Transcript Osservatorio Cardiovascolare Trieste

La Telemedicina nella
gestione della cronicità
Andrea Di Lenarda
President of Italian Association of Hospital Cardiologists
Cardiovascular Center and University of Trieste, Italy
What do we expect from Telemedicine
especially in Heart Failure?
1.
THAT CONTRIBUTES TO A MORE CAREFUL AND EFFECTIVE
MANAGEMENT OF THE PATIENT BY REDUCING THE BARRIERS
THAT HINDER THE PATHWAYS AND CONTINUITY OF CARE
2.
THAT PARTICIPATES IN THE COMPLEX SET OF EVENTS THAT CAN
IMPROVE
THE
QUALITY
OF
LIFE
HOSPITALISATIONS
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AND
REDUCE
Rate and causes
of 1-year hospital
re-admissions
(n=48549; 2.1/pt)
A System-Wide Chronic Disease
Management Program may allow an
early and more frequent identification
of clinical instability which should be
rapidly managed and resolved so as to
prevent avoidable hospitalisations.
56.6% Total re-hospitalisations
50.9% CV re-hospitalisations
(46.1% HF re-hospitalisations)
49.1% non CV hospitalisations
The new paradigm of Telemedicine:
From a «reactive» to a «pro-active» approach
Increase of filling pressure
Dyspnea, oedema,
weight increase
Neurohormonal activation;
Emergency
Room/Hosp
Impedence reduction
Stable NYHA class
Euvolemic;
Stable NYHA class
gg
> 30
-21 a -7
-6 a -2
“Pro-active”
Phase
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0a5
“Reactive”
Phase
The new paradigm of Telemedicine:
From a «reactive» to a «pro-active» approach
Home
days
> 30
-21 to -7
-6 to -2
“Pro-active”
Phase
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0 to 5
“Reactive”
Phase
TELEMEDICINE & MANAGEMENT
1°) Effective transmission
of clinical variables
reliable for HF
2°) Qualified personnel
receive informations
to prescribe effective
interventions
3°) Patients receive
recommandations and
prescriptions to be
implemented
- weight
Integrated
evaluation!!
- Heart rate
- Rhythm
- Temperature
- Impedence?
- SaO2
- Creatinine
- NA+/K+
- Hb, BNP?
- Score (dyspnea)
- Score (fatigue)
- Treatment changes
(diuretics,TELEMONITORING
etc.)
- Lifestyles changes
- Others
TELE-MANAGEMENT
Revaluation to verify if the
problem is solved or other
interventions are needed
modified by Desai AS and Stevenson LW, NEJM 2010
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• A personalized hospital-discharge programme, founded on individuals’
needs and risk profiles, might be the best approach to plan the follow-up
care of patients with chronic HF.
• ICT will be helpful to disseminate clinical information to all health-care
professionals in real time, and thus reduce the time and duplication of
procedures and improve the overall care and health of patients.
• Telemedicine has been used to support (not replace!) integrated care in
the management of chronic diseases and, in particular, to provide
education to improve self-management, enable information transfer
(such as by telemonitoring), facilitate contact with health-care
professionals (such as via telephone support and follow-up), and
improve electronic records.
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Case manager, Continuity of Care, Multidisciplinary Team, GP’s role
GP
Specialist
Nurse
INTERNET
Service Center
WEB SITE
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Trieste
But what are the risks?
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Trieste
Cagliari 15/05 mobile-health tra rischi e
10
Consumer o Medical devices?
• They perform the same function, but they give the same
guarantees in terms of reliability? Hygiene? Precision?
• You'd never allow to be treated with any drill?
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Top 10 hazards
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Cagliari 15/05 mobile-health tra rischi e benefici
13
… and more hazards
• Potential for errors due to software bugs (most are not medical
devices!)
• Telemedicine does not substitute the emergency system
• Risks of wrong/late/missing interpretation of the data and
consequently wrong/late/missing decision (devices, variables, data,
decision support systems, competence/responsibility of HC
providers, integrated health network able to take in charge the
problem)
• Legal responsibility to take a clinical decision on the base of some
(often incomplete) informations
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TELEMEDICINE & HEART FAILURE
- Metanalysis (All cause mortality) -
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TELEMEDICINE & HEART FAILURE
- Risultati dei Trials 1. Chaudhry SI et al N Engl J Med 2010, 2. Kholer F et al Circulation 2011, 3. Cleland J JACC 2009, 4. Mortara A et al Eur J Heart Fail 2009
2.
1.
Telemonitoring
Nurse supp.
Usual care
3.
4.
TELEMEDICINE & HEART FAILURE
- Results of Trials Possible explanations for the negative results of most recent multicenter trials
on the implementation of remote telemonitoring (TLM) in patients with HF
• In the study design TLM is treated as a “drug” while only it is a system to improve the
communication among health care providers.
• None of the trials gives the methods of intervention in relation the significant changes in vital
signs, and above all the procedures for verification that the recommendations are being
followed by the patient.
• The follow-up is always very short (6-12 months) for multicenter studies that use new
technologies.
• The choice of vital parameters to be monitored can not be appropriate to the individual case.
• Often the TLM must be activated by the patient and is shown that in the long run this leads to
an under-use of systems TLM especially if the patient does not receive a adequate feedback.
• Poor patient adherence to the monitoring program.
• The TLM can not be effective if it is not integrated in a treatment program with
individualized control algorithms for each individual patient.
CHAMPION STUDY
MONITORING AND MANAGEMENT
Reliable measure of PAP («pro-active» phase)
Clear treatment goal (lower PAP)
Well defined protocol of management («reactive» phase)
Easy to verify the results of intervention
>30%
ad 1 aa
The ECOST trial.
