Sunday, April 22, 2012

Telemonitoring's Evolution (and why it's tough to keep up with it)

Is that a fish eye or an EKG monitor?
While the sputtering skeptics in medical academia continue to demonstrate what doesn't work, the telemonitoring industry continues to evolve at a furious pace.

To wit:

Publishing in the Archives of Internal Medicine, Mayo Clinic researcher Paul Takahashi and colleagues examined the impact of telemonitoring by randomly assigning high risk and community dwelling elderly patients to either:

1) daily use of a multifunctional blood sugar, breathing airflow, blood pressure, blood oxygen and weight monitoring device. The devices' data feeds were "overseen" by a nurse who communicated with the patients as necessary and alerted the patients' physicians.


2) to usual care. 

Over 500 persons were screened for study participation. Ultimately 102 were assigned to the device and 103 were assigned to usual care.  The average age of the participants was just over 80 years and the mean SF-36 quality of life score was 35.

During the twelve months of follow-up, 89% of the planned telemonitoring was completed.
Compared to the usual care group, the persons assigned to the telemoniting had an increased rate of having had at least one hospitalization or an emergency room visit: 64% vs. 57%. This difference, however, failed to achieve statistical significance. Looking at the individual measures that made up the composite index likewise showed no meaningful outcomes differences between telemonitoring or usual care.  The only thing that was statistically different was the death rate, which was increased in the telemonitoring group: 15% vs. 4% (p=0.008).

The authors concluded that telemonitoring did not work.

The authors also pointed out that their study had limitations. It wasn't blinded, the results may not be applicable outside the Mayo system and the outcomes were based on billing, not medical, records. They also recognize that the difference in death rates could indicate that, despite randomization, there may have been a preponderance of "healthier" persons in the control group. That could have biased the results.

The Disease Management Care Blog agrees that those are limitations, but it also also offer three additional observations:

1. The mean SF-36 score of 35 and age of 80 suggests this was a very sick group of patients.  As the DMCB has pointed out before, telemonitoring-backed population health management is better suited for those patients who are in the "sweet middle" between the catastrophically ill on one side and those who are stable on the other.  Persons in their 80's with a low SF score are frail elderly who warrant a more intensive case management program. In other words, they are probably destined to be high consumers of health care resources no matter what you do.

2. The study was performed at Mayo, where health care utilization is notoriously low. So, while the study population was sick, they were already in a system and a Minnesota culture configured to only use the hospital and emergency room when it was really necessary.

3. Just because the data is given to the patients' physicians, it doesn't follow that they can act on it. Raw telemonitoring is notorious for not fitting into a physicians' office workflows.

In other words, telemonitoring is not a panacea for any sick patient anywhere in the United States. The DMCB thinks it's an excellent option in areas of the U.S. where baseline utilization is high. It should be offered to patients who are most likely to benefit: those with moderate levels of risk that can be mitigated.

As an aside, the DMCB notes that 10% of the telemonitoring was never completed. Enter mc10's "stretchable silicon technology" that can apparently be stretched and wrapped over a patient's skin in a fashion that makes it resemble a tattoo. Given its ease of use, the DMCB suspects that once it's ready for prime time, a) 100% compliance b) use by the right patients and c) being adapted to clinical workflows, it will represent a high value proposition. That's where the population health management service providers and vendors will come in.

Of course, by the time the academic community passes judgement on that, the industry will have moved on.

Image from Wikipedia

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