Telemonitoringassets.escardio.org/assets/Presentations/EPR2011/... · Telemonitoring S. Scalvini, EuroPRevent 2011, Geneve 14 April 2011 Simonetta Scalvini ... In situ monitoring

Telemonitoring

S. Scalvini, EuroPRevent 2011, Geneve 14 April 2011

Simonetta Scalvini

No conflict of interest

Telemedicine Service, IRCCS Salvatore Maugeri Foundation Lumezzane (BS)-Italy

Definitions

• Structured telephone support:“if the monitoring and/or self-care management is delivered

using simple telephone technology (data may have been

collected and stored by a computer)”

• Telemonitoring:“if there was digital/broadband/satellite/wireless

or bluetooth trasmission of physiologic and other non-invasive data”


1. Case Definition

2. Patient’s evaluation

3. Therapeutic objectives

6. Patient’s education

7. Appropriate use of the services

4. Development of a care plan

5. Monitoring


In situ monitoring of health in older adults: technologies and issues.JAGS 58:1579-1586, 2010.


Personal Tele-health System

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Glucose

Meter

Pedometer

Blood-

pressure

Medication

Tracking

Fitness

Equipment

Weight

Scale

Thermometer

Pulse

Oximeter

Spirometer

Cholesterol

Monitor

Home

sensing &

control

Bed / Chair

Sensors

Implant

Monitors

Baby

Monitors

PERS

CONNECTIVITY

ETHERNET

SENSORSAGGREGATIONCOMPUTATION SERVICES

Diet or

Fitness

Service

Disease

Management

Service

Personal

Health

Record

Service

Implant

Monitoring

Service

Healthcare

Provider

ServicePC

Cell Phone

AggregatorConsumer

Electronics

Personal

Health

System

GRID


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http://www.very-clever.com/al/index.php?l=xbdddqexsexdxk

Personal Health Record

a complete and accurate summary of the health and medical history of an individual by gathering data from many sources and making this information accessible online to anyone who has the necessary electronic credentials to view the information.


Videoconference


Point- multi point videoconference

GPs

Patients

Service Centre

Hospitals

Telemonitoring

Nurse


Telemonitoring

(scheduled call for collection of clinical data and biological signals, i.e. blood pressure)

Teleassistance

(unscheduled calls for evaluation of symptoms and/or signals)

Teleconsulting

(each calls requiring a second opinion by a specialist)

CLINICAL HEALTH RECORD

BLOOD PRESSURE

Telematic support

What the nurse do: Comprehensive assessment, proactive clinical intervention, marshalling of resources, assessment of the quality of care; enable people with multiple conditions, affecting all areas of daily living, to remain in control.

Implementsclinical guidelines of the

specific disease

Consultation withspecialist supervisions

if necessary

Formulatesdecisions aboutcare of patients

Organisationaland management

of care

Patient

Specialist

GP

Ask for diagnosticexaminations according

with specialist

Knowledge of symptomsperception

Blood Pressure Telemonitoring



2

3

Patient

Device and mobile phone for the transmission of the blood pressure

Nurse or specialist’s counselling

Service Center



Role of home blood pressure telemonitoring in hypertension management: an update.

Blood Pressure Monitoring 2010, 15:285-295.





Telemonitoring of Diabetes

J Diabetes Sci Technol 2009, 3(6):1501-1506.

Enhanced 911/Global Position System Wizard: a telemedicine application for the prevention of severe hypoglycemia-monitor, alert, and locate.

J Diabetes Sci Technol 2009, 3(6):1501-1506.

Enhanced 911/Global Position System Wizard: a telemedicine application for the prevention of severe hypoglycemia-monitor, alert, and locate.

Circ Cardiovasc Qual Outcomes 2011, 4:235-242.

Secondary prevention risk intervention via telemedicine and tailored patient education (SPRITE). A randomized trial to improve postmyocardial infarction management.

Circ Cardiovasc Qual Outcomes 2011, 4:235-242.

Secondary prevention risk intervention via telemedicine and tailored patient education (SPRITE). A randomized trial to improve postmyocardial infarction management.

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Home-based exercise rehabilitation with

telemedicine

following cardiac surgery S Scalvini et al. JTT 2009;15:297-301

The purpose of our pilot study was to evaluate programmes of primary prevention in patients with multiple risk factors for cardiovascular diseases by using TMS to achieve the following objectives: control of hypertension, changes in lifestyle, and adherence to physical training.


