Transcript Diapositivo 1
Mobile Systems for Chronic Diseases Telemonitoring: Current Status
1 Introdução à Medicina 08/09
Class no.5
DEFINITION
Telemonitoring:
collection, record and transmission of clinical data between a patient at a distant location and a healthcare provider via remote telecommunications. It is provided on an outpatient basis. 2
(http://www.homehealthquality.org/shared/content/hhqi_campain/bpip_tm/Therapy.pdf)
DEFINITION
Chronic diseases:
Permanent disease, which leave residual disability, caused by nonreversible pathological alteration. They require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation or care.
3 Dictionary of Health Services Management, 2nd edition
DEFINITION
Physiological data:
observable or measurable characteristics of the ocular system, the respiratory system, the musculoskeletal system, the nervous system or of the blood.
4
(http://www.ncbi.nlm.nih.gov.sites/entrez)
In this new century medicine is facing a new challenge called
TELEMONITORING
Revolution in the healthcare delivery processes 5 Telemonitoring allows the use of electronic equipment to observe or record physiologic processes while the patient undergoes normal daily activities [Mehmet R. Yuce, Peng Choong Ng, Jamil Y. Khan, Monitoring of Physiological Parameters from Multiple Patients Using Wireless Sensor Network, April 2008, Springer Science + Business Media, LLC 2008 ]
6 A wide range of telemonitoring devices available, nowadays, for several diseases monitoring Chronic diseases: the most promising applications (cardiopulmonary disease, asthma, heart failure, diabetes) Most patients are elderly people – need to be regularly monitored (length of their disease, nature of their health condition, therapy) Telemonitoring is a way of responding to new needs in home care in an ageing population Isolated areas do not have easy access to healthcare or specialized medical staff
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TELEMONITORING ALLOWS
Earlier detection of abnormal health parameters Corrective measures to be taken before more complications appear Less frequent visits to healthcare facilities, shorter hospital stays and decrease of hospital admissions Increased patient’s quality of life Cost-effectiveness
Chronic diseases telemonitoring systems allow:
• To collect part of the diagnostic's relevant information • To gather more information with less effort • To follow the patients closely spending less time. 8 [Otto, C. A., Jovanov, E., and Milenkovic, E., A WBAN-based system for health monitoring at home. In 3rd IEEE/EMBS Int.
Summer School, Medical Devices and Biosensors. Sept, 20 –23, 2006.] [N. Oliver and F. F. Mangas, “HealthGear: a real-time wearable system for monitoring and analyzing physiological signals,” Tech. Rep. MSR-TR-2005-182, Microsoft Corporation, Red-mond, Wass, USA, 2005 ]
A simple and not very restricted search at Pubmed ...
QUERY: (telemonitoring[All Fields] OR "telemedicine"[MeSH Terms] OR "telemedicine"[All Fields]) AND ambulatory[All Fields]
Publications indexed by Pubmed from 1990 9
500 articles about telemonitoring - more than 93% of the publication's dates are from 2000 to the present year .
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MobiHealth is an healthcare project created for the development of mobile health services and funded by the European Commission. A patient who requires monitoring for short or long periods of time doesn't have to stay in hospital for monitoring. With the MobiHealth BAN the patient can be free to pursue daily life activities www.mobihealth.org
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This revels not only how recent this matter is, but also its emerging relevance
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Telemonitoring Status:
Despite their potential, most telemonitoring services are still limited to the status of temporary projects without clear prospects for wider use and proper integration into healthcare system .
There is limited evidence of the effectiveness of telemedicine services on a large scale. Awareness, confidence and acceptance still need to be strengthened.
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On which chronic diseases have mobile telemonitoring systems been used?
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OBJECTIVES
Expose the scientific evidence, produced by experimental studies, supporting the use of mobile telemonitoring systems.
Determine which chronic diseases have been targeted by telemonitoring of physiological data.
Analyze which types of physiological data have been monitored and transmitted in chronic diseases telemonitoring.
Identify on which healthcare effects scientific evidence exists on the advantages or disadvantages of chronic diseases telemonitoring (health improvement, system usability, patient acceptance, etc.).
METHODS:
Systematic Review
15 Keywords: physiological, physiologic, process, phenomena, monitor, ambulatory, outpatients, non- hospital, telemedicine, telemonitoring, self monitoring, supervise, telesurveillance.
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METHODS:
Systematic Review
D) A comprehensive literature search was conducted on
Pubmed
and
ISI
to identify relevant published articles.
