Telemedical Disease Management in Europe: What are the Chances and Risks

1. Telemedical Disease Management in Europe: What are the Chances and Risks Dr. med. Andy Fischer , Swiss Center for Telemedicine MEDGATE Med _e_Tel, Luxembourg, 18.04.2008

2. Disease Management Definition(Disease Management Association of America, DMAA) • Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant

3. 24h Service Home visits by nurses Telebiomonitoring/ Feedback Anamnesis Clinical signs, Symptoms Follow-upBiomarker Recruiting Doctor Studies New clinical symptoms Stable Situation Cont. therapy adjustment Monitoring phase Adjustment phase Diagnosis Self management Follow-upBiomarker Follow-up goals Risk-Stratification Therapy-Plan Doctor Basic training Cooperation GP Basic investigation and Treatment planning OBC Management Peer Groups Telemedical Disease Management:Today up to 10 described Intervention Models

4. Telemedical Management Concepts

5. Chances

6. Today: Medical Care for each patient by a Health Care Provider in a 1:1-setting

7. 4 Number of patients per practicing Medical Doctor (Decline of 2.4% p.a. from 1970-2005) In 200 years 1 MD per family! Quelle: Das Gesundheitswesen der Schweiz, Pharma Information

8. In the Future: Medical Care for each patient in a 1:n-setting: Equal Medical Requirements

9. The „Big Five“ are the same in Europe:Medically there are no differences • Heart failure • COPD • Asthma bronchiale • Diabetes mellitus • Hypertension „Diabetes kit“

10. We have promising results but no evidence yet (I) • Heart failure • Remote monitoring programmes reduced the rates of admission for chronic heart failure and all cause mortalityClarc RA et al. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis. BMJ 2007; May 5; 334(7600):942 • 1-year home-based telemanagement (HBT) reduced hospital readmission and costs in chronic heart failure patients Giordano A. et al. Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure. Int. J. Cardiol. 2008 Jan 25 Epub ahead of print • Hypertension • Telecommunication service with home service of automatic transmission of blood pressure data showed efficacy in reducing the mean arterial pressure of patients with established hypertension Rogers MA et al. Home monitoring service improves mean arterial pressure in patients with essential hypertension. A randomized controlled trial. Ann. Intern Med. 2001 Jun 5;134(11):1024-32 • Telemonitoring of BP over a 12-month period resulted in clinically and statistically significant reductions in systolic BPArtinian NT et al. Effects of nurse-managed telemonitoring on blood pressure at 12-month follow-up among urban African Americans. Nurse Res. 2007 Sept.-Oct;56(5):312-22

11. We have promising results but no evidence yet (I) • Diabetes mellitus • Telemedicine Diabetes Disease Management Program: Reduction of over all charges, decrease in hospital admissions and emergency room encounters as well as improvements in quality of lifeCherry JC et al. Diabetes Disease management program for an indigent population empowered by telemedicine technology. Diabetes Technol Ther 2002; 4 (6): 783-91 • Diabetes education via telemedicine and in person was equally effective in improving glycemic control and both methods are well accepted by patients Izquierdo RE et al. A comparison of diabetes education administered through telemdicine versus in person. Diabtes Care. 2003 Apr; 26(4):1002-7 • COPD / Asthma bronchiale • Effects of telemonitoring: Decrease in hospital admission rates and in total number of exacerbations. Trappenburg JC et al.Effects of telemonitoring in patients with chronic obstructive pulmonary disease.Telemed J E Health. 2008 Mar; 14 (2): 138-46 • Spirometry self-testing by asthma patients during telemonitoring is comparable to those under supervision of medical professionals. Internet-based home asthma telemonitoring can be successfully implemented in a group of patients with no computer background Finkelstein J. et al. Internet-based home asthma telemonitoring: can patients handle the technology? Chest. 2000 Jan;117(1):148-55

12. Challenges and open questions

13. The balance of risk determines the insurers’ incentive to provide DMP Costs per insured and month (CHF) Redistribution 700 600 500 400 300 Mean 200 100 0 } } } } } } } } } } } } } } } 19- 26- 31- 36- 41- 46- 51- 56- 61- 66- 71- 76- 81- 86- 91+ 25 30 35 40 45 50 55 60 65 70 75 80 85 90 risk groups: age and sex

14. Risk adjustment formula • The risk adjustment formula computes risk-related compensations. The variables included in the formula differ by country. • For example: • Belgium: socio-economic, disability, diagnosis of invalidity, eligibility of social exemption, chronic illness • Germany: age, gender, disability, registration in a certified DMP, and high-costs pooling • Netherlands: age, gender, urbanization, disability, pharmacy-based cost groups, and diagnostic cost groups • Switzerland: age, gender, and region • The more powerful this formula is, the more incentive insurers have to offer disease management programs

15. Decrease of costs Increase of costs Increase of costs Decrease of mortality Delay of disease progression and reduction of complications Without Disease Management Program With Disease Management Program Improved medical therapy Therapy costs Reduction of risk group Improved Compliance Disease progression Do TDMP really save costs?

16. 24h Service Home visits by nurses Telebiomonitoring/ Feedback Anamnesis Clinical signs, Symptoms Follow-upBiomarker Recruiting Doctor Studies New clinical symptoms Stable Situation Cont. therapy adjustment Monitoring phase Adjustment phase Diagnosis Self management Follow-upBiomarker Follow-up goals Risk-Stratification Therapy-Plan Doctor Basic training Cooperation GP Basic investigation and Treatment planning OBC Management Peer Groups Which intervention models have which advantages?

17. How shall we recruit patients?

18. Challenges in the following years • Guidelines, Best Practice and Quality Assurance for TDMP • Evidence for the use of the individual intervention models (multicentre studies) • Medical outcome • Cost effects • Strategy for solving the problem of recruitment • The single national players are too small to answer these questions on their own

19. European and International Collaboration

20. Even Europe has remote valleys...