Telemonitoring for Heart Failure
Evidence & Practice
Professor John G.F. Cleland
Department of Cardiology,
Hull York Medical School
University 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
1.00
Survival of Patients with a Primary Discharge Diagnosis of Heart Failure
England & Wales 2009-2010
Audit
0.75
•
0.00
0.25
0.50
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)
0
90
Median age 79 years
<65 years
~3,000
65-75 years
~4,000
75-85 years
~7,000
>85 years
~5,000
180
Survival time (days)
55-64 years
75-84 years
270
65-74 years
>=85 years
360
Cleland et al
HEART 2011
TeleHealth
Why is it Likely to Become Essential?
1. More patients with long-term conditions
–
–
–
More older people
Longer survival with illness
Better primary & secondary prevention
2. 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
3. More monitoring required
–
–
–
Higher expected standards of care
More treatments that need to be monitored
More things that can be monitored
TeleHealth
Why is it Likely to Become Essential?
4. Patient preference & Convenience
–
Patients, Carers, Staff
5. Reduced Costs
–
Buildings, Staff, Transport
6. Environmental impact
–
–
–
Transport
Parking
Buildings
7. Better record keeping !!!!!!!!!!!!!!!!!!!!!!!
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 healthcare provider opportunity
• Invest in patients
– Education
– Active Partnership
– Empowerment
TeleHealth - What Might it Achieve?
Ultimate
Intermediate
Titration of
therapy
Compliance
Detection of
exacerbation
Cause of
exacerbation
Treatment of
WHF
Selection for
Admission
Discharge
planning
Patient
Reassurance
ReDuration Mortality Patient
Costs
admission of adm.
Experience of care
TEN-HMS
The Trans-European Network–Home-Care Management System
Patients about to be discharged from hospital after an
exacerbation of chronic heart failure
54% of Patients Aged >70 years
(Published JACC 2005)
Mortality
TEN-HMS
Reduction in Mortality
NTS or HTM v UC
Absolute 16.4%
Relative 36 %
p < 0,05
Cleland et al JACC 2005
TEN-HMS
“ How do you feel about your health since receiving Telemonitoring? “
48.9%
38.9%
7.8%
3.3%
much
safer
safer
no
change
more
anxious
1.1%
much
more
anxious
Undef
.
TEN-HMS
Achieving Therapeutic Target
100
UC
***
95
*** NTS
90
HTM
85
***
80
%
75
70
65
60
55
50
ACEi
BB
Spirono
120 Days
Patient Clinical Status
70
60
50
40
30
20
10
0
.
I/II
ACEi
IV or Dead
III
BB
Spirono
240
240 Days
Days
*** differences between HTM and other groups. No difference between UC and NTS
TEN-HMS: Total Patient Contacts
Contacts Per 1,000 Days Alive and Out of Hospital
80
Telephone Contact
70
Office Visits
60
Home Visits
50
Hospitalisation
40
#
30
20
10
0
UC
NTS
# under-reporting of events likely in this group
HTM
P<0.01 HTM v NTS
Structured Telephone Support
n = 5,563
(Cochrane Review)
Mortality
New Trials
• Tele-HF
• TEHAF
All-Cause Hospitalisation
HR 0.88 (0.76-1.01); p=0.08
Inglis et al 2010
HR 0.77 (0.68-0.87.01); p<0.0001
Home Telemonitoring
n = 2,710
(Cochrane Review)
Mortality
New Trials
• TIM-HF
• COMPASS
• CHAMPION
• SENSE-HF
All-Cause Hospitalisation
HR 0.66 (0.54-0.87); p<0.0001
HR 0.91 (0.84-0.99); p=0.02
Inglis et al 2010
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
Percent of Days Lost To Hospitalisation or Death
TEN-HMS (15 months)
37.0% 21.3% 22.6%
40
1.7
2.4
40
TIM-HF (26 months)
8.9% 8.4%
TEHAF (12 months)
40
35
35
30
30
30
25
25
25
20
20
35
20
15
10
32.9
2.6
2.3
16.4
2.1
1.9
18.5
15
15
10
10
5
5
0
0
UC
NTS
HTM
Death WHF Hosp Other Hosp
2
1.1
5.8
2.1
1.3
5
UC
NTS
HTM
Death WHF Hosp Other Hosp
4.5%
6.1%
0.9
1.2
0.5
0.4
3.1
4.5
5
0
UC
NTS
HTM
Death WHF Hosp Other Hosp
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
– >500 PubMed citations in related fields
– TEN-HMS, Concept Papers, Editorials
– Systematic Reviews (EJHF, BMJ & Cochrane)
• Inventions
– Dynamic risk analysis
– Complex management algorithms
The Hull Model for TeleHealth
MEMS-based pressure sensor
Device
Implant
Non-Invasive
Home
Monitoring
Community TeleKiosks
Screening
Long-Term Conditions
Services for Patients with Heart Failure
The Kingston-upon-Hull Model
Heart Failure
Discharge Nurse
Heart Failure
Telemonitoring Nurse
Community Heart Failure
Specialist Nurses
Voluntary
Patient-Support
Organisations
Patients in Hospital
Patients at Home
Family Doctor
(NT-proBNP)
Specialist Clinics
Hull Telemonitoring Service
Outcomes Compared to Historical Data, Surveys & Trials
40
35
30
Observed
HEY 2007
Surveys
Trials
25
20
15
£350,000
10
£300,000
5
£250,000
Cost-Effectiveness of
TeleHealth (Hull)
Total gross savings
Total service cost
£200,000
0
£311,573
£224,416
Total net savings
£150,000
B
H
ed
Ap
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Ma 0
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Jul
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Se 0
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No 0
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Jan
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To
ta l
10
s/
£0
ns
io
ed
lis
at
lis
ta
pi
os
£50,000
£87,157
y
Da
H
ta
pi
os
s
hs
t
ea
Pt
D
£100,000
Where Next?
• Interactive TV
• New monitoring technologies
• Implanted devices
• More intelligent use of the patient data
• Investing in patients as health-care providers
The Hull Heart Failure Life-Lab
30,000 patient-years of follow-up
Largest, Longest Follow-up, Epidemiologically-Representative
Cohort of Heart Failure in the World
Rich in phenotyping, serial biomarker and outcome data
50
Probability of Death (%)
45
50
40
40
35
30
30
20
25
10
20
0
15
10
NT
-p
2
10
r oB
NP
( pm
ol/L
10
10
)
1
10
0
1
5
g/L)
0
(m
CRP
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
Motivation: feedback on
measures and trends, what they
mean and what to do about them
Health-Care
Provider
Secondary
Loop
Analysis
Intelligent,
integrated, multimeasure (time &
type) personalised
analysis
Education: on healthy lifestyle,
reasons for treatments, self
management
Patient / Carer
Primary
Loop
70% of Care Decisions
Communication
System
‘Monitor’
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
Conclusion
• The first era of telemonitoring is over
• Time to move from
– Crisis Detection
to
– Health Maintenance