse or physician, or through a telephone
service, which the patients can contact if questions arise or symptoms of
deterioration occur.
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2008
Heart failure management programmes
Class of recommendation I, level of evidence A
-Telemonitoring is another form of management that allows daily monitoring of
symptoms and signs measured by patients, family, or caregivers at home
while allowing patients to remain under close supervision.
-Telemonitoring equipment may include recording BP, heart rate, ECG,
oxygen saturation, weight, symptom response systems, medication
adherence, device control and video consultation equipment—all of which can
be installed in the patient’s home.
- Cardiac rehabilitation, as multifaceted and multidisciplinary interventions,
has been proven to improve functional capacity, recovery, and emotional wellbeing, and to reduce hospital readmissions.
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2008
Heart failure management programmes
-The meta-analyses (> 8000 Pts) demonstrated that home-based follow-up or
follow-up in a clinic setting significantly reduced hospitalization. The risk
reduction ranged between 16 and 21%. Mortality is also significantly reduced.
-The most recent meta analysis of 14 randomized trials involving 4264
patients incorporating sophisticated models of remote HF management
demonstrated 21 % significant reduction in the risk of a HF-related admission
and 20% of all-cause mortality.
-HF management programmes are likely to be cost-effective in that they
reduce hospital readmissions and can be established on a relatively modest
budget.
-It has not been established which of the various models of care is optimal.
Both clinic- and home-based models seem to be equally effective.
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Telemonitoring or structured telephone support programmes for patients with chronic
heart failure : meta-analysis (all cause mortality)
Study
No with
event/
No in group
Treatment
group
Control
group
1765
1777
Relative
risk
(random)
(95 % CI)
Weight
(%)
Relative risk
(random) (95 %
CI)
Structured telephone
Subtotal (95 % Cl)
78.75
0.85 (0.72 to 1.01)
21.25
0.62 (0.45 to 0.85)
100.00
0.80 (0.69 to 0.92)
Test for heterogeneity : 2 = 6.41, df = 8,P = 0.60, l 2 = 0%
Test for overall effect : 2 = 1.88, P = 0.06
Telemonitoring
Subtotal (95 % Cl)
445
362
Test for heterogeneity :  2 = 2.22, df = 4,P = 0.70, l 2 =0%
Test for overall effect : 2 = 2.93, P = 0.003
01. 02 05 1 2 5 10
Favours control
Favours treatment
Clark RA. Br Med J. 2007;334:942.
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Telemonitoring or structured telephone support programmes for patients with chronic
heart failure : meta-analysis (all cause admission to hospital)
Study
No with
event/
No in group
Treatment
group
Control
group
1578
1622
Relative
risk
(random)
(95 % CI)
Weight
(%)
Relative risk
(random) (95 %
CI)
Structured telephone
Subtotal (95 % Cl)
79.85
0.94 (0.87 to 1.02)
20.15
0.98 (0.84 to 1.15)
100.00
0.95 (0.89 to 0 1.02)
Test for heterogeneity :  2 = 4.78, df = 6,P = 0.57, l 2 0%
Test for overall effect : 2 = 1.44, P = 0.15
Telemonitoring
Subtotal (95 % Cl)
244
197
Test for heterogeneity :  2 = 2.22, df = 4,P = 0.70, l 2 =0%
Test for overall effect : 2 = 0.21, P = 0.83
01. 02 05 1 2 5 10
Favours treatment
Favours control
Clark RA. Br Med J. 2007;334:942.
