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The use of technology in managing patients with cardiovascular disease
Associate Professor Andrew MaioranaHead of Department, Exercise Physiology, FSH
&Research Academic,
School of Physiotherapy and Exercise ScienceCurtin University
Technology in medicine
What is cardiac rehabilitation and secondary prevention?
Cardiac rehabilitation (CR) – processes to accelerate recovery and optimise physical, psychological and socialfunctioning to enable people with CVD to live fulfilling lives with confidence.
How can technology support cardiac rehabilitation?
“Digital health” - overarching term, includes eHealth and mHealth
electronic health records
telehealth
computing science – machine learning, artificial intelligence and
‘big data’
wearable sensors
telemonitoring
<
“The two areas that are changing... are information technology and medical technology. Those are the things that the world will be very
different 20 years from now than it is today.”
Bill Gates (2012)
“Machines will not replace physicians,
… but physicians using AI will soon replace those not using it.”
(Di leva, The Lancet, 2019)
What’s required to make digital technology ‘fit for purpose’ in cardiac rehabilitation?
Robust evaluation of new digital health innovations
Disseminating effective health innovations rapidly
Upskilling health providers in these innovations
Empowering consumers to be active participants in digital health
Ensuring equity and access for all - particularly among the
disadvantaged
Know your patients
Engage with patients
Managepatients’ care
Sweet spot
What are the capabilities of digital health?
1. Know your patients
Risk intelligence solutions that deliver population analytics and individual patient profiles to enable proactive care.
2. Engage with patients
Provide health engagement that supports self-management, enhances patients’ experience and improves outcomes.
3. Manage patients’ care
Care management that encompasses evidence-based best practice and appropriate service utilization.
Project 1: Innovative elemonitoring-enhanced Care for CHF (ITEC-CHF)
Background
Chronic heart failure (CHF) is a progressive condition complicated by
episodes of exacerbation, recurrent hospitalisations
Rapid weight gain reflects fluid retention
Daily weight monitoring is an important component of self-
management
< 40% patients monitor weight according to recommendations¹ 1. Jaarsma T, et al. Comparison of self-care behaviors of heart failure patients in 15 countries worldwide. Patient education and counseling. 2013; 92(1):114. OI:10.1016/j.pec.2013.02.017.
Purpose of the project
To develop and trial an automated model of body weight telemonitoring to support clinical surveillance in patients with CHF.
Overview of the Project
184 patients recruited through tertiary hospitals:
– Fiona Stanley Hospital/Royal Perth Hospital (WA)
- Peninsula Health (Vic)
Randomised to ITEC-CHF or usual care control
Ding et al. BMJ Open 2017;7:e017550
Process flow diagram for ITEC-CHF telemonitoring system
Patient weighs themself
VitelMed app receives the data entry
Sends weight data to ManageMyHealth
STEP 1 STEP 2 STEP 3
System Overview
Alert level Conditions Intervention
Delivery Time
Interventions
Urgent Fluctuation of 2Kg in 2
days.
In real time, 24
hours, 7 days a
week.
Nurse calls patient for further assessment
and activates CHF action plan.
High Fluctuation of 5 Kg in 28
day
Mon -Fri. Nurse follows up with the patient, and
engages with CHF clinics for further clinical
assessments.
Medium Technical issues, such as
battery low.
In real time, 24
hours, 7 days a
week.
Operators at MEPACS call the patients to
solve the issues, and call nurses to follow-up
if needed.
Medium Noncompliance of daily
weight monitoring (no
weight entry before 10AM)
In real time, 24
hours, 7 days a
week.
Operators at MEPACS call the patients to
remind them to weigh, and call nurse to
follow-up if needed
Low Fluctuation of 1 Kg in 1 day. In real time, 24
hours, 7 days a
week.
Questionnaire is triggered and appears on the
table. Patient answers questionnaire. Nurse
calls the patient for a clinical assessment, if
the questionnaire is unanswered.
Results:
Figure 1. Distribution of 6 major types of alerts in the ITEC-CHF group.
change
change
change
Excluding participants who discontinued the study, weighing compliance
was: ≥ 4 days a week; ITEC-CHF 97% vs CONTROL 69%; (p<0.0001) ≥ 6 days a week; ITEC-CHF, 61% vs CONTROL, 28%; (p<0.0001)
Figure 2. Comparison of participant compliance with daily weight monitoring between the ITEC-CHF and control group.
Heart Failure Compliance Questionnaire
ITEC-CHF was associated with a significantly improved score for:
health maintenance (p<0.05);
medication adherence (p<0.05);
diet (p<0.01).
No change in controls.
Figure 3. ED presentations in the ITEC-CHF vs Control group
Project 2: Smartphone and social media-based cardiac rehabilitation and secondary prevention in
China (SMART-CR/SP) study
Background There is an urgent need to improve access to cardiac rehabilitation and
secondary prevention (CR/SP) services in China
Innovative CR/SP models that are easy to access, affordable andscalable are required to optimise the management of CHD in China
Mobile health-based CR/SP may be a promising solution
What is WeChat ?
SMART-CR/SP study : Trial Design
Dorje T et al., BMJ Open 2018
Figure 1. Components of the SMART-CR/SP system
(Perth-based)
SMART-CR/SP study: Intervention
SMART-CR/SP study: Intervention
Results:
Cardihab
Cardihab
A cautionary tale…
https://t.co/fzyyBEq34s
Some take home thoughts….Digital health is promising for many health issues but:
Importance of maintaining patient autonomy
Public trust
Need for transparency behind algorithms - augmented rather than
artificial intelligence otherwise AI is seen as a ‘black box
Requirement to integrate digital health into work flow
Cost effectiveness
How to handle live identified data sets and sharing patient
information across health sectors ?
Legislative issues – the technology needs to drive the legislation!
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