Transforming the Experience for Patients Living with Congestive Heart Failure: Services, Protocols and Results

Transcription

1 Transforming the Experience for Patients Living with Congestive Heart Failure: Services, Protocols and Results Iain Findlay Scotland

2 HF Epidemiology World pandemic 26 millions patients (15 millions in Europe) General Prevalence 1-2% ( >70 years old >10%) 1/5 adults will have HF symptoms 1/8 death certificates incudes HF as one of the causes (USA) 2/3 admissions could be prevented Quality of life McMurray et al. EHJ 2012; Cowie et al. EHJ 2013; Go A S et al. Circulation. 2014

3 High hospitalisations rates Most common cause of hospitalisation >65y Emergency admissions >5% Primary diagnosis: 1-4% >50% >80y Germany: +40% (2000-7) UK: +57% ( ) Spain: +22% ( ) USA: 1 million/y (stable) Typical progression of AHF Baker, DW et al. Am Heart J 2003; 146(2): Ho KK, et al. Circulation 1993; 88(1): Jong P, et al. Arch Int Med 2002; 162(15) Narang R,et al. Eur Heart J 1996; 17(9) ED visits: > 3% LOS = 5-10 days Cowie et al. ESC-HF 2014: Improving care for patients with AHF Go A S et al. Circulation. 2014;129:e28-e292

4 Number LOS in days

5 Sicker than we think!!! More deaths from HF than from all forms of cancer combined Rehospitalisations Mortality: 30-day: 20-25% In-hospital: 4-10% 1-year: 60-70% 30-day: 10-13% 1-year: 20-40% Disease Comparative 5-years mortality CHF 60-70% Adenocarcinoma of the colon (IIIB) 36% COPD (FEV % predicted) 53% ESRD (dialysis-dependent) 60-80% Cowie et al. ESC-HF 2014: Improving care for patients with AHF Baker, DW et al. Am Heart J 2003; 146(2): Ho KK, et al. Circulation 1993; 88(1): Jong P, et al. Arch Int Med 2002; 162(15) Narang R,et al. Eur Heart J 1996; 17(9)

6 Disease population Direct cost of CHF management varies between 1-3% of total healthcare costs > 65 years old> 75% of total cost Disease prevalence projected to increase by about 46% in the next years 18/03/2016 United4Health Year 3 Review 6

7 Tele-Health Available Evidence Publications in PubMed

8 Transforming the Experience for Patients Living with Congestive Heart Failure: Services, Protocols and Results Iain Findlay Scotland

9 Protocol Eligibility criteria Hospitalisation or ED visit for decompensated HF in the previous 6 months AND, at least one of the following three conditions: LVEF < 45% LVEF > 45% but BNP > 400 Confirmed diagnosis of CHF by a cardiologist 18/03/2016 United4Health Year 3 Review 9

10 Heart Failure Risk Stratification 2215 people diagnosed with Heart Failure in Renfrewshire and East Renfrewshire (Source: GP QOF register as at 1/8/14) Full telehealth package Usual Care 6 (0.1%) had 3 admissions Case Management 23 (1.2%) of people had 2 hospital admissions Anticipatory Care Plan (ACP) Care Management 224(10.1%) of people had 1 hospital admission Lite Touch Telehealthcare Patient led supported self management Disease specific co-ordination Simple Telehealth Supported Self Management 1962 (88.6%) people diagnosed with Heart Failure not admitted Web based remote health coaching, interactive educational programmes, NHS inform, Living it Up, Digital TV, Digital Postcards Note: Calculations are based on emergency admissions for exacerbation of HF duringfinancial year 2013/14

11 Protocol- study follow-up period Intervention group: Enrolment started on 1st January 2014 and continued until 31st March Patients screened: 1,106 Patients evaluated: 611 (control and intervention) Comparator group: Prospective collection of the data Minimum follow-up for the evaluation: 6 months 18/03/2016 United4Health Year 3 Review 11

12 Generic telehealth configuration & key interactions 18/03/2016 United4Health Year 3 Review 12

13 CHF pilot version of

14 Headline Impact of study Clinical Patient Economic

15 Population characteristics Intervention (n=277) Comparator (n=334) P-value Age (years) 72.5± ± Male (n, %) 197 (71%) 189 (57%) Smokers (n, %) 18 (7.2%) 21 (6.8%) >0.05 BMI (kg/m 2 ) 29.1± ± SBP (mmhg) 131±22 138± DBP (mmhg) 76±14 79± LVEF (%) 40±14 42± egfr (MDRD) ml/min/1.73m 2 63±23 59± Number of comorbidities 3.6± ± CCI (Charlson Comorbidity) 2.7± ± /03/2016 United4Health Year 3 Review 15

16 Follow-up and impact on patients vital signs Differences in hemodynamic parameters such as HR have demonstrable consequences in clinical outcomes 18/03/2016 United4Health Year 3 Review 16

17 Predefined outcomes (adjusted only for length of follow-up) Intervention Comparator Absolute Difference Relative Difference (Delta, %) P- value CHF-admissions % Hospital Services CHF-days hospitalised % Number of admissions % Days hospitalised % Number of ED visits % Primary Care Services GP/cardiologist contacts % All primary care contacts % /03/2016 United4Health Year 3 Review 17

18 Adjusted primary outcomes (Logistic regression analysis) Patients in intervention group were: 4.62 times less likely to have a heart failure related hospitalisation 5.22 times less like to have days hospitalised due to HF than the patients in the comparative group. 18/03/2016 United4Health Year 3 Review 18

19 Headline Impact of study Clinical Patient Economic

20 Median Satisfaction Scores across Regions Scotland, NW Moravia, Slovenia Basque Country

21 Patient safety (mortality) Group Intervention Comparator Absolute Difference Relative Difference (Delta, %) P-value CHF-related mortality 3 (1.4%) 8 (2.3%) -0.9% -38.8% Total mortality 5 (2.3%) 19 (5.4%) -3.1% -57.1% /03/2016 United4Health Year 3 Review 21

22 Headline Impact of study Clinical Patient Economic

23 Results - CHF Average projected costs per patient of the telemonitoring intervention per 6 months Type of costs ( 2015) Scotland Basque Country Moravia Slovenia Weighted average Investment costs Variable costs Total costs Expected number of patient per year ,500/ 1,250 1,600/ /03/2016 United4Health Year 3 Review 23

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25 Results - CHF Total costs per patient per 6 months - CHF Regression analysis found: Reduced number of ED visits and admissions ( 2015) Region Type of health care costs Costs of telemonitoring Scotland Basque Country Northwest Moravia Slovenia Change in costs of GP visits Change in costs of ED visits Change in costs of outpatient visits Change in costs of admissions -1, Total net costs per patient Weighted average , /03/2016 United4Health Year 3 Review 25

26 Conclusion - CHF study Costs per patient of telehealth intervention: Mean = 277 ( 168 to 731) Total costs per patient: Mean = ( to 465) Main reason: Cost Increase in GP and outpatient visits < reduction of admissions Comparison with Renewing Health: Costs of telehealth intervention: Mean = 606 Strength of study: Accordance with Drummond (2005) guideline Weakness of study: Estimated costs of intervention is not on patient level Clinical results based on regression analysis with subsample of patients Clinical results are mean values for all regions Large variation in regional organisation in care service 18/03/2016 United4Health Year 3 Review 26

27 Conclusions Large-scale deployment of telemonitoring for CHF is feasible Patient safety was not compromised A positive impact in CHF patients health A reduction in the use of expensive hospital services Improved continuity of care 18/03/2016 United4Health Year 3 Review 27