There are some interesting telehealth monitoring facts, figures and conclusions lurking in a recently published report by the Vlerick Leuven Gent Management School: Health for All, Care for You: Unlocking the value of Personalised Healthcare in Europe. (PDF download). It is a review of a number of studies and is worth adding to the ‘evidence’ file. Study Two (page 8) on the cost effectiveness of prevention, point-of-care monitoring and telemonitoring in cardiovascular disease, indicates that a combined approach using exercise, point-of-care [diagnostic tests], and telemonitoring for acute heart patients is both cost effective and has health benefits despite possible increasing GP workloads. However, of the three, telehealth monitoring had the largest individual return on investment (ROI) although the population it would benefit would be smaller. Apart from the 15% reduction in referrals to A&E; 59% fall in angioplasty; 17% reduction in bypass surgery; 14% drop in the use of medicines; and 13% reduction in the use of rehabilitation services from the combined approach, enabling patients to be responsible for monitoring their own vital signs (such as blood pressure and temperature) and sending them into a central nursing unit electronically, resulted in patient adherence to prescribed treatment increasing from 30% to 92%. Heads up thanks to Dr Lance Forbat, Independent Cardiologist.
Though there is hopefully a more detailed account of the research available elsewhere, this overview document raises some real concerns. Firstly, the clinical focus of study two is unclear – the final bullet point of the ‘Why study Acute Coronary Syndrome’ box (page 7) states incorrectly that “ACS is a chronic disease”. It’s not: it’s an acute (hence the name) condition that can kill very quickly and needs rapid management in hospital. It should not be thought of a chronic condition such as heart failure or stable angina (though the conditions are linked).
The interventions studied also confuse me. There is no doubt that increased exercise can mitigate against the development of coronary artery disease (which can cause ACS) and that enhanced adherence to statins could reduce the likelihood of an acute cardiac event. It’s therefore feasible that the researchers may have been able to draw a line between interventions that support these and reduced healthcare costs in the long run (though the claims are not underpinned by references to any previous evidence in this area).
My biggest concern relates to the point-of-care intervention to try and keep people out of emergency departments. What exactly was being measured during these tests? Given that the study was on ACS, the only obvious candidate is a type of substance called a troponin, which is released into the body when the heart is damaged. There may be a small and specific role for POC troponin testing in primary care, but patients with cardiac-sounding chest pain should be assessed and managed in hospital as soon as possible. The suggestion that GPs should pre-screen patients suffering cardiac-sounding chest pain with POC troponin (if that is indeed what the study was looking at) is impractical and dangerous.
Finally (before I get off my soapbox), though I’m comfortable with the role of telemonitoring in improving adherence to medication in the context described, it can’t really – as suggested – provide early warning of a heart attack. The early warning function of telemonitoring works best with chronic conditions such as COPD and HF because there may be a period of steady deterioration that can be recognised and acted upon. ACS usually comes out of the blue and requires a rapid emergency response.
It would be really useful to know if a more detailed document exists that outlines the exact interventions explored and includes references for the evidence that underpins conclusions. Without this information, the report is of limited use and may confuse people over the role and function of telemonitoring.
Dr. Lance Forbat
In reply to David Barrett, The researchers studied the cost effectiveness of prevention (exercise), point-of-care diagnostics and telemonitoring.
Acute coronary syndrome is a consequence of cumulative vascular risk factors leading to cholesterol plaque rupture and is therefore affected by long-term lifestyle traits amenable to intervention as well as genetic predisposition to cardiovascular disease that is polygenic.
Monitoring blood pressure, weight, waist circumference, blood sugar, cholesterol, alcohol consumption, smoking etc. are chronic markers amenable to intervention. Seeing adverse trends in these risk factors over time and using telemedicine to educate the patients to reduce these and or intervening to reverse them (the strongest is smoking cessation) can be achieved with telehealth. He refers to chronic conditions such as COPD and heart failure having a steady deterioration and being suitable to monitor. The same occurs in the vascular tree in ischaemic heart disease and acute coronary syndrome is an end point, just as an acute admission is for heart failure (the majority is due to coronary disease) or COPD. Many patients have periods over months with unrecognised cardiac events not labelled or recognised as acute coronary syndrome. A troponin rise would alert the GP to the underlying mechanism and prompt screening for risk factors if not already known and commencing ‘secondary’ prevention measures with aspirin, statin, ACE inhibitors, smoking cessation, blood pressure control, weight loss, glycaemic control etc.
There is plenty of evidence to show this will reduce acute coronary syndromes, full thickness myocardial infarction and heart failure.
The clever part is how you design changes in the delivery of care that will reproduce the changes on which this modelling is based. This is possible but needs commitment from champions at local levels and development from the bottom up, with guidelines and funding both from central government and private sources. The lessons how not to implement a large IT project a well known in the UK, avoid implementation from the top down approach without ‘stakeholder’ input at the outset.
I have experience of the influence of telemedicine on my patients’ understanding of managing their risk factors and changing their lifestyle as a result of telehealth. Mr latest patient has sent a blog (http://vsta.pr/Jhf2MZ) from holiday in Australia making just this point.
I am very hopeful that this study can be replicated in the ‘real world’.
Many thanks to Dr Forbat for his comments. I wholeheartedly agree with him that telehealth has an important role in the prevention and management of heart disease.
There’s no doubt that in the majority of cases, an Acute Cardiac Event is the end point of a long-developing disease process. This disease process can be slowed through reduction of risk factors (such as obesity and high cholesterol) – as I mentioned in my first comment, I’m pefectly happy with the idea of a line being drawn between interventions promoting exercise and medication adherence with long-term clinical and cost benefits. Equally, its clear that telehealth has a role in supporting these interventions.
However, I’m still not convinced of the role of telemonitoring in providing an ‘early warning’ of ACS in the way that it can in relation to COPD exacerbation and HF decompensation. I’m just not convinced that the ‘trend monitoring’ nature of telemonitoring fits the pattern of acute coronary syndromes.
Despite Dr Forbat’s comments and his specific description of the appropriate use of troponin testing in primary care, I still have reservations about the way this is described in the report. Though retrospective diagnosis of ACS in primary care with POC troponin may be valuable, any patient with ongoing symptoms of ACS should be managed immediately in the emergency department.
Overall, my concern with the report is not simply some of the interventions alluded to, but the manner in which substantial benefits are claimed without providing any of the supporting evidence. We’ve seen with the WSD ‘headline findings’ that this approach can often raise more questions than it answers!
Dr. Lance Forbat
David asks for more specific evidence, we do require this. I agree with the management of ACS once diagnosed. The point I am making is the diagnosis is not that easy in many people and a troponin rise in an non-specifically unwell diabetic, who visits the GP a few days later, might be the only clue to the diagnosis. Near patient testing kits may have a role in high risk patients here.