Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan CNCF 8-10...

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Assistance PubliqueHôpitaux de Paris

Disease management and telephone monitoring

Plan

CNCF 8-10 octobre 2009

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Plan

• Disease Management dans l’insuffisance cardiaque

• Disease Management dans la maladie coronaire

• Avantages et limites des formes de Disease Management

• ConclusionCNCF 8-10 octobre 2009

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Heart failure management programmes

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008

Class of recommendation I, level of evidence A

-Heart failure management programmes are recommended for patients with HF recently hospitalized and for other high-risk patients.

-It is recommended that HF management programmes include the following components shown (Table). Adequate education is essential. Remote management is an emerging field within the broader context of HF management programmes.

-Telephone support is a form of remote management that can be provided through scheduled calls from a HF nurse or physician, or through a telephone service, which the patients can contact if questions arise or symptoms of deterioration occur.

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Class of recommendation I, level of evidence A

-Telemonitoring is another form of management that allows daily monitoring of symptoms and signs measured by patients, family, or caregivers at home while allowing patients to remain under close supervision.

-Telemonitoring equipment may include recording BP, heart rate, ECG, oxygen saturation, weight, symptom response systems, medication adherence, device control and video consultation equipment—all of which can be installed in the patient’s home.

- Cardiac rehabilitation, as multifaceted and multidisciplinary interventions, has been proven to improve functional capacity, recovery, and emotional well-being, and to reduce hospital readmissions.


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-The meta-analyses (> 8000 Pts) demonstrated that home-based follow-up or follow-up in a clinic setting significantly reduced hospitalization. The risk reduction ranged between 16 and 21%. Mortality is also significantly reduced.

-The most recent meta analysis of 14 randomized trials involving 4264 patients incorporating sophisticated models of remote HF management demonstrated 21 % significant reduction in the risk of a HF-related admission and 20% of all-cause mortality.

-HF management programmes are likely to be cost-effective in that they reduce hospital readmissions and can be established on a relatively modest budget.

-It has not been established which of the various models of care is optimal. Both clinic- and home-based models seem to be equally effective.


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No in groupNo with event/

Telemonitoring or structured telephone support programmes for patients with chronic heart failure : meta-analysis (all cause mortality)

Test for heterogeneity : 2 = 2.22, df = 4,P = 0.70, l 2 =0%

0.62 (0.45 to 0.85)21.25362445Subtotal (95 % Cl)

Telemonitoring

0.80 (0.69 to 0.92)100.00Test for overall effect : 2 = 2.93, P = 0.003

Test for overall effect : 2 = 1.88, P = 0.06

Test for heterogeneity : 2 = 6.41, df = 8,P = 0.60, l 2 = 0%

0.85 (0.72 to 1.01)78.7517771765Subtotal (95 % Cl)

Structured telephone

Relative risk (random) (95 % CI)

Weight

(%)

Relative risk

(random) (95 % CI)

Control group

Treatment group

Study

01. 02 05 1 2 5 10Favours treatment Favours control

Clark RA. Br Med J. 2007;334:942.

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Telemonitoring or structured telephone support programmes for patients with chronic heart failure : meta-analysis (all cause admission to hospital)

01. 02 05 1 2 5 10

0.98 (0.84 to 1.15)

Telemonitoring

0.95 (0.89 to 0 1.02)

0.94 (0.87 to 1.02)




Test for heterogeneity : 2 = 2.22, df = 4,P = 0.70, l 2 =0%

20.15197244Subtotal (95 % Cl)

100.00Test for overall effect : 2 = 0.21, P = 0.83


Test for heterogeneity : 2 = 4.78, df = 6,P = 0.57, l 2 0%

79.8516221578Subtotal (95 % Cl)

Weight

(%)

Relative risk

(random) (95 % CI)

Control group

Treatment group

Study

Favours treatmentFavours control

Clark RA. Br Med J. 2007;334:942.

