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-upBiomarker
Self 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 region
The 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-upBiomarker
Self 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...
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