Mobile Systems for Chronic Diseases Telemonitoring:Current Status

Introdução à Medicina 08/09

Class no.5

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DEFINITION

Telemonitoring: collection, record and transmission of clinical data between a patient at a distant location and a healthcare provider via remote telecommunications. It is provided on an outpatient basis.

(http://www.homehealthquality.org/shared/content/hhqi_campain/bpip_tm/Therapy.pdf)

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Chronic diseases: Permanent disease, which leave residual disability, caused by nonreversible pathological alteration. They require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation or care. 

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Dictionary of Health Services Management, 2nd edition

DEFINITION

Physiological data: observable or measurable characteristics of the ocular system, the respiratory system, the musculoskeletal system, the nervous system or of the blood.

(http://www.ncbi.nlm.nih.gov.sites/entrez)

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DEFINITION

In this new century medicine is facing a new challenge called TELEMONITORING

Revolution in the healthcare delivery processes

Telemonitoring allows the use of electronic equipment to observe or record physiologic processes while the patient

undergoes normal daily activities

[Mehmet R. Yuce, Peng Choong Ng, Jamil Y. Khan, Monitoring of Physiological Parameters from Multiple Patients Using Wireless Sensor Network, April 2008, Springer Science + Business Media, LLC 2008 ]

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Telemonitoring is a way of responding to new needs in home care in an ageing population

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A wide range of telemonitoring devices available, nowadays, for several diseases monitoring

Chronic diseases: the most promising applications (cardiopulmonary disease, asthma, heart failure, diabetes)

Most patients are elderly people – need to be regularly monitored (length of their disease, nature of their health condition, therapy)

Isolated areas do not have easy access to healthcare or specialized medical staff

TELEMONITORING ALLOWS

Earlier detection of abnormal health parameters

Corrective measures to be taken before more complications appear

Less frequent visits to healthcare facilities, shorter hospital stays and decrease of hospital admissions

Increased patient’s quality of life

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Cost-effectiveness

Chronic diseases telemonitoring systems allow:

• To collect part of the diagnostic's relevant information

• To gather more information with less effort

• To follow the patients closely spending less time.

[N. Oliver and F. F. Mangas, “HealthGear: a real-time wearable system for monitoring and analyzing physiological signals,” Tech. Rep. MSR-TR-2005-182, Microsoft Corporation, Red-mond, Wass, USA, 2005 ]

[Otto, C. A., Jovanov, E., and Milenkovic, E., A WBAN-based system for health monitoring at home. In 3rd IEEE/EMBS Int. Summer School, Medical Devices and Biosensors. Sept, 20–23, 2006.]

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- 500 articles about telemonitoring

- more than 93% of the publication's dates are from 2000 to the present year.

Publications indexed by Pubmed from 1990

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A simple and not very restricted search at Pubmed ...

QUERY:(telemonitoring[All Fields] OR "telemedicine"[MeSH Terms] OR

"telemedicine"[All Fields]) AND ambulatory[All Fields]

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This revels not only how recent this matter is, but also its emerging relevance

MobiHealth is an healthcare project created for the development of mobile health services and funded by the European Commission.

A patient who requires monitoring for short or long periods of time doesn't have to stay in hospital for monitoring. With the MobiHealth BAN the patient can be free to pursue daily life activities

www.mobihealth.org

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Telemonitoring Status:

Despite their potential, most telemonitoring services are still limited to the status of temporary projects without clear prospects for wider use and proper integration into healthcare system.

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There is limited evidence of the effectiveness of telemedicine services on a large scale. Awareness, confidence and acceptance still need to be strengthened.

On which chronic diseases have mobile telemonitoring systems been

used?

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OBJECTIVES Expose the scientific evidence, produced by experimental studies, supporting the use of mobile telemonitoring systems. Determine which chronic diseases have been targeted by telemonitoring of physiological data.

Analyze which types of physiological data have been monitored and transmitted in chronic diseases telemonitoring.

Identify on which healthcare effects scientific evidence exists on the advantages or disadvantages of chronic diseases telemonitoring (health improvement, system usability, patient acceptance, etc.).

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Keywords:

physiological, physiologic, process, phenomena, monitor, ambulatory, outpatients, non- hospital, telemedicine, telemonitoring, self monitoring, supervise, telesurveillance.

METHODS: Systematic Review

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D) A comprehensive literature search was conducted on Pubmed and ISI to identify relevant published articles.