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Telemonitoring or structured telephone support programmes for patients with chronic heart failure : systematic review and meta-analysis

01. 02 05 1 2 5 10

0.62 (0.45 to 0.85)

Telemonitoring

0.80 (0.69 to 0.92)

0.85 (0.72 to 1.01)




Test for heterogeneity : : 2 = 2.22, df = 4,P = 0.70, l2 = 0%

21.25362445Subtotal (95 % Cl)

100.00Test for overall effect : 2 = 2.93, P = 0.03


Test for heterogeneity : : 2 = 6.41, df = 8,P = 0.60, l 2 =0%

78.7517771765Subtotal (95 % Cl)

Weight

(%)

Relative risk

(random) (95 % CI)

Control group

Treatment group

Study

Favours treatmentFavours control

Clark RA. Br Med J. 2007;334:942

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Recommended components of HF management programmes

-Multidisciplinary approach frequently led by HF nurses in collaboration with physicians and other related services

-First contact during hospitalization, early follow-up after discharge through clinic and home-based visits, telephone support, and remote monitoring

-Target high-risk, symptomatic patients

-Increased access to healthcare (telephone, remote monitoring, and follow-up)

-Facilitate access during episodes of decompensation


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Recommended components of HF management programmes

-Optimized medical management

-Access to advanced treatment options

-Adequate patient education with special emphasis on adherence and self-care management

-Patient involvement in symptom monitoring and flexible diuretic use

-Psychosocial support to patients and family and/or caregiver


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Dickstein K. Eur Heart J 2008; 29:2388–2442

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Plan





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Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired,

cluster-randomised controlled trial

Wood DA. Lancet 2008; 371: 1999–2012

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EUROACTION preventive cardiology intervention programme in hospital and general practice

-In hospitals and general-practice centres, cardiologists and nurses recruited eligible patients and their families (open in GP).

-Multidisciplinary assessment of lifestyle, risk factors, and drug treatment by a nurse, dietitian, and physiotherapist, couples attended at least eight sessions—one every week—in which they were assessed by each member of the team (nurse, dietitian, and physiotherapist).

-The cardiologists initiated and uptitrated the cardioprotective drugs

-The nurses monitored risk factors and adherence to drug treatments at each session.

-At 16 weeks,patients and their partners were reassessed by the whole team and a report was sent to their family doctors.



Wood DA. Lancet 2008; 371: 1999–2012

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EUROACTION preventive cardiology intervention programme in hospital and general practice

-The nurses assessed the smoking status, health beliefs, and history of tobacco smoking, and previous attempts to quit.

-Patients and their families’ knowledge and attitudes to diet were assessed by the dietitian (in hospital) or nurse (in general practice).

-To achieve a 30–45 min of moderate intensity activity, four to five times a week as a family, the physiotherapist (in hospital) or nurse (in general practice) assessed habitual and physical activity patterns, functional capacity, and other factors that affected activity participation by families

-Nurses monitored the blood pressure and concentrations of cholesterol and glucose in all patients, and reviewed the results with physicians who treated the patients appropriately to achieve targets

-In the hospitals, nurses coordinated a rolling programme of eight workshops—one a week—for coronary heart disease, cardiovascular risks.



Wood DA. Lancet 2008; 371: 1999–2012

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Tabagisme : zéroTabagisme : zéro

Régime :• Graisses saturées < 10 %• Fruits et légumes > 400 g/j• Poissons > 20 g/j• Huile de poissons > 3 / sem

Régime :• Graisses saturées < 10 %• Fruits et légumes > 400 g/j• Poissons > 20 g/j• Huile de poissons > 3 / sem

Activité physique :• 30 à 45 minutes d’activité physiques à 60-75 % de FMT 4-5 fois/semaine

Activité physique :• 30 à 45 minutes d’activité physiques à 60-75 % de FMT 4-5 fois/semaine

Pression artérielle :• < 140/90 mmHg (<130/85 si diabète)

Pression artérielle :• < 140/90 mmHg (<130/85 si diabète)

Lipides :• cholestérol T > 5 mmol/l•LDL-c < 3 mmol/

Lipides :• cholestérol T > 5 mmol/l•LDL-c < 3 mmol/

Diabète :• Contrôle de glycémie

Diabète :• Contrôle de glycémie

Wood DA. Lancet 2008; 371: 1999–2012

EUROACTION - Objectifs

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54

20

0

20

40

60

p = 0,002p = 0,002

InterventionIntervention Prise en charge conventionnellePrise en charge conventionnelle

+ 36 % (+ 20 % to 51 %)+ 36 % (+ 20 % to 51 %)

50

22

0

20

40

60

p = 0,001p = 0,001

+ 29 % (+ 11 % to 48 %)+ 29 % (+ 11 % to 48 %)

Proportion de patients atteignant les objectifs des recommandations européennes pour l’activité physique

