Telehealth for COPD An evidence update

Transcription

1 Telehealth for COPD An evidence update Professor Hilary Pinnock The University of Edinburgh Whitstable Medical Practice I have no conflicts of interest relevant to this presentation

2 Telehealth for COPD aukcar.ac.uk Potential role of telehealth Hospital at Home Early post-discharge Supporting self-management The future

3 A framework COPD admissions aukcar.ac.uk Normal coping Home Hospital at Home Stabilising during a virtual admission less dependent than during an admission Virtual Hospital TELEKOL Regaining control Hospital Dependency Out of control Emme et al. Journal of Clinical Nursing, 23,

4 A framework COPD admissions aukcar.ac.uk Normal coping Home Early post-discharge care HomePod Regain confidence in ability to cope Regaining control Out of control Odense system Hospital Dependency Emme et al. Journal of Clinical Nursing, 23,

5 A framework COPD admissions Denmark; Northern Ireland Supporting self-management: Learning to recognise and act on symptoms and signs TeleScot Regaining control aukcar.ac.uk Normal coping Home Out of control Hospital Dependency Emme et al. Journal of Clinical Nursing, 23,

6 Hospital at Home

7 The Virtual Hospital Trial: Copenhagen aukcar.ac.uk Patients: Telemedicine-supported Hospital at Home vs inpatient hospital treatment. Acute exacerbation of COPD, expected to need admission >2days Not requiring a hospital-based intervention (NIV, IV antibiotics) and without an unstable co-morbidity Primary outcome: readmission due to COPD within 30 days after discharge Assessed, recruited and randomised within 24 hours of arriving at the hospital Jakobsen et al. Trials; 14:280

8 The Virtual Hospital Trial: Copenhagen aukcar.ac.uk Telemedicine-supported Hospital at Home vs inpatient hospital treatment. Telemonitoring equipment Touch screen, webcam, spirometer, oximeter, thermometer Treatment Medicine box containing antibiotics, inhalation medicine, corticosteroids and sedatives; nebuliser, oxygen Under the care of the hospital admitting unit Scheduled daily ward round Call hospital button on the touch screen Jakobsen et al. Trials; 14:280 Until satisfied hospital discharge criteria

9 The Virtual Hospital Trial: Copenhagen aukcar.ac.uk Telemedicine-supported Hospital at Home vs inpatient hospital treatment. Recruited: 58 patients over 18 months. 647 respiratory admissions assessed 117 potentially eligible 58 recruited to trial 59 declined 35 felt too unwell to make the journey home 9 felt uncomfortable with telemedicine 4 did not feel sufficiently ill 11 patients gave no reason. Jacobsen et al. J Telemed Telecare 2013

10 The Virtual Hospital Trial: Copenhagen aukcar.ac.uk Telemedicine-supported Hospital at Home vs inpatient hospital treatment. Recruited: 58 patients over 18 months. No significant difference in re-admissions (under-powered) Jacobsen et al. J Telemed Telecare 2013 No clinically significant difference in SGRQ, HADS, ADL Schou et al. J Telemed Telecare 2013 No difference in self-efficacy Emme et al. J Clin Nursing 2014; 23: Jacobsen et al. J Telemed Telecare 2013

11 The Virtual Hospital Trial: Copenhagen aukcar.ac.uk Telemedicine-supported Hospital at Home vs inpatient hospital treatment. Recruited: 58 patients Stabilising over 18 the months. out of control exacerbation Returning No significant to every day difference life in re-admissions (under-powered) but security of being monitored Still coping with symptoms No clinically significant difference in SGRQ, HADS, ADL but with the aid of medical equipment Supported by relatives/friends but medical help at the touch of a button No difference in self-efficacy Jacobsen et al. J Telemed Telecare 2013 Schou et al. J Telemed Telecare 2013 Emme et al. Journal of Clinical Nursing, 23, Emme et al. J Clin Nursing 2014; 23: Jacobsen et al. J Telemed Telecare 2013

