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MOBILE SYSTEMS FOR CHRONIC DISEASES TELEMONITORING: CURRENT STATUS Authors: ALVES, José Pedro Figueiral Oliva Soares; CAMPOS, Marta Sofia Gomes; DATA, Tânia Rodrigues; ESTEVES, Alexandra Sofia Moreira; FARIA, Carlos Augusto da Silva; FERNANDES, Diana da Silva; GUEDES, Paulo Renato Moreira; MACHADO, Marino João Pinto; MAGALHÃES, Ana Isabel Pereira; MARQUES, Pedro Seabra; MATOS, José Pedro Rodrigues; MELO, Inês Marisa Tribuzi de Magalhães; MOREIRA, Pedro Manuel Costa; NASCIMENTO, João António Santos; PEREIRA, Maria Francisca Azevedo Marques; SILVA, Ana Rita Carneiro. Authors’ e-mail: [email protected] Adviser: RODRIGUES, Pedro Pereira. Class Number: 05 ABSTRACT Background: Chronic diseases telemonitoring is a result of recent technological breakthroughs which allows clinicians to make use of electronic equipment with the intent to record physiological processes while the patients undergo normal daily activities, becoming a more efficient process of chronic diseases management and early detection of abnormal health parameters. Aim: Expose scientific evidence which supports the use of mobile telemonitoring systems in different chronic diseases, as well as the advantages to patients, physicians and healthcare institutions. Methods: A comprehensive literature search was conducted in Pubmed and ISI Web of Knowledge, to identify relevant published articles which were, then, submitted to a process of quality assessment according to the established criteria. The results of individual studies were synthesized and statistically analyzed. Results: A total of 13 studies were found in the literature (5 Diabetes, 5 cardiac disease and 3 hypertension). Most articles (76.9 %) described potential benefits for the patient. Telemonitoring has a high level of acceptance (23%) and provides a larger amount of information available about the patient’s condition (23%). It influences patient and physician attitudes and behaviours (54%), leading to an apparent better disease self-management (23%). The costs (15%), lack of physical contact (15%) and difficulties in using computer technology (15%) are the main reported disadvantages. Conclusion: Mobile Telemonitoring systems are likely to be a useful tool for chronic diseases management since they are well-accepted, increase patients’ compliance and enable to diagnose and apply treatment at distance. An adaptation of clinical guidelines for the implemantation of this technology is needed as well as further research to assess its cost-effectiveness. 1 KEY-WORDS: telemonitoring, physiological data, telemedicine, self monitoring, chronic diseases, cardiovascular disease, diabetes, hypertension, mobile telemonitoring, mobile devices and their synonyms. INTRODUCTION supervision, observation or care[17]. Many of In this new century, medicine is facing a new these patients – who are often elderly people – challenge called telemonitoring[1], which will need regular monitoring because of the length revolutionize healthcare delivery processes by of their disease, the nature of their health changing some of the long-held assumptions condition and the drugs that they are using. and creating innovative alternative models[2]. Therefore telemonitoring is also a way of Telemonitoring of physiological data consists responding to the new needs of home care in on the collection, record and transmission of an ageing population. clinical data between a patient at a distant location and a healthcare provider through electronic information processing technologies[34] . This implies that the patient undergoes normal daily activities and is provided on an outpatient basis[34]. Hence, healthcare services are delivered via remote telecommunications. The so-called "objective technological monitoring" is no longer the only way to monitor physiological data from patients[3], and a wide range of telemonitoring devices is available nowadays, enabling several diseases monitoring. The most ambulatory promising Fig. 1 Benefits of mobile telemonitoring systems for both the patient and healthcare providers[4]. Telemonitoring can bring benefits for patients, applications telemonitoring healthcare professionals and intitutions[4]. chronic Its use can allow symptoms and abnormal illnesses, such as cardiopulmonary disease, health parameters to be detected earlier than asthma, heart failure and diabetes[1]. Chronic during a routine or emergency consultation, diseases are residual and corrective measures can be taken before disability, are nonreversible more serious complications appear. It may also pathological alteration, require special training result in less frequent visits to healthcare of the patient for rehabilitation, or