Post on 16-Apr-2017
Ambulatory monitor derived clinical measures for continuous assessment of cardiac rehabilitation patients
Dr Niranjan P BidargaddiResearch Scientist28th August 2008
Patient centred health care
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
CSIROCommonwealth Scientific and Industrial Research Organization
www.csiro.au
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
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CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
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CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
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Wireless TechnologiesNetworking
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Technologies
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CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
e-Health Research Centre
• Joint venture between CSIRO and the Queensland Government
• Largest single-funded e-healthresearch and development facilityin the Southern Hemisphere
• Aims to improve the quality and safety of healthcare for individuals and communities through an ICT research program focused on applied outcomes and active adoption by the health system
• Multi-disciplinary team of over 50, including Research scientists, software engineers and PhD students
• Core Projects:• Biomedical Imaging• Health Data Integration (HDI)• e-Health Metadata and Ontologies• Care Assessment Platform (CAP)
• Several Partner and Affiliate Projects
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Care Assessment Platform project aims to develop and show evidence of IT/ telemonitoring tools in supporting Community Care teams focused on
secondary prevention of Cardiovascular Diseases
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Outline
1. Cardiovascular diseases – Facts
2. Care model: Hospital based cardiac rehabilitation Benefits and drawbacks
3. Alternative care models : Patient centric care models
4. Clinical Trial Objectives Trial setup
5. Clinically relevant measures for cardiac rehabilitation
6. Future works
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Cardiovascular diseases- Facts
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Burden of Cardiovascular Diseases on Healthcare
• Affects more than 3.5 million Australians.
• 1.4 million people have reduced quality of life because of disability caused by the disease.
• In 2004 CVD claimed the lives of almost 48,000 Australians; 35% of all deaths.
CVD is one of the largest health problems in Australia,USA, and other western countries
Source: National Heart Foundation of Australia
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Care model: Benefits and drawbacks
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Prevention of Cardiovascular disease
Cardiac events
HealthyLifestyle
• Post-operation• Inpatient• 1 week
• 6-8 weeks cardiac Rehab programme• Outpatient • Hospital based• Supervised ExerciseCardiac events
• Angina (chest pain), • Coronary artery disease (blockages in the coronary arteries),• Heart attack (myocardial infarction), • Chronic heart failure, (CHF) (reduced pump function or cardiomyopathy),• Coronary arterial bypass graft (CABG), and stent or angioplasty procedures.
Stage-1
Primary prevention Secondary prevention
Stage-2 Sustain HealthyLifestyle
Reduces risk ofCardiac events
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Role of Exercises in Cardiac Rehabilitation
• Improves autonomic nervous systems regulation of heart ( or heart rate imbalance)
• Parasympathetic/ vagal tone (reduces heart rate) and sympathetic nervous system (increases heart rate).
• Anxiety, fear, depression and other negative emotional states (even positive emotional states) can trigger excessive sympathetic nervous system which raises heart rate.
• Exercise can improve cardiac autonomic balance (increasing parasympathetic while decreasing sympathetic regulation of heart)
• Improves heart rate recovery*
• Increases heart rate variabilty#
*M. Kukielka, et al., Cardiac vagal modulation of heart rate during prolonged submaximal exercise in animals with healed myocardial infarction: effects of training, Am J Physiol. Heart Circ Physiol. 290,1680-1685 2005.#J. Myers et al., Effects of exercise training on heart rate recovery in patients with chronic heart failure, American Heart Journal, 153(6), 1056-1063, 2007.
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Cardiac Rehabilitation: Core elements
• Cardiac Rehabilitation programs should offer a multifaceted approach to overall cardiovascular risk reduction– not only exercise training!
G.J. Balady et.al., “Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update”, Circulation 2007;115:2675-2682
• Core components of secondary prevention programs:• Nutritional counselling• Risk factor management: lipids, blood pressure, weight, diabetes,
and smoking• Psychosocial interventions• Physical activity and exercise training• Baseline patient assessment
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
CVD Management Programmes- Underused?
• There is a significant underutilisation of Cardiac Rehabilitation programs. Only 16% of all the eligible patients complete a program in QLD.
I.A.Scott et.al. “Utilisation of outpatient cardiac rehabilitation in Queensland”, MJA 2003; 179(7)
• In the USA 18.7% of the eligible patients participate in rehabilitation programs.
• Reasons:• Patient barriers:
• self-care preferred• negative perception of gym-based group exercise• travel, work, cost, time issues and complex enrolment process
• Provider barriers: lack of referrals (Around 30% of eligible patients are referred)• System barriers: competing demands, lack of support within the organization• Community barriers: lack of community support and positive media messaging
R.J. Thomas, “Cardiac Rehabilitation/Secondary Prevention Programs; A Raft for the Rapids: Why Have We Missed The Boat?”, Circulation 2007;116:1644-1646
->Alternative care models are required.
