The document summarizes a literature review and field research on telemonitoring by Flemish general practitioners. It examines telemonitoring for arterial hypertension, heart failure, and diabetes mellitus. For arterial hypertension, meta-analyses show telemonitoring improves systolic blood pressure by 4-5 mmHg and diastolic blood pressure by 1.5-2.5 mmHg. Telemonitoring may also allow for more timely medication changes. However, its impact on hard clinical endpoints like mortality remains unclear. The literature review on heart failure and diabetes is still ongoing.

1. Literatuurstudie en veldonderzoek
Telemonitoring
bij de
Vlaamse huisarts
o.l.v. prof. dr. P. De Cort
Nele Bollen
Tobias De Caesemaeker
Jeroen Sissau
KimVan den Zegel
BryanVermeersch

2. • Wat is TM?
Inleiding
2/44

3. • Wat is TM?
Inleiding
“Het bewaken (meten) van de gezondheidssituatie van de patiënt
in het kader van preventie, diagnostiek en/of nazorg
door middel van registratie, transport, opslag en analyse van gegevens
buiten de fysieke aanwezigheid van (de) zorgverlener(s) om,
door op een geavanceerde wijze gebruik te maken
van medische technologie en ICT”1
Monitoring gezondheid op afstand
1 Kruijff et al. 1999
3/44

4. • Belang?
– Explosie in onderzoek
– Vlaanderen
Inleiding
Wootton et al. 2012
4/44

5. Inleiding
‘Scanadu Scout’ 5/44

6. • Is TM een alternatief voor huidige aanpak ziekten?
• Wat zijn de implementatiedrempels bij Vlaamse HA?
Startvragen
6/44

7. 1. Literatuurstudie
2. Enquête over TM bij Vlaamse huisarts
3. Domus Medica – Dag van de huisarts
Aanpak
7/44

8. 1. Literatuurstudie
2. Enquête over TM bij Vlaamse huisarts
3. Domus Medica – Dag van de huisarts
Aanpak
8/44