Methods

1

Nurse-tutor

Service Center

2° opinion

consultation

4

Patients in Tele-training: 3-5 times/week

Devices, ECG and BP telemonitoringS. Scalvini, EuroPRevent 2011, Geneve 14 April 2011

Blood pressure monitoring

Twenty-four-hour ambulatory blood pressure (BP) monitoring was

performed at T0 and T6 using a validated Mobil O Graph Ambulatory

BP monitor (IEM, Stolberg, DE). In case of clinically significant

changes during the 24-h BP monitoring, antihypertensive treatment

was adjusted accordingly.

Home self-measurement with an oscillometric device was also

performed (Omron M6 Comfort; Omron, Kyoto, Japan) at least three

times a week.

Home self-measurement with BP-Tel (Aerotel) device for 1 week at T0

and T6. The system includes:

(i) a home BP measuring device that uses the oscillometric system;

(ii) a built-in proprietary communicator which automatically transmits

data from home to the service centre via telephone; and

(iii) a computer programme at the service centre for receiving and

storing measurements in a database and preparing reports.


• Physiotherapist go at patient’shome monthly

• During the visit thephysiotherapist evaluates thecorrect execution of physicaltraining

• Increases the work load

• Personalises the exercise incase of physical limitations,(osteoarthritis, fractures,etc.)

Home visits by physiotherapist


Physical activity programme

Patients had to undergo a minimum of three sessions a week of bicycle exercise training or fast walking for at least 30 min and calisthenic exercises.

Physical programme had three basic activities: (i) 5–10-min warming, (ii) 20-min active exercise, and (iii) 5–10-min cool-down phase. A baseline 1-lead electrocardiogram followed by the trans-telephonic delivering of all tracks recorded had to be performed.

Physiotherapists organized home visits and/or telephone contacts aimed at increasing workload and evaluating the proper execution of calisthenic exercises.

At both T0 and T6, all patients performed one maximal effort test and the metabolic Holter monitoring using the Body Monitoring Multi-Sensor Armband

(BMSA) (SenseWear) worn at the triceps of the right arm for at least 72 h. The activation of the BMSA was completed using the InnerView Research software version 2 (BodyMedia) measuring energy expenditure and duration and quantification of physical activity.


SenseWear® Armband


Teletraining


Questionnaires

Quality of life (WHO QoL-short)13 at both T0 and T6;

Pisa Stress (PSQ-form A), which assesses presence and

type of stress-related behavioural responses,14 at

both T0 and T6;

Diary of daily eating habits (only at T0) needed to arrange

an individual programme of nutrition education;

Questionnaire of satisfaction only at T6: a 10-item

questionnaire which focused on patients’ satisfaction,

acceptance of the technology used, and efficiency of

personnel.


Tele-psychology online

Patients

Nurse

Service Centre

Psychologist


Scheduled one domiciliary

visit at the beginning of

prevention programme and,

however in case of need.

Evaluates vitals signs

Sanitary education reinforce

Help patient to fill in

questionnaires (nutritional

habits and stress)

Home visits by nurse


General characteristics of the patient population (1)


General characteristics of the patient population (2)


• 1706 contacts, 63±33 calls/patient were performed. Each call required a

mean-time of 12.8 ± 1.4 min each

• Each patient performed 61±32 scheduled and 2.2±2.5 unscheduled calls

• During the call 39±23 BP measurements and 50±26 ECG-transmission were

referred per patient.

Calls and consequences

REASONS FOR CALLING ACTION TAKEN

Scheduled controls

Palpitations 16 Therapy modification 28

13

Educational reinforcement

9Dyspnoea 1

Hypertensive Attack

8 137

General weakness 4

General malaise

General communications 123

New scheduled contacts 1508

Telephone consultations 22

Further examinations

1547

• 281 contacts with specialists, 218 contacts with hypertension or cardiologist

specialist

• 140 home visits of physiotherapists (5.0±1.0/patient)

• 52 psychological contacts (7±3/patient performed only in six patients)

Physical Activity Programme at Home


Body Monitoring Multi-Sensor Armband at T0 and T6


Systolic blood pressure


Diastolic blood pressure


Telemonitoring in

chronic heart failure

Structured telephone support or telemonitoring programmes for patients with chronic heart failure (Review)

All-cause hospitalization (full-peer reviewed pubblication only)

Telemonitoring vs usual care

Clark RA et al. 2010

Structured telephone support or telemonitoring programmes for patients with chronic heart failure(Review)

CHF-related hospitalization (full-peer reviewed pubblication only)




Structured telephone support or telemonitoring programmes for patients with chronic heart failure(Review)

All-cause mortality (full-peer reviewed pubblication only)