Main Problem in Cardiac Rehabilitation:
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Alternative care models
Patient centric care models
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Patient Centric Care Model
CAP ServerWellness
DiaryNutrition
InfoExcercise
infoHealth
Reports
Wellness Diary
Exercise coachTele-
Consultation
Personal devices
Server
DatabaseHealth Records
CAP.COM.AU
Organisation: Redcliffe Rehab
Thomas Anderson
Redcliffe Rehab
Summary
View Type Start date30 days before
End date
Today
Import Data Patient Info
Update
Good
Poor
Sit to Stand Time4
2
0
Tim
e [s
]
Current:
Average:
0.88 s
1.9 s
Start: 2.3 s
Good
Poor
6 Minute Walk6
3
0
Spee
d [km
/h] Current:
Average:
4.5 km/h
3.1 km/h
Start: 2.1 km/h
View
User: Mary Smith
Exit
System User Change Password
Anderson ThomasBrown MaryDavis JackDoe JohnJackson EmilyJohnson RyanJones MiaMiller PatrickMoore EmmaSmith JoeTaylor SamuelThomas SophieWilliams JoshWilson Jessica
Patients:
Add Remove
Cardiac Rehab #3
Patient Group:
Patients Settings
Select graphs
6min walk
Heart Rate
Good
Poor180
100
Fr 02.02.07Tu 23.01.07Sa 13.01.07
40Poor
HR [b
pm]
Current:
Average 30 days:
59 120 42
Start:
Average Max Min
85 143 50
103 135 62
HR 24 Hour Values
HealthInformatio
n
Self management
Treatment Counselli
ng Coaching
- Movement activity- Heart Rate- Blood Pressure- Weight scale- Sleep-wake rhythm
Mobile/PC Applications:
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Clinical Trial
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Why Trials? New Technology
Relevance
Positive Outcomes
Uptake
Phase 1 trial
Phase 2 trial
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Project phase 1 (2007) objectives
Conduct clinical trial for continuous physiological monitoring of patients undergoing cardiac rehabilitation using ambulatory monitoring devices to:
• Identify various measures/tools used in hospitals to assess the patients conditions.
• Develop and derive clinical measures/tools from free living environment.
• Validate the clinical significance of free living based measures/tools• Use the validated free living measures to find new trends/patterns
in patient’s behaviour and physiological signals.
What automatically derived measures can be used to assess and follow the patient’s condition during the program?
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Trial setup
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Phase 1 trial: Hospital-based cardiac rehabilitation program in Caboolture & Redcliffe hospitals (QLD)
• 6 weeks cardiac rehabilitation program• Patient condition assessed at the beginning and end
of the program using six minute walk test (6MWT)• Consent asked to participate in the research study
• Patients attend physical exercise session twice a week at the hospital gym
• Typical exercises: biking, rowing, walking, stepping, arm exercise and ball work out
• Exercise duration and load varied by the physiotherapist to achieve optimal exercise level and increase the patient’s performance
• Device worn continuously in the home for the duration of rehab
• Device attached to waist with a belt and pouch, remove device only during shower
• Data downloaded weekly from memory cards during rehab session
• Patients wear ECG leads for the first half of the week and during exercise
Monitor attached to waist
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Cardiac rehabilitation exercise program
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Clinically relevant measures for cardiac rehabilitation
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Activities of Daily Living (ADL) Sit to stand transition duration Metabolic expenditure Walking speed Walking durations Gait pattern – Fractal dimensions Adverse events such as falls
derived from measures of accelerometer signals…
Clinically significant measures
Respiratory rate Heart rate variability (HRV) RMSSD
derived from measures of ECG signals…
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Metabolic expenditure, daily profile
12:00 18:00 00:00 06:001
1.5
2
2.5
3
3.5
time
ME
T
Patient R1CR Metabolic expenditure 21.5.-22.5
Device not in use
Walking
Sleep
Rehab in Redcliffe 11am-12
Cardiac Rehabilitation aims at an accumulation of 30 minutes or more of light to moderate (3.2 – 4.7 MET) physical activity on most days of the week
Minute by minute metabolic expenditure can be calculated from the accelerometer signal
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Metabolic expenditure trend during 6 week CR
5 10 15 20 251.05
1.1
1.15
Patient R5 mean 24h Energy Expenditure
day
MET
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Active/Inactive Ratio trend during 6 weeks of CR