METHODS: Systematic Review

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("physiological"[All Fields] OR "physiologic"[All Fields] OR physiologically[All Fields] OR process[All Fields] OR phenoma[All Fields] OR phenomal[All Fields]) AND (monitor [All Fields] OR ambulatory OR "outpatients"[MeSH Terms] OR "outpatients"[All Fields] OR "outpatient"[All Fields] OR non-hospital[All Fields] OR "monitoring, ambulatory"[MeSH Terms]) AND ("telemedicine"[MeSH Terms] OR "telemedicine"[All Fields] OR telemonitoring[All Fields] OR telemonitor[All Fields] OR "self monitor"[All Fields] OR "self monitoring"[All Fields] OR "supervise"[All Fields] OR "telesurveillance"[AllFields]).

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Research results

502502TOTAL

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Pubmed ISI Web of Knowledge

Methods

The articles obtained were subjected to a process of critical appraising according to its quality.

1st. REVISION: Revision by title and abstract 2 reviewers

- Articles excluded didn’t fit the inclusion/exclusion criteria. Any articles about mobile systems for chronic diseases telemonitoring were included.

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Inclusion/Exclusion criteria

Inclusion criteria (1)experimental studies which include direct data collection from patients(2) in humans(3) using outdoor-usable devices and (4) document scientific evidence of telemonitoring effects

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Exclusion criteria (1) do not include detailed description of the study, (2) are focused on athletes telemonitoring or (3) monitoring which does not make use of mobile systems, (4) general reviews and (5) conference and poster abstracts without study details.

Methods2nd. REVISION:

- Extensive analysis of the full article

- 2 reviewers

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- The inclusion/exclusion criteria were changed

- None of the articles excluded in the first revision would have been included in the second revision since the new criteria is a restriction of the previous one.

Inclusion criteria (1)articles written in English, (2)with full text available, (3)regarding chronic diseases telemonitoring, (4)experimental studies which include direct data collection from patients, (5)using mobile telemonitoring systems(6)those which document scientific evidence of telemonitoring effects (health improvement, system usability, etc.).

Inclusion/Exclusion criteria

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Exclusion criteria (1)do not present a detailed description of the study, (2)describes a project of a new instrument, (3) general reviews

STUDY VARIABLES:

Benefits and drawbacks (health improvement, system usability, cost-effectiveness, etc.) mobile systems for chronic diseases telemonitoribg can bring for the:

clinician patient healthcare institution

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Types of chronic disease targeted by telemonitoring

Types of physiological data monitored

Country and publication date of the article

MethodsAfter the data extraction:

Check for and identify sources of heterogeneity in results across studies

Findings/Results of individual studies are synthesised and subsequently statistically analysed in SPSS

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Percentage of included, excluded articles and those who needed a 3rd reviewer

10,92%

85,06%

4,02%

Graphic 1: Percentage of included, excluded articles and those who needed a 3 rd reviewer

Methods – Final decision

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After completing the articles revision we had:

• 7,5% of the articles included

• 92,5% of the articles excluded

Methods – 3rd Reviewer

Regarding the articles subjected to a 3rd revision:

• 68,4% of the articles were included

• 31,6% were excluded

Methods– Number of included and excluded articles by each reviewer

27 Graphic 2: Number of included and excluded articles by each reviewer

Methods

A Chi-Square test was performed in order to check if there was

any statistically significant difference between the expected and

the actual number of excluded articles per reviewer. (p=0,668)

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Methods – Frequency of use of each inclusion criteria

29 Graphic 3: Frequency of use of each inclusion criteria

Methods – Frequency of use of each exclusion criteria

30 Graphic 4: Frequency of use of each exclusion criteria

ResultsProfile of Chronic Diseases Telemonitoring Studies

31 Table 1: Profile of chronic diseases telemonitoring studies

RESULTS

  DIABETES CARDIAC DISEASES

HYPERTENSION TOTAL

How many?      Total numbers of studies

5 5 3 13

Where?      USA 3 1 2 6Australia 1 2 - 3Canada - 1 1 2UK - 1 - 1Norway 1 - - 1When?      1996 - 1 - 12004 2 - - 22005 2 1 - 32006 1 - - 12007 - 2 3 52008 1 1

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ResultsProfile of Chronic Diseases Telemonitoring Studies

With whom?      

Patients with cardiovascular disease - 5 -

               -      Adults hospitalized with heart failure. - 1 -

- Enrolled in health centers. - 1 -

               -      Recently implanted with CRT-D. - 1 -

               -      With symptomatic chronic heart failure                        and left ventricular ejection.

- 1 -

               -      Undergoing cardiac rehabilitation. - 1 -

Patients with Diabetes 3     

- Young patients and their parents. 1 - -

- Young patients using insulin for at least one year.

