Transforming the Experience for Patients Living with Congestive Heart Failure: Services, Protocols and Results Iain Findlay Scotland
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
High hospitalisations rates Most common cause of hospitalisation >65y Emergency admissions >5% Primary diagnosis: 1-4% >50% >80y Germany: +40% (2000-7) UK: +57% (2006-12) Spain: +22% (2000-11) USA: 1 million/y (stable) Typical progression of AHF Baker, DW et al. Am Heart J 2003; 146(2): 258-64 Ho KK, et al. Circulation 1993; 88(1): 107-15 Jong P, et al. Arch Int Med 2002; 162(15) 1689-94 Narang R,et al. Eur Heart J 1996; 17(9) 1390-1403 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
Number LOS in days
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 1 30-39% 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): 258-64 Ho KK, et al. Circulation 1993; 88(1): 107-15 Jong P, et al. Arch Int Med 2002; 162(15) 1689-94 Narang R,et al. Eur Heart J 1996; 17(9) 1390-1403
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 15-20 years 18/03/2016 United4Health Year 3 Review 6
Tele-Health Available Evidence 80 60 40 20 0 1995 1998 2001 2004 2007 2010 2013 Publications in PubMed
Transforming the Experience for Patients Living with Congestive Heart Failure: Services, Protocols and Results Iain Findlay Scotland
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
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
Protocol- study follow-up period Intervention group: Enrolment started on 1st January 2014 and continued until 31st March 2015. 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
Generic telehealth configuration & key interactions 18/03/2016 United4Health Year 3 Review 12
CHF pilot version of 26-11-2013
Headline Impact of study Clinical Patient Economic
Population characteristics 70 + 70 Intervention (n=277) Comparator (n=334) P-value Age (years) 72.5±11 76.7±10 0.000 Male (n, %) 197 (71%) 189 (57%) 0.000 Smokers (n, %) 18 (7.2%) 21 (6.8%) >0.05 BMI (kg/m 2 ) 29.1± 6.3 28.8±6.0 0.560 SBP (mmhg) 131±22 138±22 0.000 DBP (mmhg) 76±14 79±14 0.048 LVEF (%) 40±14 42±13 0.022 egfr (MDRD) ml/min/1.73m 2 63±23 59±30 0.177 Number of comorbidities 3.6±1.3 3.5±1.2 0.174 CCI (Charlson Comorbidity) 2.7±1.9 2.5±1.6 0.256 18/03/2016 United4Health Year 3 Review 15
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
Predefined outcomes (adjusted only for length of follow-up) Intervention Comparator Absolute Difference Relative Difference (Delta, %) P- value CHF-admissions 0.38 0.61-0.23-37.7% 0.000 Hospital Services CHF-days hospitalised 2.22 4.58-2.36-51.5% 0.000 Number of admissions 0.83 1.15-0.32-27.8% 0.000 Days hospitalised 3.94 7.71-3.77-48.9% 0.000 Number of ED visits 1.05 1.25-0.2-16.0% 0.064 Primary Care Services GP/cardiologist contacts 26.31 17.98 8.4 46.9% 0.000 All primary care contacts 34.07 20.84 13.23 63.5% 0.000 18/03/2016 United4Health Year 3 Review 17
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
Headline Impact of study Clinical Patient Economic
Median Satisfaction Scores across Regions 6.00 0.00 Scotland, NW Moravia, Slovenia Basque Country
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% 0.225 Total mortality 5 (2.3%) 19 (5.4%) -3.1% -57.1% 0.014 18/03/2016 United4Health Year 3 Review 21
Headline Impact of study Clinical Patient Economic
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 17 127 191 365 74 151 431 248 366 203 168 558 439 731 277 2,500/ 1,250 1,600/ 300 100 200 200 18/03/2016 United4Health Year 3 Review 23
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 168 558 439 731 Change in costs of GP visits 386 333 43 99 Change in costs of ED visits -35-21 -3-6 Change in costs of outpatient visits 403 382 83 171 Change in costs of admissions -1,624-787 -192-858 Total net costs per patient -702 465 370 137 Weighted average 277 296-25 322-1,198-329 18/03/2016 United4Health Year 3 Review 25
Conclusion - CHF study Costs per patient of telehealth intervention: Mean = 277 ( 168 to 731) Total costs per patient: Mean = - 329 ( - 702 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
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