may be facilities, thereby increasing the quality of life expected for patients[5]. Furthermore, it seems to be to are for permanent, caused require leave by a long period of 2 [5]. cost-effective This may also be a useful method, for clinicians, to gather more information with less Fig. 2 Growth in the number of published articles about Ambulatory Telemonitoring, indexed in Pubmed, between 1990 and 2007. effort and, moreover, healthcare professionals Despite the fact that the domains in which are able to follow the patients closely spending telemonitoring has been used remain slightly [6- unclear, the creation in 2002 of a project called Despite its potential, most telemonitoring MobiHealth for the development of mobile services are still limited to the status of health services, funded by the European temporary projects without clear prospects for Commission, only reinforces the above results wider [15]. less time, through ambulatory telemonitoring 10]. use and healthcare system proper [11-13]. integration into There is limited In 2008, the global market for telemedicine is estimated to be worth €4.7bilion increasing cost- to over €11.2 billion by 2012, an average effectiveness of telemedicine services on a annual growth rate of 19%[16]. This reveals not large only how recent this matter is, but also its evidence of scale. the effectiveness Awareness, and confidence and acceptance by health authorities, professionals emerging relevance. and patients still needs to be strengthened[17]. This The advantages telemonitoring may possibly supporting the use of mobile systems for bring for patients make it an important and chronic diseases telemonitoring, by means of a relevant problem to be investigated. A simple systematic review, identifying which chronic and not very restricted search at Pubmed diseases have been targeted, analysing the about ambulatory telemonitoring found more types of physiological data monitored and the than 500 articles, and 93% of those were advantages published between 2000 and 2008. healthcare intervenients, namely the patient, article exposes and scientific disadvantages evidence for the the physician and the healthcare institution. METHODS A comprehensive literature conducted in Pubmed Knowledge [33] [32] search was and ISI Web of to identify relevant published articles, using keywords such as: ambulatory, physiological data, telemonitoring and synonymous . The research was limited to articles with abstract available in English and about human telemonitoring. 3 The 502 articles obtained were submitted to a examined the outcomes of telemonitoring process of critical appraising according to its using mobile systems. quality in order to select potential articles using Study variables are the types of chronic the following inclusion criteria: (1) studies disease and physiological data monitored as which involve direct data collection from well as the benefits and drawbacks mobile human patients, (2) using outdoor-usable telemonitoring systems can bring for the devices and (3) which document scientific patient, clinician and the healthcare institution evidence of telemonitoring effects (health (health improvement, system usability, cost- improvement, We effectiveness, etc.), which were extracted excluded articles which: (1) were focused on through an extensive analysis of the articles. athletes telemonitoring (2) address monitoring The statistical study was carried out in SPSS®. system usability, etc.). which does not make use of mobile systems, (3) were general reviews or (4) conference and RESULTS poster abstracts. General Overview After abstract revision, 174 articles were The majority of the studies included were included (34.7%). conducted in the United States (46.1%) and Then, an extensive analysis of the full-text took 92.3% were reported in the past five years place using the additional criteria: we included (Table 1). articles: (1) with full-text available (2) written in A similar number of articles related to mobile English diseases telemonitoring systems were found for each mobile one of the three chronic illnesses: diabetes telemonitoring systems. We excluded articles (n=5), cardiac diseases (n=5) and hypertension which: (1) do not present a detailed description (n=3), involving both adult and child patients. of the study, (2) describes a project of a new The type of study design, samples size and instrument and (3) general reviews. Despite study duration varied according to the chronic the change in the inclusion and exclusion disease and the study in question. Overall, criteria, none of the articles excluded in the first more than half (54%) of the studies were revision would have been included in the nonrandomized