12 Early post-discharge Regaining confidence in ability to cope

13 Telehealth intervention: Odense aukcar.ac.uk Daily monitoring and video-consultations for one week vs conventional postdischarge management No difference in: Mean number of admissions over the 6 month trial Time to first admission Bed days 266 patients Sorknaes et al. J Telemed Telecare 2013, 19:

14 Barnsley aukcar.ac.uk 8 weeks post-discharge support by a community team 2 visits + daily telemonitoring vs 6 visits No statistical comparison (pilot study) but: Feedback indicated that both groups expressed a preference for personalised face-to-face service Bentley et al. Trials 2014, 15:313

15 HomePods (Salford) aukcar.ac.uk Observational study of early supported discharge with HomePods for 30 days (Abstract: BTS) 73 (25%) patients under ESD team selected for HomePods 30 day re-admission rates 3% (vs 8%) Efficient: able to increase caseload (15 ->18cases) Patients survey showed excellent impact on: Patients satisfaction Confidence in self care Patients acceptability

16 Supported selfmanagement Preventing admissions

17 What is self-management? aukcar.ac.uk Self management is defined as the tasks that individuals must undertake to live with one or more chronic conditions. These tasks include having the confidence to deal with: medical management, role management & emotional management of their conditions US Institute of Medicine

18 n=128 n=128 Time to COPD admission: 362 days (IQR 131 to >365) 361 days (IQR 113 to >365) Hazard ratio 0.98 (0.66 to 1.44) Pinnock et al. BMJ 2013; 347:f6070

19 n=128 n=128 A contact every Time to COPD admission: weeks days (IQR 131 to >365) Cost/QALY 361 days (IQR 137, to >365) Hazard ratio 0.98 (0.66 to 1.44) Alerts: Home visit Telephone Home visit Stoddart Zoumot et et al. al. Thorax J Telemed doi: /thoraxjnl Telecare 2015; 21: Pinnock et al. BMJ 2013; 347:f6070 Allergy and Respiratory Research Pinnock Group et al. BMJ 2013; 347:f6070

20 n=128 A contact every n=128 Time to COPD admission: weeks days (IQR 131 to >365) 361 days (IQR 113 to >365) I ve Hazard never ratio felt 0.98 (0.66 so well to 1.44) looked after in my life. I think it s a godsend like [Male, aged 58yrs] Fairbrother Pat Ed Counsel 2013; 93: Pinnock et al. BMJ 2013; 347:f6070 Allergy and Respiratory Research Pinnock Group et al. BMJ 2013; 347:f6070

21 n=128 n=128 Time to COPD admission: He s petrified 362 days (IQR that 131 to when >365) the 361 days trial (IQR ends 113 to that >365) machine Hazard will ratio be 0.98 taken (0.66 away to from 1.44) him, because it has become his life line. he s become dependant and believes he should be getting phone calls on a regular basis. [Tele-monitoring team member] Fairbrother Pat Ed Counsel 2013; 93: Pinnock et al. BMJ 2013; 347:f6070

22 n=128 n=128 It's a comfort zone really Time to COPD admission: 362 days (IQR 131 to >365) 361 days (IQR 113 to >365) it's like having someone sitting beside you Hazard ratio 0.98 (0.66 to 1.44) and saying, right we'll go this way. It's like another arm in your body saying, right we'll do this. It's been a brilliant thing as far as I'm concerned... it's like having a nurse beside you. (Male, aged 69yrs) Fairbrother Pat Ed Counsel 2013; 93: Pinnock et al. BMJ 2013; 347:f6070

23 Quality of life, anxiety and depression n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) Mean difference 1.39 (95% CI 1.57 to 4.35) HADS (anxiety): 9.6 (5.0) 9.1 (5.1) HADS (depression): 9.1 (4.6) 8.4 (4.2) Pinnock et al. BMJ 2013; 347:f6070

24 Quality Four-centre of trial in life, Denmark (n=281) anxiety and depression n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) COPD admissions (mean (range)) 0.55 (0 5) 0.54 (0.4) p=0.74 At least one admission (%) 29.1% 31.4% p=0.67 Mean difference 1.39 (95% CI 1.57 to 4.35) HADS (anxiety): 9.6 (5.0) 9.1 (5.1) Length of stay (days (range)) 1.76 (0 52) 2.02 (0 31) p=0.51 HADS (depression): 9.1 (4.6) 8.4 (4.2) Exacerbation of COPD not requiring hospital admission p=0.001 mean (range) 1.21 (0 17) 0.73 (0 8) Ringbaek et al. In J COPD 2015;10: Pinnock et al. BMJ 2013; 347:f6070

