Internet-based Telemedicine for Cardiovascular Disease Management (Text version)

AHRQ 2008 Annual Conference

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Alfred A. Bove, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.4 MB).

Slide 1

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Slide 2

Internet-based Telemedicine for Cardiovascular Disease Management

Alfred A. Bove, MD, PhD
Cardiology Section
Temple University Medical Center.

Slide 3

Why Telemedicine?

• Shift in incidence from acute to chronic disease.
  • Heart Failure.
  • Hypertension.
  • Diabetes.
  • Respiratory Disease.
  • Renal Disease.

Slide 4

New Concepts

• Toward a National Health Information Infrastructure
  June 2000
  National Committee on Vital and Health Statistics.

Slide 5

Heart Failure Demographics

The bar graph shows an increasing incidence of heart failure patients from 1970 to 2040.

• 1970: approximately 3.8 million.
• 1980: approximately 4 million.
• 1990: approximately 4.4 million.
• 2000: approximately 4.9 million.
• 2010: approximately 5.2 million.
• 2020: approximately 6 million.
• 2030: approximately 6.8 million.
• 2040: approximately 8 million.

Slide 6

HF Telephone Intervention

The bar graphs show the numbers for both Usual Care and Telephone Intervention in regard to Death and Hospitalization for 1,518 heart failure patients during a 20 month period.

• Death (P=0.69)
  • Usual care: 1
  • Telephone intervention: .9
• Hospitalization (P=.005)
  • Usual care: 1
  • Telephone intervention: .7

• Note: Grancelli H, Varini S, Ferrante D, Schwartzman R, Zambrano C, Soifer S, Nul D, Doval H; GESICA Investigators. J Card Fail 2003 Jun;9(3):172-9. The graph shows a reduction in hospitalization for heart failure in patients using a telephone surveillance system.

Slide 7

Telephone Surveillance

The bar graphs show the numbers for both Usual Care (UC) and UC plus Telephone in regard to Admissions and Emergency Department (ED) Visits for 47 heart failure patients during a 20 month period.

• Admissions.
  • Usual Care: 90.
  • UC + Telephone: 30.
• ED Visits.
  • Usual Care: 55.
  • UC + Telephone: 15.

• Note: Chrysogelos E et.al. J Card Fail 2000; 6:II-6. The graph shows a reduction in hospitalization and ED visits in heart failure patients using a telephone surveillance system.

Slide 8

Telehealth System

The diagram shows a centered image of a cloud (Internet) with lines radiating to small computer screens (Patient Web terminals), a computer (Provider Workstation), and a server (Server/Database).

• The diagram shows the connections between the patient, provider and information database via the internet for communications.

Slide 9

Patient Management Patient Management

The figure shows a screen from the Internet communication system used for hypertension management.

Slide 10

Patient Management

The figure shows a screen from the Internet communication system used for hypertension management. The sub screen shows a line graph for an individual's recorded weight.

• Graphics.

Slide 11

The bar graph shows the number of hospital days for both Control and Telemedicine in 48 heart failure patients during a 12 month period.

• Control: 225.
• Telemedicine: 75.

• Note: P=0.025.
• Note: The graph shows a reduction in hospital days in patients with heart failure who used our Internet communication system. Kashem at al. J. Cardiac Failure 2008.

Slide 12

Cardiovascular disease (CVD) Risk

• High in Underserved populations.
  • Inadequate care availability.
  • Inadequate health education.
    • The "Medical Divide."
  • Increased Obesity/Metabolic Syndrome.

Slide 13

CVD Risk Management

The figure shows a Web screen used for cardiovascular risk management.

• Record Risk Factors.
  • Date of Measurements.
  • Your Weight.
  • Your Systolic Pressure.
  • Your Diastolic Pressure.
  • Today's Exercise Minutes.
  • Today's Cigarettes.

Slide 14

Patient Management

The figure shows a Web screen used for cardiovascular risk management.

• Make a personal Health file.
  • Date.
  • Risk Score.
  • Weight.
  • Body mass index (BMI) Blood Pressure.
  • Low-density lipoprotein (LDL).
  • Glucose.
  • Cigarettes.
  • Steps per Day.
  • Your Medications.

Slide 15

Patient Management

The figure shows a Web screen used for cardiovascular risk management. A sub screen showing a line graph is opened.

• Provide longitudinal feedback.

Slide 16

Patient Management

The figure shows a Web screen used for cardiovascular risk management. A sub screen for Cholesterol (LDL and high-density lipoprotein [HDL]) is opened.

• Provide education.

Slide 17

Risk Factors

The bar graphs show the distribution of risk factors in urban and rural subjects.

• Rural vs. Urban.
• Current Smoker:
  • TUMC: 30%
  • GMC: 19%
• Diabetes:
  • TUMC: 50%
  • GMC: 35%
• Htn:
  • TUMC: 80%
  • GMC: 69%
• Hyperlipid:
  • TUMC: 73%
  • GMC: 68%

Slide 18

Health Knowledge

The bar graphs show the health knowledge scores (percent correct) in Urban and Rural subjects.

