Building a patient-centered, comprehensive digital network ... · Dr. med. Frank Rassouli...

Building a patient-centered, comprehensive digital

network for COPD

SGK/SGHC/SGP 16.06.16 Lausanne

Dr. med. Frank Rassouli

Clinic for Pulmonology and Sleep Medicine

Cantonal Hospital St. Gallen

Building a patient-centered, comprehensive digital

network for COPD

SGK/SGHC/SGP 16.06.16 LausanneDr. med. Frank Rassouli

Structure of the talk

1. Goals of telemedicine for COPD

2. What’s the evidence?

3. Summary of main findings

4. What did / do we do in St. Gallen?


1. Goals of telemedicine for COPD

- Improve QoL

- Reduce hospitalisations due to AECOPD

- Reduce ED visits due to AECOPD

- Reduce and better allocate healthcare activities

- Reduce healtcare costs

Building a patient-centered, comprehensive digital network for COPD



Pubmed (last 5 years):

«telemedicine COPD» 193

«telehealthcare COPD» 12

«telehealth COPD» 221

«telemonitoring COPD» 58

• 8 relevant RCTs (2013-2016)

• Thorax

• Respirology

• Int J COPD (2)

• BMJ

• J Telemed Telecare

• Scientific Reports

• BMC Health Services Research




3. Summary of main findings

- Inconsistent results in all mentioned goals!

- Likely contributing factors

- Different healthcare settings (6 countries)

- Different inclusion criteria

- Different interventions

- Different intervention intervals (daily to every 2 weeks!

Tendency: negative studies had rather longer reaction intervals)



4. What did / do we do in St. Gallen?

Pilot study: «Telehealthcare in COPD – a feasibility trial»

(PP-135)

- Objective: test the feasibility and patient acceptance of telehealthcare

for COPD in our healthcare setting



Methods

- THC-platform was integrated in a comprehensive electronic patient

data repository has to be available for all patients in Switzerland by

law by 2017

- We use Evita by Swisscom

Patient General practitioner

Specialist

Decides who has access



Methods

Phone call, if red signal

(suspected AECOPD)



Results

• Data completeness 88%

• Patient acceptance 94%

• 230 phone calls in 38 patients

• 60 AECOPD in 22 patients confirmed

• 3 AECOPD in 3 patients missed

• Sensitivity 95% / PPV 26% / NPV 99.9%



Results



Conclusions

• Adding THC to state-of-the-art COPD management is feasible in a selected subgroup

of patients

• Up to 50% of COPD patients could be eligible for a THC strategy

• Patient compliance, acceptance and satisfaction were very high

• With the proposed approach we missed only very few AECOPD events

• However, a telephone-based verification of THC alerts was required

• Overall, in this proof-of-concept study we experienced a positive effort-to-benefit ratio



What’s an adequate primary endpoint for a RCT in this area?

ED visits / hospitalisations for AECOPD?

- 6/8 trials negative

- Probably underpowered

- Rare event in our pilot study

- Not adequate

Number of exacerbations?

- 4/5 trials negative: plausible (higher sensitivity)!

- Pilot study: higher than expected

- Not adequate



What’s an adequate primary endpoint for a RCT in this area?

QoL parameters?

- Mixed results in RCTs

- Pilot study: CAT score

- 28% improved (>MCID of 2), 66% improved or stable

- Overall slope: -0.45 points per year (rather increase expected!)

improved worsenedstable

examples



Currently ongoing (started May 2016)

- Multicenter crossover RCT

- Centers (until now): KSSG / USB / USZ / Glarus / Wangen (D)

- Primary endpoint: change of CAT score (slope)



Supplemental material…

Efficacy of multiparametric telemonitoring on respiratory outcomes in elderly people with COPD: a

RCT (Italy)Pedone et al. BMC Health Services Research 2013

Intervention: Wristband (heart rate, physical activity, temperature) + pulse oxymeter

Bluetooth Smartphone Server

Daily analysis by pulmonologist phone call when suspected deterioration

«events»: 50% hospital admission

50% AECOPD outpatient



Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for

exacerbation of COPD: researcher blind, multicentre, RCT (UK)Pinnock et al. BMJ 2013

Intervention: Daily online questionnaire (symptoms and treatment use) + SpO2

phone call when suspected deterioration

Results: n = 256

No difference: time to first AECOPD admission

number of AECOPD admissions

QoL (SGRQ)



A telehealth program for self-management of COPD exacerbations and promotion of an active

lifestyle: a pilot RCT (Netherlands)Tabak et al. Int J COPD 2014



High adherence and satisfaction

A randomised clinical trial of the effectiveness of home-based health care with telemonitoring in

patients with COPD (Ireland)McDowell et al. (only abstract available) J Telemed Telecare 2015

Intervention: «Home telemonitoring» + standard care vs. standard care

Results: n = 100 (48 telemonitoring, 52 control)

SGRQ and HADS anxiety score sig. improved

No difference: GP activity

ED visits

Hospital admissions

Exacerbations



Telemedicine, the effect of nurse-initiated telephone follow up, on health status and health-care

utilization in COPD patients: a RT (Netherlands)Berkhof et al. Respirology 2015

Intervention: Medical call center (nurses): phone call every 2 weeks: «Clinical COPD

Questionnaire» (CCQ)

If deterioration: phone call by pulmonologist



Effect of tele health care on exacerbations and hospital admissions in patients with COPD: a RCT

(Denmark)Ringbaek et al. Int J COPD 2015

Intervention: - Tablet + camera + microphone / spirometer / pulse oxymeter

- Report changes in dyspnea, sputum color, volume and purulence

- Measurements 3 times per week (4 weeks), then once weekly +

video consultation once weekly (4 weeks), then once monthly

- Phone call (study nurse), if deterioration suspected (pulmonologist as backup)



Randomized crossover trial of telemonitoring in chronic respiratory patients (TeleCRAFT trial) (UK)Chatwin et al. Thorax 2016

Intervention: - Daily questionnaire on dyspnoea, wheeze, sputum production, sleep quality,

therapy alterations

- Daily heart rate + SpO2

- Results reviewed daily by study team (nurse; pulmonologist if needed)

advice to patient by phone or online



Hospitalisations for exacerbations

(1° endpoint)

QoL: no difference

Effectiveness of Telemonitoring in Patients with COPD in Taiwan: A RCT (Taiwan)Ho et al. Scientific Reports 2016



Daily for 2 months after discharge

Review by pulmonologist

Phone call when deemed necessary

Building a patient-centered, comprehensive digital network ... · Dr. med. Frank Rassouli...

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