Telemonitoring for Heart Failure Evidence

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Telemonitoring for Heart FailureEvidence
Practice

• Professor John G.F. Cleland
• Department of Cardiology,
• Hull York Medical SchoolUniversity of Hull
• Kingston-upon-Hull
• UK

Conflict of Interest I have received honoraria
and/or research support from Philips, Bosch, GE,
Alere and St Jude
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Survival of Patients with a Primary Discharge
Diagnosis of Heart Failure England Wales
2009-2010

• Audit

About 1 million people affected in the
UK 450,000 admissions per year (65,000 in first
diagnostic position) N 19,240 (about 30 of
all expected cases) Median age 79 years lt65 years
3,000 65-75 years 4,000 75-85 years
7,000 gt85 years 5,000
Cleland et al HEART 2011
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TeleHealthWhy is it Likely to Become Essential?

• More patients with long-term conditions
• More older people
• Longer survival with illness
• Better primary secondary prevention
• Fewer professionals to provide health-care
• Smaller proportion of population of working age
• Loss of migrant workforce as economies rival UK
• Better paid or more attractive / less stressful
  jobs
• More monitoring required
• Higher expected standards of care
• More treatments that need to be monitored
• More things that can be monitored

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TeleHealthWhy is it Likely to Become Essential?

• Patient preference Convenience
• Patients, Carers, Staff
• Reduced Costs
• Buildings, Staff, Transport
• Environmental impact
• Transport
• Parking
• Buildings
• Better record keeping !!!!!!!!!!!!!!!!!!!!!!!

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The Opportunity of Chronic Illness

• Most patients soon learn routines
• Or have relatives / friends that do
• Most patients are interested in maintaining or
  improving their health
• Patients are an inexpensive but neglected
  health-care provider opportunity
• Invest in patients
• Education
• Active Partnership
• Empowerment

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TeleHealth - What Might it Achieve?
Ultimate Intermediate
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TEN-HMSThe Trans-European NetworkHome-Care
Management SystemPatients about to be discharged
from hospital after an exacerbation of chronic
heart failure
54 of Patients Aged gt70 years
(Published JACC 2005)
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TEN-HMS
Reduction in Mortality NTS or HTM v UC Absolute
16.4 Relative 36
Mortality
No reduction in hospitalisation Shortening of
hospital stay with HTM
p lt 0,05
Cleland et al JACC 2005
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TEN-HMS
How do you feel about your health since
receiving Telemonitoring?
much safer
no change
much more anxious
safer
more anxious
Undef.
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TEN-HMS
Achieving Therapeutic Target
Patient Clinical Status




240 Days
120 Days
240 Days
differences between HTM and other groups. No
difference between UC and NTS
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TEN-HMS Total Patient Contacts
Contacts Per 1,000 Days Alive and Out of Hospital

Plt0.01 HTM v NTS
under-reporting of events likely in this group
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Structured Telephone Supportn 5,563(Cochrane
Review)
Mortality

• New Trials
• Tele-HF
• TEHAF

HR 0.88 (0.76-1.01) p0.08
Inglis et al 2010
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Home Telemonitoringn 2,710 (Cochrane Review)

• New Trials
• TIM-HF
• COMPASS
• CHAMPION
• SENSE-HF

Mortality
HR 0.66 (0.54-0.87) plt0.0001
Inglis et al 2010
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Major Problems with RCTs of Service Delivery

• Technology differs
• Telephone Support including Voice Activated
  Systems
• Physiological telemonitoring
• Implanted or Not
• Care usually improves if it is the focus of
  attention
• Effect in control group
• Beware before v after comparisons
• Lack of integration into existing services
• Puts innovative interventions at a disadvantage
• Selection of patients at low risk with modern
  treatment

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Percent of Days Lost To Hospitalisation or Death
TEHAF (12 months)
TEN-HMS (15 months)
TIM-HF (26 months)
8.9 8.4
37.0 21.3 22.6
4.5 6.1
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What Have We Done for TeleHealth in Hull?

• Established
• International reference site (LifeLab) for HF
  epidemiology research
• International reputation for research excellence
  in telehealth
• A model telehealth service
• Grants
• TEN-HMS
• Four FP7 grants relating to telehealth heart
  failure
• EDRF
• Industry Partnerships
• Philips, GE, Bosch, Cardiomems, St Jude others
• Publications
• gt500 PubMed citations in related fields
• TEN-HMS, Concept Papers, Editorials
• Systematic Reviews (EJHF, BMJ Cochrane)
• Inventions
• Dynamic risk analysis
• Complex management algorithms

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The Hull Model for TeleHealth

• HeartCycle
• Heart Failure
• Post-MI Rehab

Device Implant
Non-Invasive Home Monitoring
Community TeleKiosks Screening Long-Term
Conditions
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Services for Patients with Heart FailureThe
Kingston-upon-Hull Model
Heart Failure Discharge Nurse
Heart Failure Telemonitoring Nurse
Voluntary Patient-Support Organisations
Community Heart Failure Specialist Nurses
Patients in Hospital
Patients at Home
Family Doctor (NT-proBNP)
Specialist Clinics
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Where Next?

• Interactive TV
• New monitoring technologies
• Implanted devices
• More intelligent use of the patient data
• Investing in patients as health-care providers

Centre for Telehealth
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The Hull Heart Failure Life-Lab30,000
patient-years of follow-upLargest, Longest
Follow-up, Epidemiologically-Representative
Cohort of Heart Failure in the WorldRich in
phenotyping, serial biomarker and outcome data
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HeartCycle Programme

• Shift from crisis detection to health maintenance
• Health Maintenance Envelope
• More optimistic
• Better way to engage/motivate patients
• More active management
• More activity likely to hold actors attention
• Clinical calibration
• Addresses the issue of false alerts
• Personalised Careplan
• Treatments
• Ideal monitoring envelope

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Motivation feedback on measures and trends, what
they mean and what to do about them Education
on healthy lifestyle, reasons for treatments,
self management
Health-Care Provider
Secondary Loop
Patient / Carer
Analysis
Primary Loop 70 of Care Decisions
Monitor
Intelligent, integrated, multi-measure (time
type) personalised analysis
Communication System
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Opportunities for TeleHealth

• Change in Philosophy
• Investment in patients (rather than experts)
• Patients as first and possibly main tier of
  healthcare
• Communication
• Patient, community health social services,
  specialists
• Common health record
• Checked (at least in part) by the patient
  themselves
• Decision support analysis
• Patient professional support
• Research potential
• Healthcare innovation
• Pharmaceutical industry especially
• Route to faster (ethical) adoption
• Convenience Preference
• Patient, Carer, Health Professional
• Environmental impact

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Conclusion

• The first era of telemonitoring is over
• Time to move from
• Crisis Detection
• to
• Health Maintenance

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