Telemedical Disease Management in Europe: What are the Chances and Risks

Dr. med. Andy Fischer , Swiss Center for Telemedicine MEDGATEMed _e_Tel, Luxembourg, 18.04.2008

Disease Management Definition(Disease Management Association of America, DMAA)

Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant

Telemedical Disease Management:Today up to 10 described Intervention Models

AnamnesisClinical signs, Symptoms

Studies

Diagnosis

Risk-Stratification

Therapy-Plan

Follow-up goals

Adjustment phase Monitoring phase

New clinical symptoms Stable Situation

Follow-upBiomarker

Doctor

Follow-upBiomarkerSelf management

Doctor

Telebiomonitoring/Feedback

Recruiting

Basic investigation and Treatment planning

Basic training

Cont. therapy adjustment

OBC Management

24h ServiceHome visits by nurses

Cooperation GP

Peer Groups

Telemedical Management Concepts

Chances

Today: Medical Care for each patient by a Health Care Provider in a 1:1-setting

Number of patients per practicing Medical Doctor (Decline of 2.4% p.a. from 1970-2005)

Quelle: Das Gesundheitswesen der Schweiz, Pharma Information

488

1'127

1

10

100

1'000

10'000

1970 1980 1990 2000 2010 2020 2030 2040 2050 2060 2070 2080 2090 2100 2110 2120 2130 2140 2150 2160 2170 2180 2190 2200

4

In 200 years 1 MD per family!

In the Future: Medical Care for each patient in a 1:n-setting: Equal Medical Requirements

The „Big Five“ are the same in Europe:Medically there are no differences

Heart failure

COPD

Asthma bronchiale

Diabetes mellitus

Hypertension

„Diabetes kit“

We have promising results but no evidence yet (I)

Heart failure• Remote monitoring programmes reduced the rates of admission

for chronic heart failure and all cause mortality Clarc RA et al. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. BMJ 2007; May 5; 334(7600):942

• 1-year home-based telemanagement (HBT) reduced hospital readmission and costs in chronic heart failure patients Giordano A. et al. Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure. Int. J. Cardiol. 2008 Jan 25 Epub ahead of print

Hypertension• Telecommunication service with home service of automatic

transmission of blood pressure data showed efficacy in reducing the mean arterial pressure of patients with established hypertension Rogers MA et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized controlled trial. Ann. Intern Med. 2001 Jun 5;134(11):1024-32

• Telemonitoring of BP over a 12-month period resulted in clinically and statistically significant reductions in systolic BP Artinian NT et al. Effects of nurse-managed telemonitoring on blood pressure at 12-month follow-up among urban African Americans. Nurse Res. 2007 Sept.-Oct;56(5):312-22

We have promising results but no evidence yet (I)

Diabetes mellitus• Telemedicine Diabetes Disease Management Program:

Reduction of over all charges, decrease in hospital admissions and emergency room encounters as well as improvements in quality of life Cherry JC et al. Diabetes Disease management program for an indigent population empowered by telemedicine technology. Diabetes Technol Ther 2002; 4 (6): 783-91

• Diabetes education via telemedicine and in person was equally effective in improving glycemic control and both methods are well accepted by patients Izquierdo RE et al. A comparison of diabetes education administered through telemdicine versus in person. Diabtes Care. 2003 Apr; 26(4):1002-7

COPD / Asthma bronchiale• Effects of telemonitoring: Decrease in hospital admission rates

and in total number of exacerbations. Trappenburg JC et al. Effects of telemonitoring in patients with chronic obstructive pulmonary disease.Telemed J E Health. 2008 Mar; 14 (2): 138-46

• Spirometry self-testing by asthma patients during telemonitoring is comparable to those under supervision of medical professionals. Internet-based home asthma telemonitoring can be successfully implemented in a group of patients with no computer background Finkelstein J. et al. Internet-based home asthma telemonitoring: can patients handle the technology? Chest. 2000 Jan;117(1):148-55

Challenges and open questions

The balance of risk determines the insurers’ incentive to provide DMP

0

100

200

300

400

500

600

700

19-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

66-70

71-75

76-80

81-85

86-90

91+

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Mean

Costs per insured and month (CHF)

risk groups: age and sex

Redistribution

Risk adjustment formula

The risk adjustment formula computes risk-related compensations. The variables included in the formula differ by country. For example:• Belgium: socio-economic, disability, diagnosis of

invalidity, eligibility of social exemption, chronic illness• Germany: age, gender, disability, registration in a

certified DMP, and high-costs pooling• Netherlands: age, gender, urbanization, disability,

pharmacy-based cost groups, and diagnostic cost groups

• Switzerland: age, gender, and regionThe more powerful this formula is, the more incentive insurers have to offer disease management programs

Do TDMP really save costs?

Disease progression

Therapy costs

Without Disease

ManagementProgram

With DiseaseManagement

Program

Improved Compliance Reduction of risk group

Improved medical therapy

Decrease of costs

Increase of costs

Increase of costs

Delay of disease progression and reduction of complications

Decrease of mortality

Which intervention models have which advantages?

AnamnesisClinical signs, Symptoms

Studies

Diagnosis

Risk-Stratification

Therapy-Plan

Follow-up goals

Adjustment phase Monitoring phase

New clinical symptoms Stable Situation

Follow-upBiomarker

Doctor

Follow-upBiomarkerSelf management

Doctor

Telebiomonitoring/Feedback

Recruiting

Basic investigation and Treatment planning

Basic training

Cont. therapy adjustment

OBC Management

24h ServiceHome visits by nurses

Cooperation GP

Peer Groups

How shall we recruit patients?

Method of recruiting Success of recruiting

Data mining by the insurer and selective addressing of the target customer

2.9%

Information letter from the insurer 3.0%

Information letter to the general practitioner

4.0%

Challenges in the following years

Guidelines, Best Practice and Quality Assurance for TDMP

Evidence for the use of the individual intervention models (multicentre studies)• Medical outcome• Cost effects

Strategy for solving the problem of recruitment

The single national players are too small to answer these questions on their own

European and International Collaboration

Even Europe has remote valleys...