Hospitalisation à domicile et l`i t d l télé éd i l`i t d l télé

Hospitalisation à domicile et
l’i
l’importance
t
de
d la
l télémédecine
télé éd i
Th i h
Thuishospitalisatie
it li ti en het
h t
belang van telegeneeskunde
UNAMEC - 05/12/2012
C i ti Gómez
Cristina
Gó
Suárez
S á
Global Business Development Manager,
Telehealth
Linde Healthcare
A home telehealth service for patients with
severe COPD.
Th “PROMETE” study
The
t d
Segrelles G (1), Gómez-Suárez C (2), Soriano JB (3), Zamora E (1), Gónzalez-Gamarra A (4), González-Béjar
M (5), Ancochea J (1).
(1) S
Servicio
i i d
de N
Neumología
l í L
La P
Princesa.
i
H
Hospital
i lU
Universitario
i
i i L
La P
Princesa
i
(M
(Madrid).
d id)
(2) Linde Healthcare
(3) Programa de Epidemiología e Investigación Clínica, CIMERA, Bunyola (Illes Balears)
(4) Centro de Salud de Goya.
(5) Centro de Salud de Montesa.
2
THE CHALLENGE OF CHRONICITY - Prevalence of
chronic diseases in Spain
Prevalence (%) of chronic disease by age
and sex
Distribution of the population
(>65 years) as the number of chronic
conditions
Year
2010
Linde: Living healthcare
Year
2050
3
Source: Estrategia para afrontar el reto de la cronicidad en Euskadi- Julio 2010
Chronic diseases represent a very high economic
cost to society
Complex chronic patients with more than 3 comorbidities costs: x8
more than a non-chronic patient, and x3 more than a chronic
patient with only one chronic disease.
Total healthcare
p
expenditure
Expenditure per patient (€) by number of chronic
diseases
20-30%
70-80%
x10
Other
expenses
x8
Health
expenditure
motivated by
y
chronic
conditions
Average cost associated to a chronic
condition/year: 3400 €
Number or associated chronic conditions
Complex chronic patient
National Health Survey 2006
source: T.Bodenheimer 2009
Telecare is a mainstream service in Spain …
• Telecare is the most common form of ICTbased technology for independent living, and
are available throughout the country.
• Take-up is estimated around 8% of the
population aged 65 years and older (>600.000
users, in 2011).
• Main providers are municipalities under the
Autonomous Communities of Spain, who
subsidise the service.
• The Law on the Promotion of Personal
Autonomy and Care of Those in Dependent
Situations (39/2006) defines and sets the
remit for telecare services.
• As regards charging/reimbursement, each
Autonomous Community determines the
price of the telecare service and the
requirements for users to qualify for the
different discounts available.
… while telehealth services are not yet mainstream, but are under
development and being included within the deployment of Chronic
Patient Management Strategies
6
Who benefits the most from home telehealth
programmes?
High
complexity
l it chronic
h
i patients
ti t
Adapted Kaiser Permanente pyramid
Spanish Risk pyramid
The PROMETE study - “PROyecto Madrileño de
EPOC Telemonitorizado”
Telemonitorizado
Telehealth Madrilène PROject for COPDs
The PROMETE Study - Goals
Primary:
y
To evaluate a home telehealth programme (HT) in severe COPD patients,
measured as the number of exacerbations
exacerbations, number of hospitalisations and exitus
exitus.
S
Secondary:
d
•
To determine evolution of functional parameters and quality of life related to
health (HRQOL).
•
Analyze the satisfaction and compliance of patients and caregivers to the HT
programme.
•
Analyze causes of study withdrawal.
•
Evaluate the impact of HT on the use of healthcare resources and evaluate
associated costs.
•
Analyze impact on HRQOL and caregiver burden.
The PROMETE study
y - Methodology
gy
Randomized controlled trial:
 Home Telehealth (HT) (30 patients) vs
s Conventional
Con entional care (CC)(30 patients)
patients).
