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Implantable Electronic Cardiovascular Devices: IS REMOTE MONITORING THE SOLUTION?

Implantable Electronic Cardiovascular Devices: IS REMOTE MONITORING THE SOLUTION?. Introdução à Medicina II Class 6 24 th May 2011. Index. Background and justification Main problem Research question Methods Results Discussion References. Background And Justification.

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Implantable Electronic Cardiovascular Devices: IS REMOTE MONITORING THE SOLUTION?

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  1. Implantable Electronic Cardiovascular Devices:IS REMOTE MONITORING THE SOLUTION? Introdução à Medicina II Class 6 24th May 2011

  2. Index Background andjustification Mainproblem Researchquestion Methods Results Discussion References

  3. Background And Justification

  4. Background AndJustification Aged, hypertensive and obese population [1] GREATER INCIDENCE OF CARDIOVASCULAR DISEASES References [1] Thibault B, Guerra PG. 2010.

  5. Background And Justification Not wasting time with stable patients, without complications, so that the doctors can pay more attention to more urgent and serious patients[2] So, we should pay more attention to cardiovascular diseases’ PREVENTIONand to its TREATMENT, to optimize the treatment conditions, not only for the doctor but also for the patient[2]. Better quality of life [2] References [2] Jung W, Rillig A, Birkemeyer R, Miljak T, Meyerfeldt U. 2008.

  6. Background AndJustification Some of cardiovascular diseasesrequireIECD[4] • Pacemakers • ICDs(implantable cardioverter defibrillators) • CRTs(cardiac resynchronization devices) • Loop recorders • Implantable hemodynamic monitors Thisway, doctorscouldfollowpatients more carefully[4] References [4] Costa PD, Rodrigues PP, Reis AH, Costa-Pereira A. 2010.

  7. Background And Justification Sincethe 70s • REMOTE MONITORING • Hasbeenusedinthefollow-upof patientswith IECD inalternativeto monitoringon a presentialconsultation[4, 5, 7, 8] • It consists on the use of electronic information and communication technologies to provide health care at distance and allow remote decisions, in order of maintaining or improving patients’ health [8] References [4] Costa PD, Rodrigues PP, Reis AH, Costa-Pereira A. 2010. [5] Guevara, Valdivia ME. 2009. [7] Burri H, Senouf D. 2009. [8] Angaran DM. 1999.

  8. Main Problem IS REMOTE MONITORING REALLY IMPROVING PATIENT CARE? [9] References [9] Guédon-Moreau L, Chevalier P, Marquié C, Kouakam C, Klug D, Lacroix D, Brigadeau F, Kacet S; ECOST trialInvestigators. 2010.

  9. Aim Research Question IS REMOTE MONITORING IN THE FOLLOW-UP OF PATIENTS WITH IECD REDUCING THE MORTALITY RATE, THE NUMBER OF HOSPITAL ADMISSIONS AND IMPROVING PATIENTS’ QUALITY OF LIFE, IN COMPARISON WITH MONITORING AT PRESENTIAL CONSULTATION? To collectevidenceregardingwhether remotemonitoringof IECD IMPROVES PATIENT CARE

  10. Specific Objectives • Does remote monitoring: • Reduce the mortality rate and the number of hospital visits and admissions?[5,7] • Provide real time information regarding device operation and patient diagnosis/therapies between appointments?[2,3,4] • Reduce costs, not only for the patient, but also for the hospital?[2,6] • Improve patients’ quality of life? [3,6] References [2] Jung W, Rillig A, Birkemeyer R, Miljak T, Meyerfeldt U. 2008. [3] Sticherling C, Kühne M, Schaer B, Altmann D, Osswald S. 2009. [4] Costa PD, Rodrigues PP, Reis AH, Costa-Pereira A. 2010. [5] Guevara, Valdivia ME. 2009. [6] Al-Khatib SM, Piccini JP, Knight D, Stewart M, Clapp-Channing N, Sanders GD. 2010. [7] Burri H, Senouf D. 2009.