Cumulative
survival free from
major adverse
events in the
intention to treat
(A) and perprotocol (B)
population.
The COMPAS
trial.
Major adverse
events (MAEs)
were unchanged
but face-to-face
visits were
reduced.
Mabo P, Victor F, Bazin P, Ahres S, Babuti D, Da
Guédon-Moreau L. Eur Heart J 2013; 34:605-14.
CA et al. Eur Heart J 2012; 33:1105-11.
TELEMONITORING PROGRAMS & DEVICES
IN-HF Program
2662
835
240
Patients with chronic HF
With indication to
implantation but…
Effectively implanted
1827 + 595 (91%) without devices
and not monitored
Dati IN-HF Outcome F. Oliva, A.Mortara et al submitted
Which patients are more likely to benefit
from Remote Telemonitorig?
• Patients defined at high risk of events for worsening
heart failure or CV hospitalisations (risk-driven
management, NYHA class III e IV)
• Patients in the vulnerable phase
discharge (30 days – 3 months)
after
hospital
• Patients with objective limitation due to functional,
geographic, socioeconomical barriers
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TLM
Rehospitalization is particularly high in
the early phase after hospitalization
30 days from discharge
Multiple HF Hosp.
BNP++, Multimorbidity,
CKD +, LVEF<40%
1 patient out of 4 is readmitted
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SmartCare
The way to Integrated Care
SmartCare
Conventional Care
SmartCare Services
Service Models
Health
care
silo
Care protocols / pathways
Health care centred pathways
ICT / telehealth infrastructure
Social care centred pathways
SmartCare
integrated
pathways
Cared-for &
self-caring person
Integrated Support Services (ICT)
disempowered care recipient
misinformation & patient risk
suboptimal task distribution
Social
care
silo
Care plans / protocol
ICT / telecare infrastructure
Cared-for
person
Integrated
data access
Access to homebased Systems
Coordination
between
provision steps
taken
Joint response to
ad hoc requests
Real-time
communication
Building
Bocks
SmartCare ICT Integration Infrastructure
 inclusive
 collaborative
safety enhancing
responsive
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efficient
 empowering
FVG study design and enrolment
inclusion criteria
Design: local randomized study design (200 elderly citizens with
HC/SC needs to be enrolled by the end of the study: 100 in usual
care control group, 100 in ‘new ICT supported integrated care’
intervention group).
Short and Long-Term Pathways:
• Short term home monitoring (>3 mo). Before H discharge,
multiprofessional H team together with district nurse select
eligible care recipient according to a set of HC/SC inclusion criteria
(eg Heart Failure, COPD, diabetes, social isolation)
• Long term care (≥6 mo). Elderly individuals with chronic/stable,
relevant health and/or social needs assessed by HC/SC staff at the
joint point of referral (PUA).
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Results – General findings
• 201 randomized patients (100 Intervention vs 101 Usual)
• 19 early drop-out (12 Intervention vs 7 Usual care; 12 Short-term post-discharge vs 7 Longterm chronic)
• 182 patients followed (88 Intervention vs 94 Usual care)
• Follow-up 7.1±3.8 months (119 patient-year):
– Short-term post-discharge vs Long-term chronic: 4.1±1.3 months vs 9.9±3.3 months)
• Events (16 deaths; 126 Hospital/Health Care facility admissions; 1758 days of stay)
– 16 deceased patients (8.8%; 13.4 deaths/100 patient-year)
– 108 Hospitalizations (1342 days of hospital stay)
– 18 Intermediate Care/Nursing Home admission (416 days)
• Home Nursing Healthcare: 3053 total contacts (2.14 pt-month); 2417 (79.2%) Home Care,
160 (6.6%) unplanned; 536 (20.8%) Phone calls.
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Results: Main clinical findings
All population
(n=201)
Intervention
(n=100)
Usual Care
(n=101)
p=
81±7.8
81.2±7.9
80.9±7.7
NS
53.8
60.2
47.9
NS
Heart Failure (1st Dx) (%)
79.1 (52.7)
76.1
81.9
NS
COPD (1st Dx) (%)
37.9 (17.6)
40.9
35.1
NS
Diabetes (1st Dx) (%)
68.1 (29.7)
64.8
71.3
NS
Charlson index ≥5 (%)
44.5
48.2
40.4
NS
Prescription ≥7
Medications
Living alone
58.2
60.2
56.4
NS
38%
32%
43%
NS
Reliant on care
43%
46%
40%
NS
Primary school
58%
57%
58%
NS
Age (years)
Male gender (%)
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Short-term Post-discharge Pathway
p=NS
p=0.048
5.7 days saved in 3 months for 1 post-discharge intervention
patients as compared to usual care pts
Short-term Post-discharge Pathway
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Planned/Unplanned Contacts
Short-term Post-discharge Pathway
p=NS
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p=0.04
PRACTICAL GUIDE ON HOME HEALTH IN HEART FAILURE PATIENTS
Tiny Jaarsma, Torben Larsen, Anna Strömberg
“Most heart failure management programmes aim at optimisation of both
pharmacological and non-pharmacological management and include
assessment and intervention of risks and co-morbidity, optimised medical
management, device therapy (pacemaker, cardiac resyncronisation therapy
and implantable cardioverter defibrillator) education and self-care
management, follow-up, access to health care and psychosocial…..”
“Currently, the most optimal model for heart failure management is not
known. Recent large-scaled studies show that not all models are equally
successful to improve the outcomes, and these results indicate that a
sophisticated approach to heart failure management is needed…”
Int J Integr Care 2013; Oct-Dec
It is in crisis that invention,
discovery and large strategies
are born.
E. Einstein