TMTT en VMD. Utilidad del modelo CAIDERbrn.cat/wp-content/uploads/2018/09/04-Anton_TMTT... ·...
Transcript of TMTT en VMD. Utilidad del modelo CAIDERbrn.cat/wp-content/uploads/2018/09/04-Anton_TMTT... ·...
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Conflicto de intereses
• Beca Linde; curso VM Sat Pau
Linde
• Advisory board; Res Med
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Indice (10-15´)
• VMD hoy, Icare Survey
• TMTT en VMD
• Modelo CAIDER
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28,02
116,259
115 115
258297
267
591
1086
10,11 29 29 34
-200
0
200
400
600
800
1000
1200
1400
1978 1983 1988 1993 1998 2003 2008 2013 2018
Tasa
uso
/1
00
.00
0 h
ab.
Año
OCD 1978
CPAP 1992
VMD 1994
Lineal (OCD 1978)
Exponencial (CPAP 1992)
Lineal (VMD 1994)
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Zilberg M et al.BMJ Health Services Research 2008; 8: 242
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NIV Clinical Working Habits
(Spain and Portugal)
2016
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©ResMed 2014 I
55%
Country Age Range
Medical Speciality
Job Title
Region/Province
Gender
Sample: 36
57%
43%
Alicante 3%
Barcelona 22%
Burgos 3%
Cáceres 3%
Cádiz 3%
Cantabria 6%
Granada 3%
Las Palmas 3%
Madrid 25%
Murcia 3%
Pontevedra 3%
Asturias 3%
Sevilla 11%
Valencia 6%
Zaragoza 6%
* A physician may have several specialities
Respondents Split: Spain
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©ResMed 2014 I
45%
33%
67%
Sample: 30
Braga 17%
Castelo Branco 3%
Coímbra 10%
Faro 7%
Lisboa 17%
Porto 43%
Vila real 3%
Country Age IntervalJob TitleGender
* A physician may have several specialities
Medical Specialty Region/Province
Respondents Split: Portugal
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©ResMed 2014 I
3.2.1. What is the profile of these patients?
Spain Sample: 36
Portugal Sample: 30
Spain
Portugal
Global (Spain + Portugal)
Global Sample: 66
Patients average percentage with each profile
“Obesity Hypoventilation Syndrome”, “Neuromuscular Disorders”
and “Obstructive Diseases” are the 3 main diseases for home NIV
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©ResMed 2014 I
% of patientsSpain Sample: 36 Portugal Sample: 30
Total Sample: 66
3.2.2. What is the ventilation profile of these home NIV patients?
7 out of 10 patients treated with NIV receive less than 16h
ventilation.
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©ResMed 2014 I
Spain Sample: 36 Portugal Sample: 30
Total Sample: 66
4.5. After implementing a long-term NIV, when do you re-evaluate the patient?
There isn’t a specific pattern for re-evaluations,
there is a well balanced time period distribution.
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©ResMed 2014 I
2.7 Once the patient leaves the hospital and starts NIV at home, describe the control and management of
these patients at home.
Global
(Spain + Portugal)
Spain
Portugal
Spain Sample: 36
Portugal Sample: 30
Total Sample: 66
Mainly pulmonologists are the ones managing home NIV. HCPs
also play an important role but to a lesser extent.
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©ResMed 2014 I
2.9 Do your patients receive home care attention regarding their NIV treatment?
Sample: 36 Sample: 30
Total Sample: 66 - It’s not telemedicine but consultations
are made by phone
- Using GPs support
- Specific program dealing with severe
Cardio-Respiratory Insufficiency patients
depending on NIV
- Always in the scope of home respiratory
care services
Home care NIV monitoring is perceived to be
part of the service provided by HCPs.
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©ResMed 2014 I
2.11 How is the home NIV monitored in your workplace?
Spain Sample: 36 Portugal Sample: 30Total Sample: 66
In Portugal, NIV is usually monitored through data downloadIn Spain it’s usually monitored in the hospital
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©ResMed 2014 I
2.12 When parameters have to change, how are these changes performed?
Sample: 36 Sample: 30
Total Sample: 66- In the NIV consultancy by a doctor and the
provider company nurse, evaluating the
changes together.
- Outpatient entry (sleep room).
- Hospitalisation for very particular cases.
- Ratification in NIMV follow-up consultancy
Global (Spain+Portugal) Spain Portugal
There are two main ways in which home NIV parameters are changed: Physician in the external consultancy/day hospital (Spain) requesting the changes to HCP(Portugal).