9. 1. Literatuurstudie
9/44

10. A. Arteriële hypertensie
B. Hartfalen
C. Diabetes Mellitus
1. Literatuurstudie
10/44

11. A. Arteriële hypertensie
B. Hartfalen
C. Diabetes Mellitus
1. Literatuurstudie
11/44

12. A. Arteriële hypertensieArtikel Studie Score Opmerkingen
Paré, G. Systematic Review of Home Telemonitoring for Chronic Diseases : The Evidence Base
Home Telemonitoring : A Definition. Journal of the American Medical Information Association 14,
269–277(2007).
Systematic review 4/10 Zwak opgebouwde studie
Peirce, S. C., Hardisty, A. R., Preece, A. D. & Elwyn, G. Designing and implementing telemonitoring
for early detection of deterioration in chronic disease: defining the requirements. Health
informatics journal 17, 173–90 (2011).
Kwalitatieve
studie
/ Te kleine en subjectieve studie
Terschüren, C., Mensing, M. & Mekel, O. C. L. Is telemonitoring an option against shortage of
physicians in rural regions? Attitude towards telemedical devices in the North Rhine-Westphalian
health survey, Germany. BMC health services research 12, 95 (2012).
survey / Vergelijkbare situatie in Vlaanderen
Hovey, L., Kaylor, M. B., Alwan, M. & Resnick, H. E. Community-based telemonitoring for
hypertensionmanagement: practical challenges and potential solutions. Telemedicine journal
and e-health : the official journal of the American Telemedicine Association 17, 645–51 (2011).
Pilot study / Te kleine studie
Wootton, R. Twenty years of telemedicine in chronic disease management--an evidence
synthesis. Journal of telemedicine and telecare 18, 211–20 (2012).
Literature review 7/10 Grote heterogeniteit en toch pooling
Omboni, S., Gazzola, T., Carabelli, G. & Parati, G. Clinical usefulness and cost effectiveness of
home blood pressure telemonitoring: meta-analysis of randomizedcontrolled studies. Journal of
hypertension 455–468 (2013).
Meta-analyse 4/5 Goed opgebouwde studie
Omboni, S. & Guarda, A. Impact of home blood pressure telemonitoring and blood pressure
control: a meta-analysis of randomized controlled studies. American journal of hypertension 24,
989–98 (2011).
Meta-analyse 4/5 Goed opgebouwde studie
Jones, M. I. et al. Patients ’ experiences of self-monitoring blood pressure and self-titration of
medication. British journal of general practice 62, 135-142(2012).
Patients interview / Veel dropouts, enkel trend
Agarwal, R., Bills, J. E., Hecht, T. J. W. & Light, R. P. Role of home blood pressure monitoring in
overcoming therapeutic inertia and improving hypertension control: a systematic review and
meta-analysis. Hypertension 57, 29–38 (2011).
Meta-analyse 5/5 Voornamelijk over home monitoring ipv telemonotoring
Kerby, T. J. et al. Adherence to blood pressure telemonitoring in a cluster-randomizedclinical
trial. Journal of clinical hypertension (Greenwich, Conn.) 14, 668–74 (2012).
Clustered RCT 2/5 Niet geblindeerd
Wang, V. et al. Economic evaluation of telephone self-management interventions for blood
pressure control. American heart journal 163, 980–6 (2012).
RCT 3/5 Goed opgebouwde studie
McManus, R. J. et al. Telemonitoring and self-managementin the control of hypertension
(TASMINH2): a randomised controlled trial. Lancet 376, 163–72 (2010).
RCT 3/5 Niet geblindeerd, goed opgebouwde studie
Møller, D. S., Dideriksen, a, Sørensen, S., Madsen, L. D. & Pedersen, E. B. Accuracy of telemedical
home blood pressure measurementin the diagnosis of hypertension. Journal of human
hypertension 17, 549–54 (2003).
RCT 2/5 Te kleine populatie, niet geblindeerd
Rogers, M. A. Home Monitoring Service Improves Mean Arterial Pressure in Patients with
Essential Hypertension. A randomized, controlled trial. Annals of Internal Medicine 11, 1024 –
1032 (2001).
RCT 3/5 Goed opgebouwde studie
Artikel Studie Score Opmerkingen
Paré, G. Systematic Review of Home Telemonitoring for Chronic Diseases : The Evidence Base
Home Telemonitoring : A Definition. Journal of the American Medical Information Association 14,
269–277(2007).
Systematic review 4/10 Zwak opgebouwde studie
Peirce, S. C., Hardisty, A. R., Preece, A. D. & Elwyn, G. Designing and implementing telemonitoring
for early detection of deterioration in chronic disease: defining the requirements. Health
informatics journal 17, 173–90 (2011).
Kwalitatieve
studie
/ Te kleine en subjectieve studie
Terschüren, C., Mensing, M. & Mekel, O. C. L. Is telemonitoring an option against shortage of
physicians in rural regions? Attitude towards telemedical devices in the North Rhine-Westphalian
health survey, Germany. BMC health services research 12, 95 (2012).
survey / Vergelijkbare situatie in Vlaanderen
Hovey, L., Kaylor, M. B., Alwan, M. & Resnick, H. E. Community-based telemonitoring for
hypertension management: practical challenges and potential solutions. Telemedicine journal and
e-health : the official journal of the American Telemedicine Association 17, 645–51 (2011).
Pilot study / Te kleine studie
Wootton, R. Twenty years of telemedicine in chronic disease management--an evidence synthesis.
Journal of telemedicine and telecare 18, 211–20 (2012).
Literature review 7/10 Grote heterogeniteit en toch pooling
Omboni, S., Gazzola, T., Carabelli, G. & Parati, G. Clinical usefulness and cost effectiveness of
home blood pressure telemonitoring: meta-analysis of randomizedcontrolled studies. Journal of
hypertension 455–468 (2013).
Meta-analyse 4/5 Goed opgebouwdestudie
Omboni, S. & Guarda, A. Impact of home blood pressure telemonitoring and blood pressure
control: a meta-analysis of randomized controlled studies. American journal of hypertension 24,
989–98 (2011).
Meta-analyse 4/5 Goed opgebouwde studie
Jones, M. I. et al. Patients ’ experiences of self-monitoring blood pressure and self-titration of
medication. British journal of general practice 62, 135-142 (2012).
Patients interview / Veel dropouts, enkel trend
Agarwal, R., Bills, J. E., Hecht, T. J. W. & Light, R. P. Role of home blood pressure monitoring in
overcoming therapeutic inertia and improving hypertension control: a systematic review and
meta-analysis. Hypertension 57, 29–38 (2011).
Meta-analyse 5/5 Voornamelijk over home monitoring ipv telemonotoring
Kerby, T. J. et al. Adherence to blood pressure telemonitoring in a cluster-randomized clinical trial.
Journal of clinical hypertension (Greenwich, Conn.) 14, 668–74 (2012).
Clustered RCT 2/5 Niet geblindeerd
Wang, V. et al. Economic evaluation of telephone self-management interventions for blood
pressure control. American heart journal 163, 980–6 (2012).
RCT 3/5 Goed opgebouwde studie
McManus, R. J. et al. Telemonitoring and self-management in the control of hypertension
(TASMINH2): a randomised controlled trial. Lancet 376, 163–72 (2010).
RCT 3/5 Niet geblindeerd, goed opgebouwde studie
Møller, D. S., Dideriksen, a, Sørensen, S., Madsen, L. D. & Pedersen, E. B. Accuracy of telemedical
home blood pressure measurement in the diagnosis of hypertension. Journal of human
hypertension 17, 549–54 (2003).
RCT 2/5 Te kleine populatie, niet geblindeerd
Rogers, M. A. Home Monitoring Service Improves Mean Arterial Pressure in Patients with
Essential Hypertension. A randomized, controlled trial. Annals of Internal Medicine 11, 1024 –
1032 (2001).
RCT 3/5 Goed opgebouwdestudie