 Randomization by Primary Care Centre (PC) (Goya, Montesa, Castelló, Lagasca).
Approved by the Ethics Committee of Hospital Universitario La Princesa (HULP) (Madrid).
Study period: October 2011
2011- May 2012 (7 months)
months).
•
Inclusion criteria:
•
Exclusion criteria:
– Sign
Si IInformed
f
d Consent.
C
t
– Do
D nott sign
i IInformed
f
d Consent.
C
t
– Age ≥ 50.
– Active smoker.
– COPD diagnosis according to GOLD
standard
t d d (FEV1/FVC postBD<0,7).
tBD<0 7)
– On a palliative care programme or
suffering
ff i off another
th terminal
t
i l
disease
– Stage IV GOLD: FEV1<30% or
FEV1<50%.
– Follow-up
F ll
b PC and
by
d HULP
HULP.
– Inability to understand the
procedure
procedure.
– 1 EXCOPD during the year prior to
inclusion which required
hospitalisation
hospitalisation.
– Patient institutionalized (geriatric
centre) or at risk of social
exclusion.
– Non smoker (6 previous months).
The PROMETE study - Results
Socio‐demographic characteristics:
Socio
demographic characteristics:
HT
CC
p‐value*
A
Age
75 03
75,03
72 73
72,73
0 385
0,385
Sex (M:F)
22:7
22:8
0,824
Education (P:S:U) (28/29) 10:10:8
Education (P:S:U) (28/29)
10:10:9
0,998
Retiree
23
25
0,443
Carer
18
19
0,789
Mobility (BS:H:S)
0:10:19
3:8:19
0,201
HOT
27
26
Education: P = primary, S = secondary, U = university.
M bilit BS b d f H h
Mobility: BS=bed‐sofa, H=home, S=street.
S t t
*p‐value <0,05 statistically significant.
The PROMETE Study - Results
Clinical characteristics:
HT
CC
p‐value*
FEV1
37,76
37,10
0,460
BODEX index
5,43
5,63
0,200
CAT questionnaire
17,69
17,32
0,850
Previous hospitalisations
Previous hospitalisations
1 72
1,72
1 80
1,80
0 590
0,590
Acidosis
0,17
0,10
0,108
100% of patients D classification according to GOLD 2011: severe patients with 100%
f ti t D l ifi ti
di t GOLD 2011
ti t ith
comorbidities.
Clinical questionnaires:
‐
‐
‐
Charlson comorbidity index: 3,71
Barthel index: 88,29 (moderate dependency)
Goldberg test:
Goldberg test:
‐ Anxiety : 3,71 (“positive”>=4).
‐ Depression: 3,75 (“positive”>=2).
The PROMETE studystudy Results
Comorbidities: Comorbidity
y
Number of
patients
% total
Hypertension
31
53
C di d
Cardiac
dysrhythmia
h th i
22
38
Heart failure
11
19
Depression
11
19
Diabetes Mellitus type II
10
17
Ischemic heart disease
9
15
Chronic kidney disease
6
10
A&E
Specialist A
Specialist B
Home Care
Primary Care
112 calls & visits
The PROMETE Study – Results: PROMETE
classification of exacerbation severity (non
(non-validated
validated
scale)
0 points
1 point
2 point
Sputum
colour
White
Yellow
Green-brown
Peak flow
>50%
50-30%
<30%
Temperature
(ºC)
<37,2
37,2-38
(dysthermia)
>38
(chills)
Dyspnoea
(MRC)
I-II
III
IV
Tachypnea
<20
20-25
(slurred speech)
>25
(unable to speak
due to fatigue)
SatO2
(%drop)
<5%
5-7%
>7%
16
The PROMETE study – Results: Classification and
Response to exacerbations
Total score
Classification
Response
<6 points
Moderated
 Telephone contact with the patient and medical
recommendations are made
 Thorough TH follow-up 24-48 h
 If worsens to Primary Care
6 – 9 points
Severe




> 9 points
Very severe
 Home visit: clinical evaluation, treatment adjustment/start
 Referral to pneumology A&E, previous notice
Home visit: clinical evaluation, treatment adjustment/start
Thorough TH follow-up 24-48 h
