Web Health Monitoring Survey: a new approach to enhance effectiveness of telemedicine systems

Aging of the European population and interest in a healthy population in western countries have contributed to an increase in the number of health surveys, where the role of survey design, data collection, and data analysis methodology is clear and recognized by the whole scientific community. Survey methodology has had to couple with the challenges deriving from data collection through information and communications technology (ICT). Telemedicine systems have not used patients as a source of information, often limiting them to collecting only biometric data. A more effective telemonitoring system would be able to collect objective and subjective data (biometric parameters and symptoms reported by the patients themselves), and to control the quality of subjective data collected: this goal be achieved only by using and merging competencies from both survey methodology and health research. The objective of our study was to propose new metrics to control the quality of data, along with the well-known indicators of survey methodology. Web questionnaires administered daily to a group of patients for an extended length of time are a Web health monitoring survey (WHMS) in a telemedicine system. We calculated indicators based on paradata collected during a WHMS study involving 12 patients, who signed in to the website daily for 2 months. The patients’ involvement was very high: the patients’ response rate ranged between 1.00 and 0.82, with an outlier of 0.65. Item nonresponse rate was very low, ranging between 0.0% and 7.4%. We propose adherence to the chosen time to connect to the website as a measure of involvement and cooperation by the patients: the difference from the median time ranged between 11 and 24 minutes, demonstrating very good cooperation and involvement from all patients. To measure habituation to the questionnaire, we also compared nonresponse rates to the items between the first and the second month of the study, and found no significant difference. We computed the time to complete the questionnaire both as a measure of possible burden for patient, and to detect the risk of automatic responses. Neither of these hypothesis was confirmed, and differences in time to completion seemed to depend on health conditions. Focus groups with patients confirmed their appreciation for this “new” active role in a telemonitoring system. The main and innovative aspect of our proposal is the use of a Web questionnaire to virtually recreate a checkup visit, integrating subjective (patient’s information) with objective data (biometric information). Our results, although preliminary and if need of further study, appear promising in proposing more effective telemedicine systems. Survey methodology could have an effective role in this growing field of research and applications

The ICT monitoring of chronic patients as a longitudinal survey: an innovative approach and a challenge for internet survey methodologists

Purpose of the study Significant efforts have been made to design telemedicine systems. But few researchers have taken into account the collection of data and information given from the patients. Yet the clinicians agree in the role of the “clinical interview” in health status monitoring of chronic patients. Design/methodology/approach The “classic” clinical interview (that can be seen as a face-to-face interview) can be transformed in a virtual medical visit, carried out with ICT tools (as a CAWI). Moreover, in a telemedicine system the questionnaires are collected daily and a longitudinal survey of chronic patients. This innovative approach is a challenge for survey methodologists: at least new data quality measures are needed, and the asssessment of the effectiveness of data collected. Findings In Tuscany 11 heart failure patients were enrolled the telemedicine study named ASCOLTA (Romano and al, 2014). After a training, they had to compile daily a web questionnaire at home. After 2 months we had 478 questionnaires (243 in the first and 235 in the second month) As a measure of cooperation we calculated the rate of missing questionnaires (6%) and of item non responses (from 0% to 7.4%). Using paradata, we calculated the time spent to complete the questionnaires (mean =1 minute and 31 seconds ). The hypothesis of “automated” or repetitive responses was rejected: no difference were found in completion time between the first and second month for each patient. Originality/value The tools and methodology developed for web surveys can be used to simulate a "face-to-face" situation between patient and doctor: continuous and remote health monitoring could be a challenge for survey methodologists. Our results, although preliminary, appear promising and, in our opinion, could be of significance on the ongoing debate on the most appropriate type of telemonitoring and remote care of patients. Furthermore, these longitudinal surveys have few missing data and have a very high response rate, due to the strong involvement of respondents. Research limitations/implications The results presented here have several limitations, also critical, such as: the small number of patients studied; the short follow-up of patients; the results relate only to heart failure patients. Practical implications In the last years, the increasing diffusion of smartphones and tablets has generated a still increasing number of health apps (not only for diagnosed patients). Skills and competencies of survey methodologists and statisticians have to guide data collection and data analysis in this new application field. References Anker SD, Koehler F, Abraham WT (2011) Telemedicine and remote management of patients with heart failure, The Lancet, 378, 731-739. Antonelli D., Bellomo D, Bruno G, Villa A (2012) Evaluating collaboration effectiveness of patient-to-doctor interaction in a healthcare territorial network, IFIP Advances in Information and Communication Technology, 380 AICT, pp. 128-136. Couper MP (2011), The Future of Modes of Data Collection, Public Opinion Quarterly, 75(5): 889-908. Nangalia V, et al. (2010) Health technology assessment review: Remote monitoring of vital signs - current status and future challenges. Critical Care, 14:233. Romano MF, Sardella MV, Alboni F, L’Abbate A, Mariotti R, Di Bello V (2014), The incremental value of the “virtual clinic visit” versus the instrumental conventional parameters’ information in a new heart failure telemonitoring integrated system. Telemedicine and e-Health., 20(6): 508-521. doi:10.1089/tmj.2013.02