trials without control group, second revision since the new criteria is a while 46% involved randomization with (31%) restriction of the previous one. Moreover, no and without (15%) control group. Contrarily to heterogeneity between reviewers was found diabetes and heart disease telemonitoring regarding the number of included/excluded studies, articles (Chi-Squared test: p=0.668). As shown nonrandomized trials, 66% of hypertension in Table 1, a total of 13 studies were found in studies were randomized trials with control the groups. (Table 2) (3) telemonitoring scientific addressing and (3) literature chronic using (1996–2008) that most of which (66%) were 4 The size of the experimental group varied control group (80). In terms of proportion of the between 10 for Diabetes and 750 for cardiac control group in relation to the experimental diseases with heart diseases telemonitoring group, diabetes has the highest percentage having the largest average samples of patients (50%). The study duration varied among the (236), followed by hypertension (168) and three groups. It ranged from a minimum of 3 diabetes (55). The control group varied from 10 days for Diabetes to a maximum of 18 months to 150 patients with hypertension having a for hypertension and cardiac diseases (Table considerably larger average of patients in 2). Table 1 – Profile of mobile telemonitoring systems studies – Number of studies, country and date of publication and type of patient sample for each chronic disease How many? Total numbers of studies Where? USA Australia Canada UK Norway When? 1996 2004 2005 2006 2007 2008 With whom? Patients with cardiovascular disease - Adults hospitalized with heart failure. - Enrolled in health centers. - Recently implanted with CRT-D. - With symptomatic chronic heart failure and left ventricular ejection. - Undergoing cardiac rehabilitation. Patients with Diabetes - Young patients and their parents. - Young patients using insulin for at least one year. - Wide-ranging patients with type I Diabetes - Adult patients with type II Diabetes and uncontrolled blood pressure. Patients with uncontrolled hypertension DIABETES CARDIAC DISEASES HYPERTENSION TOTAL 5 5 3 13 3 1 1 1 2 1 1 - 2 1 - 6 3 2 1 1 2 2 1 - 1 1 2 1 3 1 2 3 1 5 1 - 5 1 1 1 1 - 3 1 1 1 - - - 1 - - - - 1 - - 2 CRT-D - cardiac resynchronization therapy defibrillator 5 Table 2 – Overview of research designs – Type of study design, size of experimental and control groups and study duration DIABETES CARDIAC DISEASE HYPERTENSION TOTAL 5 5 3 13 Randomized trial with control group 1 (20) 1 (20) 2 (66) 4 Randomized trial without control group 1 (20) 1 (20) Nonrandomized trial without control group 3 (60) 3 (60) 1 (33) 7 Maximum 200 750 450 750 Minimum 10 30 20 10 Mean 55 236 168 Median 18 81,5 33 Maximum 18 (50) 54 (44) 150 (25) 150 Minimum 18 (50) 54 (44) 10 (33) 10 Mean 18 (50) 54 (44) 80 (29) 18 54 80 Maximum 6 months 18 months 18 months 18 months Minimum 3 days 6 weeks 4 months 3 days 3,82 months 4 months 7,9 months 6 months 11,3 months Number of studies Type of design, n (% within disease) 2 Size of experimental group Size of control group, n (% within the respective experimental group) Median Study duration Mean Median 12 months Table 3 – Types of data transferred in chronic diseases telemonitoring and frequency of data transmission to healthcare provider DIABETES HYPERTENSION TOTAL 5 CARDIAC DISEASE 5 3 13 Heart Rate - 3 1 4 Blood pressure - 1 3 4 Heart electrical activity - 2 - 2 5 - - 5 Number of studies Main types of data transferred Blood glucose Frequency of data transmission to health care provider More than once a day 3 - 1 4 Once a day - 2 - 2 A few times a week - 2 1 3 Once a week 1 - - 1 Once a month 1 - - 1 Once every three months - - 1 1 Once every six months - - 1 1 6 Moreover, every telemonitoring study involved disease (4 out of 5 articles), stating whether collection and transference of clinical data the system was cost-effective or not for the about the patient’s health parameters. Blood patient and the hospital. However, it remains glucose was the parameter transferred most inconsistent across the studies since some frequently (38% of the studies) and was report contradictory results. Almost every exclusive for diabetes telemonitoring. Heart article did not present any cost extensive rate (31%) and blood pressure (31%) was analysis. common to heart disease and hypertension Third, patient attitudes and behaviors were studies while heart electrical activity (15%) was mentioned in 46% of the articles (every article only monitored in heart diseases (Table 3). about hypertension, 2 out of 5 articles about Finally, the information collected from the diabetes, and 1 out of 5 about