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Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan CNCF 8-10 octobre 2009.

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Presentation on theme: "Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan CNCF 8-10 octobre 2009."— Presentation transcript:

1 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan CNCF 8-10 octobre 2009

2 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan Disease Management dans linsuffisance cardiaque Disease Management dans la maladie coronaire Avantages et limites des formes de Disease Management Conclusion CNCF 8-10 octobre 2009

3 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Heart failure management programmes ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 Class of recommendation I, level of evidence A -Heart failure management programmes are recommended for patients with HF recently hospitalized and for other high-risk patients. -It is recommended that HF management programmes include the following components shown (Table). Adequate education is essential. Remote management is an emerging field within the broader context of HF management programmes. -Telephone support is a form of remote management that can be provided through scheduled calls from a HF nurse or physician, or through a telephone service, which the patients can contact if questions arise or symptoms of deterioration occur.

4 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 Class of recommendation I, level of evidence A -Telemonitoring is another form of management that allows daily monitoring of symptoms and signs measured by patients, family, or caregivers at home while allowing patients to remain under close supervision. -Telemonitoring equipment may include recording BP, heart rate, ECG, oxygen saturation, weight, symptom response systems, medication adherence, device control and video consultation equipmentall of which can be installed in the patients home. - Cardiac rehabilitation, as multifaceted and multidisciplinary interventions, has been proven to improve functional capacity, recovery, and emotional well- being, and to reduce hospital readmissions. Heart failure management programmes

5 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure The meta-analyses (> 8000 Pts) demonstrated that home-based follow-up or follow-up in a clinic setting significantly reduced hospitalization. The risk reduction ranged between 16 and 21%. Mortality is also significantly reduced. -The most recent meta analysis of 14 randomized trials involving 4264 patients incorporating sophisticated models of remote HF management demonstrated 21 % significant reduction in the risk of a HF-related admission and 20% of all-cause mortality. -HF management programmes are likely to be cost-effective in that they reduce hospital readmissions and can be established on a relatively modest budget. -It has not been established which of the various models of care is optimal. Both clinic- and home-based models seem to be equally effective. Heart failure management programmes

6 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring No in groupNo with event/ Telemonitoring or structured telephone support programmes for patients with chronic heart failure : meta-analysis ( all cause mortality ) Test for heterogeneity : 2 = 2.22, df = 4,P = 0.70, l 2 =0% 0.62 (0.45 to 0.85) Subtotal (95 % Cl) Telemonitoring 0.80 (0.69 to 0.92)100.00Test for overall effect : 2 = 2.93, P = Test for overall effect : 2 = 1.88, P = 0.06 Test for heterogeneity : 2 = 6.41, df = 8,P = 0.60, l 2 = 0% 0.85 (0.72 to 1.01) Subtotal (95 % Cl) Structured telephone Relative risk (random) (95 % CI) Weight (%) Relative risk (random) (95 % CI) Control group Treatment group Study Favours treatment Favours control Clark RA. Br Med J. 2007;334:942.

7 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Telemonitoring or structured telephone support programmes for patients with chronic heart failure : meta-analysis ( all cause admission to hospital ) (0.84 to 1.15) Telemonitoring 0.95 (0.89 to ) 0.94 (0.87 to 1.02) Structured telephone Relative risk (random) (95 % CI) No in groupNo with event/ Test for heterogeneity : 2 = 2.22, df = 4,P = 0.70, l 2 =0% Subtotal (95 % Cl) Test for overall effect : 2 = 0.21, P = 0.83 Test for overall effect : 2 = 1.44, P = 0.15 Test for heterogeneity : 2 = 4.78, df = 6,P = 0.57, l 2 0% Subtotal (95 % Cl) Weight (%) Relative risk (random) (95 % CI) Control group Treatment group Study Favours treatment Favours control Clark RA. Br Med J. 2007;334:942.