("physiological"[All Fields] OR "physiologic"[All Fields] OR physiologically[All Fields] OR process[All Fields] OR phenoma[All Fields] OR phenomal[All Fields]) AND (monitor [All Fields] OR ambulatory OR "outpatients"[MeSH Terms] OR "outpatients"[All Fields] OR "outpatient"[All Fields] OR non hospital[All Fields] OR "monitoring, ambulatory"[MeSH Terms]) AND ("telemedicine"[MeSH Terms] OR "telemedicine"[All Fields] OR telemonitoring[All Fields] OR telemonitor[All Fields] OR "self monitor"[All Fields] OR "self monitoring"[All Fields] OR "supervise"[All Fields] OR "telesurveillance"[AllFields]).
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Research results
Pubmed ISI Web of Knowledge
18 TOTAL
502
Methods
The articles obtained were subjected to a process of critical appraising according to its quality.
1 st . REVISION:
Revision by
title
2 reviewers and
abstract
Articles excluded didn’t fit the inclusion/exclusion criteria. Any articles about mobile systems for chronic diseases telemonitoring were included.
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Inclusion/Exclusion criteria
Inclusion criteria
(1)experimental studies which include direct data collection from patients (2) in humans (3) using outdoor-usable devices and (4) document scientific evidence of telemonitoring effects
Exclusion criteria
(1) do not include detailed description of the study, (2) are focused on athletes telemonitoring or (3) monitoring which does not make use of mobile systems, (4) general reviews and (5) conference and poster abstracts without study details.
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Methods
2
nd
. REVISION:
- Extensive analysis of the full article - 2 reviewers - The inclusion/exclusion criteria were changed - None of the articles excluded in the first revision would have been included in the second revision since the new criteria is a restriction of the previous one.
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Inclusion/Exclusion criteria
Inclusion criteria
(1) articles written in English, (2) with full text available, (3) regarding chronic diseases telemonitoring, (4) experimental studies which include direct data collection from patients, (5) using mobile telemonitoring systems (6) those which document scientific evidence of telemonitoring effects (health improvement, system usability, etc.).
Exclusion criteria
(1) do not present a detailed description of the study, (2) describes a project of a new instrument, (3) general reviews
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STUDY VARIABLES:
Types of chronic disease targeted by telemonitoring Types of physiological data monitored Country and publication date of the article Benefits and drawbacks (health improvement, system usability, cost-effectiveness, etc.) mobile systems for chronic diseases telemonitoribg can bring for the: clinician patient healthcare institution
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Methods
After the data extraction:
Check for and identify sources of heterogeneity in results across studies Findings/Results of individual studies are synthesised and subsequently statistically analysed in SPSS
Percentage of included, excluded articles and those who needed a 3
rd
reviewer
4,02% 10,92% 85,06% 25 Graphic 1: Percentage of included, excluded articles and those who needed a 3 rd reviewer
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Methods – 3
rd
Reviewer
Regarding the articles subjected to a 3 rd revision: • 68,4% of the articles were included • 31,6% were excluded
Methods – Final decision
After completing the articles revision we had: • 7,5% of the articles included • 92,5% of the articles excluded
Methods – Number of included and excluded articles by each reviewer
27 Graphic 2: Number of included and excluded articles by each reviewer
Methods
A Chi-Square test was performed in order to check if there was any statistically significant difference between the expected and the actual number of excluded articles per reviewer. (p=0,668) 28
Methods – Frequency of use of each inclusion criteria
29 Graphic 3: Frequency of use of each inclusion criteria
Methods – Frequency of use of each exclusion criteria
30 Graphic 4: Frequency of use of each exclusion criteria
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Results Profile of Chronic Diseases Telemonitoring Studies
DIABETES CARDIAC DISEASES HYPERTENSION TOTAL
How many?
Where?
USA
RESULTS
Australia 1 2 Canada UK Norway 1 1 1 1 -
When?
1996 2004 2005 2006 2007 2008 2 2 1 1 1 2 1 3 Table 1: Profile of chronic diseases telemonitoring studies 13 1 2 3 1 5 1 6 3 2 1 1
Results Profile of Chronic Diseases Telemonitoring Studies
DIABETES CARDIAC DISEASES HYPERTENSION
-
With whom?
Patients with cardiovascular disease
Adults hospitalized with heart failure.
Enrolled in health centers.
