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  1. 1. Telemonitoring for Heart Failure Evidence & Practice Professor John G.F. Cleland Department of Cardiology, Hull Y o rk 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
  2. 2. <ul><li>Audit </li></ul>Survival of Patients with a Primary Discharge Diagnosis of Heart Failure England & Wales 2009-2010 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 <65 years ~3,000 65-75 years ~4,000 75-85 years ~7,000 >85 years ~5,000 Cleland et al HEART 2011
  3. 3. TeleHealth Why is it Likely to Become Essential? <ul><li>More patients with long-term conditions </li></ul><ul><ul><li>More older people </li></ul></ul><ul><ul><li>Longer survival with illness </li></ul></ul><ul><ul><li>Better primary & secondary prevention </li></ul></ul><ul><li>Fewer professionals to provide health-care </li></ul><ul><ul><li>Smaller proportion of population of working age </li></ul></ul><ul><ul><li>Loss of migrant workforce as economies rival UK </li></ul></ul><ul><ul><li>Better paid or more attractive / less stressful jobs </li></ul></ul><ul><li>More monitoring required </li></ul><ul><ul><li>Higher expected standards of care </li></ul></ul><ul><ul><li>More treatments that need to be monitored </li></ul></ul><ul><ul><li>More things that can be monitored </li></ul></ul>
  4. 4. TeleHealth Why is it Likely to Become Essential? <ul><li>Patient preference & Convenience </li></ul><ul><ul><li>Patients, Carers, Staff </li></ul></ul><ul><li>Reduced Costs </li></ul><ul><ul><li>Buildings, Staff, Transport </li></ul></ul><ul><li>Environmental impact </li></ul><ul><ul><li>Transport </li></ul></ul><ul><ul><li>Parking </li></ul></ul><ul><ul><li>Buildings </li></ul></ul><ul><li>Better record keeping !!!!!!!!!!!!!!!!!!!!!!! </li></ul>
  5. 5. The Opportunity of Chronic Illness <ul><li>Most patients soon learn routines </li></ul><ul><ul><li>Or have relatives / friends that do </li></ul></ul><ul><li>Most patients are interested in maintaining or improving their health </li></ul><ul><li>Patients are an ‘inexpensive’ but neglected health-care provider opportunity </li></ul><ul><li>Invest in patients </li></ul><ul><ul><li>Education </li></ul></ul><ul><ul><li>Active Partnership </li></ul></ul><ul><ul><li>Empowerment </li></ul></ul>
  6. 6. TeleHealth - What Might it Achieve? Ultimate Intermediate
  7. 7. TEN-HMS The Trans-European Network–Home-Care Management System Patients about to be discharged from hospital after an exacerbation of chronic heart failure (Published JACC 2005) 54% of Patients Aged >70 years
  8. 8. p < 0,05 Mortality Cleland et al JACC 2005 TEN-HMS Reduction in Mortality NTS or HTM v UC Absolute 16.4% Relative 36 % No reduction in hospitalisation Shortening of hospital stay with HTM
  9. 9. TEN-HMS much safer safer no change more anxious much more anxious “ How do you feel about your health since receiving Telemonitoring? “ Undef.
  10. 10. TEN-HMS 120 Days 240 Days % *** *** *** *** differences between HTM and other groups. No difference between UC and NTS Achieving Therapeutic Target 240 Days Patient Clinical Status
  11. 11. TEN-HMS: Total Patient Contacts Contacts Per 1,000 Days Alive and Out of Hospital # # under-reporting of events likely in this group P<0.01 HTM v NTS
  12. 12. Structured Telephone Support n = 5,563 (Cochrane Review) Mortality Inglis et al 2010 HR 0.88 (0.76-1.01); p=0.08 <ul><li>New Trials </li></ul><ul><li>Tele-HF </li></ul><ul><li>TEHAF </li></ul>All-Cause Hospitalisation HR 0.77 (0.68-0.87.01); p<0.0001
  13. 13. Home Telemonitoring n = 2,710 (Cochrane Review) Inglis et al 2010 Mortality HR 0.66 (0.54-0.87); p<0.0001 <ul><li>New Trials </li></ul><ul><li>TIM-HF </li></ul><ul><li>COMPASS </li></ul><ul><li>CHAMPION </li></ul><ul><li>SENSE-HF </li></ul>All-Cause Hospitalisation HR 0.91 (0.84-0.99); p=0.02
  14. 14. Major Problems with RCTs of Service Delivery <ul><li>Technology differs </li></ul><ul><ul><li>Telephone Support including Voice Activated Systems </li></ul></ul><ul><ul><li>Physiological telemonitoring </li></ul></ul><ul><ul><ul><li>Implanted or Not </li></ul></ul></ul><ul><li>Care usually improves if it is the focus of attention </li></ul><ul><ul><li>Effect in control group </li></ul></ul><ul><ul><li>Beware: “before v after” comparisons </li></ul></ul><ul><li>Lack of integration into existing services </li></ul><ul><ul><li>Puts innovative interventions at a disadvantage </li></ul></ul><ul><li>Selection of patients at low risk with modern treatment </li></ul>