13. • Betere bloeddrukcontrole?
A. Arteriële hypertensie
Artikel Systolische
bloeddruk
CI p
Omboni et al.
2013
- 4.71 mmHg 3.28 – 6.18 p= 0,003 MA, n = 3509,
FU: 24w
Agarwal et al.
2011
-2,63 mmHg 1,02 – 4,24 p<0,0001 MA, n=9446,
FU: 2-36m
McManus et al.
2010
- 5,4 mmHg p=0,0004 RCT, n=527,
FU: 12m
Rogers et al.
2001
- 2,52 mmHg 1,13 – 5,64 p= 0,047 RCT, n=121,
FU 11w
13/44

14. Artikel Diastolische
bloeddruk
CI p
Omboni et al.
2013
- 2.45 mmHg 1.57 – 3.33 p=0,048 MA, n = 3509,
FU: 24w
Agarwal et al.
2011
- 1,68 mmHg 0,79 – 2,58 p< 0,0001 MA, n=9446,
FU: 2-36m
McManus et al.
2010
geen
significante
daling
/ / RCT, n=527,
FU: 12m
Rogers et al.
2001
- 2,32 mmHg 1,05 – 5,15 p=0,012 RCT, n=121,
FU 11w
• Betere bloeddrukcontrole?
A. Arteriële hypertensie
14/44

15. Omboni et al. 2013
15/44

16. • Klinische meerwaarde?
A. Arteriële hypertensie
16/44

17. • Harde eindpunten (mortaliteit)
– Omboni et al.: geen aangetoond – wel via extrapolatie?
• Beleid
– Omboni et al.: meer antihypertensiva (0,4 med, p<0,001)
– Agarwal et al.: minder antihypertensiva, sneller
omschakelen van medicatie
A. Arteriële hypertensie
17/44

