Presented - ICMCC

icmcc.org

Presented - ICMCC

Telemedicine and CHF

SHAHAL experience in Israel and Germany

Arie Roth

Tel Aviv Sourasky Medical Center, Dept. of Cardiology

Ronen Gadot

SHL-Telemedicine International LTD and

Eric S.J. Kalter

Dutch Healthcare Insurance Board,


Future care giving

HA

specialist

Paramedics

Nurses

Assistants

Management


Disease Management

Disease Management is a system of

coordinated healthcare interventions and

communications for populations with conditions in

which patient self-care efforts are significant [1].

• cardiovascular diseases

• asthma and COPD,

• Diabetes Mellitus and

• psychiatric disorders

[1] Disease Management Association of america (DMAA).



What Is Personal TeleMedicine?

Personal telemedicine is the transmission of medical

data via telecommunication networks by an

individual patient from a remote location to a medical

call center for the purpose of monitoring, diagnosis,

patient & disease management, etc.


Counseling, reassuring

Emergency care facilitation

Medical call

Center

Patient information

Transmission of medical data

Patient/Subscribers

Real time patient information

Real time patient information

Healthcare providers

NOTE:

1

Data encrypted - proper security

clearance required

WWW 1


Wide Range of Services and Technologies

Blood Tests

Cardio-

Vascular

Personal

Emergency

Response

Medical

Call Center

CHF

Weight

Management

Hypertension

Anti

Coagulation

(INR)

Respiratory

ICD

Monitoring

Arrhythmia &

Holter

Monitoring

Pacemaker

Monitoring


ECG from Anywhere Concept

12-lead ECG

1-lead ECG


The “Home Care Center”

Other Devices

INR Test

GlucoMeter

WatchMan

Emergency Response

TelePulse Oximeter

Home Care Center

Tele Weight

To Telemedicine Center/

Patient medical record

Tele Marker

TeleBreather

TelePress


“Home Care Center” Example Services

♦ Personal Emergency Response

WatchMan

♦ Hypertension Management

TelePress

♦ Respiratory Management

Home Care Center

AM1

♦ Weight Management

Tele Weight


What is heart failure

• Heart Failure is a condition initiated by

impairment of the heart's function as a pump

• With complaints (signs & symptoms)

http://www.heartfailure.org/eng_site/hf_signsympt.htm


Chronic Heart Failure

signs and symptoms

• Shortness of Breath

– paroxysmal nocturnal dyspnea

• Fatigue

• Swollen Ankles or Legs

• Angina

• Loss of Appetite

• Weight Gain or Loss

http://www.heartfailure.org/eng_site/hf_signsympt.htm


change the lifestyle!!!

• Weight Management

• Low salt diet, low cholesterol

• Stress reduction

• Moderate aerobic excercise

• Stop Smoking

• Avoid alcohol

• http://www.heartfailure.org/eng_site/hf_signsympt.htm


Routine

• Take your medications at the same time each day

• Check to see if your medications need to be taken

with food.

• Try taking your diuretic medication in the morning to

prevent frequent urination at night. If a second dose

per day is prescribed, try to take it in the afternoon.

• Keep a medicine chart of all of your medications and

times to take dosages.

• Keep a daily weight chart

• http://www.heartfailure.org/eng_site/hf_signsympt.htm


Chronic Heart Failure

• Prevalence:

The absolute number of cases of a disease

in a population at a given moment in time

• Incidence:

The percentage (%) of new cases of a

certain disease in a population per year


Chronic Heart Failure in NL

(2000)

• Total number in NL: 170.000

• Number of new cases/yr: 35.400

• Prevalence: male: 12/1000

female 9/1000

• Incidence: male 2,4/1000

female 2,3/1000

• CHF as cause of death: 16/100.000


Chronic Heart Failure in NL

(2000)

200

180

160

140

120

100

80

60

40

20

0

Prevalence/1000 Incidence/1000/yr)

35.400

new cases

Male Female Male Female

Age (yr)

55-59

60-64

65-69

70-74

75-79

80-84

85+

Source: RIVM http://www.rivm.nl/vtv/object_document/o1650n17965.html


Chronic Heart Failure in NL

(2002)

25

20

15

10

5

Hospital admissions / 1000 inhabitants

11.887 11.453

Age (yr)