8 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Telemonitoring or structured telephone support programmes for patients with chronic heart failure : systematic review and meta-analysis (0.45 to 0.85) Telemonitoring 0.80 (0.69 to 0.92) 0.85 (0.72 to 1.01) Structured telephone Relative risk (random) (95 % CI) No in groupNo with event/ Test for heterogeneity : : 2 = 2.22, df = 4,P = 0.70, l 2 = 0% Subtotal (95 % Cl) Test for overall effect : 2 = 2.93, P = 0.03 Test for overall effect : 2 = 1.88, P = 0.06 Test for heterogeneity : : 2 = 6.41, df = 8,P = 0.60, l 2 =0% Subtotal (95 % Cl) Weight (%) Relative risk (random) (95 % CI) Control group Treatment group Study Favours treatment Favours control Clark RA. Br Med J. 2007;334:942

9 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 Recommended components of HF management programmes -Multidisciplinary approach frequently led by HF nurses in collaboration with physicians and other related services -First contact during hospitalization, early follow-up after discharge through clinic and home-based visits, telephone support, and remote monitoring -Target high-risk, symptomatic patients -Increased access to healthcare (telephone, remote monitoring, and follow-up) -Facilitate access during episodes of decompensation Heart failure management programmes

10 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 Recommended components of HF management programmes -Optimized medical management -Access to advanced treatment options -Adequate patient education with special emphasis on adherence and self-care management -Patient involvement in symptom monitoring and flexible diuretic use -Psychosocial support to patients and family and/or caregiver Heart failure management programmes

11 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Dickstein K. Eur Heart J 2008; 29:2388–2442

12 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan Disease Management dans linsuffisance cardiaque Disease Management dans la maladie coronaire Avantages et limites des formes de Disease Management Conclusion CNCF 8-10 octobre 2009

13 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial Wood DA. Lancet 2008; 371: 1999–2012

14 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring EUROACTION preventive cardiology intervention programme in hospital and general practice -In hospitals and general-practice centres, cardiologists and nurses recruited eligible patients and their families (open in GP). -Multidisciplinary assessment of lifestyle, risk factors, and drug treatment by a nurse, dietitian, and physiotherapist, couples attended at least eight sessionsone every weekin which they were assessed by each member of the team (nurse, dietitian, and physiotherapist). -The cardiologists initiated and uptitrated the cardioprotective drugs -The nurses monitored risk factors and adherence to drug treatments at each session. -At 16 weeks,patients and their partners were reassessed by the whole team and a report was sent to their family doctors. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial Wood DA. Lancet 2008; 371: 1999–2012

15 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring EUROACTION preventive cardiology intervention programme in hospital and general practice -The nurses assessed the smoking status, health beliefs, and history of tobacco smoking, and previous attempts to quit. -Patients and their families knowledge and attitudes to diet were assessed by the dietitian (in hospital) or nurse (in general practice). -To achieve a 30–45 min of moderate intensity activity, four to five times a week as a family, the physiotherapist (in hospital) or nurse (in general practice) assessed habitual and physical activity patterns, functional capacity, and other factors that affected activity participation by families -Nurses monitored the blood pressure and concentrations of cholesterol and glucose in all patients, and reviewed the results with physicians who treated the patients appropriately to achieve targets -In the hospitals, nurses coordinated a rolling programme of eight workshopsone a weekfor coronary heart disease, cardiovascular risks. Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial Wood DA. Lancet 2008; 371: 1999–2012

16 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Tabagisme : zéro Régime : Graisses saturées < 10 % Fruits et légumes > 400 g/j Poissons > 20 g/j Huile de poissons > 3 / sem Régime : Graisses saturées < 10 % Fruits et légumes > 400 g/j Poissons > 20 g/j Huile de poissons > 3 / sem Activité physique : 30 à 45 minutes dactivité physiques à % de FMT 4-5 fois/semaine Activité physique : 30 à 45 minutes dactivité physiques à % de FMT 4-5 fois/semaine Pression artérielle : < 140/90 mmHg (<130/85 si diabète) Pression artérielle : < 140/90 mmHg (<130/85 si diabète) Lipides : cholestérol T > 5 mmol/l LDL-c < 3 mmol/ Lipides : cholestérol T > 5 mmol/l LDL-c < 3 mmol/ Diabète : Contrôle de glycémie Diabète : Contrôle de glycémie Wood DA. Lancet 2008; 371: 1999–2012 EUROACTION - Objectifs

