Mobile Systems for Chronic Diseases Telemonitoring: Current Status

1. Mobile Systems for Chronic Diseases Telemonitoring: Current Status Introdução à Medicina 08/09 Class no.5 1

2. DEFINITION Telemonitoring:collection, record and transmission of clinical data between a patient at a distant location and a healthcare provider via remote telecommunications. It is provided on an outpatient basis. (http://www.homehealthquality.org/shared/content/hhqi_campain/bpip_tm/Therapy.pdf)‏ 2

3. DEFINITION Chronic diseases: Permanent disease, which leave residual disability, caused by nonreversible pathological alteration. They require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation or care. Dictionary of Health Services Management, 2nd edition 3

4. DEFINITION Physiological data: observable or measurable characteristics of the ocular system, the respiratory system, the musculoskeletal system, the nervous system or of the blood. (http://www.ncbi.nlm.nih.gov.sites/entrez)‏ 4

5. In this new century medicine is facing a new challenge called TELEMONITORING Revolution in the healthcare delivery processes Telemonitoring allows the use of electronic equipment to observe or record physiologic processes while the patient undergoes normal daily activities [Mehmet R. Yuce, Peng Choong Ng, Jamil Y. Khan, Monitoring of Physiological Parameters from Multiple Patients Using Wireless Sensor Network, April 2008, Springer Science + Business Media, LLC 2008 ] 5

6. A wide range of telemonitoring devices available, nowadays, for several diseases monitoring Chronic diseases: the most promising applications (cardiopulmonary disease, asthma, heart failure, diabetes) Most patients are elderly people – need to be regularly monitored (length of their disease, nature of their health condition, therapy) Telemonitoring is a way of responding to new needs in home care in an ageing population Isolated areas do not have easy access to healthcare or specialized medical staff 6

7. TELEMONITORING ALLOWS Earlier detection of abnormal health parameters Corrective measures to be taken before more complications appear Less frequent visits to healthcare facilities, shorter hospital stays and decrease of hospital admissions Increased patient’s quality of life Cost-effectiveness 7

8. Chronic diseases telemonitoring systems allow: • To collect part of the diagnostic's relevant information • To gather more information with less effort • To follow the patients closely spending less time. [Otto, C. A., Jovanov, E., and Milenkovic, E., A WBAN-based system for health monitoring at home. In 3rd IEEE/EMBS Int. Summer School, Medical Devices and Biosensors. Sept, 20–23, 2006.] [N. Oliver and F. F. Mangas, “HealthGear: a real-time wearable system for monitoring and analyzing physiological signals,” Tech. Rep. MSR-TR-2005-182, Microsoft Corporation, Red-mond, Wass, USA, 2005 ] 8

9. A simple and not very restricted search at Pubmed ... QUERY:(telemonitoring[All Fields] OR "telemedicine"[MeSH Terms] OR "telemedicine"[All Fields]) AND ambulatory[All Fields] Publications indexed by Pubmed from 1990 - 500 articles about telemonitoring - more than 93% of the publication's dates are from 2000 to the present year. 9

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11. MobiHealth is an healthcare project created for the development of mobile health services and funded by the European Commission. A patient who requires monitoring for short or long periods of time doesn't have to stay in hospital for monitoring. With the MobiHealth BAN the patient can be free to pursue daily life activities www.mobihealth.org This revels not only how recent this matter is, but also its emerging relevance 11

12. Telemonitoring Status: Despite their potential, most telemonitoring services are still limited to the status of temporary projects without clear prospects for wider use and proper integration into healthcare system. There is limited evidence of the effectiveness of telemedicine services on a large scale. Awareness, confidence and acceptance still need to be strengthened. 12

13. On which chronic diseases have mobile telemonitoring systems been used? 13

14. OBJECTIVES • Expose the scientific evidence, produced by experimental studies, supporting the use of mobile telemonitoring systems. • Determine which chronic diseases have been targeted by telemonitoring of physiological data. • Analyze which types of physiological data have been monitored and transmitted in chronic diseases telemonitoring. • Identify on which healthcare effects scientific evidence exists on the advantages or disadvantages of chronic diseases telemonitoring (health improvement, system usability, patient acceptance, etc.). 14

15. METHODS:Systematic Review Keywords: physiological, physiologic, process, phenomena, monitor, ambulatory, outpatients, non- hospital, telemedicine, telemonitoring, self monitoring, supervise, telesurveillance. 15

16. METHODS: Systematic Review D) A comprehensive literature search was conducted on Pubmed and ISI to identify relevant published articles. 16