55-59

60-64

65-69

70-74

75-79

80-84

85+

0

Male

Female

Source: RIVM http://www.rivm.nl/vtv/object_document/o1650n17965.html


Chronic Heart Failure in NL

(2002)

1600

1400

1200

1000

800

600

400

200

Cause of Death / 100.000 inhabitants

2.358 3.829

Age (yr)

55-59

60-64

65-69

70-74

75-79

80-84

85+

0

Male

Female

Source: RIVM http://www.rivm.nl/vtv/object_document/o1650n17965.html


Chronic Heart Failure

consensus medical guidelines

USA

• ACC/AHA Guidelines

– http://www.acc.org/clinical/guidelines/failure/hf_index.htm

Europe

• ESC guidelines updated May 20 2005

– http://www.escardio.org/

Netherlands:

• Multidisciplinary Guideline Chronic Heartfailure

• http://www.cbo.nl/product/richtlijnen/folder20021023121843/article20021118165847/pdf/hartfalen2002


• Duration of (retrospective) study: 1 year (1989)

• Population:

• Age

10.304 subscribers with a

cardiobeeper

16 - 91 yrs (mean 67 ± 13 yrs)

• Question: To assess ‘decision time’ to call for

medical assistance in case of cardiac

complaints


Median delay: 44 min

range: < 15 min - >3 hr

from 73% of subscribers

No calls from 27% of subscribers


Ambulance Dispatches (AD)

• Observation period: 1 year (1989)

• Total nr of subscribers: n=10.304

• 27% of subscribers: No calls:

• 73% of subscribers: 16.801 calls

• Mean nr of calls: 0.87± 2.3 per subscriber

• 1 AD: 15%

• 2 AD: 6.6%

• 3 or more AD: 10%

• Hospital admissions after AD: 60%


Conclusion

• Compared to historical groups time to

call for medical help was markedly

shortened

• 60% called within 1 hour

• Most patients could be reassured

• Ambulance Dispatch in 15% of cases

• Only 9% had to be presented at ER


A double edged sword:

1. Those in need were helped faster

2. Pressure on ER was relieved


To asses value of blood tests to rule out ischemic

events, 6-48 hrs after onset of complaints

• Population: SHAHAL subscribers (60.000)

• Being treated at home by mobile ICU team

• Physician in doubt about diagnosis AMI

• Time episode 1999-2000 (1 year)


Follow up during ≥7 days for all patients tested

Telephone calls

Self reports

EKG (12 lead) < 24 hrs


14000

132.038

12000

10000

8000

6000

4000

2000

0

5.328

777

30

Callsx10 ICU team Doubtfull Positive


Presented at ER: 30

30

25

23

20

15

10

5

7

4

0

Positive Admitted Unstable AP AMI

Course of callers with a positive cardiac status kit result (30)


40

35

30

25

20

15

10

5

0

37 1 (84): Stroke

2 (88): SD @home day 5

3 (53): SD @home day 3

3 5

1

Seen again

by SAHAL

Died

Unstable

angina

AMI

Course of callers with a negative cardiac status kit result (747)


25

25

20

15

10

5

0

12

Hospital Non

specific

chest

pain

5

Atrial

Fibr.

CHF

Non

Cardiac

Course of callers with a negative cardiac status kit result (747)

3

5


• Predictive Value of cardiac status kit result:

• Negative: 99.2%

• Positive: 36.7%


Effects of a comprehensive management system for

CHF.

West e.a. Am J Cardiol 1997;79:58-63

• Problems:

– Poor adherence to guidelines by physicians

– Poor adherence to diet and therapy by

patients

– Lack of systematic monitoring of outpatients


Effects of a comprehensive management system for

CHF.

West e.a. Am J Cardiol 1997;79:58-63

• Solution:

– Physician supervised, Nurse-mediated home based

system (Multifit)

– Self monitoring (a.o. weight)

– Regular telephone contacts for endorsement

• Design:

– Paired comparisons of parameters during

observation (10 months) with the period 6 months

before enrollment in the study


Effects of a comprehensive management system for CHF.

West e.a. Am J Cardiol 1997;79:58-63

Results (n=51,1994)

100

90

80

70

60

50

40

30

20

10

0

Medical Cardiology ER Hospitalisation

Before

After

Visits visits Visits for CHF


Fewer hospitalisations and decrease in

length of stay with homecare strategies.

1. Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. A

multidisciplinary intervention to prevent the readmission of elderly patients with

congestive heart failure. N Engl J Med 1995;333:1190-5.