Recently implanted with CRT-D.
With symptomatic chronic heart failure and left ventricular ejection.
Undergoing cardiac rehabilitation.
Patients with Diabetes
Young patients and their parents.
Young patients using insulin for at least one year.
3 1 1 5 1 1 1 1 1 Wide-ranging patients with type I Diabetes Adult patients with type II Diabetes and uncontrolled blood pressure.
1 1 32
Patients with uncontrolled hypertension
2
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Results Overview of Research Designs
DIABETES
5
CARDIAC DISEASE
5 Number of studies
Type of design, n (% within disease)
Randomized trial with control group Randomized trial without control group Nonrandomized trial without control group
Size of experimental group
Maximum Minimum Mean Median
Size of control group, n (% within experimental group)
Maximum Minimum Mean Median
Study duration
Maximum 1 (20) 1 (20) 3 (60) 200 10 55 18 18 (50) 18 (50) 18 (50) 18 1 (20) 1 (20) 3 (60) 750 30 236 81,5 54 (44) 54 (44) 54 (44) 54 Minimum Mean Median
HYPERTENSION
3 2 (66) 1 (33) 450 20 168 33 150 (25) 10 (33) 80 (29) 80 6 months 3 days 3,82 months 18 months 6 weeks 7,9 months 6 months months 18 months 4 months 11,3 months 12 months
TOTAL
13 4 2 7 750 10 150 10 18 months 3 days
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Results Overview of Research Designs Number of studies Main types of data transferred
DIABETES
5
CARDIAC DISEASE
5
HYPERTENSION TOTAL
3 13
Heart Rate Blood pressure Heart electrical activity Blood glucose
Frequency of data transmission to health care provider
More than once a day Once a day A few times a week Once a week Once a month Once every three months Once every six months 5 3 1 1 2 2 3 1 2 1 3 1 1 1 1 4 4 2 5 4 2 3 1 1 1 1
Results - Frequencies of types of effects
DIABETES CARDIAC DISEASE HYPERTENSION TOTAL
Number of studies
Data quality Patient condition Patient attitudes and behaviors Physician attitudes and behaviors Physician facilities Clinical efectiveness/ structural effects Economic viability 4 2
5
3 1 2 1 2 3 4
5
1 1 2 3 3 1
3
3 3 3 5 10 7
13
4 4 6 35
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Results - Frequencies of advantages and disadvantages
DIABETES CARDIAC DISEASE HYPERTENSION TOTAL
5 5 3 13 Number of studies
Advantages to:
Patient Physician Health care institutions
Disadvantages to:
Patient Physician Health care institutions 1 1 4 1 3 3 3 2 1 1 2 2 3 2 1 10 6 6 4 4 -
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Results – Advantages and disadvantages for the patient
DIABETES
5
CARDIAC DISEASE
5
HYPERTENSIO N
3
TOTAL
13 Number of studies
Patient Advantages
- Ability to overcome the problems. - Increased level of patients’ responsibility. - Helps in disease self-management.
- Patients received an alert everytime the values of blood pressure are lower or higher than the normal - Patient enthusiam and acceptance. - System easily integrated into everyday life.
- Child independence while being monitored by their parents.
- Allows patients with memory problems to remember to take medication.
- Allows the introduction of healthy habits of practice of physical exercise and alimentation in patients.
Disadvantages
- Costs.
- Difficulty in using Internet.
- Difficulty in accepting new technologies. - No physical contact with the doctor.
- Problems of integration of other diseases.
- Problems of adaptation in the routine.
- Warns unnecessarily in situations of low levels of glucose, especially during the night.
1 2 2 3 1 1 1 1 1 1 1 1 2 2 1 1 1 1 2 1 1 1 1 3 3 1 1 2 3 4 2 1 1 2 2 1 1 1 1 1
Results - Advantages and disadvantages for the
Number of studies
physician
DIABETES
5
CARDIAC DISEASE
5
HYPERTENSION TOTAL
3 13
Physician Advantages
- Facilitates realtime discussions between physicians in primary and secondary care.
- Less acute care needs when admitted.
- More accurate decision regarding the treatment of BP.
- Larger amount of information about the patient’s condition enabling the patients’ follow-up the patient on a daily basis rather than just on the day of the medical exam.
- Shows when the medication has adverse effects.
38 - Integration of physician in the patient routine.
Disadvantages
- No longer able to contact the patient directly.
- Has to adapt its guidelines to the new technology.
