Telemonitoring for Heart Failure Evidence & Practice Professor John G.F. Cleland Department of Cardiology, Hull York Medical School University of Hull Kingston-upon-Hull UK Conflict of Interest: I have received honoraria and/or research support from Philips, Bosch, GE, Alere and St Jude

Audit Survival of Patients with a Primary Discharge Diagnosis of Heart Failure England & Wales About 1 million people affected in the UK ~450,000 admissions per year (65,000 in first diagnostic position) N = 19,240 (about 30% of all expected cases) Median age 79 years <65 years ~3, years ~4, years ~7,000 >85 years ~5,000 Cleland et al HEART 2011

TeleHealth Why is it Likely to Become Essential? 1.More patients with long-term conditions –More older people –Longer survival with illness –Better primary & secondary prevention 2.Fewer professionals to provide health-care –Smaller proportion of population of working age –Loss of migrant workforce as economies rival UK –Better paid or more attractive / less stressful jobs 3.More monitoring required –Higher expected standards of care –More treatments that need to be monitored –More things that can be monitored

TeleHealth Why is it Likely to Become Essential? 4.Patient preference & Convenience –Patients, Carers, Staff 5.Reduced Costs –Buildings, Staff, Transport 6.Environmental impact –Transport –Parking –Buildings 7.Better record keeping !!!!!!!!!!!!!!!!!!!!!!!

The Opportunity of Chronic Illness Most patients soon learn routines –Or have relatives / friends that do Most patients are interested in maintaining or improving their health Patients are an inexpensive but neglected health- care provider opportunity Invest in patients –Education –Active Partnership –Empowerment

TeleHealth - What Might it Achieve? Ultimate Intermediate

TEN-HMS The Trans-European Network–Home-Care Management System Patients about to be discharged from hospital after an exacerbation of chronic heart failure (Published JACC 2005) 54% of Patients Aged >70 years

p < 0,05 Mortality Cleland et al JACC 2005 TEN-HMS Reduction in Mortality NTS or HTM v UC Absolute 16.4% Relative 36 % No reduction in hospitalisation Shortening of hospital stay with HTM

TEN-HMS much safer safer no change more anxious much more anxious How do you feel about your health since receiving Telemonitoring? Undef.

TEN-HMS 120 Days 240 Days % *** *** differences between HTM and other groups. No difference between UC and NTS Achieving Therapeutic Target 240 Days Patient Clinical Status

TEN-HMS: Total Patient Contacts Contacts Per 1,000 Days Alive and Out of Hospital # # under-reporting of events likely in this group P<0.01 HTM v NTS

Structured Telephone Support n = 5,563 (Cochrane Review) Mortality Inglis et al 2010 HR 0.88 ( ); p=0.08 All-Cause Hospitalisation HR 0.77 ( ); p< New Trials Tele-HF TEHAF

Home Telemonitoring n = 2,710 (Cochrane Review) Inglis et al 2010 Mortality HR 0.66 ( ); p< All-Cause Hospitalisation HR 0.91 ( ); p=0.02 New Trials TIM-HF COMPASS CHAMPION SENSE-HF

Major Problems with RCTs of Service Delivery Technology differs –Telephone Support including Voice Activated Systems –Physiological telemonitoring Implanted or Not Care usually improves if it is the focus of attention –Effect in control group –Beware: before v after comparisons Lack of integration into existing services –Puts innovative interventions at a disadvantage Selection of patients at low risk with modern treatment

Percent of Days Lost To Hospitalisation or Death 8.9% 8.4% 37.0%21.3% 22.6% TEN-HMS (15 months) TIM-HF (26 months) TEHAF (12 months) 4.5% 6.1%

What Have We Done for TeleHealth in Hull? Established –International reference site (LifeLab) for HF epidemiology & research –International reputation for research excellence in telehealth –A model telehealth service Grants –TEN-HMS –Four FP7 grants relating to telehealth & heart failure –EDRF Industry Partnerships –Philips, GE, Bosch, Cardiomems, St Jude + others Publications –>500 PubMed citations in related fields –TEN-HMS, Concept Papers, Editorials –Systematic Reviews (EJHF, BMJ & Cochrane) Inventions –Dynamic risk analysis –Complex management algorithms

The Hull Model for TeleHealth Non-Invasive Home Monitoring Community TeleKiosks Screening Long-Term Conditions Device Implant HeartCycle Heart Failure Post-MI Rehab MEMS-based pressure sensor

Heart Failure Discharge Nurse Heart Failure Telemonitoring Nurse Community Heart Failure Specialist Nurses Patients in HospitalPatients at Home Voluntary Patient-Support Organisations Services for Patients with Heart Failure The Kingston-upon-Hull Model Specialist Clinics Family Doctor (NT-proBNP)

Cost-Effectiveness of TeleHealth (Hull)

Where Next? Interactive TV New monitoring technologies Implanted devices More intelligent use of the patient data Investing in patients as health-care providers Centre for Telehealth

The Hull Heart Failure Life-Lab 30,000 patient-years of follow-up Largest, Longest Follow-up, Epidemiologically-Representative Cohort of Heart Failure in the World Rich in phenotyping, serial biomarker and outcome data

Shift from crisis detection to health maintenance Health Maintenance Envelope –More optimistic –Better way to engage/motivate patients –More active management –More activity likely to hold actors attention –Clinical calibration –Addresses the issue of false alerts Personalised Careplan –Treatments –Ideal monitoring envelope HeartCycle Programme

Patient / Carer Communication System Monitor Analysis Health-Care Provider Secondary Loop Primary Loop 70% of Care Decisions Motivation: feedback on measures and trends, what they mean and what to do about them Education: on healthy lifestyle, reasons for treatments, self management Intelligent, integrated, multi- measure (time & type) personalised analysis

Opportunities for TeleHealth Change in Philosophy Investment in patients (rather than experts) Patients as first and possibly main tier of healthcare Communication Patient, community health & social services, specialists Common health record Checked (at least in part) by the patient themselves Decision support analysis Patient & professional support Research potential +++ Healthcare innovation Pharmaceutical industry especially Route to faster (ethical) adoption Convenience & Preference Patient, Carer, Health Professional Environmental impact

Conclusion The first era of telemonitoring is over Time to move from –Crisis Detection to –Health Maintenance