2. Hanumanthu S, Butler J, Chomsky D, e.a.: Effect of a heart failure program on

hospitalization frequency and exercise tolerance. Circulation 1997;96:2843-8

3. Fonarow GC, Lynne WS, Walden JA, Livingstone NA, e.a.:Inpact of a

Comprehensive Heart Failure Program on Hospital Readmission and Functional

Status of Patients with Advanced Heart Failure. J Am Coll Cardiol 1997;30:725-32

4. Stewart S, Pearson S, Horowitz J: Effects of a home based intervention among

patients with congestive heart failure discharged from acute hospital care. Arch

Intern Med 1998;158:1067-72

5. Stewart S, Marley JE, Horowitz JD: Effects of a multidisciplinary home-based

intervention on planned readmissions and survival among patients with chronic

congestive heart failure: a randomized controlled clinical trial. Lancet

1999;354:1077-83

6. Cordisco ME, Beniaminovitz A, Hammond K, Mancini D: Use oftelemonitoring to

decrease the rate of hospitalization in patienst with severe congestive heartfailure.

Am J Cardiol 1999;84:860-2


Fewer hospitalisations and decrease in

length of stay with homecare strategies.

“The largest successful randomized

controlled trial of disease management

targeted elderly patients who had been

hospitalized for HF, had a prior history of

HF, had 4 or more hospitalizations within 5

years, or had an HF exacerbation caused by

an acute myocardial infarction or uncontrolled

Hypertension” (ACC/AHA Guidelines)


European Journal of Heart Failure 3 (2001) 723-730

• N=20, Control 10, Telemedicine 10

• BP, HR, Weight, Videoconsult via

Phone

• QOL & Heart Failure Health

questionnaire


European Journal of Heart Failure 3 (2001) 723-730


European Journal of Heart Failure 3 (2001) 723-730

• Conclusion

• High compliance rates

• Long term Telemonitoring is feasible

• Series too small for clinical conclusions


• Prospective study during 1 year

• Assessment of SAHAL programm on

– Admission rate

–L.O.S

– Q.O.L.

• Population: SAHAL subscribers (> 60.000)

• Admitted ≥ 2 times in previous year for

acute worsening of CHF


NYHA Classification

Symptoms of Heart Failure

• class I: only at levels of exertion that

would limit normal individuals

• class II: on ordinary exertion,

• class III: on less-than-ordinary exertion,

• class IV: symptoms of HF at rest


• Daily measurement of

– Weight

– Blood Pressure

–Heartrate

• Automatically transmitted to SHL center

• Routine interview by nurses every 2 weeks

• Follow up according to protocol

• Unscheduled calls


• Alarm if:

– Weight + 1.5 Kg over baseline

– BP (Syst) >180 mmHg or < 90 mmHg

– BP (Diast) > 110 mmHg

– No data from patient > 3 days


• Action for increase in weight:

– Day 1: Furosemide 40-80 mg orally (+KCL)

– Day 2: Furosemide repeat double dose

– Day 3: Mobile unit for Furosemide 100-250 mg IV

• Action for increase/decrease in BP:

– Advancing or skipping antihypertensive medication

according to protocol.


Weight alarm:

• Increase in furosemide 155 times in 66 patients

• Mobile Unit (furosemide iv) 97 cases

• Ultimately hospitalized: 38 patients

• 32 with Hx of extra furosemide given

• 6 without Hx of extra furosemide given


15 patients died during the study

9

8

7

6

5

4

3

2

1

0

Non cardiac

Cardiac

NYHA III-IV

Oost


Decrease in nr. of hospitalizations for CHF

90

80

70

60

50

40

30

20

10

0

82% 75%

57%

Class II Class III Class IV

NYHA


Decrease in Days of hospitalization for CHF

2000

1500

1623

P< 0.0001

1000

500

558

0

Previous year

Study year

Oost


14

12

10

8

6

4

2

0

Mean LOS for CHF

13,75

Previous year

P< 0.0001

3,06

Study year

Oost


Risk factors of the 38 hospitalized patients♥:

• Lower body mass index + female

• Diabetes

• Previous MI

• Smoking

♥ P


Not Risk factors of 38 hospitalized patients:

• Dx of Hypertension

• Dx of Hyperlipidemia

• Hx of revascularization in the past

• Hx of Arrhytmias in the past

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