17 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring p = 0,002 Intervention Prise en charge conventionnelle Prise en charge conventionnelle + 36 % (+ 20 % to 51 %) p = 0, % (+ 11 % to 48 %) Proportion de patients atteignant les objectifs des recommandations européennes pour lactivité physique Intervention Prise en charge conventionnelle Prise en charge conventionnelle Intervention Prise en charge conventionnelle Hôpital Pratique de ville Wood DA. Lancet 2008; 371: 1999–2012 EUROACTION

18 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring p = 0,28* + 6 % (- 7 % to +19 %) p = 0,005* + 10 % (+ 6 % to +15 %) * Patients avec BMI > 25 kg/m² Proportion de patients atteignant les objectifs de réduction pondérale > 5 % Proportion de patients atteignant les objectifs de réduction pondérale > 5 % Intervention Prise en charge conventionnelle Prise en charge conventionnelle Prise en charge conventionnelle Prise en charge conventionnelle Intervention Prise en charge conventionnelle Wood DA. Lancet 2008; 371: 1999–2012 EUROACTION Hôpital Pratique de ville

19 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring p = 0, % (+ 0,6 % to +20 %) p = 0, % (+2 % to +32 %) Proportion de patients atteignant les objectifs des recommandations européennes pour la pression artérielle Intervention Prise en charge conventionnelle Prise en charge conventionnelle Prise en charge conventionnelle Prise en charge conventionnelle Intervention Prise en charge conventionnelle EUROACTION Wood DA. Lancet 2008; 371: 1999–2012 Hôpital Pratique de ville

20 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring p = 0,004 p = 0,02 p = 0,98 p = 0,51 Anti-agrégants plaquettaires Anti-agrégants plaquettaires Beta bloquants IEC Statines p = 0,002 Anticalciques p = 0,07 p = 0,90 p = 0,03 p = 0,21 p = 0,03 Intervention Prise en charge conventionnelle Proportion de patients sous traitement cardio-protecteur Anti-agrégants plaquettaires Anti-agrégants plaquettaires Diurétiques Beta bloquants IEC Statines Anticalciques EUROACTION Wood DA. Lancet 2008; 371: 1999–2012 Hôpital Pratique de ville

21 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Plan Disease Management dans linsuffisance cardiaque Disease Management dans la maladie coronaire Avantages et limites des formes de Disease Management Conclusion CNCF 8-10 octobre 2009

22 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Advantages and disadvantages of different models of HF programmes AdvantagesDisadvantages Clinic visits -Convenient with medical expertise, facilities and equipment available. -Facilitates diagnostic investigation and adjustments of treatment strategy. Frail, non-ambulatory patients not suitable for out-patient follow-up Home care -Access to immobile patients -More reliable assessment of the patients needs, capabilities and adherence to treatment in their own home environment -Convenient for a follow-up visit shortly after hospitalization. -Time consuming travel for the HF team -Transportation and mobile equipment required -Nurses face medical responsibilities alone and may have difficulty contacting the responsible physician. Conn VS. Journal of Cardiology xx (2008)

23 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Advantages and disadvantages of different models of HF programmes AdvantagesDisadvantages Telephone support -Low cost, time saving and convenient both for the team and the patient. -Difficult to assess symptoms and signs of heart failure and no tests can be performed -Difficult to provide psychosocial support, adjust treatment and educate patients. Remote monitoring -Facilitates informed clinical decisions -Need is increasing as care shifts into patients homes -New equipment and technology becoming rapidly available. -Requires education on the use of the equipment -Time-consuming for HF team -Difficult for patients with cognitive disability -Most helpful measurements not known. Conn VS. Journal of Cardiology xx (2008)

24 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring Conclusion Intérêt de la mise en place dune plateforme téléphonique de suivi des patients insuffisants cardiaques ou coronariens selon le modèle du Disease Management et des critères et objectifs bien définis Mobilisation des cardiologues de ville et rapprochement ville – hôpital - établissements de santé privés Information et formation des patients Évaluation simple Dispositif à un coût modéré CNCF 8-10 octobre 2009

25 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring

26 Assistance Publique Hôpitaux de Paris Disease management and telephone monitoring


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