1 - -

- Wide-ranging patients with type I Diabetes 1 - -

- Adult patients with  type II Diabetes and                       uncontrolled blood pressure.

- - 1

Patients with uncontrolled hypertension - - 2

  DIABETES CARDIAC DISEASES

HYPERTENSION

ResultsOverview of Research Designs

33 Table 2: Overview of research designs

  DIABETES CARDIAC DISEASE

HYPERTENSION TOTAL

 Number of studies  5 5 3 13 Type of design, n (% within disease)    Randomized trial with control group  1 (20) 1 (20) 2 (66) 4    Randomized trial without control group 1 (20) 1 (20) 2    Nonrandomized trial without control group 3 (60) 3 (60) 1 (33) 7 Size of experimental group     Maximum  200 750 450 750    Minimum  10 30 20 10    Mean  55 236 168    Median 18 81,5 33 Size of control group, n (% within experimental group)    Maximum  18 (50) 54 (44) 150 (25) 150    Minimum  18 (50) 54 (44) 10 (33) 10    Mean  18 (50) 54 (44) 80 (29)    Median 18 54  80  Study duration     Maximum  6 

months18 

months18 months 18 

months    Minimum 3 days 6 weeks 4 months 3 days    Mean 3,82 

months7,9 

months11,3 months

    Median 4 months

6 months 12 months 

ResultsOverview of Research Designs

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DIABETES CARDIAC DISEASE

HYPERTENSION TOTAL

Number of studies 5 5 3 13Main types of data transferred

   Heart Rate     - 3 1 4   Blood pressure - 1 3 4   Heart electrical activity  - 2 -  2   Blood glucose 5  - - 5Frequency of data transmission to health care provider

     

  More than once a day 3 - 1 4  Once a day  - 2 - 2  A few times a week - 2 1 3  Once a week  1 - - 1  Once a month 1 - - 1  Once every three months  - - 1 1  Once every six months  - - 1 1

  DIABETES CARDIAC DISEASE

HYPERTENSION TOTAL

 Number of studies  5 5 3 13

Data quality 3 1 - 4

Patient condition 1 - 3 4

Patient attitudes and behaviors 2 1 3 6

Physician attitudes and behaviors - 1 2 3

Physician facilities - 2 3 5

Clinical efectiveness/ structural effects 4 3 3 10

Economic viability 2 4 1 7

Results - Frequencies of types of effects

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Results - Frequencies of advantages and disadvantages

  DIABETES CARDIAC DISEASE

HYPERTENSION TOTAL

 Number of studies  5 5 3 13

Advantages to:

   Patient 4 3 3 10

   Physician 1 3 2 6

   Health care institutions 3 2 1 6

Disadvantages to:

   Patient 1 1 2 4

   Physician 1 1 2 4

   Health care institutions - - - -

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Results – Advantages and disadvantages for the patient  DIABETES CARDIAC

DISEASEHYPERTENSIO

NTOTAL

Number of studiesPatient

5 5 3 13

Advantages-  Ability to overcome the problems.  - 1 - 1-  Increased level of patients’ responsibility.                  - 1 1 2-  Helps in disease self-management. 1 - 2 3-  Patients received an alert everytime  the values of blood pressure are lower or higher than the normal-

2 - 2 4

-  Patient enthusiam and acceptance.  2 - 1 3-  System easily integrated into everyday life. 3 -  - 3-  Child independence while being monitored by their parents.

1 - - 1

-  Allows patients with memory problems to remember to take medication.

1 - 1 2

-  Allows the introduction of healthy habits of  practice of physical exercise and alimentation in patients.

- - 1 1

Disadvantages  1  - 1 - Costs. 1 - 1 2 - Difficulty in using Internet. - - 2 2 - Difficulty in accepting new technologies.  - - 1 1 - No physical contact with the doctor. - - 1 1 - Problems of integration of other diseases. - - 1 1 - Problems of adaptation in the routine. - - 1 1 - Warns unnecessarily in situations of low levels of glucose, especially during the night.

1 - - 1

  DIABETES CARDIAC DISEASE

HYPERTENSION TOTAL

Number of studies 5 5 3 13

PhysicianAdvantages

 

  -  Facilitates realtime discussions between physicians in primary and secondary care.

2 2 - 4 

  - Less acute care needs when admitted. 1 - - 1    - More accurate decision regarding the treatment of BP. - - 1 1    - Larger amount of information about the patient’s condition   enabling the patients’ follow-up the patient on a daily basis rather than just on the day of the medical exam.