Active (Running,
Walking, working,
etc)
(Moderate and
Vigorous intensity
activities > 3MET)
Inactive (Sleep,
Lying down,
Sitting)Days
05/13 05/20 05/27 06/03 06/10 06/17 06/240
500
1000
1500
Dur
atio
n (m
inut
es)
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Gait stability trend during 6 weeks of CR
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Walking duration trend during 6 weeks of CR
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Ambulatory ECG Derived features
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Exercise heart rate distribution
20 40 60 80 100 120 140 1600
500
1000
1500
20 40 60 80 100 120 140 1600
5000
10000
15000
40 50 60 70 80 90 100 110 1200
500
1000
1500
40 60 80 100 120 140 1600
500
1000
1500
50 60 70 80 90 100 1100
500
1000
1500
40 60 80 100 120 140 160 1800
1000
2000
50 60 70 80 90 100 110 1200
1000
2000
3000
4000
40 60 80 100 120 140 1600
500
1000
1500
2000
Dur
atio
n (s
econ
ds)
Heart rate (beats per minute)
29th May 2007 (Rehabilitation)
14th May 2007 (Rehabilitation) 21th May 2007 (Day and Night)
4th June 2007 (Rehabilitation)
12th June 2007 (Rehabilitation)6th June 2007 (Rehabilitation)
20th June 2007 (Rehabilitation)18th June 2007 (Day time)
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Respiratory rate regularity (Smoothness)
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Heart rate variability (RMSSD) during exercise
10:00 10:15 10:30 10:45 11:000
20
40
60
12:00 15:00 18:00 21:00 00:00 03:000
50
100
11:00 11:10 11:20 11:30 11:40 11:50 12:00 12:100
20
40
60
11:00 11:10 11:20 11:30 11:40 11:50 12:00 12:10 12:200
20
40
60
11:15 11:30 11:45 12:00 12:150
20
40
11:00 11:10 11:20 11:30 11:40 11:50 12:00 12:10 12:200
20
40
11:00 12:00 13:00 14:00 15:00 16:000
20
40
60
80
10:00 10:30 11:00 11:30 12:00 12:300
20
40
60
5th May 2007 (Day and Night)14th May 2007 (Rehab Session)
29th May 2007 (Rehab Session) 4th June 2007 (Rehab Session)
6th June 2007 (Rehab Session) 12th June 2007 (Rehab Session)
18th June 2007 (Day) 20th June 2007 (Rehab Session)
Du
ratio
n (
mill
iSe
con
ds)
Resting – Parasympathetic/vagal tone active Exercise – Sympathetic > Parasympathetic
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Phase 1 clinical trial, summary
Derived from accelerometer signal: Sit to Stand transition duration Metabolic expenditure Walking speed (6MWT) Walking durations Gait pattern Sleep-wake patterns Activities of Daily Living (ADL) Adverse events such as falls
Derived from ECG signal: Heart Rate distribution Heart Rate Variability (HRV)
and various derivatives (such as RMSSD)
Respiratory rate
Set of clinically relevant measures to assess patient’s condition during cardiac rehabilitation
Patient R1RC data
Good
Bad
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Human Factors
Unacceptable
Poor
Average
Good
Excellent
Comfortness of monitor on waist
Comfortness ECG leads
Trial satisfaction
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Human Factors
No
Sometimes
Yes
Disruption toNormal activities?
Wear monitors During sleep?
Did wearing monitorEncourage in settingexercise goals?
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Future works
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
CAP phase 2 (2008): objectives
Establish a sustainable and comprehensive home-based care process assisted with IT solutions and show its benefits compared to
conventional approaches through a randomized controlled clinical trial
Create new clinical information on the behavioural and exercise patterns of the home-care patients through dynamic analysis of free living
unconstrained physiological data
To develop data analysis tools and a software framework to process clinically relevant information from the home-monitoring systems.
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
Phase 2, Clinical study setupPatient Consent
Test Group 2
Randomization
Test Group 1Control Group
Pre- assessment of outcome measures
Evaluation, analysis, reporting
Hospital rehabilitation
without IT, N=80
Test Group 3Hospital
rehabilitation using IT, N=80
Home-based care without IT
N=80
Home-based care using IT
N=80
Post- assessment of outcome measures Cos
t-effe
ctiv
enes
s an
alys
isSite1 Site2
No rehabilitation- self care, N=80
Test Group 4
6 months follow-up
Drop out
Evaluation, analysis, reporting
CSIRO. 2nd International Conference on Pervasive Computing Technologies for Healthcare, Tampere, Finland. 2008
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Thank you
e-Health Research Centre/ICT Centre
Phone: +61 7 3024 1651Email: niranjan.bidargaddi@csiro.auWeb: http://e-hrc.net/cap/index.html