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SP sample: 36 PT sample: 30
Spain PortugalGlobal (Spain + Portugal)Iberia sample: 66
5.5. In relation to monitoring
-Telemedicine will play an important role in the future
-New ventilation devices will modify their own set parameters constantly in
order to get a standard prefixed ventilation
Strong understanding that equipment software improvements will
lead to reliable tools, enabling patient monitoring and will detect
and correct asynchronies
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Spain Sample: 22 Portugal Sample: 11
Spain PortugalGlobal (Spain + Portugal)Global Sample: 33
5.6.4 How can telemonitoring improve the therapy results?
Telemonitoring can improve the therapy results, by “evaluating patient-
ventilator interactions” and “using NIV telemonitoring in real life”
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1.La TM no parece ser un tema prioritario
para los profesionales prescriptores
2. Las empresas de servicios y TR están
tomando un papel clínico fundamental en
el seguimiento de pacientes con VMD
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Ambrosino N, et al. Eur Respir J 2016; 48: 648-663
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Ambrosino N, et al. Eur Respir J 2016; 48: 648-663
TMTT, escenarios
• Enfermedades neuromusculares
• EPOC y VMD
• Retirada de VM
• SAOS (CPAP)
• Fisioterapia respiratoria (TT)
• Curas paliativas (TMTT)
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Kessler, el al. Eur Respir J 2018; 51: 1701612
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Kessler, el al. Eur Respir J 2018; 51: 1701612
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Kessler, el al. Eur Respir J 2018; 51: 1701612
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Ambrosino N, et al. Eur Respir J 2016; 48: 648-663
TMTT, características
del sistema
• Sincronicidad en el tiempo: si, no
• Configuración: privada, internet, RS
• Conectividad: Wired/wireless
• Interoperatividad
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Ambrosino N, et al. Eur Respir J 2016; 48: 648-663
TM, ejemplos
• Llamada telefónica
• Videoconferencia
• Transmisión de datos clinicos/respirador
• Plataforma wew, app
• Mixtos
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TT, ejemplos
• Llamada/videoconferencia
• Plataforma wew
• Telemodificación de parámetros
ventilatorios, programa específico
(modem)
• Automático
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Hwang D, et al. Am J Respir Crit Care Med 2018; 197: 117-126
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Ambrosino N, et al. Eur Respir J 2016; 48: 648-663
TMTT, legalidad
• Confidencialidad de datos
• Responsabilidades clínicas
• Papel de la empresa suministradora
• Teletratamiento
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Ambrosino N, et al. Eur Respir J 2016; 48: 648-663
TMTT, limitaciones y
oportunidades
• Coste/beneficio?
• Interoperatividad
• Disponibilidad y respuesta inmediata
• Relación de los diversos profesionales y
recursos asistenciales
• Adaptación domiciliaria a VMD/soporte
vital
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TMTT y la VMD hoy
• TM universal
• TM en soporte vital
• TT en pacientes seleccionados
• Papel protagonista de las empresas
• Necesidad de mejorar la coordinación
asistencial
• Asignación de funciones
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Programas especiales
seguimiento y monitorización de
pacientes
Apoyo a las consultas médicas
Tratamientos domiciliarios y en
centros asistenciales
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Centro para la Atención Integral De Enfermedades
Respiratorias (CAIDER), objetivos
1-Atención completa e integral del paciente
con VMD
2-Optimizar recursos (seleccionar atención
a domicilio)
3-Integración real de profesionales
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CAIDER, actividades
• Atención integral y compartida (agenda común)
– Profesional sanitaria (enfermería y médico)
– Técnica
• Otras funciones
– Atención domiciliaria (apoyo al alta)
– Call center
– Telemonitor/Telemedicina center
– Coordinación atención domiciliaria
– Educación grupal
– Docencia
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CAIDER, personal
• Técnico (1), Linde
• Personal sanitario (St Pau-Linde)
– 2 enfermeras fijas
– 1 enfermera (invierno; Linde)
– 1 neumologo (invierno; Linde)
Equipo VM: 3 neumologos y una FT
con permanente disponibilidad presencial
y telefónica. Apoyo del MG fuera de horario
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TMTT y CAIDER hoy
• TM
– Llamada telefónica (demanda, control)
– Asincrónica (volcado), universal
• TT
– Indicación telefónica
– Ajuste en domicilio (empresa)
TMTT: AirView, experiencia piloto
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AirView Dashboard –
Panel de cumplimiento
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Leyenda de iconos
Uso > 4h Uso < 4h
Fuga alta
IAH alto
Fuga e IAH altos
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53
AirView – Informes estadísticos
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Pulsioxímetria, fr, volumen corriente…
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Cambio de parámetros remoto
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Borel, et al. Thorax 2015; 70: 284-285
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TMTT, AirView, Catalunya
• Total 700 ptes
• No conexión hospitalaria
• Empresas
– Oxigen salud
– Oximesa
Fuente: Res Med 2018
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TMTT y CAIDER, retos futuros
• Monitorización básica universal
• Monitorización ampliada selectiva
• Teletratamiento selectivo
• App , videoconferencia, plataforma wew
• Estudios de sueño (PLG de VM +capnografía) a
domicilio
• Visita hospitalaria a domicilio (GSA, eco, analitica,
espiromería, endoscopia…)
• Integración y compatibilidad de programas
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Conclusiones
• La TM básica debería ser ya universal. Las empresas de TR
deberían ser responsables de la misma
• La TM ampliada debería poder aplicarse a pacientes con soporte
vital y durante algunas adaptaciones a VMD. Los prescriptores de
TR deberían ser sus responsables.
• Es preciso conocer el nivel de TMTT adecuado a cada paciente
• El TT puede ser útil en pacientes seleccionados
• La visita hospitalaria a domicilio es ya una realidad
• Los modelos asistenciales mixtos (CAIDER) pueden ser una
buena solución asistencial
• Los costes y la integración de sistemas siguen siendo una barrera
para la TMTT de pacientes con VMD
• Existen dudas legales que deberían resolverse