18. A. Arteriële hypertensie
B. Hartfalen
C. Diabetes Mellitus
1. Literatuurstudie
18/44

19. B. Hartfalen
Artikel Studie Score Opmerkingen
Terschüren, C., Mensing, M. & Mekel, O. C. L. Is telemonitoring an option against shortage of
physicians in rural regions? Attitude towards telemedical devices in the North Rhine-Westphalian
health survey, Germany. BMC health services research 12, 95 (2012).
survey / Vergelijkbare situatie in Vlaanderen
Peirce, S. C., Hardisty, A. R., Preece, A. D. & Elwyn, G. Designing and implementing telemonitoring
for early detection of deterioration in chronic disease: defining the requirements. Health
informatics journal 17, 173–90 (2011).
Kwalitatieve
studie
/ Te kleine en subjectieve studie
Wootton, R. Twenty years of telemedicine in chronic disease management--an evidence
synthesis. Journal of telemedicine and telecare 18, 211–20 (2012).
Literature review 7/10 Grote heterogeniteit en toch pooling
Inglis, S. C., Clark, R. a, McAlister, F. a, Stewart, S. & Cleland, J. G. F. Which components of heart
failure programmes are effective? A systematic review and meta-analysis of the outcomes of
structured telephone support or telemonitoring as the primary componentof chronic heart
failure managementin 8323 patients: Abridged Coc. European journal of heart failure 13, 1028–40
(2011).
Meta-analyse 5/5 Goed opgebouwde studie
Klersy, C. et al. Economic impact of remote patient monitoring: an integrated economic model
derived from a meta-analysis of randomizedcontrolled trials in heart failure. European journal of
heart failure 13, 450–9 (2011).
Meta-analyse 3/5 Grote heterogeniteit
Schmidt, S., Schuchert, A., Krieg, T. & Oeff, M. Home telemonitoring in patients with chronic heart
failure: a chance to improve patient care? Deutsches Ärzteblatt international 107, 131–8 (2010).
SR 6/10 Eerder beschrijvende studie
Giamouzis, G. et al. Telemonitoring in chronic heart failure: a systematic review. Cardiology
research and practice 2012, 410820 (2012).
SR 7/10 Goed opgebouwde studie
Chaudry, S. I. Telemonitoring in Patients with Heart Failure. New England journal of medicine
2301–2309(2010).
RCT 3/5 Grote drop-out
Koehler, F. et al. Impact of remote telemedical management on mortality and hospitalizations in
ambulatory patients with chronic heart failure: the telemedical interventional monitoring in
heart failure study. Circulation 123, 1873–80 (2011).
RCT 3/5 Goed opgebouwde studie
Cleland, J. G. F., Louis, A. a, Rigby, A. S., Janssens, U. & Balk, A. H. M. M. Noninvasive home
telemonitoring for patients with heart failure at high risk of recurrent admission and death: the
Trans-EuropeanNetwork-Home-Care ManagementSystem (TEN-HMS) study. Journal of the
American College of Cardiology 45, 1654–64 (2005).
RCT 3/5 Goed opgebouwde studie
Oeff, M., Kotsch, P., Gösswald, a & Wolf, U. Monitoring multiple cardiovascular paramaters using
telemedicine in patients with chronic heart failure. Herzschrittmachertherapie &
Elektrophysiologie 16, 150–8 (2005).
Cohort studie / Geen randomisatie en blindering
Anker et al. Telemedicine and remote managementof patients with heart failure. The lancet 378,
731-739(2011).
/ / Interessante schema’s
Artikel Studie Score Opmerkingen
Terschüren, C., Mensing, M. & Mekel, O. C. L. Is telemonitoring an option against shortage of
physicians in rural regions? Attitude towards telemedical devices in the North Rhine-Westphalian
health survey, Germany. BMC health services research 12, 95 (2012).
survey / Vergelijkbare situatie in Vlaanderen
Peirce, S. C., Hardisty, A. R., Preece, A. D. & Elwyn, G. Designing and implementing telemonitoring
for early detection of deterioration in chronic disease: defining the requirements. Health
informatics journal 17, 173–90 (2011).
Kwalitatieve
studie
/ Te kleine en subjectieve studie
Wootton, R. Twenty years of telemedicine in chronic disease management--an evidence
synthesis. Journal of telemedicine and telecare 18, 211–20 (2012).
Literature review 7/10 Grote heterogeniteit en toch pooling
Inglis, S. C., Clark, R. a, McAlister, F. a, Stewart, S. & Cleland, J. G. F. Which components of heart
failure programmes are effective? A systematic review and meta-analysis of the outcomes of
structured telephone support or telemonitoring as the primary componentof chronic heart
failure managementin 8323 patients: Abridged Coc. European journal of heart failure 13, 1028–
40 (2011).
Meta-analyse 5/5 Goed opgebouwdestudie
Klersy, C. et al. Economic impact of remote patient monitoring: an integrated economic model
derived from a meta-analysis of randomizedcontrolled trials in heart failure. European journal of
heart failure 13, 450–9 (2011).
Meta-analyse 3/5 Grote heterogeniteit
Schmidt, S. et al. Home telemonitoring in patients with chronic heart failure: a chance to improve
patient care? Deutsches Ärzteblatt international 107, 131–8 (2010).
SR 6/10 Eerder beschrijvende studie
Giamouzis, G. et al. Telemonitoring in chronic heart failure: a systematic review. Cardiology
research and practice 2012, 410820 (2012).
SR 7/10 Goed opgebouwdestudie
Chaudry, S. I. Telemonitoring in Patients with Heart Failure. New England journal of medicine
2301–2309(2010).
RCT 3/5 Grote drop-out
Koehler, F. et al. Impact of remote telemedical managementon mortality and hospitalizations in
ambulatory patients with chronic heart failure: the telemedical interventional monitoring in
heart failure study. Circulation 123, 1873–80 (2011).
RCT 3/5 Goed opgebouwde studie
Cleland, J. G. F., Louis, A. a, Rigby, A. S., Janssens, U. & Balk, A. H. M. M. Noninvasive home
telemonitoring for patients with heart failure at high risk of recurrent admission and death: the
Trans-EuropeanNetwork-Home-Care ManagementSystem (TEN-HMS) study. Journal of the
American College of Cardiology 45, 1654–64 (2005).
RCT 3/5 Goed opgebouwde studie
Oeff, M., Kotsch, P., Gösswald, a & Wolf, U. Monitoring multiple cardiovascular paramaters using
telemedicine in patients with chronic heart failure. Herzschrittmachertherapie &
Elektrophysiologie 16, 150–8 (2005).
Cohort studie / Geen randomisatie en blindering
Anker et al. Telemedicine and remote managementof patients with heart failure. The lancet 378,
731-739(2011).
/ / Interessante schema’s