Proportion de patients atteignant les objectifs des recommandations européennes pour l’activité physique



HôpitalHôpital Pratique de villePratique de ville

Wood DA. Lancet 2008; 371: 1999–2012

EUROACTION

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19

13

0

20

p = 0,28*p = 0,28*

+ 6 % (- 7 % to +19 %)+ 6 % (- 7 % to +19 %)

16

7

0

20

p = 0,005*p = 0,005*

+ 10 % (+ 6 % to +15 %)+ 10 % (+ 6 % to +15 %)

* Patients avec BMI > 25 kg/m²* Patients avec BMI > 25 kg/m²

Proportion de patients atteignant les objectifs de réduction pondérale > 5 %

Proportion de patients atteignant les objectifs de réduction pondérale > 5 %


Prise en charge conventionnellePrise en charge conventionnelle

InterventionIntervention


Wood DA. Lancet 2008; 371: 1999–2012

EUROACTION HôpitalHôpital Pratique de villePratique de ville

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65

55

40

60

80

p = 0,04p = 0,04

+ 10 % (+ 0,6 % to +20 %)+ 10 % (+ 0,6 % to +20 %)

58

41

0

20

40

60

80

p = 0,03p = 0,03

+ 17 % (+2 % to +32 %)+ 17 % (+2 % to +32 %)

Proportion de patients atteignant les objectifs des recommandations européennes pour la pression artérielle

Proportion de patients atteignant les objectifs des recommandations européennes pour la pression artérielle


Prise en charge conventionnellePrise en charge conventionnelle

InterventionIntervention


EUROACTION

Wood DA. Lancet 2008; 371: 1999–2012


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93

76

52

21

86

7468

51

19

67

0

20

40

60

80

100p = 0,004p = 0,004

p = 0,02p = 0,02

p = 0,98p = 0,98

p = 0,51p = 0,51

Anti-agrégants plaquettaires


Betabloquants

Betabloquants

IECIEC StatinesStatines

p = 0,002p = 0,002

AnticalciquesAnticalciques

13

33

17

29

9

36

10

19

14

20

8

23

0

20

40 p = 0,07p = 0,07

p = 0,90p = 0,90

p = 0,03p = 0,03

p = 0,21p = 0,21

p = 0,03p = 0,03


Proportion de patients sous traitement cardio-protecteurProportion de patients sous traitement cardio-protecteur



DiurétiquesDiurétiques Betabloquants

Betabloquants

IECIEC StatinesStatinesAnticalciquesAnticalciques

EUROACTION

Wood DA. Lancet 2008; 371: 1999–2012


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Plan





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Advantages and disadvantages of different models of HF programmes

Advantages Disadvantages

Clinic visits

-Convenient with medical expertise, facilities and equipmentavailable.-Facilitates diagnostic investigation and adjustments of treatmentstrategy.

Frail, non-ambulatory patients not suitable for out-patient follow-up

Home care

-Access to immobile patients-More reliable assessment of the patient’s needs, capabilities and adherence to treatment in their own home environment-Convenient for a follow-up visit shortly after hospitalization.

-Time consuming travel for the HF team-Transportation and mobile equipment required-Nurses face medical responsibilities alone and may have difficulty contacting the responsible physician.

Conn VS. Journal of Cardiology xx (2008)

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Advantages and disadvantages of different models of HF programmes

Advantages DisadvantagesTelephonesupport

-Low cost, time saving and convenient both for the team and thepatient.

-Difficult to assess symptoms and signs of heart failure and no tests can be performed-Difficult to provide psychosocial support, adjust treatment and educate patients.

Remotemonitoring

-Facilitates informed clinical decisions-Need is increasing as care shifts into patients’ homes-New equipment and technology becoming rapidly available.

-Requires education on the use of the equipment-Time-consuming for HF team-Difficult for patients with cognitive disability-Most helpful measurements not known.

Conn VS. Journal of Cardiology xx (2008)

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Conclusion

• Intérêt de la mise en place d’une plateforme téléphonique de suivi des patients insuffisants cardiaques ou coronariens selon le modèle du Disease Management et des critères et objectifs bien définis

• Mobilisation des cardiologues de ville et rapprochement ville – hôpital - établissements de santé privés

• Information et formation des patients

• Évaluation simple

• Dispositif à un coût modéré

CNCF 8-10 octobre 2009

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Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan CNCF 8-10...

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