cardiac mobile system was then transmitted to the diseases). Overall, there was a high level of healthcare provider. The frequency of data patient’s acceptance and satisfaction (23%), transmission varied throughout the studies, yet the system was easily integrated into everyday most studies reported several times a day life (23%) and increased patient’s responsibility (31%), once a day (15%) and a few times a and compliance with the medication and week (23%), mainly for diabetes and heart treatment (31%). diseases, data Fourth, physician facilities (38%), attitudes and transmission. A few studies (31%) considered behaviors (23%) were referred only in cardiac data transmission over longer periods of time diseases and hypertension, specifically the fact and that telemonitoring allows clinical discussion this as the was regularity particularly of common in hypertension. (Table 3) between the physicians (31%) as well as a As shown in Table 4, different types of effects larger amount of information about the patient were observed in the studies regarding mobile condition (23%). telemonitoring then Fifth, data quality (31%) was found in 3 out of 5 divided into seven categories: data quality, articles about diabetes and in 1 article about patient heart disease, but it was not referred in systems conditions, which patient were attitudes and behaviors, physician attitudes and behaviors, hypertension studies. The accuracy and physician facilities, clinical effectiveness and reliability of data transmitted was referred to be economic viability. First, it should be noticed the same of those traditional monitoring that clinical effectiveness and structural effects systems. However, sometimes the system was the most focused aspect in studies found warned the patient and the healthcare provider in the literature (77%). without necessity, specially in case of diabetes. Second, assessment of economic viability was Finally, 31% of the studies discussed the referred in 54% of the articles, mainly in heart patient condition (1 out of 5 about diabetes and 7 all about hypertension) referring that a significant improvement in blood pressure and glucose was achieved. Table 4 – Frequencies of types of effects observed in mobile telemonitoring systems studies. DIABETES CARDIAC DISEASE HYPERTENSION TOTAL 5 3 1 2 4 2 5 1 1 1 2 3 4 3 3 3 2 3 3 1 13 4 4 6 3 5 10 7 Number of studies Data quality Patient condition Patient attitudes and behaviors Physician attitudes and behaviors Physician facilities Clinical efectiveness/ structural effects Economic viability Table 5 – Frequencies of advantages and disadvantages observed in mobile telemonitoring systems studies. DIABETES CARDIAC DISEASE HYPERTENSION TOTAL 5 5 3 13 4 1 3 3 3 2 3 2 1 10 6 6 1 1 - 1 1 - 2 2 - 4 4 - Number of studies Advantages to: Patient Physician Health care institutions Disadvantages to: Patient Physician Health care institutions In terms of advantages and disadvantages, this revolutionary technology were reported. every article referring to hypertension, 80% of First, 6 out of 13 studies stated an increase in the diabetes and 60% of the heart diseases patients’ responsibility and awareness of their articles describe potential benefits for the health condition as well as a more active role patient. Nevertheless, it is important to point in their disease self-management. Second, out that 28.6% and 36% of studies stated alerts sent to patient by the mobile device are considerable disadvantages refered in 4 out of 13 studies and they can play patient the and healthcare both for the professionals, an essential role to overcome memory respectively (Table 5). problems with the purpose of a better control Despite the variability of telemonitoring effects, and increased compliance with the treatment several positive and negative aspects about (Table 6). The physician work can be facilitated 8 by realtime discussions between specialists in condition enabling the physician to follow up primary and secondary care (31%). 21% of the the patient on a daily basis rather than just on articles the day of the medical exam or consultation mentioned information the available larger about amount of the patient’s (Table7). Table 6 – Advantages and disadvantages of mobile telemonitoring systems for the patient DIABETES CARDIAC DISEASE HYPERTENSION TOTAL 5 5 3 13 Advantages - Ability to overcome the problems. - Increased level of patients’ responsibility. - Helps in disease self-management. - Patients received an alert everytime the values of blood pressure are lower or higher than the normal- 1 2 1 1 - 1 2 2 1 2 3 4 - Patient enthusiam and acceptance. - System easily integrated into everyday life. - Child independence while being monitored by their parents. 