25 Quality Respiratory of service life, in Northern anxiety Ireland (n=110) and depression n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) COPD admissions (mean (SD)) 0.50 (0.9) 0.65 (1.0) p=0.42 Mean difference 1.39 (95% CI 1.57 to 4.35) Length of stay (days (range)) 3.4 (7.7) 4.3 (8.5) p=0.59 HADS (anxiety): 9.6 (5.0) 9.1 (5.1) HADS (depression): 9.1 (4.6) 8.4 (4.2) Respiratory team contacts mean (range) 10.1 (7.8) 6.9 (7.0) p=0.029 MacDowell et al. J Telemed Telecare 2015;21:80-87 Pinnock et al. BMJ 2013; 347:f6070

26 Quality of life, anxiety and depression n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) Mean difference 1.39 (95% CI 1.57 to 4.35) HADS Same (anxiety): clinical 9.6 care (5.0) to both groups 9.1 (5.1) HADS Some (depression): hospital 9.1 (4.6) admissions are inevitable 8.4 (4.2) Old technology? Installation time? Pinnock et al. BMJ 2013; 347:f6070 The algorithm?

27 Quality of life, anxiety and depression n=105 n=100 The early signs of an exacerbation can be detected SGRQ: 68.2 (16.3) 67.3 (16.3) Mean difference 1.39 (95% CI 1.57 to 4.35) HADS (anxiety): 9.6 (5.0) 9.1 (5.1) Effective treatment can be commenced HADS (depression): 9.1 (4.6) 8.4 (4.2) Severe exacerbations / hospital admissions can be prevented Pinnock et al. BMJ 2013; 347:f6070

28 19 patients Quality in the pilot of study life, anxiety and depression n=5 n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) n=9 Mean difference 1.39 (95% CI 1.57 to 4.35) Rolling pattern HADS (anxiety): 9.6 (5.0) 9.1 (5.1) 42% (75/150) of patients HADS (depression): 9.1 (4.6) 8.4 (4.2) in the intervention group were classified n=4 as successful self managers Burton C et al. J Telemed Bucknall Telecare et al. 2015; BMJ Pinnock 21: ;344:e1060 et al. BMJ 2013; 347:f6070 Discrete exacerbations Over-ridden pattern

29 Quality of life, anxiety and depression Usually I go by the sputum. If it changes n=105 n=100 colour, I go on antibiotics and steroids. SGRQ: (HA007) 68.2 (16.3) 67.3 (16.3) Mean difference 1.39 (95% CI 1.57 to 4.35) When I know that it s unbearable to breathe and if I get tight. (HA007) HADS (anxiety): 9.6 (5.0) 9.1 (5.1) I just feel rough when I m feeling really rough (GP1052) HADS (depression): 9.1 (4.6) 8.4 (4.2) I know when I m really bad (HA007) I know exactly when it s time to take them [antibiotics] (OC1065) Williams V et al. npjprim Care Respir Med 24, 14062

30 Quality of life, anxiety and 1. Chest congested 2. Cough today 3. Mucus when coughing 4. Difficulty with mucus Mean difference 1.39 (95% CI 1.57 to 4.35) 6. Chest discomfort 8. Chest tight 9. Breathless today 10. How breathless today 15. SOB with personal care SOB with indoor 19. SOB with outdoor 20. Weak/tired 21. Sleep disturbed 23. Scared/worried depression Is there a better symptom score? n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) HADS (anxiety): 9.6 (5.0) 9.1 (5.1) HADS (depression): 9.1 (4.6) 8.4 (4.2)