  11. Methods

  12. Study Design To perform a SYSTEMATIC REVIEW to determine whetherremotemonitoringisbetterthanmonitoringon a presentialconsultation for patientswith IECD PubMed • Construct a Query ISI Web ofKnowledge • Import articles’ information to EndNote • Eliminateduplicated articles • Assigneacharticle to 2 reviewers for REVISION BY TITLE AND ABSTRACT - Ifthe articles metallinclusioncriteriaanddidn’tmeettheexclusioncriterion - Ifbothreviewersagree INCLUDED - Ifthe 2 reviewersdon’tagree – thirdrevisionwill decide articles’ inclusion • Extractstudyvariablesfromtheincluded articles on a REVISION BY FULL TEXT

  13. Data Collection Methods • POPULATION • IECD OR ICD OR… • INTERVENTION • remotemonitoringORtelemedicineOR… • OUTCOMES • - mortality rate ORnumberof hospital admissionsORqualityoflifeOR… • TYPE OF STUDY • - randomizedcontrolledtrial AND QUERY 4 elements AND AND

  14. Data Collection Methods ((("cardiovascular system"[MeSH Terms] OR ("cardiovascular"[All Fields] AND "system"[All Fields]) OR "cardiovascular system"[All Fields] OR "cardiovascular"[All Fields]) AND ("electronics"[MeSH Terms] OR "electronics"[All Fields] OR "electronic"[All Fields]) AND ("instrumentation"[Subheading] OR "instrumentation"[All Fields] OR "devices"[All Fields] OR "equipment and supplies"[MeSH Terms] OR ("equipment"[All Fields] AND "supplies"[All Fields]) OR "equipment and supplies"[All Fields])) OR "CIED"[All Fields] OR (implantable[All Fields] AND ("cardiovascular system"[MeSH Terms] OR ("cardiovascular"[All Fields] AND "system"[All Fields]) OR "cardiovascular system"[All Fields] OR "cardiovascular"[All Fields]) AND ("defibrillators"[MeSH Terms] OR "defibrillators"[All Fields])) OR "ICD"[All Fields] OR "defibrillators"[MeSH Terms] OR "defibrillators"[All Fields] OR "cardiac resynchronization"[All Fields] OR "CRT devices"[All Fields] OR "pacemakers"[All Fields] OR "IECD"[All Fields]) AND(("remote"[All Fields] OR "distant"[All Fields] OR "far"[All Fields] OR "faraway"[All Fields]) AND ("monitoring"[All Fields] OR "supervising"[All Fields] OR "observing"[All Fields] OR "overseeing"[All Fields] OR "managing"[All Fields] OR "following"[All Fields] OR "consultation"[All Fields])) OR "telemedicine"[MeSH Terms] OR "telemedicine"[All Fields] OR "tele-medicine"[All Fields] OR "tele-health"[All Fields] OR "telehealth"[All Fields] OR "telecare"[All Fields] OR "tele-care"[All Fields] OR "telemonitoring"[All Fields] OR "tele-monitoring"[All Fields] OR "e-health"[All Fields] OR "eHealth"[All Fields] OR "e-healthcare"[All Fields] OR "mHealth"[All Fields] OR "m-health"[All Fields] OR "telecardiology"[All Fields] OR "tele-cardiology"[All Fields] OR "Remote Consultation"[Mesh] OR "Telemedicine"[Mesh]) AND ("mortality"[All Fields] OR "mortality rate"[All Fields] OR "arrhythmia"[All Fields] OR "heart failure"[All Fields] OR (("hospitalar"[All Fields] OR "institution"[All Fields]) AND "admission"[All Fields]) OR "patient admission"[Mesh] OR "life quality"[All Fields] OR "quality of life"[All Fields] OR "efficiency"[All Fields] OR "patient acceptance"[All Fields] OR "patient satisfaction"[All Fields] OR "patient satisfaction"[Mesh] OR "patient acceptance of health care"[Mesh]) AND"trial"[All Fields]