20. • TM = opvolgen ECG, BD, gewicht, saturatie, AH
en/of medicatie-inname
• Mortaliteit?!
B. Hartfalen
Inglis et al. 2011
20/44

21. • Mortaliteit
B. Hartfalen
Artikel Mortaliteit CI p
Inglis et al.
2011
Relatief: - 34%
Absoluut: - 5,1%
19%-46% p=0,0001 SR, 30RCT’s,
n=9805, FU >6m
Schmidt et al.
2010
Relatief: - 21% 11%-31% SR, 19 RCT’s
Cleland et al.
2005
Absoluut: -16% p= 0,032 RCT, n=426
Koehler et al.
2011 (TIM-HF)
Geen significante
daling
8,4% vs 8,7% = -0,3% 0,67-1,14 p=0,87
RCT, n= 710
FU = 26m
Chaudhry et
al.
2010 (Tele-HF)
Geen significant
verschil
52,3% vs 51,3%= +1% -4,0 – 5,6 p=0,75
RCT, n= 1653
FU = 6m
21/44

22. • Ziekenhuisopnames
Artikel Ziekenhuisopname CI p
Inglis et al.
2011
Aantal ikv HF: - 21%
Totaal: - 9%
Duur: geen verschil
(I²= 39%)
(I²=0,02)
p=0,008
p=0,02
SR, 30RCT’s,
n=9805, FU >6m
Schmidt et al.
2010
Aantal ikv HF: - 21% 11%-31% SR, 19 RCT’s
Klersy et al.
2011
Aantal ikv HF - 23 %
Totaal: - 13%
Duur: geen verschil
9%-35%
(I²= 53,5%)
p= 0,003
p=0,013
MA, n = 5715; 21
RCT’s
FU 6-12m
Koehler et al.
2011 (TIM-HF)
Aantal: geen significant
verschil
14,7% vs 16,5%= - 1,8% 0,67-1,19 p=0,44
RCT, n= 710
FU 26m
Chaudhry et al.
2010
Aantal: geen significant
verschil
49,3% vs 47,4%= +1,9% -3,0 – 2,8 p=0,88
RCT, n= 1653
FU 6m
B. Hartfalen
22/44