2 3 1 - 1 - 3 3 1 - Allows patients with memory problems to remember to take medication. - Allows the introduction of healthy habits of practice of physical exercise and alimentation in patients. 1 - 1 2 - - 1 1 1 1 1 - 1 2 1 1 1 1 - 1 2 2 1 1 1 1 1 Number of studies Patient Disadvantages - Costs. - Difficulty in using Internet. - Difficulty in accepting new technologies. - No physical contact with the doctor. - Problems of integration of other diseases. - Problems of adaptation in the routine. - Warns unnecessarily in situations of low levels of glucose, especially during the night. clinician (66% of articles about hypertension) Regarding the disadvantages, 20% of the and the necessity of clinician availability to articles analyze patient data (20% Cardiac diseases about Hypertension Diabetes articles and referred 33% costs of and and 33% Hypertension) were the most economical issues as one of the drawbacks for reported negative aspects for the physician the patient. Difficulty in using the internet by (Table 7). No negative impact on the hospital elderly people was also reported in 66% of was referred in any of the included articles articles about hypertension (Table 6). The lack (Table 8). of physical contact between the patient and the 9 Table 7 – Advantages and disadvantages of mobile telemonitoring systems for the physician DIABETES CARDIAC DISEASE HYPERTENSION TOTAL 5 5 3 13 Number of studies Physician Advantages - Facilitates realtime discussions between physicians in primary and secondary care. 2 2 - 4 - Less acute care needs when admitted. - More accurate decision regarding the treatment of BP. 1 - - 1 1 1 1 1 1 3 - - 1 1 1 - - 1 - Larger amount of information about the patient’s condition enabling the patients’ follow-up the patient on a daily basis rather than just on the day of the medical exam. - Shows when the medication has adverse effects. - Integration of physician in the patient routine. Disadvantages - No longer able to contact the patient directly. - Has to adapt its guidelines to the new technology. - Availability of the physician to analyze patient data. - Failure in detection of low blood glucose values. 1 1 - 2 1 1 - 2 1 2 1 Table 8 – Advantages and disadvantages of mobile telemonitoring systems for the healthcare institution Number of studies DIABETES CARDIAC DISEASE HYPERTENSION TOTAL 5 5 3 13 2 1 - 2 - 4 1 - 1 - 1 Hospital Advantages - Reduction of hospitalization - Automatically generated historical graphics transferred to the healthcare provider, feasibility of the system. - Reduction of hospital overcrowding. to the fact that a sensitive but not so specific DISCUSSION query was used in order to prevent interesting With this systematic review we intended to articles from being excluded. Although our synthesize and analyze information from a research was focused in all chronic diseases group of studies regarding chronic diseases only articles about Diabetes, Cardiac Diseases telemonitoring and assemble the results of and Hypertension were found, contrarily to these studies. This review aims at finding out Paré et al. on mobile pulmonary disease telemonitoring. Perhaps telemonitoring systems have been used, a pulmonary health parameters can only be recent subject with emerging relevance. The measured by home-telemonitoring systems, large number of articles found (502) was due which is in agreement with Paré et al. and the which chronic diseases [7] who also made reference to 10 articles excluded regarding pulmonary diseases in our initial research. systems. According to the included articles, USA is the country which Advantages and Disadvantages has Patient most explored the use of mobile technology to follow up chronic patients, Despite rare exceptions, all the studies seem followed and to confirm the accuracy and reliability of the Canada. The date of publication of the articles transferred data, which supports the success ranges between from 1996 to 2008. No articles of the use of this emerging technology. The between 1996 and 2004 were found which findings presented in this review are in favor of could be explained by the fact that the article the idea that, in general, it brings advantages by UK, Australia, Norway any to the patients enabling a better quality of life. technological breakthrough since it is based on It allows active participation in the process of a healthcare, increased patient’s independence 1996[18] from does pre-existent not present telemonitoring (electrocardiograph). Otherwise, system the other and responsibility [19, 20, 21]. General satisfaction articles included reveal the development of and a high level of acceptance of the system original new devices. By assembling the was also