  15. Data Collection Methods • Weadaptedthepreviousquery, inorder to beable to search articles inISI Web ofKnowledge(e.g. weeliminatedMeshTerms) (("electronic"[All Fields] OR "instrumentation"[All Fields]) OR "devices"[All Fields] OR ("equipment"[All Fields] AND "supplies"[All Fields]) OR "CIED"[All Fields] OR (implantable[All Fields] AND ("cardiovascular"[All Fields] AND "system"[All Fields])) OR "defibrillators"[All Fields] OR "ICD"[All Fields] OR "cardiac resynchronization"[All Fields] OR "CRT devices"[All Fields] OR "pacemakers"[All Fields] OR "IECD"[All Fields]) AND((("remote"[All Fields] OR "distant"[All Fields] OR "far"[All Fields]) AND ("monitoring"[All Fields] OR "supervising"[All Fields] OR "overseeing"[All Fields] OR "following"[All Fields] OR "consultation"[All Fields])) OR "telemedicine"[All Fields] OR "tele-health"[All Fields] OR "telecare"[All Fields] OR "tele-care"[All Fields] OR "telemonitoring"[All Fields] OR "tele-monitoring"[All Fields] OR "e-health"[All Fields] OR "eHealth"[All Fields] OR "e-healthcare"[All Fields] OR "mHealth"[All Fields] OR "m-health"[All Fields] OR "telecardiology"[All Fields] OR "tele-cardiology"[All Fields])AND("mortality"[All Fields] OR "mortality rate"[All Fields] OR "arrhythmia"[All Fields] OR "heart failure"[All Fields] OR (("hospitalar"[All Fields] OR "institution"[All Fields]) AND "admission"[All Fields]) OR "life quality"[All Fields] OR "quality of life"[All Fields] OR "efficiency"[All Fields] OR "patient acceptance"[All Fields] OR "patient satisfaction"[All Fields]) AND("trial"[All Fields])

  16. Selection Criteria

  17. Review

  18. CitationsidentifiedfromelectronicsearchonPubMed (498) Citationsidentifiedfromelectronicsearchon ISI Web ofKnowledge (411) Duplicated data excluded (16) Articlesselected for reviewbytitleandabstract (893) Selected articles onpeer’sreview (23) Excluded articles onpeer’sreview (819) Articlessubmited to a 3rdreviewbytitleandabstract (51) Selected articles on 3rdpeer’sreview (4) • Articlesexcludedbecause: • Languageisnotenglish…..(11) • Don’tmention IECD……..(774) • Mention IECD, butnot • remotemonitoring • of IECD................................(19) • Mention IECD, • remotemonitoringof IECD, • butaren’t RCT……..............(14) • Mention IECD, • remotemonitoringof IECD, • are RCT butdon’tmention • outomes………………….…...(1) Excluded articles onthirdpeer’sreview (47) Articlesincludedbyreference (1) • Articlesexcludedbecause: • Languageisnotenglish……………………....(1) • Don’tmention IECD……………………..…..(40) • Mention IECD, butnotremotemonitoring • of IECD………………………………………….(3) • Mention IECD, remotemonitoringof IECD, • butaren’t RCT……………………….………...(3) Articlesselected for fulltextreview (28)

  19. Articlesselected for fulltextreview (28) Selected articles excludedonfulltextreview (24) Selected articles includedonfulltextreview (4) • Articlesexcludedbecause: • Don’tmention IECD................................(12) • Mention IECD, butnotremotemonitoring • of IECD......................................................(3) • Mention IECD, remotemonitoringof IECD, • butaren’t RCT...........................................(5) • Mention IECD, remotemonitoringof IECD, • are RCT butdon’tmention • outomes......................................................(4)

  20. Newfulltextreviewof articles that wereexcludedonreviewbytitleandabstractbecause theymetallcriteriabut RCT and outcomes (17) Articlesexcluded (17) Articlesincluded (0) • Articlesexcludedbecause: • Don’tmention IECD.....................................(11) • Mention IECD, butnotremotemonitoring • of IECD...........................................................(3) • Don’tmention IECD norremotemonitoring • of IECD...........................................................(5) Newfulltextreviewof articles that wereexcludedonfulltextreview (24) Observationalstudiesincluded (5)

  21. Selected articles includedonfulltextreview (4) Observationalstudiesincluded (5) INCLUDED Articlesincluded for systematicreview (9) So, we’ve already extracted all variables from these articles... • Nextstep: StatisticalAnalysis

  22. Results

  23. Preliminary conclusions • Mortality rate • Article 41 shows a decreaseonremotemonitoring, butit’snotsignificant. • Article 80 shows anincreaseonremotemonitoring, butit’snotsignificant. • Article 147 shows a non-singificant diference betweenremotemonitoringandpresentialmonitoring. • In-clinicand hospital visits • Article 41 shows a significantdecreaseonremotemonitoring. • Article 80 shows a decreaseonremotemonitoring, butit’snotsignificant. • Lenghtofstayperhospitalization • Article 147 showed a significantreductiononremotemonitoring. • Reductionofscheduled hospital visits • Articles 41, 80 and 154 showed a reductiononremotemonitoring. • Unscheduledin-clinic hospital visits • Article 41 showed a significantincreaseonremotemonitoring.