- Availability of the physician to analyze patient data.
- Failure in detection of low blood glucose values.
2 1 1 1 1 2 1 1 1 1 1 2 1 1 4 1 1 3 1 1 2 1 2 1
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Results - Advantages for the hospital
Number of studies
Hospital Advantages
- Reduction of hospitalization - Automatically generated historical graphics transferred to the healthcare provider, feasibility of the system.
- Reduction of hospital overcrowding.
DIABETES
5
CARDIAC DISEASE HYPERTENSI ON TOTAL
5 3 13
2 1 1 2 4 1 1
Discussion
Only articles about
Diabetes
,
Cardiac Diseases
found.
and
Hypertension
were Comparing to Paré et all, the number of included articles was considerably smaller since our research was restricted to experimental studies making use of mobile systems
USA is the country which has most explored the use of mobile technology
to follow up chronic patients, as well as UK, Australia, Norway and Canada.
The date of publication of the articles ranges between from
1996 to 2008.
The majority of the articles were regarding Diabetes type I
, revealing the importance to closely monitor and control the levels of blood glucose on a daily basis.
Cardiac diseases were also frequently targeted
incidence and prevalence due to its high level of 40
Discussion
Benefits of mobile telemonitoring systems for the patients
Telemonitoring systems enable patient’s quality of life This kind of systems allows active participation in the process of healthcare, more patient ’s independence and responsibility, General satisfaction and a high level of acceptance Minimal patient intervention in the collection and transference of data, reducing bias and subjectivity Promotion of a healthy lifestyle with an improvement in physical exercise practice and balanced diet as it increases patient awareness of their health condition Increasing of patients’ compliance with the treatment, medication and telemonitoring which is a result of a tighter control achieved by an alarm system warning the patient .
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Discussion
Disadvantages of mobile telemonitoring systems for the patients
Problems related to the usage and access to the internet namely among elderly people since they are not used to deal with computer technology The cost-effectiveness is quite controversial Although it requires an initial investment in the equipment purchase, it may compensate in the long run, since it decreases future expenditures in healthcare services Undesirable changes in the daily routine may happen as a result of the permanent monitoring which leads to dependency towards the equipment 42
Discussion
Benefits of mobile telemonitoring systems for healthcare professionals
Telemonitoring promotes the knowledge integration from the different healthcare areas, encouraging discussion The physician has easier access to the patient information, and can be warned through an alarm system every time the patients’ health parameters are not normal Emergency situations can be detected earlier preventing the occurrence of more serious complications It is possible to follow closely the evolution of a patient health condition and consequently diagnose and apply treatment at distance 43
Discussion
Disadvantages of mobile telemonitoring systems for healthcare professionals
Less physical contact between physicians and patients Adaptation of clinical guidelines to this new way of healthcare delivery service It requires availability of the physician in order to analyze the patient data as well as ensure the maintenance of the equipment 44
Discussion
Little evidence was found on the telemonitoring effects on the hospital
and additional research is required to further investigate and analyze the impact of chronic disease telemonitoring in healthcare facilities
Effects of mobile telemonitoring systems on the hospitals
Less frequent visits to the healthcare facilities, shorter hospital stays and decrease of hospital admissions 45 Decrease in waiting lists associated with cost-effectiveness The hospital can be notified in case of medical emergency Previous professional training is needed in order to make an adequate use of this equipment, benefiting from all its potentialities
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[18]- Otto, C. A., Jovanov, E., and Milenkovic, E., A WBAN-based system for health monitoring at home. In 3rd IEEE/EMBS Int.
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Authors:
ALVES, DATA, José Pedro Figueiral Oliva Soares; CAMPOS, Marta Sofia Gomes; Tânia Rodrigues; ESTEVES, Alexandra Sofia Moreira; FARIA, Carlos Augusto da Silva; FERNANDES, Diana da Silva; GUEDES, Paulo Renato Moreira; MACHADO, Marino João Pinto; MAGALHÃES, Ana Isabel Pereira; MARQUES, Pedro Seabra; MATOS, Marisa Tribuzi NASCIMENTO, de Magalhães; José Pedro Rodrigues; MELO, Inês MOREIRA, Pedro Manuel Costa; João António Santos; PEREIRA, Maria Francisca Azevedo Marques; SILVA, Ana Rita Carneiro.
Authors ’ e-mail: [email protected]
Adviser:
RODRIGUES, Pedro Pereira.
Class Number:
05