The Pandemic, Telemedicine & CVD
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Symposium presentation at the 2021 Philippine Society of Hypertension & Philippine Lipid & Atherosclerosis Society annual convention, 17 Feb 2021
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The Pandemic, Telemedicine & CVD
- 6. Scoping review of 36 studies
- 29. @endocrine_witch
Editor's Notes
- Thank you for the kind invitation to talk about the pandemic, telemedicine and cardiovascular disease. I have no conflicts of interest for this presentation.
- Iโve divided my presentation into three parts. First to discuss how CVD care was disrupted or even neglected during the pandemic and how telemedicine can widen previously existing inequities. Second to take a look at some new models of care that emerged during the pandemic - attempts to ensure continuity of care. And lastly, to look at some research directions, minding the gaps that exist.
- With the limiting of โnon-essentialโ clinical services, the usual delivery of CVD care was significantly hampered โwith deferral of face to face clinic consults, postponement of screening programs and limitation of rehab services. Most human and material resources were allocated to the pandemic. And even if services became available as the quarantine rules relaxed somewhat, the patients were afraid to follow up because of the fear of contracting CoVID19.
- Whatโs worse, we have the technology paradox. Those most in need of assistance have the poorest access to technology. Gadgets with internet access may be out of reach for low-income households. Even with gadgets, the elderly who are less tech savvy may be unable to access telehealth services. Continuity of care may also require access to devices such as BP apps or glucometers. Lab tests for monitoring may be needed. All these add to the costs, which may not be affordable for some. Thus Wang et al warn that rapid telehealth utilisation without improving access, affordability and digital health literacy increases health disparity, further widening the digital divide.
- Wang et al are from Singapore. Singaporeโs pandemic response was challenged by an outbreak in the crowded dorms of immigrant workers. In their paper, they write about the challenges and potential solutions for those in the lower socioeconomic classes. For the challenges โฆ For solutions, they suggest still using traditional media to improve access to informationโฆ
- More than ever, unable to seek care because of the pandemic, we need to empower our patients for self-management. In a scoping review of interventions enabling self-management of NCDs in low and middle-income countries, most interventions involved the use of SMS or phone calls, followed by educational sessions and last, the deployment of medical devices. In a 2019 Pew Internet survey, about 80% of adult Filipinos owned a mobile phone and only 53% owned smartphones so the use of SMS and phone calls in more studies was not surprising, given the low cost of SMS and the ubiquity of mobile phones.
- For self-management of diabetes in low- to middle-income countries, the following were the interventions used โฆ The scoping review noted that most of these studies were only at pilot-level implementation and that sustainability, scalability and integration with existing services of local health organizations or governmental agencies was lacking. Sound familiar?
- And so to end the this part of the presentation, Dr. Tedros of WHO had this to say -
- Going to the second part of this presentation, letโs take a look at new models of care that emerged during the pandemic - attempts to ensure continuity of care. But first, I will discuss several studies on telemedicine before the pandemic because yes, telemedicine was around before the pandemic, and then go to two illustrative studies during the pandemic.
- First this 2018 study, TASMINH4 which looked at the efficacy of self-monitored blood pressure, with or without telemonitoring for titration of antihypertensive medications, an unmasked randomized controlled trial. There were 3 arms: self monitoring BP only, self monitoring with telemonitoring vs usual care where BP was checked at clinic visits. For self-monitoring arm, they were asked to monitor their own blood pressure in their non-dominant arm, twice each morning and evening, for the first week of every month using standard recommendations and their GPs were asked to use the self-monitored measurements for titration of antihypertensive medication. At the end of each monitoring week they were asked to record their readings on paper and send them for review to their practice in a reply-paid envelope.
- Participants in the telemonitoring group were trained to send readings via a simple free SMS text-based telemonitoring service with web-based data entry back-up. The telemonitoring system incorporated an algorithm that alerted participants to contact their clinic in the light of very high or very low readings, reminded them if insufficient readings were transmitted, prompted them to make contact with their clinic if their average blood pressure was above target, and presented readings to attending clinicians via a web interface. This secure web page automatically calculated mean blood pressure for each monitoring week, highlighted very high or very low readings, and presented a graphical display of blood pressure measurements. Attending clinicians were asked to review both self-monitoring and telemonitoring groups' readings on a monthly basis and usual care patients as often as they wished.
