Telemonitoring for Heart Failure

Evidence & Practice

Professor John G.F. ClelandDepartment of Cardiology,Hull York Medical School

University of HullKingston-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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0 90 180 270 360Survival time (days)

55-64 years 65-74 years75-84 years >=85 years

Survival of Patients with a Primary Discharge Diagnosis of Heart FailureEngland & 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 ~4,00075-85 years ~7,000>85 years ~5,000

Cleland et alHEART 2011

TeleHealthWhy 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

TeleHealthWhy 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 health-care provider opportunity

• Invest in patients– Education– Active Partnership– Empowerment

Re-admission

Duration of adm.

Mortality Patient Experience

Costs of care

Titration of therapy

Compliance

Detection of exacerbation

Cause of exacerbation

Treatment of WHF

Selection for Admission

Discharge planning

Patient Reassurance

TeleHealth - What Might it Achieve?

UltimateIntermediate

TEN-HMSThe 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

p < 0,05

Mo

rtal

ity

Cleland et al JACC 2005

TEN-HMS

Reduction in MortalityNTS or HTM v UCAbsolute 16.4%Relative 36 %

No reduction in hospitalisation

Shortening of hospital stay with HTM

TEN-HMS

48.9%

38.9%

7.8%3.3%

1.1%

much safer

safer no change

more anxious

much more

anxious

“ How do you feel about your health since receiving Telemonitoring? “

Undef.

TEN-HMS

50556065707580859095

100

ACEi BB Spirono . ACEi BB Spirono

UCNTSHTM

120 Days 240 Days

%

******

***

*** differences between HTM and other groups. No difference between UC and NTS

Achieving Therapeutic Target

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I/II III IV or Dead240 Days

Patient Clinical Status

TEN-HMS: Total Patient Contacts

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UC NTS HTM

Telephone Contact

Office Visits

Home Visits

Hospitalisation

Contacts Per 1,000 Days Alive and Out of Hospital

#

# under-reporting of events likely in this group P<0.01 HTM v NTS

Structured Telephone Supportn = 5,563

(Cochrane Review)

Mortality

Inglis et al 2010

HR 0.88 (0.76-1.01); p=0.08

All-Cause Hospitalisation

HR 0.77 (0.68-0.87.01); p<0.0001

New Trials• Tele-HF• TEHAF

Home Telemonitoringn = 2,710

(Cochrane Review)

Inglis et al 2010

Mortality

HR 0.66 (0.54-0.87); p<0.0001

All-Cause Hospitalisation

HR 0.91 (0.84-0.99); p=0.02

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

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

5.8 5

1.1 1.32 2.1

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UC NTS HTM

Death WHF Hosp Other Hosp

8.9% 8.4%

32.9

16.4 18.5

2.4

2.31.9

1.7

2.6 2.1

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UC NTS HTM

Death WHF Hosp Other Hosp

37.0% 21.3% 22.6%

TEN-HMS (15 months) TIM-HF (26 months)

3.1 4.5

0.5 0.4

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UC NTS HTM

Death WHF Hosp Other Hosp

TEHAF (12 months)

4.5% 6.1%

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

Non-InvasiveHome

Monitoring

Community TeleKiosksScreening

Long-Term Conditions

DeviceImplant HeartC

ycle

• Heart F

ailure

• Post-M

I Rehab

MEMS-based pressure sensor

Heart Failure Discharge Nurse

Heart Failure Telemonitoring Nurse

Community Heart Failure Specialist Nurses

Patients in Hospital Patients at Home

Voluntary Patient-Support Organisations

Services for Patients with Heart FailureThe Kingston-upon-Hull Model

Specialist ClinicsFamily Doctor(NT-proBNP)

Hull Telemonitoring ServiceOutcomes Compared to Historical Data, Surveys & Trials

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Observed

HEY 2007

Surveys

Trials£311,573

£224,416

£87,157

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£50,000

£100,000

£150,000

£200,000

£250,000

£300,000

£350,000

Total gross savingsTotal service cost

Total net savings

Cost-Effectiveness of TeleHealth (Hull)

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

The Hull Heart Failure Life-Lab30,000 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

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CRP (mg/L)

NT-proBNP (pmol/L)

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• 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

HeartCycle Programme

Patient / Carer

Communication System

‘Monitor’Analysis

Health-CareProvider

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

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