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Telemonitoring or structured telephone support programmes for patients with chronic
heart failure : systematic review and meta-analysis
Study
No with
event/
No in group
Treatment
group
Control
group
1765
1777
Relative
risk
(random)
(95 % CI)
Weight
(%)
Relative risk
(random) (95 %
CI)
Structured telephone
Subtotal (95 % Cl)
78.75
0.85 (0.72 to 1.01)
21.25
0.62 (0.45 to 0.85)
100.00
0.80 (0.69 to 0.92)
Test for heterogeneity : : 2 = 6.41, df = 8,P = 0.60, l 2 =0%
Test for overall effect : 2 = 1.88, P = 0.06
Telemonitoring
Subtotal (95 % Cl)
445
362
Test for heterogeneity : : 2 = 2.22, df = 4,P = 0.70, l2 = 0%
Test for overall effect : 2 = 2.93, P = 0.03
01. 02 05 1 2 5 10
Favours treatment
Favours control
Clark RA. Br Med J. 2007;334:942
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2008
Heart failure management programmes
Recommended components of HF management programmes
-Multidisciplinary approach frequently led by HF nurses in
collaboration with physicians and other related services
-First contact during hospitalization, early follow-up after
discharge through clinic and home-based visits, telephone
support, and remote monitoring
-Target high-risk, symptomatic patients
-Increased access to healthcare (telephone, remote
monitoring, and follow-up)
-Facilitate access during episodes of decompensation
Disease management and telephone monitoring
Assistance Publique
Hôpitaux de Paris
ESC Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2008
Heart failure management programmes
Recommended components of HF management programmes
-Optimized medical management
-Access to advanced treatment options
-Adequate patient education with special emphasis on
adherence and self-care management
-Patient involvement in symptom monitoring and flexible
diuretic use
-Psychosocial support to patients and family and/or
caregiver
saint
antoine
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Dickstein K. Eur Heart J 2008; 29:2388–2442
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Plan
• Disease Management dans l’insuffisance
cardiaque
• Disease Management dans la maladie
coronaire
• Avantages et limites des formes de Disease
Management
• Conclusion
CNCF 8-10 octobre 2009
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Nurse-coordinated multidisciplinary, family-based cardiovascular disease
prevention programme (EUROACTION) for patients with coronary heart disease
and asymptomatic individuals at high risk of cardiovascular disease: a paired,
cluster-randomised controlled trial
Wood DA. Lancet 2008; 371: 1999–2012
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Nurse-coordinated multidisciplinary, family-based cardiovascular disease
prevention programme (EUROACTION) for patients with coronary heart disease
and asymptomatic individuals at high risk of cardiovascular disease: a paired,
cluster-randomised controlled trial
EUROACTION preventive cardiology intervention programme in hospital
and general practice
-In hospitals and general-practice centres, cardiologists and nurses recruited
eligible patients and their families (open in GP).
-Multidisciplinary assessment of lifestyle, risk factors, and drug treatment by a
nurse, dietitian, and physiotherapist, couples attended at least eight
sessions—one every week—in which they were assessed by each member of
the team (nurse, dietitian, and physiotherapist).
-The cardiologists initiated and uptitrated the cardioprotective drugs
-The nurses monitored risk factors and adherence to drug treatments at each
session.
-At 16 weeks,patients and their partners were reassessed by the whole team
and a report was sent to their family doctors.
Wood DA. Lancet 2008; 371: 1999–2012
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Nurse-coordinated multidisciplinary, family-based cardiovascular disease
prevention programme (EUROACTION) for patients with coronary heart disease
and asymptomatic individuals at high risk of cardiovascular disease: a paired,
cluster-randomised controlled trial
EUROACTION preventive cardiology intervention programme in hospital
and general practice
-The nurses assessed the smoking status, health beliefs, and history of
tobacco smoking, and previous attempts to quit.
-Patients and their families’ knowledge and attitudes to diet were assessed by
the dietitian (in hospital) or nurse (in general practice).
-To achieve a 30–45 min of moderate intensity activity, four to five times a
week as a family, the physiotherapist (in hospital) or nurse (in general
practice) assessed habitual and physical activity patterns, functional capacity,
and other factors that affected activity participation by families
-Nurses monitored the blood pressure and concentrations of cholesterol and
glucose in all patients, and reviewed the results with physicians who treated
the patients appropriately to achieve targets
-In the hospitals, nurses coordinated a rolling programme of eight
workshops—one a week—for coronary heart disease, cardiovascular risks.