17. ("physiological"[All Fields] OR "physiologic"[All Fields] OR physiologically[All Fields] OR process[All Fields] OR phenoma[All Fields] OR phenomal[All Fields]) AND (monitor [All Fields] OR ambulatory OR "outpatients"[MeSH Terms] OR "outpatients"[All Fields] OR "outpatient"[All Fields] OR non-hospital[All Fields] OR "monitoring, ambulatory"[MeSH Terms]) AND ("telemedicine"[MeSH Terms] OR "telemedicine"[All Fields] OR telemonitoring[All Fields] OR telemonitor[All Fields] OR "self monitor"[All Fields] OR "self monitoring"[All Fields] OR "supervise"[All Fields] OR "telesurveillance"[AllFields]). 17

18. Research results Pubmed ISI Web of Knowledge 502 TOTAL 18

19. Methods The articles obtained were subjected to a process of critical appraising according to its quality. • 1st. REVISION: • Revision by title and abstract • 2 reviewers - Articles excluded didn’t fit the inclusion/exclusion criteria. Any articles about mobile systems for chronic diseases telemonitoring were included. 19

20. Inclusion/Exclusion criteria Inclusion criteria (1)experimental studies which include direct data collection from patients (2) in humans (3) using outdoor-usable devices and (4) document scientific evidence of telemonitoring effects Exclusion criteria (1) do not include detailed description of the study, (2) are focused on athletes telemonitoring or (3) monitoring which does not make use of mobile systems, (4) general reviews and (5) conference and poster abstracts without study details. 20

21. Methods 2nd. REVISION: • Extensive analysis of the full article ‏ - 2 reviewers - The inclusion/exclusion criteria were changed - None of the articles excluded in the first revision would have been included in the second revision since the new criteria is a restriction of the previous one. 21

22. Inclusion/Exclusion criteria • Inclusion criteria • articles written in English, • with full text available, • regarding chronic diseases telemonitoring, • experimental studies which include direct data collection from patients, • using mobile telemonitoring systems • those which document scientific evidence of telemonitoring effects (health improvement, system usability, etc.). • Exclusion criteria • do not present a detailed description of the study, • describes a project of a new instrument, • general reviews 22

23. STUDY VARIABLES: Types of chronic disease targeted by telemonitoring Types of physiological data monitored • Benefits and drawbacks (health improvement, system usability, cost-effectiveness, etc.) mobile systems for chronic diseases telemonitoribg can bring for the: • clinician • patient • healthcare institution Country and publication date of the article 23

24. Methods After the data extraction: • Check for and identify sources of heterogeneity in results across studies • Findings/Results of individual studies are synthesised and subsequently statistically analysed in SPSS 24

25. Percentage of included, excluded articles and those who needed a 3rd reviewer 4,02% 10,92% 85,06% 25 Graphic 1: Percentage of included, excluded articles and those who needed a 3rd reviewer

26. Methods – 3rd Reviewer • Regarding the articles subjected to a 3rd revision: • 68,4% of the articles were included • 31,6% were excluded Methods – Final decision • After completing the articles revision we had: • 7,5% of the articles included • 92,5% of the articles excluded 26

27. Methods– Number of included and excluded articles by each reviewer 27 Graphic 2: Number of included and excluded articles by each reviewer

28. Methods A Chi-Square test was performed in order to check if there was any statistically significant difference between the expected and the actual number of excluded articles per reviewer. (p=0,668) 28

29. Methods – Frequency of use of each inclusion criteria 29 Graphic 3: Frequency of use of each inclusion criteria

30. Methods – Frequency of use of each exclusion criteria 30 Graphic 4: Frequency of use of each exclusion criteria

31. Results Profile of Chronic Diseases Telemonitoring Studies RESULTS 31 Table 1: Profile of chronic diseases telemonitoring studies

32. Results Profile of Chronic Diseases Telemonitoring Studies 32

33. Results Overview of Research Designs 33 Table 2: Overview of research designs

34. Results Overview of Research Designs 34

35. Results - Frequencies of types of effects 35

36. Results - Frequencies of advantages and disadvantages 36

37. Results – Advantages and disadvantages for the patient 37

38. Results - Advantages and disadvantages for the physician 38

39. Results - Advantages for the hospital 39

40. Discussion • Only articles about Diabetes, Cardiac Diseases and Hypertension were found. • Comparing to Paré et all, the number of included articles was considerably smaller since our research was restricted to experimental studies making use of mobile systems • USA is the country which has most explored the use of mobile technology to follow up chronic patients, as well as UK, Australia, Norway and Canada. • The date of publication of the articles ranges between from 1996 to 2008. • The majority of the articles were regarding Diabetes type I, revealing the importance to closely monitor and control the levels of blood glucose on a daily basis. • Cardiac diseases were also frequently targeted due to its high level of incidence and prevalence 40

