mHealth Symposium 2013 ISMETT UPMC

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mHealth Symposium 2013 ISMETT UPMC

  1. 1. “Bending the Cost-Quality Curve:Leveraging mHealth for Home Monitoring and Remote Care”Dublin, May 13, 2013How to deliver high-specialty care at home after liver transplantation:a sustainable approachGiovanni Vizzini, MDDepartment of Medicine - Transplant Hepatology UnitISMETT-UPMCPalermo - Italy
  2. 2. Agenda• A clinical perspective1. ISMETT-UPMC: a multi-organ transplant center in Palermo (Italy)2. The clinical patient’s needs after discharge from hospital3. The limited resources4. The challenge: Best care at the lower cost5. The innovative use of available (and simple) technology6. Clinical Results and Sustainability
  3. 3. ISMETT-UPMC in Palermo (Italy)• ISMETT is a public-privatepartnership (The Sicilian Region -The University of PittsburghMedical Center) situated inPalermo, Sicily. It is the onlymultiorgan (liver, heart, lung, kidneyand pancreas) transplant centre inSouthern Italy.• We provide high specialty surgicaland non-surgical procedures to theentire regional population(approximately 5 million peopleliving in the Sicilian Region).• More than 1.300 patients have hadtransplants at ISMETT in the last 10years.78-bed hospital
  4. 4. Solid organs transplant recipients: a growing population122749405891104150 146127 131118135 13302040608010012014016019992000200120022003200420052006200720082009201020112012ISMETT: 1378 transplants from July 1999 to Dec 2012
  5. 5. Solid organs transplant recipients: a growing population122749405891104150 146127 131118135 13302040608010012014016019992000200120022003200420052006200720082009201020112012ISMETT: 1378 transplants from July 1999 to Dec 2012Every year, 120-130 newpatients in follow upAt present, more than onethousand of transplantrecipients in follow up atISMETT
  6. 6. Patients’ Needs• In the early post-transplant period, the need to maintain tight clinicalfollow up results in prolonged time of hospitalization or, alternatively,forces patients (still in not optimal conditions) to travel frequentlyBUT• approximately one third of patients live in the city area (about one millioninhabitants), while two third of them live in other areas of the SicilianRegion or outside Sicily. The distances between Palermo and other Siciliancities vary from 100 to more than 250 Km.and• the state of the road network and other communication routes is notoptimal and it represents a problem in maintaining a strict and continuousfollow-up in the post-transplant period
  7. 7. Patients’ NeedsLiver transplantation at ISMETT- PalermoPatients survival curve
  8. 8. Patients’ NeedsLiver transplantation at ISMETT- PalermoPatients survival curve
  9. 9. Patients’ NeedsWhat we usually do in the early post-operative courseThe early post-transplant period iscrucial due to:High risk of rejectionHigh risk of infectionsHigh risk of drug toxicityThe rigid clinical surveillance is mandatory, in order to obtain:• early diagnosis of clinical complications• correct dosage of immunosuppressive medications• best compliance with therapyLiver transplantation at ISMETT- PalermoPatients survival curve
  10. 10. Patients’ NeedsWhat we usually do in the early post-operative course
  11. 11. Patients’ NeedsWhat we usually do in the early post-operative courseFor these reasons, the usual approach of the TransplantCenters is to force patients to stay in hospital or inresidences near the hospital for a long time aftertransplant or, alternatively, to travel frequently (back andforth from home)
  12. 12. Patients’ Needs• In the early post-transplant period, the need to maintain tight clinicalfollow up results in prolonged time of hospitalization or, alternatively,forces patients (still in not optimal conditions) to travel frequentlyBUT• approximately one third of patients live in the city area (about one millioninhabitants), while two third of them live in other areas of the SicilianRegion or outside Sicily. The distances between Palermo and other Siciliancities vary from 100 to more than 250 Km.and• the state of the road network and other communication routes is notoptimal and it represents a problem in maintaining a strict and continuousfollow-up in the post-transplant period
  13. 13. Distance (Km of highway) between the ISMETT venue (Palermo)and the major sicilian cities
  14. 14. Palermo to:Trapani  107 KmAgrigento  126 KmCaltanissetta  127 KmEnna  136 KmPalermo to:Catania  207 KmMessina  237 KmRagusa  248 KmSiracusa  259 KmDistance (Km of highway) between the ISMETT venue (Palermo)and the major sicilian cities
  15. 15. Best care at the lower cost:Recommendations of Institute of Medicine
  16. 16. Best care at the lower cost:Recommendations of Institute of Medicine
  17. 17. Best care at the lower cost:Recommendations of Institute of Medicine
  18. 18. The innovative use of available (and simple) technologyPost liver transplant “Home-monitoring”.The solution:we teamed-up with Intel-GE Care Innovations TM to design a studyusing its tele-health technology with the aims of speeding up hospital discharge of post-liver transplant patients enabling uninterrupted recovery at home maintaining close contact with our medical teamsThe technology allows nurses and physicians to monitor and support transplant patients from their homes to check their general condition to collect biometric data to manage their treatmentto offer face to face appointments via video conferencing.
