Implementation of a Wireless Device for Real-Time Telemedical Assistance of Home-Ventilated Amyotrophic Lateral Sclerosis Patients: A Feasibility Study

The Transitions to Long-term In Home Ventilator Engagement Study (Transitions to LIVE): study protocol for a pragmatic randomized controlled trial

Background overview and rationale

We co-developed a multi-component virtual care solution (TtLIVE) for the home mechanical ventilation (HMV) population using the aTouchAway™ platform (Aetonix). The TtLIVE intervention includes (1) virtual home visits; (2) customizable care plans; (3) clinical workflows that incorporate reminders, completion of symptom profiles, and tele-monitoring; and (4) digitally secure communication via messaging, audio, and video calls; (5) Resource library including print and audiovisual material.

Objectives and brief methods

Our primary objective is to evaluate the TtLIVE intervention compared to a usual care control group using an eight-center, pragmatic, parallel-group single-blind (outcome assessors) randomized controlled trial. Eligible patients are children and adults newly transitioning to HMV in Ontario, Canada. Our target sample size is 440 participants (220 each arm). Our co-primary outcomes are a number of emergency department (ED) visits in the 12 months after randomization and change in family caregiver (FC) reported Pearlin Mastery Scale score from baseline to 12 months. Secondary outcomes also measured in the 12 months post randomization include healthcare utilization measured using a hybrid Ambulatory Home Care Record (AHCR-hybrid), FC burden using the Zarit Burden Interview, and health-related quality of life using the EQ-5D. In addition, we will conduct a cost-utility analysis over a 1-year time horizon and measure process outcomes including healthcare provider time using the Care Coordination Measurement Tool. We will use qualitative interviews in a subset of study participants to understand acceptability, barriers, and facilitators to the TtLIVE intervention. We will administer the Family Experiences with Care Coordination (FECC) to interview participants. We will use Poisson regression for a number of ED visits at 12 months. We will use linear regression for the Pearlin Mastery scale score at 12 months. We will adjust for the baseline score to estimate the effect of the intervention on the primary outcomes. Analysis of secondary outcomes will employ regression, causal, and linear mixed modeling. Primary analysis will follow intention-to-treat principles. We have Research Ethics Board approval from SickKids, Children’s Hospital Eastern Ontario, McMaster Children’s Hospital, Children’s Hospital-London Health Sciences, Sunnybrook Hospital, London Health Sciences, West Park Healthcare Centre, and Ottawa Hospital.

Discussion

This pragmatic randomized controlled single-blind trial will determine the effectiveness and cost-effectiveness of the TtLIVE virtual care solution compared to usual care while providing important data on patient and family experience, as well as process measures such as healthcare provider time to deliver the intervention.

Trial registration

ClinicalTrials.gov NCT04180722. Registered on November 27, 2019.

Neuromuscular monitoring devices - where to go next?

PURPOSE OF REVIEW

This paper reviews the clinical applications, technology, and evidence supporting the use of telemedicine devices and telehealth in neuromuscular disease.

RECENT FINDINGS

The COVID-19 pandemic interrupted standard multidisciplinary care of patients with neuromuscular disease and created a need to adapt to remote care. Telemedicine applications were rapidly introduced and have rapidly proved an important tool in maintaining specialist care. This review presents the current data being gathered identifying the patients who benefit from telehealth applications, the appropriate type of telemedicine approach to specific conditions, the conditions needed to optimise telehealth approaches, and potential pitfalls and limitations in their use.

SUMMARY

Telemedicine is an important tool in providing robust remote care for patients with neuromuscular disorders, but further investigation is needed to optimise applications.

Telemedicine in the management of patients with chronic respiratory failure

Patients with chronic respiratory failure are often required to attend multiple hospital appointments, which may be difficult due to their physical disabilities and the amount of equipment they are required to bring. Their caregivers often struggle with the lack of immediate care available when the patient suffers difficulties at home. Telemedicine is an opportunity to bridge the gap between home and healthcare professionals by allowing the healthcare team to reach into patients' homes to provide more frequent support. The evidence for the use of telemedicine in patients with chronic respiratory failure remains equivocal. Although the uptake of telemedicine has been slow, the SARS-CoV-2 pandemic has resulted in the rapid dissemination of telemedicine to allow the delivery of care to vulnerable patients while reducing the need for their attendance in hospital. Logistical and legal challenges to the delivery of telemedicine remain, but the pandemic may serve as a driver to ameliorate these challenges and facilitate wider use of this technology to improve the experience of patients with chronic respiratory failure.