- So what were the results? This is the first trial in primary care of antihypertensive titration using self-monitored blood pressure, with or without telemonitoring, to show a benefit in terms of blood pressure after 12 months. Differences in blood pressure recorded at 6 months were amplified by 1 year suggesting that the intervention increased in efficacy in the second 6 months. This was achieved without increased workload and using internationally recommended targets for home and clinic blood pressure, the former lower by 5/5 mm Hg. Additional benefit from telemonitoring was seen in terms of lower blood pressure after 6 months suggesting more efficient titration.
- That hypertension study featured a closed loop system. And this is a feature in most telemonitoring scenarios. Bashur et al did a lit review of the use of telemedicine in diabetes and he found the following common components in a closed loop system. In Stage 1, patients collect their own diabetes-related data (including insulin dosage, glucose levels, body weight, level of physical activity, etc.). They may use glucose meters and short questionnaires. One variant of the entry point to this telediabetes circuit involves nurse-initiated telephone calls to assess, monitor, and motivate patients. In Stage 2, patients transmit the data electronically to a call center or clinic, staffed by trained nurses or a nurse-lead team. In Stage 3, these data are stored, collated, and processed by various algorithms, display time trends, and trigger alarms when significant deviations in values are exceeded. Patients are alerted to these situations and given explicit guidance and assistance. Nurses may communicate with physicians, as indicated by the data, who will provide medical assistance or directions to receive in-person care. In addition, nurses may provide individualized education/motivational information directed toward encouraging patients to adopt healthy life styles.
- And Bashur et alโs closed loop system is what we see here too in Yang et alโs paper on the use of WeChat for women with GDM. Step 1โฆ
- Zooming out to the healthcare system, we see this similarly in Omboniโs paper on hypertension management in the internet of medical things (iOMT). You may have heard of IOT - internet of things before. It was a buzzword in recent years, IOT is the interconnection via the Internet of computing devices embedded in everyday objects, enabling them to send and receive data, so you can say Alexa turn on the lights! In this diagram of the internet of medical things, even if you add all the tech and software, it remains the same. The patient collects data. Data is transmitted and/or stored which may trigger alarms if not on target. Health personnel review and manage accordingly.
- Now letโs go to the pandemic studies. Due to the pandemic, Orso et al had to cancel the appointments of nearly 150 patients in their heart failure clinic. To reproduce the usual clinic evaluation, they created a standardized 23-item questionnaire for telephone follow-up. The paper reports their experience with the first 30 patients who completed a 4-week follow-up. And for those, the median phone call duration to administer the questionnaire was six minutes.
- The questionnaire had 7 domains. For adherence to pharmacological and nonpharmacological recommendations (blood pressure, heart rate, weight monitoring and fluid intake control was included. For recent evaluation by family physician or need to contact emergency services, the reasons for these medical contacts was included. General and pharmacological recommendations as well as the following telephone contact were finally recorded.
- Items in the questionnaire were allowed to points to come up with a score. The score was used as a clinical tool to define patientsโ clinical stability and timing of the following telephone contact on the basis of the assignment to progressively increasing risk score groups: green (< 4points), yellow (4 to 8 points), and red (9 points).
- I donโt have the time to discuss the study in detail but can take a look at the colors. Take a look at the left figure with the 30 patients. Basically we want them to stay green. Patient 3 is interesting because from yellow, the status became green - there was improvement with uptitration of diuretics. We do see some patients who were green for three weeks turning yellow on the 4th week. Good save for the patients who went from red to green or red to yellow. Now going to the right panel, looking at it overall, at the end of 4 weeks, red patients decreased but 3 had died, 7 hospitalized and yellow patients increased. So this is really preliminary data and I hope the authors publish again after they have more patients enrolled.