  19. 19. The innovative use of available (and simple) technologyPost liver transplant “Home-monitoring”.The solution:we teamed-up with Intel-GE Care Innovations TM to design a studyusing its tele-health technology with the aims of speeding up hospital discharge of post-liver transplant patients enabling uninterrupted recovery at home maintaining close contact with our medical teamsThe technology allows nurses and physicians to monitor and support transplant patients from their homes to check their general condition to collect biometric data to manage their treatmentto offer face to face appointments via video conferencing.The challenges:To remotely manage patients- in the aftermath of an extremely invasive surgicalprocedure- in not complete stable conditions- still suffering of the consequences of a prolongeddisease
  20. 20. Post liver transplant “Home-monitoring”Study protocolInclusion criteria:All consecutive adults patientswho live in Sicily, who receivedliver transplantation at ISMETTand were discharged from July 15,2011.Staff involved:At the patient’s home:technician for the instalment of thedevicesIn Tele-Visit (tele-consult):Physician (ISMETT-UPMC)Transplant coordinator (ISMETT)Others(physical th.- psycologist)Clinical pathway:• Clinical monitoring during the post-discharge time (first 3 months oruntil clinical stabilization)• Verification of the adherence totherapy (immunosuppression,other medications)• Verification of the adherence tothe bio-humoral surveillance aftertransplant
  21. 21. Post liver transplant “Home-monitoring”.Main functionalities:Monitoring of vitals signs, according to a pre-defined schedule(that depends on the time from transplantation) or to the patient’sclinical conditions.Tele-visit (by Videoconference patient home-ISMETT)performed by our specialists:once a day during the first weekeach other day during the first monthevery week until conclusion of the study (3 months)whenever considered useful according to the clinical needsEducational support for patient/family
  22. 22. Post liver transplant “Home-monitoring”at ISMETT-UPMCPatient information/educationPhone lineInternet3G wirelessTransplant PhysicianTransplant CoordinatorHomeTransplant Center
  23. 23. Post liver transplant “Home-monitoring” at ISMETT-UPMC
  24. 24. Post liver transplant “Home-monitoring” at ISMETT-UPMC
  25. 25. Post liver transplant “Home-monitoring” at ISMETT-UPMC
  26. 26. Post liver transplant “Home-monitoring”.Study end-pointsIn Home-monitoringJuly 2011-April 2013Hystoric controlsJuly 2009-June 2011Patients included 74 75Patients in the analysis (> 3 months of f-up) 66 75Average length of stay (days) 19.8 25.4Deaths during the 3-month study period 0 1Patients who needed urgent re-admission during the first3 months after transplant0 3Overall number of urgent re-admissions during the first 3months after transplant0 4Overall length of stay due to urgent re-admissions duringthe first 3 months after transplant (days)0 25Patient/family satisfaction rate (based on questionnaireadministered)98% NA
  27. 27. Economic impact of the home-monitoring system at ISMETT-UPMCData:– Length of stay reduction of 6 days (average) in the group ofpatients in home-monitoring– Number of liver transplant recipients discharged from ourCentre: 60-70 per year– Cost of hospital stay (no-ICU) in our organization: about 1.000Euro per day– Cost of home monitoring: 7 Euro per patient/daySavingSix days of hospital stay x 60patients = 360 days of hospitalstay360 days x 1000 Euro =360.000 Euro/yearCost7 Euro per patient/dayTotal cost of home monitoringper patient: 7 euro x 90 days =630 Euro630 Euro x 60 patients =37.800 Euro/year
  28. 28. Follow-up of liver transplant recipients: a “sustainable” approachSustainabilitySocial To guarantee that precious resourses used for the care are usedappropriately = Best standard of care for patientsEconomic Rational use of high-cost resources (hospital beds/OPC visits byspecialists).Reduction of unnecessary assistance-related costs (i.e. work-days offamily members)Environmental Reduction of the impact to the enviroment (i.e. reduction of fuelconsumption for travel and related CO2 production)A possible solution to the challenges we face:home-monitoring/tele-consult
  29. 29. How to deliver high-specialty care at home after liver transplantation:a sustainable approachConclusion- The adoption of this simple technical solution has allowedus to maintain an effective clinical and therapeuticremote management in a group of patients dischargedfrom the hospital after a liver transplantation  Best care at the lower cost, according to therecommendations of The Institute of Medicine:Partner with patientsUse Information Technology more effectivelyDecrease waste and increase efficiency- The result can be considered a “proof of concept”:home-monitoring seems to be a safe and effectivesolution not only in stable “chronic” patients, but also inunstable patients with difficult issues in the clinical andtherapeutic management
  30. 30. Thank youGiovanni Vizzini, MDDepartment ofMedicineISMETT-UPMCPalermo- Italygvizzini@ismett.eduwww.ismett.edu

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