Educational aims

To provide an overview of the rationale for delivering care via telemedicine for patients with chronic respiratory failure.To provide the evidence base for establishing a telemedicine service.To highlight the potential opportunities and challenges in delivering a telemedicine service for patients with chronic respiratory failure.

Telehealth in Neurodegenerative Diseases: Opportunities and Challenges for Patients and Physicians

Telehealth, by definition, is distributing health-related services while using electronic technologies. This narrative Review describes the technological health services (telemedicine and telemonitoring) for delivering care in neurodegenerative diseases, Alzheimer's disease, Parkinson's Disease, and amyotrophic lateral Sclerosis, among others. This paper aims to illustrate this approach's primary experience and application, highlighting the strengths and weaknesses, with the goal of understanding which could be the most useful application for each one, in order to facilitate telehealth improvement and use in standard clinical practice. We also described the potential role of the COVID-19 pandemic to speed up this service's use, avoiding a sudden interruption of medical care.

How to manage with telemedicine people with neuromuscular diseases?

INTRODUCTION

COVID-19 pandemic radically transformed our daily clinical practice, raising the need not to lose close contact with patients without being able to see them face-to-face. These issues are even more felt and evident in fragile patients, as those affected by neuromuscular disease. An important help came from new digital technologies that allow clinicians to remotely monitor health status and any deterioration of chronically ill patients.

METHODS

In this mini-review, an initiative of the "Digital Technologies, Web and Social Media Study Group" of the Italian Society of Neurology, we propose to analyze the approach to neuromuscular patients by looking over raising evidence on the main cornerstones of Telemedicine (TM): clinician-patient interaction, remote clinical assessment, remote monitoring, and digital therapeutics. In particular, we explored the strategies developed by researchers and their impact on the physical and emotional status of the patients, with particular focusing on their adherence to the program of virtual monitoring.

RESULTS

TM plays an important role in each of four stages of approach to neuromuscular disease, having demonstrated validity in keep close clinical patient interaction, clinical assessment, remote monitoring, and telerehabilitation. Nevertheless, there is no remote alternative to electrophysiological testing neither validate tools to assess disability.

CONCLUSION

The role of TM in neuromuscular care is yet underestimated but is crucial, beyond the pandemic era. Further development of TM is advisable, through making specific apps, remotely controlled by clinicians, and making more engaging clinicians-patients interaction. Last, it is necessary to ensure adequate internet access to everyone.

Telemedicine in neurology: current evidence

BACKGROUND

Telemedicine was first introduced in Neurology as a tool to facilitate access to acute stroke treatment. More recently, evidence has emerged of the use of telemedicine in several other areas of Neurology. With the advent of the COVID-19 pandemic and the need for social isolation, Brazilian authorities have expanded the regulation of the use of telemedicine, thus allowing the treatment of many patients with neurological diseases to be conducted with less risk of SARS-CoV-2 contamination.

OBJECTIVE

This study aimed to critically review the current evidence of the use, efficacy, safety, and usefulness of telemedicine in Neurology.

METHODS

A review of PubMed indexed articles was carried out by searching for the terms "telemedicine AND": "headache", "multiple sclerosis", "vestibular disorders", "cerebrovascular diseases", "epilepsy", "neuromuscular diseases", "dementia", and "movement disorders". The more relevant studies in each of these areas were critically analyzed.

RESULTS

Several articles were found and analyzed in each of these areas of Neurology. The main described contributions of telemedicine in the diagnosis and treatment of such neurological conditions were presented, indicating a great potential of use of this type of assistance in all these fields.

CONCLUSION

Current evidence supports that teleneurology can be a tool to increase care for patients suffering from neurological diseases.

New technologies and Amyotrophic Lateral Sclerosis - Which step forward rushed by the COVID-19 pandemic?