Qualità della vita del paziente cronico e nuove tecnologie

L'invecchiamento della popolazione e la necessità di contenere i costi per il trattamento di pazienti cronici ha portato alla sperimentazione di sistemi di telemedicina per fornire un monitoraggio efficace a casa del paziente. Gli studi presenti nella letteratura internazionale mostrano che questi sistemi vengono valutati come efficaci sulla base dei soli indicatori clinici e di costo sanitario (riduzione della mortalità, riduzione dei ricoveri ospedalieri, etc) e solo in pochi casi il miglioramento della qualità della vita del paziente è tra gli obiettivi presi in considerazione o viene indicato come obiettivo principale; inoltre, solo alcuni studi indagano su come i sistemi di monitoraggio a distanza siano accettati dai pazienti. A nostro avviso una auspicata diffusione dei sistemi di telemedicina dovrebbe basarsi contemporaneamente su tutti questi macro aspetti: una valutazione della efficacia strumentale (intesa come corretta trasmissione a distanza di parametri clinici – differenziati in base al tipo di malattia); la raccolta di ulteriori informazioni direttamente dal paziente (visita clinica virtuale – utilizzando strumenti e metodologie impiegate nelle web survey – per ottenere informazioni ulteriori su sintomi e stato di salute percepita); la realizzazione di un decision support system basato sull’insieme delle informazioni raccolte (ottenute sia da registrazioni strumentali sia attraverso la visita medica virtuale) per identificare precocemente situazioni di alert e permettere decisioni clinico-terapeutiche; la identificazione di criteri che misurino il grado di accettazione del sistema da parte dei pazienti coinvolti; la convinzione che il paziente debba costituire la centralità del sistema, ponendo quindi come obiettivo il miglioramento della sua qualità di vita. Questi aspetti hanno costituito la base del progetto di ricerca multidisciplinare ASCOLTA (Assistenza domiciliare dello scompenso cardiaco attraverso tecniche avanzate di comunicazione digitale), condotto in Toscana su fondi POR-CREO e che ha completato la fase di sperimentazione nel 2012. Oltre a raccogliere quotidianamente parametri biometrici tramite sensori wireless (ECG, Sp02, frequenza cardiaca), veniva chiesto al paziente di integrare le rilevazioni strumentali con altre informazioni e coinvolgendolo nella gestione del sistema. In estrema sintesi gli aspetti salienti e peculiari del progetto Ascolta sono: al paziente veniva chiesto di partecipare quotidianamente (in orario a sua scelta) ad una “visita virtuale” attraverso un questionario che simulava il colloquio con il proprio medico, e responsabilizzandolo con la trasmissione di alcuni dati oggettivi (peso e pressione arteriosa), e comunicando informazioni su sintomi e sullo stato di salute percepita; il paziente poteva chiedere un supplemento di controllo durante la giornata, con acquisizione di dati strumentali e con una riedizione del questionario giornaliero con una domanda sui motivi del controllo richiesto; un questionario mensile indagava poi sulle difficoltà percepite a causa dello scompenso cardiaco nel corso delle azioni quotidiane e delle relazioni sociali: in sintesi, sulla qualità della sua vita; tutti gli strumenti apparivano a video con interfaccia amichevole e di facile compilazione, utilizzando il mouse o attraverso touch-screen. Nella fase sperimentale è stato alimentato un database contenente dati strumentali e informazioni fornite dal paziente: i dati sono analizzabili (e sono già stati analizzati) da più angolazioni. In questo lavoro una parte dei dati verrà utilizzata per rispondere alle seguenti domande: 1. Il paziente cronico può essere considerato un giudice affidabile del suo stato di salute? 2. Quali sono gli effetti sulla qualità della vita del paziente quando è inserito in un sistema di monitoraggio continuo? 3. Il ruolo attivo del paziente può costituire una sorta di effetto alone che si riverberi sullo stato di salute