31 Composite HR and SpO2 Quality of life, anxiety and depression Hurst et al. BMC Pulmonary Medicine 2010, 10:52 Physiological measures? n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) Mean difference 1.39 (95% CI 1.57 to 4.35) HADS (anxiety): 9.6 (5.0) 9.1 (5.1) HADS (depression): 9.1 (4.6) 8.4 (4.2) Burton C et al. J Telemed Telecare 2015; 21:29-36 Stable vs exacerbation

32 Patient 6 aukcar.ac.uk Quality of life, anxiety and depression n=105 n=100 SGRQ: 68.2 (16.3) 67.3 (16.3) Mean difference 1.39 (95% CI 1.57 to 4.35) Patient 3 Physiological measures? Exacerbation vs stable HADS (anxiety): 9.6 (5.0) 9.1 (5.1) Patient 16 HADS (depression): 9.1 (4.6) 8.4 (4.2)

33 Quality of life, anxiety and depression AUC of the standard n=105 algorithms: ~0.50 [0.46, n= ] AUC of SGRQ: machine learning 68.2 (16.3) algorithm: ~ [0.67, (16.3) 0.79] Physiological measures? Mean difference 1.39 (95% CI 1.57 to 4.35) Halved the false positive rate HADS (anxiety): 9.6 (5.0) 9.1 (5.1) HADS (depression): 9.1 (4.6) 8.4 (4.2) Use computing power and complex, personalised algorithms

34 Facilitating selfmanagement Using measurements n=105 n=100 No difference in self-efficacy (SECD6), knowledge about COPD (LINQ), or medication adherence (MARS) it's great to know that you can just take a reading and say: Well, I do need a doctor or I do need to start these steroids (Female, 67yrs) Fairbrother Pat Ed Counsel 2013; 93: Pinnock et al. BMJ 2013; 347:f6070

35 Guardian angel In a way it was a relief thinking that I should ignore my own thoughts on getting a doctor or something like that. This organisation was going to get hold of a doctor if their readings showed I needed a doctor. (Woman aged 47yrs) Fairbrother Pat Ed Counsel 2013; 93: Pinnock et al. BMJ 2013; 347:f6070

36 Guardian angel Supporting self-management? In a way it was a relief thinking that I should ignore my own thoughts on getting a doctor or something like that. This organisation was going to get hold of a doctor if their readings showed I needed a doctor. (Woman aged 47yrs) Fairbrother Pat Ed Counsel 2013; 93: Pinnock et al. BMJ 2013; 347:f6070

37 Light Touch Symptom score Oximetry Paper diary aukcar.ac.uk Self-management education Telephone helpline No professional monitoring No concerns Start emergency medication Phone telephone helpline Contact GP Emergency ambulance

38 Light Touch now I m able to keep control of my illness. I know when I m not well. I m not having to depend on a box [the telemonitoring equipment] to tell me I m ill. Now I do it myself so I feel a bit more in control now (Patient who had previously used telemonitoring) MacNab M, et al. BMC Health Serv Res 2015: 15: 485 Allergy and Respiratory Pinnock Research et al. Group Abstract BTS Winter meeting

39 Self-management with flexible access to support Regaining control Normal coping Home Out of control Monitored care? role Hospital Dependency Evolution of supported self-management

40 What is self-management support? aukcar.ac.uk How might digital technology contribute? Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support Pearce G et al. PRISMS Taxonomy J Health Serv Res Policy : 73-82

41 Telehealth is here to stay Innovative technologies Rapid evaluation Time for a new paradigm?

42 Innovative indicators aukcar.ac.uk

43 Bridge the gap aukcar.ac.uk Safe?? Clinical effectiveness Patient engagement Clinical research Commercial parties Patients Past Now Future?

44 Develop quick processes aukcar.ac.uk Feasibility/piloting of the intervention Development of the intervention Phase III randomised controlled trial Long-term follow-up Dissemination Medical device legislation Change in practice MRC Framework for development and App Development Roadmap. Oxford evaluation AHSN of complex interventions

45 New paradigm aukcar.ac.uk Purchasing solutions and then looking for a problem

46 What is the problem? aukcar.ac.uk.. might technology be part of the solution?

47 Telehealth for COPD An evidence update Professor Hilary Pinnock The University of Edinburgh Whitstable Medical Practice