Amyotrophic Lateral Sclerosis (ALS) is a fast-progressive neurodegenerative disease leading to progressive physical immobility with usually normal or mild cognitive and/or behavioural involvement. Many patients are relatively young, instructed, sensitive to new technologies, and professionally active when developing the first symptoms. Older patients usually require more time, encouragement, reinforcement and a closer support but, nevertheless, selecting user-friendly devices, provided earlier in the course of the disease, and engaging motivated carers may overcome many technological barriers. ALS may be considered a model for neurodegenerative diseases to further develop and test new technologies. From multidisciplinary teleconsults to telemonitoring of the respiratory function, telemedicine has the potentiality to embrace other fields, including nutrition, physical mobility, and the interaction with the environment. Brain-computer interfaces and eye tracking expanded the field of augmentative and alternative communication in ALS but their potentialities go beyond communication, to cognition and robotics. Virtual reality and different forms of artificial intelligence present further interesting possibilities that deserve to be investigated. COVID-19 pandemic is an unprecedented opportunity to speed up the development and implementation of new technologies in clinical practice, improving the daily living of both ALS patients and carers. The present work reviews the current technologies for ALS patients already in place or being under evaluation with published publications, prompted by the COVID-19 pandemic.

The current use of telehealth in ALS care and the barriers to and facilitators of implementation: a systematic review

Objective: We aimed to provide an overview of telehealth used in the care for patients with amyotrophic lateral sclerosis (ALS), and identify the barriers to and facilitators of its implementation. Methods: We searched Pubmed and Embase to identify relevant articles. Full-text articles with original research reporting on the use of telehealth in ALS care, were included. Data were synthesized using the Consolidation Framework for Implementation Research. Two authors independently screened articles based on the inclusion criteria. Results: Sixteen articles were included that investigated three types of telehealth: Videoconferencing, home-based self-monitoring and remote NIV monitoring. Telehealth was mainly used by patients with respiratory impairment and focused on monitoring respiratory function. Facilitators for telehealth implementation were a positive attitude of patients (and caregivers) toward telehealth and the provision of training and ongoing support. Healthcare professionals were more likely to have a negative attitude toward telehealth, due to the lack of personal evaluation/contact and technical issues; this was a known barrier. Other important barriers to telehealth were lack of reimbursement and cost-effectiveness analyses. Barriers and facilitators identified in this review correspond to known determinants found in other healthcare settings. Conclusions: Our findings show that telehealth in ALS care is well-received by patients and their caregivers. Healthcare professionals, however, show mixed experiences and perceive barriers to telehealth use. Challenges related to finance and legislation may hinder telehealth implementation in ALS care. Future research should report the barriers and facilitators of implementation and determine the cost-effectiveness of telehealth.

Telehealth applications for outpatients with neuromuscular or musculoskeletal disorders

Telehealth describes the provision of medical services remotely through technology, and may enhance patient access to specialty care services. Although teleneurology has expanded widely since the introduction of telestroke in 1999, telehealth services for outpatients with neuromuscular or musculoskeletal disorders are less widespread. In this narrative review, we will describe the current technology, applications, outcomes, and limitations of this dynamically growing field. Evidence for telehealth applications related to neuromuscular diseases, palliative care, specialized multidisciplinary services, and musculoskeletal care are reviewed. With growing demand for specialized services and finite resources, telehealth provides a promising avenue to promote access to high-quality care, decrease the cost and burden of travel for patients, and with the expansion of software to personal computing and mobile devices, offer flexible, low-overhead practice opportunities for clinicians. Providers embarking on careers in telehealth should be aware of current legal restrictions impacting care to minimize risk and avoid liability. Muscle Nerve 58: 475-485, 2018.

Experience with telemedicine in a multi-disciplinary ALS clinic

OBJECTIVE

Telemedicine using video televisits is emerging as a means to provide care directly to patients. Here we report our experience using video televisits to provide follow-up care as a part of the Massachusetts General Hospital (MGH) Telemedicine for People with ALS (TelePALS) initiative.

METHODS

This was a retrospective chart review of all video televisit encounters conducted by the MGH ALS clinic between September 2014 and January 2016.

RESULTS

A total of 97 distinct ALS patients were seen using video televisits. Twenty-four percent of these patients had more than one video televisit. The median distance of the patients' primary residence to MGH was 211 miles. The average video televisit lasted 32 min (±12). About half the patients (54%) were ambulatory at the time of their video televisit. The most commonly addressed issues were medication management (89%), discussion of goals of care (74%), research (55%) and equipment use (50%). Acute care issues were rarely discussed.

CONCLUSION

Video televisits are feasible and can be a useful tool to supplement traditional clinic-based multidisciplinary ALS care.