41. Discussion Benefits of mobile telemonitoring systems for the patients Telemonitoring systems enable patient’s quality of life This kind of systems allows active participation in the process of healthcare, more patient’s independence and responsibility, General satisfaction and a high level of acceptance Minimal patient intervention in the collection and transference of data, reducing bias and subjectivity Promotion of a healthy lifestyle with an improvement in physical exercise practice and balanced diet as it increases patient awareness of their health condition Increasing of patients’ compliance with the treatment, medication and telemonitoring which is a result of a tighter control achieved by an alarm system warning the patient . 41

42. Discussion Disadvantages of mobile telemonitoring systems for the patients Problems related to the usage and access to the internet namely among elderly people since they are not used to deal with computer technology The cost-effectiveness is quite controversial Although it requires an initial investment in the equipment purchase, it may compensate in the long run, since it decreases future expenditures in healthcare services Undesirable changes in the daily routine may happen as a result of the permanent monitoring which leads to dependency towards the equipment 42

43. Discussion Benefits of mobile telemonitoring systems for healthcare professionals Telemonitoring promotes the knowledge integration from the different healthcare areas, encouraging discussion The physician has easier access to the patient information, and can be warned through an alarm system every time the patients’ health parameters are not normal Emergency situations can be detected earlier preventing the occurrence of more serious complications It is possible to follow closely the evolution of a patient health condition and consequently diagnose and apply treatment at distance 43

44. Discussion Disadvantages of mobile telemonitoring systems for healthcare professionals Less physical contact between physicians and patients Adaptation of clinical guidelines to this new way of healthcare delivery service It requires availability of the physician in order to analyze the patient data as well as ensure the maintenance of the equipment 44

45. Discussion Little evidence was found on the telemonitoring effects on the hospitaland additional research is required to further investigate and analyze the impact of chronic disease telemonitoring in healthcare facilities Effects of mobile telemonitoring systems on the hospitals Less frequent visits to the healthcare facilities, shorter hospital stays and decrease of hospital admissions Decrease in waiting lists associated with cost-effectiveness The hospital can be notified in case of medical emergency Previous professional training is needed in order to make an adequate use of this equipment, benefiting from all its potentialities 45

46. References: [1] Louis AA, Turner T, Gretton M, Baksh A, Cleland JG., A systematic review of telemonitoring for the management of heart failure, Eur J Heart Fail. 2003 Oct;5(5):583-90, Review. [2] Mehmet R. Yuce, Peng Choong Ng, Jamil Y. Khan, Monitoring of Physiological Parameters from Multiple Patients Using Wireless Sensor Network, April 2008, Springer Science + Business Media, LLC 2008 [3] Otto, C. A., Jovanov, E., and Milenkovic, E., A WBAN-based system for health monitoring at home. In 3rd IEEE/EMBS Int. Summer School, Medical Devices and Biosensors. Sept, 20–23, 2006. [4] GUY PARÉ, et al, Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base, Journal of the American Medical Informatics Association Volume 14 Number 3 May / June 2007. [5] N. Oliver and F. F. Mangas, “HealthGear: a real-time wearable system for monitoring and analyzing physiological signals,” Tech. Rep. MSR-TR-2005-182, Microsoft Corporation, Red-mond, Wass, USA, 2005 [6] P.T. Cheng, L.M. Tsai, L.W. Lu, and D.L. Yang. The design of pda-based biomedical data processing and analysis for intelligent wearable health monitoring systems. In Proc. Intl. Conf. Computer and Information Technology (CIT’04). [7] D. Konstantas, A.V. Halteren, R. Bults, K. Wac, I. Widya, N. Dokovsky, G. Koprinkov, V. Jones, and R. Herzog. Mobile patient monitoring: the mobihealth system. In Proc. Int. Conf. on Medical and Care Compunetics, NCC’04, 2004. [8] D. Malan, T. Fulford-Jones, M. Welsh, and S. Moulton. Codeblue: An ad-hoc sensor network infrastructure for emergency medical care. In Proc. Int. Workshop on Wearable and Implantable Body Sensor Networks, 2004. 46

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49. Authors: ALVES, José Pedro Figueiral Oliva Soares; CAMPOS, Marta Sofia Gomes; DATA, Tânia Rodrigues; ESTEVES, Alexandra Sofia Moreira; FARIA, Carlos Augusto da Silva; FERNANDES, Diana da Silva; GUEDES, Paulo Renato Moreira; MACHADO, Marino João Pinto; MAGALHÃES, Ana Isabel Pereira; MARQUES, Pedro Seabra; MATOS, José Pedro Rodrigues; MELO, Inês Marisa Tribuzi de Magalhães; MOREIRA, Pedro Manuel Costa; NASCIMENTO, João António Santos; PEREIRA, Maria Francisca Azevedo Marques; SILVA, Ana Rita Carneiro. Authors’ e-mail: intromed05@gmail.com Adviser: RODRIGUES, Pedro Pereira. Class Number: 05  49