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

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“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!