23. A. Arteriële hypertensie
B. Hartfalen
C. Diabetes Mellitus
1. Literatuurstudie
23/44

24. C. Diabetes Mellitus
Artikel Studie Score Opmerkingen
Paré, G. Systematic Review of Home Telemonitoring for Chronic Diseases : The Evidence Base
Home Telemonitoring : A Definition. Journal of the American Medical Information Association 14,
269–277(2007).
Systematic review 4/10 Zwak opgebouwde studie
Peirce, S. C., Hardisty, A. R., Preece, A. D. & Elwyn, G. Designing and implementing telemonitoring
for early detection of deterioration in chronic disease: defining the requirements. Health
informatics journal 17, 173–90 (2011).
Kwalitatieve
studie
/ Te kleine en subjectieve studie
Terschüren, C., Mensing, M. & Mekel, O. C. L. Is telemonitoring an option against shortage of
physicians in rural regions? Attitude towards telemedical devices in the North Rhine-Westphalian
health survey, Germany. BMC health services research 12, 95 (2012).
survey / Vergelijkbare situatie in Vlaanderen
Wootton, R. Twenty years of telemedicine in chronic disease management--anevidence
synthesis. Journal of telemedicine and telecare 18, 211–20 (2012).
Literature review 7/10 Grote heterogeniteit en toch pooling
Liang, X. et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta-
analysis. Diabetic medicine : a journal of the British Diabetic Association 28, 455–63 (2011).
Meta-analyse 3/5 Grote heterogeniteit
Buysse, H. E. C. et al. Introducing telemonitoring for diabetic patients: developmentof a
telemonitoring “Health Effect and Readiness” Questionnaire. International journal of medical
informatics 79, 576–84 (2010).
/ Questionnaire
Polisena, J. et al. Home telehealth for diabetes management: a systematic review and meta-
analysis. Diabetes, obesity & metabolism 11, 913–30 (2009).
SR 8/10 Grote heterogeniteit
Buysse, H. E. C., De Moor, G. J. E. & De Maeseneer, J. Introducing a telemonitoring platform for
diabetic patients in primary care: Will it increase the socio-digital divide? Primary care diabetes
1–9 (2012).
/ / Questionnaire, Belgisch
Morak, J., Schwarz, M., Hayn, D. & Schreier, G. Feasibility of mHealth and Near Field
Communication technology based medication adherence monitoring. Conference proceedings :
... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE
Engineering in Medicine and Biology Society. Conference 2012, 272–5 (2012).
Pilot study / Te kleine studie, geen randomisatie, geen blindering
Jaana, M. & Paré, G. Home telemonitoring of patients with diabetes: a systematic assessment of
observedeffects. Journal of evaluation in clinical practice 13, 242–53 (2007).
SR 7/10 Is het wel een SR?
Artikel Studie Score Opmerkingen
Paré, G. Systematic Review of Home Telemonitoring for Chronic Diseases : The Evidence Base
Home Telemonitoring : A Definition. Journal of the American Medical Information Association 14,
269–277(2007).
Systematic review 4/10 Zwak opgebouwde studie
Peirce, S. C., Hardisty, A. R., Preece, A. D. & Elwyn, G. Designing and implementing telemonitoring
for early detection of deterioration in chronic disease: defining the requirements. Health
informatics journal 17, 173–90 (2011).
Kwalitatieve
studie
/ Te kleine en subjectieve studie
Terschüren, C., Mensing, M. & Mekel, O. C. L. Is telemonitoring an option against shortage of
physicians in rural regions? Attitude towards telemedical devices in the North Rhine-Westphalian
health survey, Germany. BMC health services research 12, 95 (2012).
survey / Vergelijkbare situatie in Vlaanderen
Wootton, R. Twenty years of telemedicine in chronic disease management--an evidence synthesis.
Journal of telemedicine and telecare 18, 211–20 (2012).
Literature review 7/10 Grote heterogeniteit en toch pooling
Liang, X. et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta-
analysis. Diabetic medicine : a journal of the British Diabetic Association 28, 455–63 (2011).
Meta-analyse 3/5 Grote heterogeniteit
Buysse, H. E. C. et al. Introducing telemonitoring for diabetic patients: development of a
telemonitoring “Health Effect and Readiness” Questionnaire. International journal of medical
informatics 79, 576–84 (2010).
/ Questionnaire
Polisena, J. et al. Home telehealth for diabetes management: a systematic review and meta-
analysis. Diabetes, obesity & metabolism 11, 913–30 (2009).
SR 8/10 Grote heterogeniteit
Buysse, H. E. C., De Moor, G. J. E. & De Maeseneer, J. Introducing a telemonitoring platform for
diabetic patients in primary care: Will it increase the socio-digital divide? Primary care diabetes
1–9 (2012).
/ / Questionnaire, Belgisch
Morak, J., Schwarz, M., Hayn, D. & Schreier, G. Feasibility of mHealth and Near Field
Communication technology based medication adherence monitoring. Conference proceedings :
... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE
Engineering in Medicine and Biology Society. Conference 2012, 272–5 (2012).
Pilot study / Te kleine studie, geen randomisatie, geen blindering
Jaana, M. & Paré, G. Home telemonitoring of patients with diabetes: a systematic assessment of
observedeffects. Journal of evaluation in clinical practice 13, 242–53 (2007).
SR 7/10 Is het wel een SR?
24/44