If improvement to Primary Care
If worsens to A&E dept
45
9%
40
9%
35
30
25
21%
20
61%
15
10
Recomedación
telefónica
p
Telephone
recommendation
Visita
domiciliaria
Home
visit
5
0
moderada
Moderated
grave
Severe
muy grave
Very severe
Cita
en neumolog´´ia
PC preferente
visit
17
Recomendación
A&E referral de ir a urgencias
The PROMETE study – Results: Triage Process
Results, Case Manager activity
• 720 outbound calls
• 15 technical visits
Other conditions/comorbidities
detected:
•
•
•
•
Questionn
aires
4%
Training
support
2%
Clinical
alert
50%
Inbound
calls 6%
Nonadherence
alert
38%
4 Depressive symptoms
5 Digestive symptoms
2 Hypertension symptoms
5 Ischemic heart disease
symptoms
• 1 Cardiac dysrhythmia symptoms
 12 patients referred to PC.
 1 patient referred to Generalist
 1 patient referred to NRL
NRL.
 1 patient referred to CARD.
18
The PROMETE study – Results
300
Reduced A&E visits:
250
Conventional Care
200
Home Telehealth
150
100
50
0
Home Telehealth (HT) group reduced:
•
60% number of hospitalisations due to ExCOPD
•
60% number of days in hospital
•
65% A&E dept visits
The PROMETE study – Results: Quality of Life
and Exitus
Quality of Life:
Quality of Life:
START
END
p-value*
AVE
5 25
5,25
6 30
6,30
0 003
0,003
CAT
17,69
19,00
0,311
ANXIETY
3,71
3,12
0,320
DEPRESSION
3,75
2,12
0,001
D th d i th t d
Deaths during the study:
• CC group: 4 exitus
• 3 patients due to ExCOPD
•1 patient due to other causes
• HT g
group:
p 2 exitus
• 1 patient for ExCOPD
• 1patient due to other causes
The PROMETE Study– Results: Evolution from both groups 90
days post-discontinuation of the telehealth programme
Cumulative after 7 months in telehealth
programme:
Cumulative 90 days post-discontinuation
post discontinuation of
telehealth programme:
300
40
250
35
200
Conventional Care
30
Home Telehealth
25
150
20
Conventional Care
Home Telehealth
100
15
50
0
10
5
0
After 90 days of discontinuation of thee telehealth programme, 3 patients have been included in a Home
Palliative Care Programme.
21
The PROMETE study – Satisfaction
•
O
Overall
ll satisfaction
ti f ti with
ith the
th telehealth
t l h lth programme: 8,95
8 95 (scale
(
l off 10)
•
Would you recommend the use of these telehealth services to a
friend/family
y suffering
g from severe COPD?: 100% , yes.
y
What is the level of
satisfaction with this home
telehealth
services/programme?
i
/
?
 Very satisfied 54,54%
 Satisfied
S ti fi d 40,9%
40 9%
 NA 4,5%
The PROMETE study – CONCLUSIONS
The PROMETE study:
 Combines conventional care with new technology and
information communication technology (ICT).
 Highlights the importance of the coordination of
multidisciplinary teams in chronic patient care

After 7 months of home telehealth service in severe COPD patients:
 The number of visits to A&E department, number of hospitalisations
and days of stay in hospital is much lower in the home telehealth
group.
group
 It is a very well accepted system and programme by the patient
 No secondary withdrawals due to the complexity of use have been observed.
Home telehealth allows daily monitoring and follow-up of severe COPD
patients, being a good option to optimize the management of exacerbations and
f a better
for
b tt resource management.
t
Thanks for your
attention
24