Structured telephone support or telemonitoring programmes for patients with chronic heart

failure(Review)

Implication for pratice


Structured telephone support or telemonitoring programmes for patients with

chronic heart failure(Review)

Implications for research (1)


230 CHF patients followed for 365 days usingtelephonic follow-up and ECG monitoring

230 patients in the control group

average age 57±10 y; FE 27±6%; VO2 13.3ml/kg/min

In the “Telemedicine Group” we observed a reduction in:

- hospitalizations (~ 44%)

- destabilizations (~ 50%)

- costs (~ 24%)

Multicenter randomised trial on home based

telemanagement to prevent hospital readmission of

patients with chronic heart failure

Giordano et al. IJC 2009;131:192-199

Home Based Telemanagement

programme

Total358

Cardiovascular Death19

Non Cardiovascular Death2

Drop out9

No events6 months re-evaluation

238

Cardiovascular Hospitalizations112

Non CardiovascularHospitalizations

46


HOME BASED TELEMANAGEMENT

Patients’ baseline characteristics

Years of enrollement Total

(n=358)

2000-2003

(n=210)

2004-2007

(n=148)

P

Female (%) 18.7 16 22.3 ns

Age (y) 63±12 60±11 68±13 <0.001

NYHA Class 2.6±0.5 2.5±0.5 2.7±0.5 <0.01

NHYA III (%) 60.6 50.4 75.6 <0.0001

LVEF (%) 30.1±9.6 28.7±7.6 31.9±11.7 ns

Onset of symptoms <6 m

(%)24.3 17.6 33.7 <0.0007

CAD Ethiology (%) 55.3 57.6 52.3 ns

COPD (%) 12.9 9.5 17.6 <0.03

CRI (%) 15.9 12.8 20.3 =0.07

Diabetes (%) 19.3 21.9 15.6 ns

-Blockers agents (%) 84.4 89.9 76.3 <0.01



Clinical Events

Years of enrollement Total 2000-

2003

2004-

2007

p

(n=358) (n=210) (n=148)

Acute HF Instabilization w/o hospitalization

rate (%)

9.8 11.4 7.4 ns

Cardiovascular (including HF) readmission

rate (%)

31.2 29.0 34.5 ns

Acute HF readmission rate (%) 19.6 16.7 23.6 ns

Non cardiovascular readmission rate (%) 12.9 9.5 17.6 <0.03

All-cause readmission rate (%) 38.3 33.8 44.6 <0.05

Cardiovascular mortality rate (%) 5.3 5.7 4.7 ns



Six-month re-evaluation

TOTAL (n=238)

Pre Post p

NHYA Class 2.5±0.5 2.0±0.7 <0.0001

LVEF % 30±7.8 33.1±10.6 <0.0001

6 min-WT (mt) 427.6±109 442.8±107 NS

MLHFQ 30.2±18.1 25.2±21.1 <0.01

Hb (mg/dl) 13.0±1.9 13.6±1.8 <0.0006

βBlockers (mg/day) 34.7±21.4 40.3±21 <0.001

βBlockers 88.2 89.9 NS


Extracardiac

diseasesMultiple risk

factors

Multidistrectual

Vascular disease

Multiple cardiac

disease

Oldest Old

“homeostenosis”

Primary or secondary

prevention

Multidisciplinary management


Our understanding the future

Projects

Remb. Operations

R&D

Projects

Remb.

Operations

R&D

Projects

Remb.

Operations

R&D

now

2/3 yy 3/5 yy

Cash flows from Projects still finance a large amount of

operating activities.Probably, it will take 5 years to reverse this structure. Mostly, it depends on

the speed of expansion of reimbursment, in terms of

number of services and number of types of services.

0

40,000

80,000

120,000

160,000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

€0

00

s

present value of cumulative costs present value of cumulative benefits

Telecardiology in Italy: Benefits from a telemedicine network connecting chronic patients, General Practitioners and Health

Provider Organisations

The economic impact of extending telecardiology across the whole Lombardy Region,steadily over about six years up to 2012, is material. Much of the investment needed ininformation and communication technology, electrocardiogram equipment and serviceinfrastructure has already been set in place by Health Telematic Network. The total netbenefits are considerable, with an estimated annual benefit cost ratio of more than 3.3:1 by2012

A different future, new ability,

new organizations, new

methods to prevent ….

….. In some reality a

present !!!

Documents

Telemonitoringassets.escardio.org/assets/Presentations/EPR2011/... · Telemonitoring S. Scalvini, EuroPRevent 2011, Geneve 14 April 2011 Simonetta Scalvini ... In situ monitoring