Tele-monitoring of ventilator-dependent patients: a European Respiratory Society Statement

The estimated prevalence of ventilator-dependent individuals in Europe is 6.6 per 100 000 people. The increasing number and costs of these complex patients make present health organisations largely insufficient to face their needs. As a consequence, their burden lays mostly over families. The need to reduce healthcare costs and to increase safety has prompted the development of tele-monitoring for home ventilatory assistance.

A European Respiratory Society Task Force produced a literature research based statement on commonly accepted clinical criteria for indications, follow-up, equipment, facilities, legal and economic issues of tele-monitoring of these patients.

Many remote health monitoring systems are available, ensuring safety, feasibility, effectiveness, sustainability and flexibility to face different patients' needs. The legal problems associated with tele-monitoring are still controversial. National and European Union (EU) governments should develop guidelines and ethical, legal, regulatory, technical, administrative standards for remote medicine. The economic advantages, if any, of this new approach must be compared to a “gold standard” of home care that is very variable among different European countries and within each European country.

Much more research is needed before considering tele-monitoring a real improvement in the management of these patients.

8th International conference on management and rehabilitation of chronic respiratory failure: the long summaries – Part 3

This paper summarizes the Part 3 of the proceedings of the 8^th International Conference on Management and Rehabilitation of Chronic Respiratory Failure, held in Pescara, Italy, on 7 and 8 May, 2015. It summarizes the contributions from numerous experts in the field of chronic respiratory disease and chronic respiratory failure. The outline follows the temporal sequence of presentations.

This paper (Part 3) presents a section regarding Moving Across the Spectrum of Care for Long-Term Ventilation (Moving Across the Spectrum of Care for Long-Term Ventilation, New Indications for Non-Invasive Ventilation, Elective Ventilation in Respiratory Failure - Can you Prevent ICU Care in Patients with COPD?, Weaning in Long-Term Acute Care Hospitals in the United States, The Difficult-to-Wean Patient: Comprehensive management, Telemonitoring in Ventilator-Dependent Patients, Ethics and Palliative Care in Critically-Ill Respiratory Patients, and Ethics and Palliative Care in Ventilator-Dependent Patients).

Assessment of the feasibility of an ultra-low power, wireless digital patch for the continuous ambulatory monitoring of vital signs

BACKGROUND AND OBJECTIVES

Vital signs are usually recorded at 4-8 h intervals in hospital patients, and deterioration between measurements can have serious consequences. The primary study objective was to assess agreement between a new ultra-low power, wireless and wearable surveillance system for continuous ambulatory monitoring of vital signs and a widely used clinical vital signs monitor. The secondary objective was to examine the system's ability to automatically identify and reject invalid physiological data.

SETTING

Single hospital centre.

PARTICIPANTS

Heart and respiratory rate were recorded over 2 h in 20 patients undergoing elective surgery and a second group of 41 patients with comorbid conditions, in the general ward.

OUTCOME MEASURES

Primary outcome measures were limits of agreement and bias. The secondary outcome measure was proportion of data rejected.

RESULTS

The digital patch provided reliable heart rate values in the majority of patients (about 80%) with normal sinus rhythm, and in the presence of abnormal ECG recordings (excluding aperiodic arrhythmias such as atrial fibrillation). The mean difference between systems was less than ±1 bpm in all patient groups studied. Although respiratory data were more frequently rejected as invalid because of the high sensitivity of impedance pneumography to motion artefacts, valid rates were reported for 50% of recordings with a mean difference of less than ±1 brpm compared with the bedside monitor. Correlation between systems was statistically significant (p<0.0001) for heart and respiratory rate, apart from respiratory rate in patients with atrial fibrillation (p=0.02).

CONCLUSIONS

Overall agreement between digital patch and clinical monitor was satisfactory, as was the efficacy of the system for automatic rejection of invalid data. Wireless monitoring technologies, such as the one tested, may offer clinical value when implemented as part of wider hospital systems that integrate and support existing clinical protocols and workflows.

Initiation of home mechanical ventilation at home: a randomised controlled trial of efficacy, feasibility and costs

INTRODUCTION

Home mechanical ventilation (HMV) in the Netherlands is normally initiated in hospital, but this is expensive and often a burden for the patient. In this randomised controlled study we investigated whether initiation of HMV at home in patients with chronic respiratory failure is non-inferior to an in hospital based setting.

