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1 10th International Conference on Integrated Care Telemedicine in integrated care (example: asthma treatment) Dr. Annett Kröttinger, Marcus Hohlöchter Finland, 16th 18th June 2010

2 Telemedical healthcare programmes (TMed HP ) Definition in telemedicine Structure and core elements Telecoaching Training material Feedback reports Telemedical healthcare programme for asthma Initial situation Project partners Programme objectives and implementation Telemonitoring Results of the med. evaluation Telemedical healthcare programmes Outlook and next steps

3 TMed HP telemedicine: Definition Telemedicine = The use of technical applications to care for patients over a considerable period of time and / or distance Application areas: Doctor to doctor / care provider to care provider Teleconsultation Teletraining Telesurgery Our focus on these aspects Doctor / care provider to patient Telecoaching: structured supervision of patients, mainly via telephone contact, by specialized staff with medical training Telemonitoring: continuous monitoring of vital parameters in the home environment Telediagnostics Source: Own depiction in the style of Häcker et al., 2008

4 TMed HP structure and core elements: The focus is on the patient GP / specialist Emergency / specialist hospitals, rehabilitation facilities Patient Stat. health ins. / priv. health ins. Feedback Telemonitoring Healthcare programme Telecoaching Training courses The focus is on the patient The programmes can act as a useful supplement to existing healthcare structures The core elements comprise telecoaching, telemonitoring, training and feedback

5 TMed HP telecoaching: Key to lasting lifestyle changes Structured supervision via telephone contact by specialized medical staff (health coach) Specially trained to communicate with chronically ill individuals Fixed contact over a lengthy period Focus on behaviour modification and compliance management Important topics include diet, exercise, coping with stress, smoking Based on recognised learning psychological methods (TTM, SMART)

6 TMed HP written training material: Useful supplement to telecoaching Supplements telecoaching with written training material on all relevant topics Developed specially with the needs of the target group in mind Modular structure featuring general and diseasespecific contents Quality assurance performed by experts in selected specialist fields

7 TMed HP feedback reports: Added value for patients and doctors in charge

8 Telemedical healthcare programmes (TMed HP ) Definitions in telemedicine Structure and core elements Telecoaching Training material Feedback reports Telemedical healthcare programme for asthma Initial situation Project partners Programme objectives and implementation Telemonitoring Results of the med. evaluation Telemedical healthcare programmes Outlook and next steps

9 Telemedical healthcare programme for asthma: Initial situation - asthma in Germany Prevalence: 5% (adults), 10% (children) Cost of the illness: between 2,200 and 9,300 per patient / annum, total cost to the economy of around 2.6 million per annum Current healthcare situation: Optimisation potential (examples) Misuse of medication / improper use of emergency medication Vaccination status in need of improvement (pneumococcal, influenza vaccination) Patients' self-management of their condition can be developed further (e.g. knowledge / use of personal plan of action) Failure to take relevant lifestyle factors into account to a sufficient extent (e.g. smoking, coping with stress) Sources: Nationale Versorgungsleitlinie Asthma (National Medical Care Guideline for Asthma) version 1.1 status 03 / 2010; AIRE study by Rabe et al.; interviews with experts

10 Telemedical healthcare programme for asthma: Project partners organisation and communication Integrated care agreement as per 140 a ff. Service agreement Specialist hospitals GPs Medical specialists Telemedical supervision Persons insured with TK

11 Telemedical healthcare programme for asthma: Programme objectives and implementation Establishing a common, integrated treatment path for all participants in the supervision scheme Encouraging patients' self-management of their condition Promoting the provision of medication in line with guidelines Telemonitoring of high-risk patients Preventing escalation Reducing number of emergencies and hospital admissions Enhancing the quality of life Cutting treatment costs

12 Telemedical healthcare programme for asthma: Treatment path and task sharing Doctor Information about the programme Notification of programme participants / patient registration Registration Creation and adaptation of plan of action Patient Consultation in the case of critical values Feedback - health report Information to patient Pat. data, diagnoses, findings, medication, supervision profile Programme evaluation Transfer of peak flow + symptoms info Telemedical Centre (TMC) Telecoaching and monitoring providincare

13 Telemedical healthcare programme for asthma: Concept overview Initialisation Supervision / telecoaching 3 months 12 months Welcome / introduction to the programme Starter package Brochure Peak flow metre Medidcal history Summary med. results Plan of action Risk stratification Profile for "severe asthma": for participants with severity class III + IV Telemonitoring of high-risk patients Profile for "mild asthma": for participants with severity class I + II Short profile (6 months in total): for participants with seasonal asthma Elements in all profiles (excerpt): Agreement on goals and target controlling Training Search for care providers Inbound calls Feedback reports

14 Telemedical healthcare programme for asthma: Creation of personal plan of action Based on "traffic light system" operated by German Respiratory League

15 Telemedical healthcare programme for asthma: Implementation of personal plan of action Peak flow measurement and ascertainment of symptoms by patient at home or about Data capture via mobile phone, with feedback according to plan of action, and data transfer to TMC Data bundling in providincare and automatic checks for critical trends Intervention alarm in the case of critical values with contact made by telephone to clarify the situation Involvement and provision of latest information to the doctor in charge Goal Early identification of escalation and prevention of emergencies and hospital admissions