reported articles into three groups according to the type articles presented an automated telemonitoring of disease, it was evident that the majority of system articles were addressing type I Diabetes, intervention in the collection and transference revealing it is the disease for which most of data, reducing bias and subjectivity. This telemonitoring systems have been developed, system has an identical level of effectiveness due to the importance to closely monitor and when compared to the traditional monitoring control the levels of blood glucose on a daily systems basis. promote In addition, cardiac diseases were also which [23]. [19, 20, 21, 22]. allows One of the minimal patient It was also mentioned that it can a healthy lifestyle with an improvement in physical exercise practice and frequently targeted by mobile telemonitoring balanced systems, since the adoption of a western diet awareness of their health condition allied to increased sedentary behavior leads to few weight gain, hypertension and hyperlipidaemia, compliance with the treatment, medication and factors which in turn combine to amplify the telemonitoring which is a result of a tighter chances of getting heart disease and Diabetes control achieved by an alarm system warning [25]. the patient Thereby, these two have a high level of incidence and prevalence in population in general [31,], development diet articles as stated [19, 25]. it increases increased patient [24, 25]. A patients’ On the other hand, problems related to the usage and access to the internet justifying the need for the were often referred especially among elderly of people since they are not used to deal with appropriate telemonitoring 11 computer [19,20]. technology The cost- Health care institutions effectiveness is quite controversial. Although it Little evidence was found on the telemonitoring requires an initial investment in the equipment effects on the hospital and additional research purchase, it may compensate in the long run, is required to further investigate and analyze since it decreases future expenditures in the impact of chronic disease telemonitoring on healthcare services [18,20]. Besides, undesirable healthcare institutions. Anyway, there seems changes in the daily routine may happen as a to be an agreement across a few studies result of the permanent monitoring which leads included, namely less frequent visits to the to dependency towards the equipment and, healthcare facilities, shorter hospital stays and consequently poorer quality of life [20]. decrease of hospital admissions [28, 26, 23, 20]. Healthcare professionals Study limitations This kind of telemonitoring can also bring After several literature revisions only 13 benefits to the healthcare professionals. It studies were included in this article. Since it is promotes the knowledge integration from the a different healthcare encouraging generalizations or solid conclusions can be discussion [18, 20]. Moreover, the physician has taken into account. The majority of the [19, 26], included articles included were nonrandomized and can be warned through an alarm system trials without control groups and very few were every time the patients health parameters are randomized trials with control group. It would areas, easier access to the patient information not normal [25, 27]. reduced amount of evidence no Emergency situations can be be recommended that future studies draw on detected earlier preventing the occurrence of randomized trials with control groups similar in more serious complications. It is possible to size to the experimental groups and over follow closely the evolution of a patient health longer periods of time. In addition, it was not condition [28] and consequently to diagnose and clearly stated whether the improvement shown apply distance. in the patient health condition is due to over However, a few limitations were found across supervision or to the telemonitoring itself so the studies, namely the lack of physical contact future treatment with the patients at [20, 19], adaptation of clinical guidelines to this new way of healthcare studies are needed to accurately evaluate the influence of all the variables in the observed outcome. delivery service [19] and it requires availability of the physician in order to ensure the maintenance of the equipment, as well as to analyze the patient data [20]. CONCLUSION Major Findings Despite being a recent subject, there is a growing body of knowledge about mobile 12 telemonitoring systems. According to the results of this review, there is a general REFERENCES [1] - Meystre S. The current state of telemonitoring: a comment on the literature. 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