METHODS

Seventy-seven patients were included, of which 38 patients started HMV at home. All patients were diagnosed with chronic respiratory failure due to a neuromuscular or thoracic cage disease. Primary outcome was the arterial carbon dioxide (PaCO2) while quality of life and costs were secondary outcomes. Telemonitoring was used in the home group to provide therapeutic information, for example; transcutaneous carbon dioxide, oxygen saturation and ventilator information, to the caregivers. Follow-up was six months.

RESULTS

PaCO2, improved by 0.72 (SE ± 0.16) kPa in the hospital group and by 0.91 (±0.20) in the home group, both improvements being significant and the latter clearly not inferior. There were also significant improvements in quality of life in both groups, again not being inferior with home treatment.

CONCLUSION

This study is the first to show that initiation of HMV at home in a selective group of patients with chronic respiratory failure is as effective for gas exchange and quality of life as hospital initiation. In addition we found that it is safe, technically feasible and that more than € 3000 per patient can be saved compared to our standard care.

Ethical E-Health

E-health is a rising star that marks the collaboration of medical science and information technology, a ray of hope promising a glorious future of health and prosperity, an easy solution to rely on when in need of medical assistance. But the question arises is E-health an absolute spotless option? In this paper we question the integrity with which e-health is being practised, is the code of ethics being diligently followed? And if not then is ethical e-health entirely impossible? It is of utmost importance to encourage the motivational thinkers who have taken the initiative to provide a better and quicker solution to all health problems by integrating health services and information technology. To do so it becomes necessary to remove the barriers in the way of ethical E-health.

Breathing new life into treatment advances for respiratory failure in amyotrophic lateral sclerosis patients

SUMMARY In the last three decades, improvements in respiratory management are responsible for increasing survival and improving quality of life for amyotrophic lateral sclerosis (ALS) patients. Nowadays, ALS patients with respiratory involvement are offered a support treatment other than the traditional respiratory palliative care. Knowledge about available respiratory support potentialities is essential for appropriate, customized and effective treatment of ALS, which should probably be started sooner than the conventional approach. There is evidence supporting that respiratory support has a larger impact than riluzole on survival. Noninvasive ventilation is essential in the treatment of ALS patients with respiratory involvement. In this article methods to determine respiratory failure in ALS, mechanical invasive and noninvasive ventilation, telemetry, diaphragm pacing, cough aids and respiratory exercise are reviewed, after a brief overlook of respiratory insufficiency in ALS.

Economic cost of home-telemonitoring care for BiPAP-assisted ALS individuals

Our objective was to measure direct (hospital and NHS) and indirect (patient/caregiver) costs of following up in-home compliance to non-invasive ventilation via wireless modem. We constructed a prospective controlled trial of 40 consecutive ALS home-ventilated patients, randomly assigned according to their residence area to G1 (nearby hospital, office-based follow-up) and G2 (outside hospital area, telemetry device-based follow-up). Total NHS direct cost encompassed costs related to outpatients' visits (office and emergency room) and hospitalizations. Hospital direct costs included transportation to/from hospital, office visit per hour cost and equipment maintenance. Non-medical costs considered days of wages lost due to absenteeism. G1 included 20 patients aged 60 ± 10 years and G2 included 19 patients aged 62 ± 13 years. Results showed that no differences were found regarding clinical/demographic characteristics at admission. NHS costs showed a 55% reduction in average total costs with a statistically significant decrease of 81% in annual costs per patient in G2. Hospital costs were found to be significantly higher in G2 with regard to total costs (64% average increase) but not annual costs (7%). No statistical difference was found with regard to expenses from absenteeism. In conclusion, at the cost of an initial financial constraint to the hospital per year (non-significant), telemonitoring is cost-effective, representing major cost savings to the NHS in the order of 700 euros/patient/year.

Experience of services as a key outcome in amyotrophic lateral sclerosis (ALS) care: the case for a better understanding of patient experiences

People with amyotrophic lateral sclerosis (ALS) frequently express dissatisfaction with services. Patient satisfaction with services in ALS care is not always measured and service user perspectives are not usually included when evaluating the outcomes of care. There is a lack of consensus on what constitutes satisfaction for patients in ALS care. To date, health care professionals' conceptualization of outcomes in ALS care has excluded measures of patient satisfaction with services. Exploring the context of the ALS service user experience of care will identify a conceptual framework that will include the domains of satisfaction with care for patients with ALS. An instrument that draws on the ALS patient perspective of services, developed on the basis of qualitative investigation, should be used to measure satisfaction with services.