Wood DA. Lancet 2008; 371: 1999–2012
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
EUROACTION - Objectifs
Tabagisme : zéro
Régime :
• Graisses saturées < 10 %
• Fruits et légumes > 400 g/j
• Poissons > 20 g/j
• Huile de poissons > 3 / sem
Activité physique :
• 30 à 45 minutes d’activité
physiques à 60-75 % de FMT
4-5 fois/semaine
Pression artérielle :
• < 140/90 mmHg (<130/85 si diabète)
Lipides :
• cholestérol T > 5 mmol/l
•LDL-c < 3 mmol/
Diabète :
• Contrôle de glycémie
Wood DA. Lancet 2008; 371: 1999–2012
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
EUROACTION
Proportion de patients atteignant les objectifs des recommandations
européennes pour l’activité physique
Hôpital
Pratique de ville
+ 36 % (+ 20 % to 51 %)
60
+ 29 % (+ 11 % to 48 %)
60
54
50
40
40
22
20
20
20
0
0
Intervention Prise en charge
conventionnelle
Intervention Prise en charge
conventionnelle
p = 0,002
p = 0,001
Intervention
Prise en charge conventionnelle
Wood DA. Lancet 2008; 371: 1999–2012
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
EUROACTION
Proportion de patients atteignant les objectifs de
réduction pondérale > 5 %
Hôpital
+ 6 % (- 7 % to +19 %)
20
19
Pratique de ville
+ 10 % (+ 6 % to +15 %)
20
16
13
7
0
0
Intervention
Prise en charge
conventionnelle
p = 0,28*
Intervention
Prise en charge
conventionnelle
p = 0,005*
* Patients avec BMI > 25 kg/m²
Intervention
Prise en charge conventionnelle
Wood DA. Lancet 2008; 371: 1999–2012
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
EUROACTION
Proportion de patients atteignant les objectifs des recommandations
européennes pour la pression artérielle
Hôpital
80
Pratique de ville
+ 10 % (+ 0,6 % to +20 %)
80
+ 17 % (+2 % to +32 %)
60
65
58
41
60
55
40
20
40
0
Intervention
Prise en charge
conventionnelle
p = 0,04
Intervention
Intervention
Prise en charge
conventionnelle
p = 0,03
Prise en charge conventionnelle
Wood DA. Lancet 2008; 371: 1999–2012
saint
antoine
Disease management and telephone monitoring
Assistance Publique
Hôpitaux de Paris
EUROACTION
Proportion de patients sous traitement cardio-protecteur
Hôpital
Pratique de ville
p = 0,004
100
p = 0,002
93
p = 0,02
80
74
p = 0,03
p = 0,07
40
36
86
33
p = 0,03
76
29
68
67
p = 0,98
60
p = 0,51
17
p = 0,21
14
13
10
21 19
20
20
19
20
40
23
p = 0,90
52 51
0
9 8
0
Anti-agrégants
Beta
plaquettaires bloquants
IEC
Anticalciques
Intervention
Statines
Anti-agrégants Diurétiques Beta
plaquettaires
bloquants
IEC
Anticalciques
Statines
Prise en charge conventionnelle
Wood DA. Lancet 2008; 371: 1999–2012
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Plan
• Disease Management dans l’insuffisance
cardiaque
• Disease Management dans la maladie
coronaire
• Avantages et limites des formes de Disease
Management
• Conclusion
CNCF 8-10 octobre 2009
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Advantages and disadvantages of different models of HF
programmes
Advantages
Clinic
visits
Home
care
Disadvantages
-Convenient with medical expertise,
facilities and equipment
available.
-Facilitates diagnostic investigation
and adjustments of treatment
strategy.
-Access to immobile patients
-More reliable assessment of the
patient’s needs, capabilities and
adherence to treatment in their own
home environment
-Convenient for a follow-up visit
shortly after hospitalization.
Frail, non-ambulatory patients
not suitable for out-patient
follow-up
-Time consuming travel for the
HF team
-Transportation and mobile
equipment required
-Nurses face medical
responsibilities alone and may
have difficulty contacting the
responsible physician.
Conn VS. Journal of Cardiology xx (2008)
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Advantages and disadvantages of different models of HF
programmes
Advantages
Telephone
support
Remote
monitoring
Disadvantages
-Low cost, time saving and
convenient both for the team and
the
patient.
-Difficult to assess symptoms
and signs of heart failure and no
tests can be performed
-Difficult to provide psychosocial
support, adjust treatment and
educate patients.
-Facilitates informed clinical
-Requires education on the use
decisions
of the equipment
-Need is increasing as care shifts -Time-consuming for HF team
into patients’ homes
-Difficult for patients with
-New equipment and technology cognitive disability
becoming rapidly available.
-Most helpful measurements not
known.
Conn VS. Journal of Cardiology xx (2008)
Disease management and telephone monitoring
saint
antoine
Assistance Publique
Hôpitaux de Paris
Conclusion
• Intérêt de la mise en place d’une plateforme
téléphonique de suivi des patients insuffisants
cardiaques ou coronariens selon le modèle du Disease
Management et des critères et objectifs bien définis
• Mobilisation des cardiologues de ville et rapprochement
ville – hôpital - établissements de santé privés
• Information et formation des patients
• Évaluation simple
• Dispositif à un coût modéré
CNCF 8-10 octobre 2009
Disease management and telephone monitoring
Assistance Publique
Hôpitaux de Paris
saint
antoine
Disease management and telephone monitoring
Assistance Publique
Hôpitaux de Paris
saint
antoine