25. • HbA1c reductie?
• Ziekenhuisopnames? 1
– Totaal daalt van 188/445 naar 95/445 (p=0,0001)
– Spoedraadpleging stijgt van 192/391 naar 234/391 (p=0,0001)
• Quality of life 1 : tegenstrijdige resultaten
C. Diabetes Mellitus
Artikel HbA1c CI p
Liang et al.
2010
- 0,5%
 type II: - 0,8%
 type I: -0,3%
0,3%-0,7%
0,5 – 1,1%
0 – 0,5%
p=0,000
p=0,000
p=0,002
MA, n=1657,
FU 6m
Polisena et al.1
2009
Significante daling
-0,22%
(I²=16%)
0,08-0,35
MA, n= 5069,
FU 3m-3j
Jaana et al.
2005
“significante
reductie van HbA1c”
SR, 17 studies
Fu 3-15m
25/44

26. Liang et al. 2010 26a/44

27. Polisena et al. 2009 26b/44

28. • AHT:
– Significante BD-daling
– Geen harde eindpunten
• HF:
– Harde eindpunten: mortaliteit daalt
– Minder ziekenhuisopnames
• DM:
– Daling HbA1c
– Betere survival?
SAMENVATTING literatuurstudie
27/44

29. • Grote heterogeniteit
• Publicatiebias
• Blindering?
BESLUIT literatuurstudie
Voorzichtigheid!
Nood aan nieuwe studies
• Trend naar positief effect (op lange termijn)
• Ziekenhuissetting  huisartsensetting
• Klinische eindpunten nagaan
28/44

30. • Positief effect via patiënt of via TM?
Randbemerking
29/44

31. 1. Literatuurstudie
2. Enquête over TM bij Vlaamse huisarts
3. Domus Medica – Dag van de huisarts
Aanpak
30/44

32. 2. Enquête bij de Vlaamse huisarts
• Wat?
– Zeer kort
– 6 stellingen met voornamelijk MKV
• Wie?
– 281 PO’s via e-mail
• Respons: 113 huisartsen
= 40% respons
– 38 artsen in LOK
151 enquêtes
31/44

33. Welke populatie bereikt?
• Leeftijd
• Geslacht
26-35 jaar: 21 (14%)
36-45 jaar: 35 (23%)
46-55 jaar: 59 (39%)
>55 jaar: 36 (24%)
Vrouwelijk: 81 (54%)
Mannelijk: 70 (46%)
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34. Startvraag
Ooit gewerkt metTM?
JA 18% NEE 82%
1. Gewicht en/of BD controle bij hartfalen
2. BD meting
3. Opvolging glycemies op afstand
4. “Foute” antwoorden
1. Kosten
2. Technische problemen of geen
goede ondersteuning
3. Complex voor arts en/of patiënt
4. Wie volgt wat, wie wordt
verwittigd, wie aansprakelijk?
5. Tijdsgebrek
6. Andere
Slechts 75 % “echte”TM
33/44