  24. Preliminary conclusions • Costs for healthservices • Article 147 shows a decreaseonremotemonitoring. • Costs for thepatient • Article 80 shows anincreaseonremotemonitoring. • Healthrelatedqualityoflife • Article 80 shows a decreaseonremotemonitoring, butit’snotsignificant. • Timebetweeneventandclinicaldecision • Article 147 shows a significantdecreaseonremotemonitoring. • Article 894 shows a significantdecreaseonremotemonitoring. • Devicerelatedcomplications • Article 894 shows a significantincreaseonremotemonitoring. Timeuntilevaluationofdevicerelatedcomplications- Article 894 shows a reductiononremotemonitoring , butitisnotsignificant.

  25. Discussion

  26. Discussion It was very difficult to find articles that measured our outcomes. • It maybe difficult for us to concludeanythingfromstatisticallyanalysingthesevariables. We’veextractedvariables that wedidn’tintend to analyseinthefirstplace. • Theobtained data was very heterogeneous. • Some of our expectationswerenotconfirmedbythestudiedarticles. • Remotemonitoringseems to bring some advantagesatotherlevels. • More clinicaltrialsneed to beconductedinthisarea.

  27. References

  28. References • [1] Thibault B, Guerra PG. Implanted cardiac devices with remote monitoring capacity: “it’s like having a physician follow me on a daily basis”. Expert Review of Cardiovascular Therapy. 2010; 8 (5): 617-9. • [2] Jung W, Rillig A, Birkemeyer R, Miljak T, Meyerfeldt U. Advances in remote monitoring of implantable pacemakers, cardioverter defibrillators and cardiac resynchronization therapy systems. J Interv Card Electrophysiol. 2008; 23(1): 73-85. • [3] Sticherling C, Kühne M, Schaer B, Altmann D, Osswald S. Remote monitoring of cardiovascular implantable electronic devices: Prerequisite or luxury?. Swiss Med Wkly. 2009; 139 (41-42): 596-601. • [4] Costa PD, Rodrigues PP, Reis AH, Costa-Pereira A. A Review on Monitoring Technology Applied to Implantable Electronic Cardiovascular Devices, Telemedicine and e-Health. 2010; 16(10): 1042-50. • [5] Guevara, Valdivia ME. Remote monitoring of automatic implantable cardiovascular devices (pacemakers, implantable cardioverter defibrillator and cardiac resynchronization. Arch Cardiol Mex. 2009; 79(3): 221-5. • [6] Al-Khatib SM, Piccini JP, Knight D, Stewart M, Clapp-Channing N, Sanders GD. Remote Monitoring of Implantable Cardioverter Defibrillators versus Quarterly Device Interrogations in Clinic: Results from a Randomized Pilot Clinical Trial. J CardiovascElectrophysiol. 2010; 21: 545-50. • [7] Burri H, Senouf D. Remote monitoring and follow-up of pacemakers and implantable cardioverter defibrillators. Europace. 2009; 11(6): 701-9. • [8] Angaran DM. Telemedicine and telepharmacy: current status and future implications. American Journal of Health System Pharmacy. 1999; 56(14): 1405-26. • [9]Guédon-Moreau L, Chevalier P, Marquié C, Kouakam C, Klug D, Lacroix D, Brigadeau F, Kacet S; ECOST trialInvestigators. Contributions of remote monitoring to the follow-up of implantable cardioverter–defibrillator leads under advisoryl. Eur Heart J. 2010; 31(18):2246-52. • [10] Ricci RP, Morichelli L, Quarta L, Sassi A, Porfili A, Laudadio MT, Gargaro A, Santini M. Long-term acceptance of and satisfaction with implantable device remote monitoring. Europance. 2010; 12(5): 647-9. • [11] Ricci RP, Morichelli L, Gargaro A, Laudadio MT, Santini M. Home monitoring with implantaple cardiac devices: is there a potential reduction of stroke risk? Results from a computer model testes through montecarlosimulatons. J CardiovascElectrophysiol. 2009; 20(11): 1244-51.

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