  15. 15. Percent of Days Lost To Hospitalisation or Death 8.9% 8.4% 37.0% 21.3% 22.6% TEN-HMS (15 months) TIM-HF (26 months) TEHAF (12 months) 4.5% 6.1%
  16. 16. What Have We Done for TeleHealth in Hull? <ul><li>Established </li></ul><ul><ul><li>International reference site (LifeLab) for HF epidemiology & research </li></ul></ul><ul><ul><li>International reputation for research excellence in telehealth </li></ul></ul><ul><ul><li>A model telehealth service </li></ul></ul><ul><li>Grants </li></ul><ul><ul><li>TEN-HMS </li></ul></ul><ul><ul><li>Four FP7 grants relating to telehealth & heart failure </li></ul></ul><ul><ul><li>EDRF </li></ul></ul><ul><li>Industry Partnerships </li></ul><ul><ul><li>Philips, GE, Bosch, Cardiomems, St Jude + others </li></ul></ul><ul><li>Publications </li></ul><ul><ul><li>>500 PubMed citations in related fields </li></ul></ul><ul><ul><li>TEN-HMS, Concept Papers, Editorials </li></ul></ul><ul><ul><li>Systematic Reviews (EJHF, BMJ & Cochrane) </li></ul></ul><ul><li>Inventions </li></ul><ul><ul><li>Dynamic risk analysis </li></ul></ul><ul><ul><li>Complex management algorithms </li></ul></ul>
  17. 17. The Hull Model for TeleHealth Non-Invasive Home Monitoring Community TeleKiosks Screening Long-Term Conditions Device Implant <ul><li>HeartCycle </li></ul><ul><li>Heart Failure </li></ul><ul><li>Post-MI Rehab </li></ul>MEMS-based pressure sensor
  18. 18. Services for Patients with Heart Failure The Kingston-upon-Hull Model Heart Failure Discharge Nurse Heart Failure Telemonitoring Nurse Community Heart Failure Specialist Nurses Patients in Hospital Patients at Home Voluntary Patient-Support Organisations Specialist Clinics Family Doctor (NT-proBNP)
  19. 19. Cost-Effectiveness of TeleHealth (Hull)
  20. 20. Where Next? <ul><li>Interactive TV </li></ul><ul><li>New monitoring technologies </li></ul><ul><li>Implanted devices </li></ul><ul><li>More intelligent use of the patient data </li></ul><ul><li>Investing in patients as health-care providers </li></ul>Centre for Telehealth
  21. 21. 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
  22. 22. <ul><li>Shift from crisis detection to health maintenance </li></ul><ul><li>Health Maintenance Envelope </li></ul><ul><ul><li>More ‘optimistic’ </li></ul></ul><ul><ul><li>Better way to engage/motivate patients </li></ul></ul><ul><ul><li>More active management </li></ul></ul><ul><ul><li>More activity likely to hold ‘actors’ attention </li></ul></ul><ul><ul><li>Clinical calibration </li></ul></ul><ul><ul><li>Addresses the issue of false alerts </li></ul></ul><ul><li>Personalised Careplan </li></ul><ul><ul><li>Treatments </li></ul></ul><ul><ul><li>Ideal monitoring envelope </li></ul></ul>HeartCycle Programme
  23. 23. Patient / Carer Communication System ‘ Monitor’ Analysis Health-Care Provider Secondary Loop Primary Loop 70% of Care Decisions Motivation: feedback on measures and trends, what they mean and what to do about them Education: on healthy lifestyle, reasons for treatments, self management Intelligent, integrated, multi-measure (time & type) personalised analysis
  24. 24. Opportunities for TeleHealth <ul><li>Change in Philosophy </li></ul><ul><ul><li>Investment in patients (rather than experts) </li></ul></ul><ul><ul><li>Patients as first and possibly main tier of healthcare </li></ul></ul><ul><li>Communication </li></ul><ul><ul><li>Patient, community health & social services, specialists </li></ul></ul><ul><li>Common health record </li></ul><ul><ul><li>Checked (at least in part) by the patient themselves </li></ul></ul><ul><li>Decision support analysis </li></ul><ul><ul><li>Patient & professional support </li></ul></ul><ul><ul><li>Research potential +++ </li></ul></ul><ul><li>Healthcare innovation </li></ul><ul><ul><li>Pharmaceutical industry especially </li></ul></ul><ul><ul><li>Route to faster (ethical) adoption </li></ul></ul><ul><li>Convenience & Preference </li></ul><ul><ul><li>Patient, Carer, Health Professional </li></ul></ul><ul><li>Environmental impact </li></ul>
  25. 25. Conclusion <ul><li>The first era of telemonitoring is over </li></ul><ul><li>Time to move from </li></ul><ul><ul><li>Crisis Detection </li></ul></ul><ul><ul><li>to </li></ul></ul><ul><ul><li>Health Maintenance </li></ul></ul>