1 1 1 3

 

  - Shows when the medication has adverse effects. - - 1 1    - Integration of physician in the patient routine. 1 - - 1  Disadvantages - No longer able to contact the patient directly. - - 2 2 - Has to adapt its guidelines to the new technology. - - 1 1 - Availability of the physician to analyze patient data. - 1 1 2 - Failure in detection of low blood glucose values. 1 - - 1

Results - Advantages and disadvantages for the physician

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  DIABETES CARDIAC DISEASE

HYPERTENSION

TOTAL

Number of studies 5 5 3 13

HospitalAdvantages

  - Reduction of hospitalization 2 - 2 4

  -  Automatically generated historical graphics  transferred to the healthcare provider, feasibility of the system.

1 - - 1

  - Reduction of hospital overcrowding. - 1 - 1

Results - Advantages for the hospital

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Discussion

  The date of publication of the articles ranges between from 1996 to 2008.

The majority of the articles were regarding Diabetes type I, revealing the importance to closely monitor and control the levels of blood glucose on a daily basis.

Cardiac diseases were also frequently targeted due to its high level of incidence and prevalence

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Comparing to Paré et all, the number of included articles was considerably smaller since our research was restricted to experimental studies making use of mobile systems

Only articles about Diabetes, Cardiac Diseases and Hypertension were found.

USA is the country which has most explored the use of mobile technology to follow up chronic patients, as well as UK, Australia, Norway and Canada.

Discussion

Benefits of mobile telemonitoring systems for the patients

Telemonitoring systems enable patient’s quality of life

This kind of systems allows active participation in the process of healthcare, more patient’s independence and responsibility,

General satisfaction and a high level of acceptance

Increasing of patients’ compliance with the treatment, medication and telemonitoring which is a result of a tighter control achieved by an alarm system warning the patient .

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Minimal patient intervention in the collection and transference of data, reducing bias and subjectivity

Promotion of a healthy lifestyle with an improvement in physical exercise practice and balanced diet as it increases patient awareness of their health condition

Discussion

Disadvantages of mobile telemonitoring systems for the patients

Problems related to the usage and access to the internet namely among elderly people since they are not used to deal with computer technology

The cost-effectiveness is quite controversial

Undesirable changes in the daily routine may happen as a result of the permanent monitoring which leads to dependency towards the equipment

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Although it requires an initial investment in the equipment purchase, it may compensate in the long run, since it decreases future expenditures in healthcare services

Discussion

Benefits of mobile telemonitoring systems for healthcare professionals

Telemonitoring promotes the knowledge integration from the different healthcare areas, encouraging discussion

The physician has easier access to the patient information, and can be warned through an alarm system every time the patients’ health parameters are not normal

Emergency situations can be detected earlier preventing the occurrence of more serious complications

It is possible to follow closely the evolution of a patient health condition and consequently diagnose and apply treatment at distance

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Discussion

Disadvantages of mobile telemonitoring systems for healthcare professionals

Less physical contact between physicians and patients

Adaptation of clinical guidelines to this new way of healthcare delivery service

It requires availability of the physician in order to analyze the patient data as well as ensure the maintenance of the equipment

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Discussion

Effects of mobile telemonitoring systems on the hospitals

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Little evidence was found on the telemonitoring effects on the hospital and additional research is required to further investigate and analyze the impact of chronic disease telemonitoring in healthcare facilities

Less frequent visits to the healthcare facilities, shorter hospital stays and decrease of hospital admissions

Decrease in waiting lists associated with cost-effectiveness

The hospital can be notified in case of medical emergency

Previous professional training is needed in order to make an adequate use of this equipment, benefiting from all its potentialities

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Authors:

ALVES, José Pedro Figueiral Oliva Soares; CAMPOS, Marta Sofia Gomes; DATA, Tânia Rodrigues; ESTEVES, Alexandra Sofia Moreira; FARIA, Carlos Augusto da Silva; FERNANDES, Diana da Silva; GUEDES, Paulo Renato Moreira; MACHADO, Marino João Pinto; MAGALHÃES, Ana Isabel Pereira; MARQUES, Pedro Seabra; MATOS, José Pedro Rodrigues; MELO, Inês Marisa Tribuzi de Magalhães; MOREIRA, Pedro Manuel Costa; NASCIMENTO, João António Santos; PEREIRA, Maria Francisca Azevedo Marques; SILVA, Ana Rita Carneiro.

Authors’ e-mail: intromed05@gmail.com

Adviser: RODRIGUES, Pedro Pereira.

Class Number: 05 

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