- The second pandemic study is on the expansion of Medly, an existing mobile phoneโbased telemonitoring program designed to provide remote clinical support for patients with heart failure in Canada. Patients use the Medly app, a weight scale, and a blood pressure monitor to record daily physiological readings and symptoms. Using these devices, patients are instructed to take daily weight and blood pressure readings as well as to record their symptoms through a series of self-report questions on the Medly app. A rules-based algorithm uses these data to automatically generate individualized self-care instructions for the patients while simultaneously alerting clinicians when there are changes in the patientโs health status beyond their set clinical parameters. Clinical alerts, delivered via email or the Web-based Medly dashboard, are mostly managed by the Medly Coordinator, a registered nurse within the Heart Function Clinic, with alerts being escalated to the cardiologists as needed.
- Because of the pandemic, the Medly program was expanded to accept more patients. Wali et alโs paper is qualitative research: semi-structured interviews of enrolled patients, clinicians and staff were conducted to document their experiences in the expansion of the Medly program. Four themes emerged. First, providing care continuity through tele monitoring. Cardiologists became less selective to onboard patients for telemonitoring given the pandemic and even those patients less familiar technology were able to use the Medly app with minimal assistance. The patients felt a sense of security and comfort with the Medly program providing a safety net amid the uncertainty of the pandemic
- The second theme was adapting telemonitoring operations for a more virtual healthcare system. Prior to the pandemic, onboarding to the Medly program was in person. Shifting to onboarding by telephone had mixed results. While more patients were onboarded since in-person visit was no longer required, there was a delay in participation because the patients had to wait for the equipment like the weighing scale to be delivered to be able to participate. When patient symptoms worsened beyond clinical parameters, the clinicians or the automated Medly self-care feedback would direct patients to go to the hospital. This was not acceptable to some patients given the fear of contracting CoVID19.
- The third theme was on confronting virtual workflow challenges. Clinicians had to navigate between various systems which were not integrated with the Medly app such as the lab and electronic medical records to obtain sufficient up-to-date patient information to come up with a comprehensive assessment. This increased their workload.
- The fourth theme was on fostering a meaningful patient-provider relationship. Clinicians felt that they were unable to establish a personal connection or objectively assess their patientsโ condition over the phone, in the absence of visual cues or caregiver support to obtain patient information. As patient interactions were triggered by system alerts, this meant that patients who were not experiencing severe heart failure symptoms were not generating alerts, and therefore had less connection with their physicians which left them dissatisfied.
- Interesting studies right and I am hoping we will also have researches on telemedicine emanating from the Philippines. Which brings us to the last part of my presentation. What are the research gaps?
- Visit pre-planning procedures is one research gap. In this paper by Albert & Prasun on telemedicine for heart failure during CoVID, they raise the issue that patients may not be adequately prepared for the visit. They may not anticipate the physicianโs need for data - BP, pulse and weight readings for example. How about clothing or even video setups. How can we make neck or ankles visible on cam or the time lost when patients are unprepared to remove socks or shoes? So telemedicine research must necessarily involve the patients.
- Next, whatโs the ideal number or ratio of virtual vs in-person visits? I have patients who are perfectly happy going on telemedicine visits only, perhaps even after the pandemic given the inconveniences of the traffic and waiting times in my clinic. But then how often is an objective exam needed given the limitations of tele consultations. Albert & Prasun even add more nuance when they add the context of heart failure functional class. What adjunct testing is needed - ECG? 2d echo? And how often โฆ to complement virtual visits.
- What externally available devices or procedures will provide valuable objective data that augments the subjective telephone assessment is an intriguing and important question. The picture here show a video visit but we do know that given the lack of good wifi access, telephone visits are most feasible locally. Even before the pandemic, I was asking patients to send BP and blood sugar monitoring via SMS. But what else?
- In summary, we have seen how CVD care was disrupted during the pandemic and how if weโre not careful, the use of telemedicine can widen inequity. Iโve discussed some studies on the use of telemedicine both before and during the pandemic. And lastly, I posed some interesting research questions which I hope the PLAS and PSH or the attendees can look into. Thank you and I hope to continue the conversation with you on Twitter after this conference.