• Diabetes:
  • Temple: 36%
  • Geisinger: 43%
• Exercise:
  • Temple: 71%
  • Geisinger: 73%
• High blood pressure (HBP):
  • Temple: 65%
  • Geisinger: 60%
• Lipids:
  • Temple: 56%
  • Geisinger: 70%
• Nutrition:
  • Temple: 43%
  • Geisinger: 59%
• Smoking:
  • Temple: 56%
  • Geisinger: 56%
• Weight:
  • Temple: 77%
  • Geisinger: 80%
• Total:
  • Temple: 57%
  • Geisinger: 62%

Slide 19

Baseline Data

The table shows the baseline data for the total cohort.

Slide 20

Rural vs. Urban Risk

The bar graphs show the improvement in risk factors in urban and rural subjects.

• CVD Risk.
• Rural.
  • Initial: 16.7%
  • Final: 14.1%
• Urban.
  • Initial: 18.7%
  • Final: 16%

Slide 21

Clinical vs. Telemedicine

The bar graphs show the changes in blood lipids in subjects using the telemedicine system compared to a control group.

• Blood Lipids
• Clinical:
  • Chol
    • Baseline: 203 mg/dl
    • Final: 192 mg/dl
  • LDL:
    • Baseline: 121 mg/dl
    • Final: 114 mg/dl
  • HDL:
    • Baseline: 47 mg/dl
    • Final: 49 mg/dl
• Telemedicine
  • Chol
    • Baseline: 199 mg/dl
    • Final: 190 mg/dl
  • LDL:
    • Baseline: 120 mg/dl
    • Final: 114 mg/dl
  • HDL:
    • Baseline: 47mg/dl
    • Final: 47 mg/dl

Slide 22

Clinical vs. Telemedicine

The bar graphs show the changes in systolic blood pressure in subjects using the telemedicine system compared to a control group.

• Systolic Blood Pressure.
• Clinic:
  • Baseline: 146 m mHg.
  • Final: 137 m mHg*.
• Telemedicine:
  • Baseline: 146 m mHg.
  • Final: 137 m mHg*.

• Note: Numbers on the bar graphs were not clear.

Slide 23

Clinical vs. Telemedicine

The line graph shows the time course of changes in systolic blood pressure over a one year period in subjects using the telemedicine system compared to a control group.

• Clinical Group:
  • Visit 1: 148
  • Visit 2: 142
  • Visit 3: 141
  • Visit 4: 138
• Telemedicine Group:
  • Visit 1: 147
  • Visit 2: 136
  • Visit 3: 133
  • Visit 4: 134

• Note: P=0.03

Slide 24

Clinical vs. Telemedicine

The bar graphs show the changes in CVD risk score in subjects using the telemedicine system compared to a control group.

• Clinical:
  • Baseline: 17.8%
  • Final: 15.1%
• Telemedicine:
  • Baseline: 17.5%
  • Final: 15%

Slide 25

Telemedicine Use

The slide includes a portion of a table showing "Number/year," "% of subjects," and "Average number of reports," and a bar graph measuring the "Mean Risk" for "Frequency/year."

• 22% of the clinical group monitored health status.

Slide 26

Managing Hypertension

• Over 65 million patients.
• Most not at goal BP.
• Problem with medication adherence.
• Increased risk:
  • Heart disease.
  • Stroke.
  • Renal failure.

Slide 27

Patient Centered Therapy

• Knowledge.
  • Goal BP (guideline-based).
  • Lifestyle effects.
  • Diet effects.
  • Medication effects.
• Surveillance.
  • Self measured BP.
  • Weekly reporting.
• Communication.
  • Internet.
  • Telephone.

Slide 28

Patient Centered Therapy

• Reporting.
  • Patient—monthly summaries via mail.
  • Physician—monthly summaries via fax.
• Quality.
  • Education.
  • BP goal.
  • Lifestyle changes.
  • Medication appropriateness.

Slide 29

Internet Use

The slide shows a Web screen used for the Internet-based hypertension management system. The screen shows information to be sent.

• Date of Measurement.
• Time of Measurement.
• Systolic Pressure.
• Diastolic Pressure.
• Pulse.
• Weight.
• Steps.
• Today's Cigarettes.
• Message.

Slide 30

Internet Use

The slide shows a Web screen used for the Internet-based hypertension management system. The sub screen shows information on blood pressure.

Slide 31

Information Infrastructure

The diagram shows a centered image of a cloud (Internet) with lines radiating to books (Information Center), computers (Clinic, Hospital, and Pharmacy), as well as to one lone computer (Patient), a modem (Wireless which can reach a Patient by cell phone or a Provider),and a server (Server/Database).

• This slide shows the new configuration of our Internet-based hypertension management system, and future concepts for health information.

Slide 32

What Works for Telemedicine

• Chronic Illness.
  • Patient participation.
  • Care team includes the patient.
• Home monitored status.
  • Hypertension.
  • Heart Failure.
  • Diabetes.
  • COPD/Asthma.
• Easy Communication.
• Expectation/empowerment.

Slide 33

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