35. • “De grootste drempel voor mij is…”
Artsen zonder TM-ervaring
0
10
20
30
40
50
60
70
80
34/44

36. • Investeren in TM?
– Ja: 12%
– Nee: 15%
– Ja mits goede subsidiëring: 73%
• TM gebruiken zo meerwaarde in literatuur aangetoond?
– Ja: 88%
– Nee: 12%
Algemene bevraging
35/44

37. Besluit enquête
36/44

38. 1. Literatuurstudie
2. Enquête over TM bij Vlaamse huisarts
3. Domus Medica – Dag van de huisarts
Aanpak
37/44

39. 38/44

40. • Presenteren literatuurstudie
• Discussie over TM met Vlaamse huisarts
– Polsen naar implementatiedrempels
– Meningen congruent met resultaten enquête
3. Dag van de huisarts
BESLUIT:
- Evidentie beperkt
- Studies in Vlaanderen nodig voor implementatie
- Wettelijk kader
- ‘ja, mits’, geen ‘neen, tenzij’
39/44

41. Conclusie literatuur & veldwerk
- Veelbelovend
- Meer onderzoek nodig
financiële
Duidelijkheid over praktische aspect
juridische
• Is TM een alternatief voor huidige aanpak ziekten?
• Wat zijn de implementatiedrempels bij Vlaamse HA?
40/44

42. • TM: groot potentieel
Algemeen besluit TM
Bijdrage in chronische zorg
Toekomst…
41/44

43. Bedankt!
42/44

44. Vragen?
43/44

45. Bronnen (in volgorde van verschijnen)
1. Kruijff et al. Telemonitoring, toepassingen en mogelijkheden in de Nederlandse Gezondheidszorg. HFM (1999).
2. Wootton, R. Twenty years of telemedicine in chronic disease management--an evidence synthesis. Journal of telemedicine and
telecare 18, 211–20 (2012).
3. Omboni et al. Clinical usefulness and cost effectiveness of home blood pressure telemonitoring: meta-analysis of randomized
controlled studies. Journal of hypertension 455–468 (2013).
4. Agarwal et al. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a
systematic review and meta-analysis. Hypertension 57, 29–38 (2011).
5. McManus et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial.
Lancet 376, 163–72 (2010).
6. Rogers et al. Home Monitoring Service Improves Mean Arterial Pressure in Patients with Essential Hypertension. A
randomized, controlled trial. Annals of Internal Medicine 11, 1024 – 1032 (2001).
7. Inglis et al. Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of
structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients:
Abridged Coc. European journal of heart failure 13, 1028–40 (2011).
8. Schmidt et al. Home telemonitoring in patients with chronic heart failure: a chance to improve patient care? Deutsches Ärzteblatt
international 107, 131–8 (2010).
9. Cleland et al Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the Trans-
European Network-Home-Care Management System (TEN-HMS) study. Journal of the American College of Cardiology 45, 1654–64
(2005).
10. Koehler et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart
failure: the telemedical interventional monitoring in heart failure study. Circulation 123, 1873–80 (2011).
11. Chaudry et al. Telemonitoring in Patients with Heart Failure. New England journal of medicine 2301–2309 (2010).
12. Anker et al. Telemedicine and remote management of patients with heart failure. The lancet 378, 731-739 (2011).
13. Klersy et al. Economic impact of remote patient monitoring: an integrated economic model derived from a meta-analysis of
randomized controlled trials in heart failure. European journal of heart failure 13, 450–9 (2011).
14. Liang et al. Effect of mobile phone intervention for diabetes on glycaemic control: a meta-analysis. Diabetic medicine : a journal of
the British Diabetic Association 28, 455–63 (2011).
15. Polisena et al. Home telehealth for diabetes management: a systematic review and meta-analysis. Diabetes, obesity & metabolism
11, 913–30 (2009).
16. Jaana et al. Home telemonitoring of patients with diabetes: a systematic assessment of observed effects. Journal of evaluation in
clinical practice 13, 242–53 (2007).