1 Telemedicine to Support Self-Management Dr Hilary PinnockReader, University of Edinburgh General Practitioner, Whitstable, Kent Supported Self-Management: What Really Works?
2 Telemedicine to Support Self-ManagementWhat is self-management support? How might telemedicine contribute? What is the evidence? So what is the future? Supported Self-Management: What Really Works?
3 What is self-management support?Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support Pearce G et al. PRISMS Taxonomy of self-management support J Health Serv Res Policy : 73-82
4 Long-term condition pyramidKielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61 What self-management support do patients want? Long-term condition pyramid Professional-care Self-care
5 What self-management support do patients want?Professional-care Self-care Happy to self-care “They leave me with a stock, [of antibiotics] and if … it’s a weekend or at night, I can self medicate.” [60 – 69 year old woman with bronchiectasis] Kielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61
6 What self-management support do patients want?Professional-care Self-care Happy to self-care Feeling of being abandoned “I can [manage], but should I be, should I be just doing it all on my own, do you know what I mean? I don’t know, the more independent and able to manage you are, the less keen they are to see you sometimes.” [40 – 49 year old woman with asthma] Kielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61
7 What self-management support do patients want?Professional-care Self-care Happy to self-care Feeling of being abandoned Sources of informal support Kielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61
8 What self-management support do patients want?Boundary Professional-care Self-care Patients valued flexible access and regular communication with a trusted professional Kielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61
9 What self-management support do patients want?Boundary Professional-care Self-care Kielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61
10 Flexible access to professional supportWhat self-management support do patients want? Boundary Flexible access to professional support Professional-care Self-care “..it’s nice to know that there’s somebody there if I need them, but I don’t need them until I shout, you know?” [60 – 69 year old man with COPD] Kielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61
11 Flexible access to professional supportWhat self-management support do patients want? Boundary Flexible access to professional support Professional-care Self-care “It would be nice actually to be able to somebody .. To remind me of the procedure of coming off a high steroid” [50 – 59 year old man with asthma and COPD] “I know if I have any worries, I just have to ring him”. Extract from illness diary: 50 – 59 year old woman with asthma] Kielmann T et al. From support to boundary. Pat Ed Counsel 2010; 79: 55-61
12 How might telemedicine contribute?
13 How might telemedicine contribute?Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support
14 How might telemedicine contribute?Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support
15 How might telemedicine contribute?Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support
16 How might telemedicine contribute?Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support
17 How might telemedicine contribute?Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support
18 How might telemedicine contribute?450l/min Can do usual activities 450 400 350 300 250 200 150 100 50 Mar 30 Apr 1 Apr 3 Apr 5 Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support 10l/min Very short of breath
19 103 asthma apps in English…How might telemedicine contribute? Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support 103 asthma apps in English… … but none fit for purpose Huckvale K, et al. BMC Medicine 2012,10:144
20 191 asthma apps in English…… no more likely to include action plans, or offer guidance consistent with evidence Huckvale K, et al. BMC Medicine 2015,13:58 How might telemedicine contribute? Information about the condition Information about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support
21 What is the evidence?
22 What is the evidence? Information about the conditionInformation about resources Monitoring with feedback An action plan Regular clinical review Access to advice when needed Practical support for adherence Provision of equipment Rehearsal for communication Rehearsal of practical self-management skills Psychological strategies Social support Lifestyle advice/support
23 ✓ Adherence ✗ Asthma control (ACT) What is the evidence?Practical support for adherence Foster J, et al. J Allergy Clin Immunol 2014;134:1260-8 ✓ Adherence ✗ Asthma control (ACT)
24 74% reviewed 48% reviewed What is the evidence? -10.7mins -£3.92Regular clinical review Access to advice when needed -£3.92 -10.7mins 74% reviewed 48% reviewed 278 adults with asthma Pinnock H, et al.. TONIC study BMJ 2003; 326:
25 74% reviewed 48% reviewed What is the evidence?“[The telephone is] convenient. If you have a problem with your asthma you make an appointment at the doctors” [29 F] Pinnock H, et al. Prim Care Respir J 2005; 14: Regular clinical review Access to advice when needed “A routine telephone check would be reassuring and any questions could be asked. But for specific new symptoms the face-to face meeting is preferred” [78 F] 74% reviewed 48% reviewed 278 adults with asthma Pinnock H, et al.. TONIC study BMJ 2003; 326:
26 66% 54% What is the evidence? Regular clinical reviewAccess to advice when needed Opportunistic Booked 66% 54% Pinnock H, et al. TONIC implementation Br J Gen Pract 2007; 57:
27 66% 54% What is the evidence? Equivalent morbidityRegular clinical review Access to advice when needed 66% 54% Increased enablement / confidence Pinnock H, et al. TONIC implementation Br J Gen Pract 2007; 57:
28 What is the evidence? n=128 n=128Monitoring with feedback An action plan Pinnock H, et al. TeleScot COPD BMJ 2013; 347:f6070 n=128 n=128 Time to COPD admission: days (IQR 131 to >365) days (IQR 113 to >365) Hazard ratio 0.98 (0.66 to 1.44)
29 What is the evidence? n=128 n=128Monitoring with feedback An action plan n=128 n=128 Pinnock H, et al. TeleScot COPD BMJ 2013; 347:f6070 Time to COPD admission: days (IQR 131 to >365) days (IQR 113 to >365) Hazard ratio 0.98 (0.66 to 1.44)
30 + “I’ve never felt so well looked after in my life.What is the evidence? Monitoring with feedback An action plan n=128 n=128 Pinnock H, et al. TeleScot COPD BMJ 2013; 347:f6070 A contact every 2 weeks “I’ve never felt so well looked after in my life. I think it’s a godsend like” [Male, aged 58yrs] Telephone: 521 Home visit: 819 Alerts: Home visit: 112 + Time to COPD admission: days (IQR 131 to >365) days (IQR 113 to >365) Hazard ratio 0.98 (0.66 to 1.44) Pinnock H, et al. TeleScot COPD BMJ 2013; 347:f6070
31 What is the evidence? Monitoring with feedback An action plan Fairbrother P et al. Pat Ed Counsel 2013; 93: 403–410 Supporting self-management “…it's great to know that you can just take a reading and say: ‘Well, I do need a doctor or I do need to start these steroids” (Female, 67yrs) ‘Guardian angel’ “In a way it was a relief thinking that I should ignore my own thoughts on getting a doctor or something like that. This organisation was going to get hold of a doctor if their readings showed I needed a doctor.” (Woman aged 47yrs)
32 What is the evidence? Self-management“You would feel a lot more responsible for yourself, and a lot more confident about your asthma if you were using something like that.” (Patient, pre-trial interview: female, years) Self-management What is the evidence? Monitoring with feedback An action plan Pinnock H et al. Clin Exp Allergy 2007; 37: 794–802 “...you need that information when you are having an attack, which this enables it to happen.” (Patient, focus group: male, years) Technology provides timely advice
33 What is the evidence? Self-managementMonitoring with feedback An action plan Pinnock H et al. Clin Exp Allergy 2007; 37: 794–802 Self-management “You would feel a lot more responsible for yourself, and a lot more confident about your asthma if you were using something like that.” (Patient, pre-trial interview: female, years) “Yes, I think it is easier. Almost giving somebody else the responsibility of monitoring your asthma. (Patient, focus group: female, 30-39years) Dependence on professional support
34 What is the evidence? 2.3 (1.7,2.7) 2.2 (1.7,2.7) 1.3 (0.8,2.0)Monitoring with feedback An action plan Ryan D, et al. CYMPLA BMJ 2012;344:e1756 139 p<0.0001 ACQ, median (IQR) 2.3 (1.7,2.7) 2.2 (1.7,2.7) ACQ at 6 months median (IQR) 1.3 (0.8,2.0) 1.3 (0.8,2.2) p<0.85 Change in ACQ mean (95%CI) 0.8 (0.6,0.9) 0.7 (0.6,0.9)
35 What is the evidence? Monitoring with feedback An action planHui Io. PhD student am Saturday morning Information Diary; PAAP Reminders Remote reviews CDSS Monitoring with feedback An action plan
36 Telemedicine to Support Self-Management So what is the future?Supported Self-Management: What Really Works? Telemedicine to Support Self-Management
37 n=5 n=9 n=4 So what is the future? 19 patients in the pilot studyUnresolved problems Burton C et al. J TeleMed and Telehealth 2015; 21:29–36 19 patients in the pilot study n=5 Discrete exacerbations Rolling pattern n=9 Over-ridden pattern n=4
38 So what is the future? Innovative indicators
39 Light Touch So what is the future?Empowering self-management vs engendering dependence Symptom score Oximetry Self-management education Telephone helpline Contact GP Emergency ambulance No concerns Start emergency medication Phone telephone helpline Light Touch
40 “I know when I’m not well. I’m not having to depend So what is the future? Empowering self-management vs engendering dependence “I know when I’m not well. I’m not having to depend on a box to tell me I’m ill. Now I do it myself so I feel a bit more in control now” [Patient 27] MacNab M et al. LIGHT TOUCH BMC Health Serv Res 2015: 15: 485
41 So what is the future? Empowering self-management vs engendering dependence Existing experience Heightened awareness Increased confidence Self- management Diary Oximetry Action plan Flexible support, as and when required Professionals relinquishing control MacNab M et al. LIGHT TOUCH BMC Health Serv Res 2015: 15: 485
42 Medical device legislationApp Development Roadmap. Oxford AHSN So what is the future? Develop ‘quick’ processes Development of the intervention Feasibility/piloting of the intervention Long-term follow-up Dissemination Phase III randomised controlled trial Change in practice Medical device legislation MRC Framework for development and evaluation of complex interventions
43 Integrated IT solutions…So what is the future? Support implementation Easy availability of a range of action plans Decision support prompting provision of self-management Cloud-based personal electronic health record …(tailored) monitoring data available to the practice Administrative capability: arrange review appointments, systems for handling SMS/ queries ..fitting into the routines of practice
44 Supported Self-Management: What Really Works? Take-home messagesTelemedicine can support self-management providing information, adherence reminders, improving access to professional support, providing a digital action plan Telemedicine is no panacea It can improve some process outcomes, but has inconsistent effects on health outcomes - No evidence of harm Telemedicine is an alternative mode of delivering care – should we be thinking in terms of an equivalence – an option that will suit some people and some circumstances? There are unanswered questions … but technological development won’t wait!
45 Telemedicine to Support Self-Management Dr Hilary PinnockSupported Self-Management: What Really Works? Telemedicine to Support Self-Management Dr Hilary Pinnock Reader, University of Edinburgh General Practitioner, Whitstable, Kent