16 Telemedical healthcare programme for asthma: Individual components / end devices used Patient equipment Electronic peak flow metre Mobile phone with integrated software ( Asthma Manager") and personal plan of action Functionalities Recording and input of values (peak flow and symptoms) Immediate feedback in accordance with plan of action Storage and display of values over time (> self-management!) Automatic transfer of data to the TMC

17 Telemedical healthcare programme for asthma: Symptoms questioned and data captured Structured questioning and clear portrayal over time via mobile phone Coughing Breathlessness Expectoration Fatigue Temperature Diminished vital capacity Use of emergency inhaler

18 Telemedical healthcare programme for asthma: Operative implementation: status quo May 2010 Launch of operative project implementation: Number of patients registered: 1666 Percentage of women: 59.8% Percentage of men: 40.2% Average age: / years Profile distribution following initialisation: 22% 54% 24% Profile for seasonal asthma Profile for severe asthma Profile for mild asthma

19 Telemedical healthcare programme for asthma: Benefits as highlighted by case study Marco S., 48 years old Diagnosed with asthma Known allergic reactions Critical PEF trend Intervention alarm Telephone call and explanation: early high pollen count Recommendation: increase in medication in accordance with plan of action, visit to doctor Conclusion: situation prevented from getting out of hand thanks to timely compliance assurance Intervention telephone call by the TMC

20 Telemedical healthcare programme for asthma: User feedback on asthma programme Quotations from participating patients: "I was able to stave off a night-time asthma attack by talking through the plan of action as part of the supervision scheme. I didn't panic and didn't have to call in the paramedics." "Telemonitoring has given me a much greater feeling of security and confidence in my ability to do more." Quotations from doctors in charge: "I am full of praise for peak flow metre monitoring and discuss it regularly with my patients." "The information on the guideline treatment and plan of action provides me with valuable support."

21 TMed HP for asthma - results of the med. evaluation: Changes in the perceived severity of symptoms Symptom Severity of symptom* Frequency of symptom** t 0 t 1 Change p-value*** t 0 t 1 Change p-value*** Breathlessness % < % <0.001 Expectoration % < % <0.001 Coughing % < % <0.001 Sleep disturbances % <0.001 t 0 = initial value at the start of the programme t 1 = current / latest value, at least 120 days later n = Ø 692 (participants who presented with valid value pairs t 0 / t 1 and started the programme by , excluding participants in short profile category "seasonal asthma") *Scale: 0 3, with 0 = no symptoms, 3 = severe symptoms **Scale 0 3, with 0 = never, 3 = extremely frequent *** Wilcoxon test Significant improvement of all symptom categories over the course of the programme

22 TMed HP for asthma - results of the med. evaluation: Changes in vaccination rates Influenza vaccination Pneumococcal vaccination 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% t0 vaccinated t1 not vaccinated 0% t0 vaccinated t1 not vaccinated No. of patients vaccinated against influenza No. of patients vaccinated against pneumococci t 0 = initial value according to medical documentation t 1 = current / latest value during supervision n = 1194 (participants who started the programme by ) t 0 t 1 Change p-value % < % <0.001 Increase in vaccination rates by 18% / 43% over the course of the programme

23 TMed HP for asthma - results of the med. evaluation: Provision of pharmacotherapy according to guidelines 100% PRN medication (for all severity classifications) 80% 60% 40% without with 20% 0% t0 t1 No. of patients on PRN medication t 0 t 1 Change p-value* % <0.001 t 0 = initial value according to medical documentation; t 1 = current / latest value during supervision; n = 1195 *Wilcoxon test 11% increase in the number of patients receiving pharmacotherapy according to guidelines (PRN medication)

24 TMed HP for asthma - results of the med. evaluation: Long-term medication (for severity classification 2/3) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Long-term medication severity class. 2 t0 t1 without with 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Long-term medication severity class. 3 t0 t1 without with No. of patients on long-term medication, severity classification 2 No. of patients on long-term medication, severity classification 3 t 0 = initial value according to medical documentation t 1 = current / latest value during supervision n =453 for severity classification 2 n =290 for severity classification 3 t 0 t 1 Change p-value % < % <0.001 Increase in provision of medication by 8% / 39% over the course of the programme

25 TMed HP for asthma - results of the med. evaluation: Long-term medication (for severity classification 4) 100% Long-term medication severity class. 4 80% 60% 40% without with 20% 0% t0 t1 No. of patients on longterm medication, severity classification 4 t 0 t 1 Change p-value* % <0.001 t 0 = initial value according to medical documentation; t 1 = current / latest value during supervision; n = 48 *Wilcoxon test Increase in provision of medication by 40% over the course of the programme

26 TMed HP for asthma - results of the med. evaluation: Patients with plan of action Patients with plan of action Patients familiar with plan of action 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% without with 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% not familiar familiar t0 t1 t0 t1 t 0 t 1 Change p-value No. of patients with plan of action % <0.001 No. of patients who are familiar with the plan of action t 0 = initial value according to medical documentation t 1 = current / latest value during supervision n = % <0.001 Increase in plan of action incidence and familiarity by 84% / 100% over the course of the programme

27 Telemedical healthcare programmes (TMed HP ) Definitions in telemedicine Structure and core elements Telecoaching Training material Feedback reports Telemedical healthcare programme for asthma Initial situation Project partners Programme objectives and implementation Telemonitoring Results of the med. evaluation Telemedical healthcare programmes Outlook and next steps

28 Outlook / next steps Second medical evaluation Additional analysis of the programme Integration of the Asthma Control Test (ACT) into the supervision Increase of the programme for more target groups