The informative contribution of the “virtual medical visit” in a new heart failure telemedicine integrated system

Introduction Telemedicine systems consist of collection, transmission and analysis of biometric data essentially based on instrumental measures. Our goal is to evaluate if information collected from patients have an incremental informative value in automatically rate the patient health status. Materials and Methods We present preliminary results of a new telemedicine system (ASCOLTA) obtained by observation of 12 heart failure patients (IIb-III NYHA). Instrumental data (EKG, O2 saturation level and respiration rate) were wireless daily collected together with clinical data (weight, heart rate, blood pressure values) and patients information through a web questionnaire, simulating a virtual medical visit. Health status was independently judged by two blinded cardiologists and by the patient’s cardiologist on the basis of 348 daily clinic reports. Random forest classification analysis was applied to 240 complete clinical report variables in order to estimate the judged health status. Results The results show that the use of “patients information” leads to a better predicting ability in comparison with the only physiological parameters assessed by instruments. The complete set of variables (Patient + Instrumental) achieve 84% of concordance, compared with 72% of the only instrumental variables and the 69% of patients variables. The ROC curves graphically confirm the described results. Discussion The patients have an active role in home monitoring and their information appears relevant for a new telemedicine approach integrating subjective and objective vital signs: only combining “patients information” with instrumental parameters it is possible to achieve a more correct automatic classification of health status of heart failure patient

Is the digital divide an obstacle to e-health? An analysis of the situation in Europe and in Italy

Introduction: The digital divide affecting elderly patients may compromise the diffusion of telemedicine systems for this age segment. It might be that the difficulties in the passage from trials to the effective distribution of telemedicine systems are also due to the awareness of a personal digital divide in the target population. Materials and Methods: The analysis aims to estimate the number of people over the age of 50 years with potential cardiovascular problems able to access the Web. It made use of data from several sources (the Survey of Health, Ageing and Retirement in Europe and the Istituto Nazionale di Statistica Multiscopo Survey). Furthermore, with regard to Italy, the estimates obtained from official data were compared with those obtained in a survey investigating heart failure patients in Tuscany. Results: In 2011, the percentage of people suffering from cardiovascular diseases and with Web access was 24% in Europe, with significant differences by country (ranging from 53% in Switzerland to below 20% in Italy, Spain, and Portugal). In Italy, however, the proportion of people with Web access increased from 2007 to 2011, and the survey in Tuscany showed that elderly people with limited information and communications technology skills overcame challenges and learned how to connect to the Web because they started to appreciate new technologies. Conclusions: The opportunity to use the Internet to monitor patients with chronic disease can serve as a challenge to reduce the digital divide gap and, furthermore, to increase their social and technological inclusion

Enhanced platelet MRP4 expression and correlation with platelet function in patients under chronic aspirin treatment

Platelet multidrug resistance protein4 (MRP4)-overexpression has a role in reducing aspirin action. Aspirin in vivo treatment enhances platelet MRP4 expression and MRP4 mediated transport inhibition reduces platelet function and delays thrombus formation. The aim of our work was to verify whether MRP4 expression is enhanced in platelets obtained from patients under chronic aspirin treatment and whether it correlates with residual platelet reactivity. We evaluated changes on mRNA and protein-MRP4 expression and platelet aggregation in four populations: healthy volunteers (HV), aspirin-free control population (CTR), patients who started the treatment less than one month ago (ASA< 1 month patients) and aspirinated patients who started the treatment more than two months ago (ASA> 2 months patients). In platelets obtained from ASA> 2 months patients, it was found a statistically significant MRP4 enhancement of both mRNA and protein expression compared to HV, CTR and ASA< 1 month patients. Platelets obtained from ASA> 2 months patients that present high levels of platelet MRP4, have higher serum TxB2 levels and collagen-induced platelet aggregation compared to patient with low levels of MRP4 in platelets. In addition collagen induced platelet aggregation is higher in in vitro aspirinated platelets obtained from patients with high levels of MRP4 patients compared to those obtained from patients with low MRP4 levels. We can assert that, in patients under chronic aspirin treatment, platelets that present high MRP4 levels have an increase of residual platelet reactivity, which is due in part to incomplete COX-1 inhibition, and in part to COX-1-independent mechanism