P Jourdain

Service de cardiologie CHU Bicêtre

Technological innovations in order to

reduce rehospitalizations in advanced

heart failure

Disclosures

Honorarium from: Alere, Abbott, Servier, LuminaDX,Astra zeneca, MSD, Schering, Novartis,

Daichi, Lilly, Roche, Boston, Medtronic, Sorin, Air liquide, Saint Jude médical,Livy, IQVA

Research: Servier, Novartis,,CAS, Amgen, MSD, Schering MSD,

Un défi lancé par les maladies

chroniques que nous n’arrivons pas à

remporter…

Comorbidities in GP trusts in UK

Le système de santé change

Process analysis

• Isolating the different components of advanced HF pathways:– Diagnostic

– Severity analysis

– In hospital management

– Post hospitalization management

– Patient involvement

– Patient evolution monitoring

– Medical devices monitoring

– Medical evaluation

• Regulatory support and possibilities

• Technological status (wireless capacities, population financial status,…)

Severity analysis

• In most of cases CHF patients depends from

one cardiologist (and even in some case

none…).

• If in Cancer most of patients benefit from

multidisciplinary approach why not in

cardiology ?

• HF integrates numerous prognostic markers

but not integrate in a pathway approach nor

in a therapeutic point of view.

The French touch in order to analyze the

risk of pulmonary cancer progression

Quel impact de cet outil d’adaptation du plan de

soins ?

In hospital management

• Most of HF patients are admitted in non

cardiologic departments.

• Therapy and prognostic are different in

favor of…

• Most of HF patients come through

emergency structures and spend a long

time at the ED waiting for cardiologic

advice, echo, … and diuretic therapy

Mitra clip ?

• 614 patients on 78 sites

• heart failure and moderate-to-severe or severe secondary mitral regurgitation who remained symptomatic despite the use of maximal doses of guideline-directed medical therapy

• The annualized rate of all hospitalizations for heart failure within 24 monthswas 35.8% per patient-year in the device group as compared with 67.9% per patient-year in the control group (hazard ratio, 0.53; 95% confidence interval [CI], 0.40 to 0.70; P<0.001).

• The rate of freedom from device-related complications at 12 months was96.6% (lower 95% confidence limit, 94.8%; P<0.001 for comparison with the performance goal).

• Death from any cause within 24 months occurred in 29.1% of the patients in the device group as compared with 46.1% in the control group (hazard ratio, 0.62; 95% CI, 0.46 to 0.82; P<0.001)

• But recent french studies are a bit disapointing concerning thesetechniques.

N Engl J Med 2018; 379:2307-2318

TAVICirc J 2018; 82: 874–885

TAVI

• 40,751 Medicare beneficiaries >65 years who underwent primaryisolated AVR between 2000 and 2004 were included in the study.

• median patient age was 76 years.

• At 30 days, all-cause readmission was 21.5% and HF readmissionwas 3.9%. Patients with preoperative HF had higher postoperativeHF readmission rates compared to those without (30 days, 6.3% versus 2.2%; one year, 13.9% versus 4.4%; five years, 6.6% versus 10.3%, p = 0.0001).

• In patients with preoperative HF, the number of admissions wasassociated with increased postoperative HF readmissions. At 30 days, patients with no preoperative HF admissions had a HF readmission rate of 5.3%, while those with one, two, three and four or more preoperative HF admissions had rates of 8.2%, 11.9%, 13.8% and 17.4%, respectively. This trend persisted over the five-year follow up period

J Heart Valve Dis. 2016 Jul;25(4):430-436

Post hospitalization management

• Patient refferral is depending of each region, each hospital without anay standardization.

• There is few guidelines on patients management compared to therapeutic management due to EB medicine and a publication bias.

• Some progress have been made with Prado program and telemedicine ETAPES nationwide experimental project.

• HFWG of the FSC have proposed recently a structuration of HF post hopsitalizationmanagement using check list and 3 level HF teams

Are new technologies the key ?

E Health

ElearningPredicting

medicine /

big data

Telemedicine Healthwellness

Teleconsultation

Tele expertise

Telemonitoring

Connected

medical

tools

Side effects

warning

Perception

of medical

care

Health system

quality

improvement

Risk factors

analysis

Systems do not converge toward the

clinicians but target the comunity

Some are more focusing on the pathway

rather the cloud !

Téléconsultation ?

La teleconsultation:

Pediatrics examination during epidemic flu (from GP trust)

Virtual rehabilitation

Post

surgery

J Med Internet Res. 2014 Sep; 16(9): e213

• This costing assumes that 1000 patients are enrolled in bring-your-own-device

(BYOD) mobile app follow-up per year and that 1.64 in-person follow-ups are

attended in the conventional arm within the first month postoperatively.

• The total cost difference between mobile app and in-person follow-up care is $245

CAD ($223 USD based on the current exchange rate), with in-person follow-up

being more expensive ($381 CAD) than mobile app follow-up care ($136

CAD).This takes into account the total of health care system, patient, and external

borne costs.

• If we examine health care system costs alone, in-person follow-up is $38 CAD ($35

USD) more expensive than mobile app follow-up care over the first postoperative

month.

Virtual visits post procedures

Our ecosystem is changing day

after day…

Access to highly specialized care:

téléexpertise

Telexpertise:

Discussion between healthcare professionals (patient present

or not) in order to give assistance and expertise to GP

Teleexpertise in Progress…

Only 2% for

cardiology …

Téléassistance ?

Telechography for Chagas disease, pericardial effusions or for

thrombolysis

Do we need an echocardiographist

everywhere ?

Teleradiology is already a reality

Incredible things could be possible…

mobile tomodensitometry for stroke

Telemonitoring

With structured telephone support could help to monitore

patient and to adapt care plans due to patient home

evolution

Could be healthcare professional based or Patient’s

based

How to simplify your rythmologic life

Sometimes it’s works

Cardiomems

Sometimes it don’t works…

Et effectivement….• TIM HF 2 est positive sur le nombre de jours passés à

l’hôpital mais aussi sur la mortalité et les rehospitalisations….

Effect of telehealth on use of secondary care and

mortality: findings from the Whole System Demonstrator

cluster randomised trial

• 238 practices (trusts) to control or intervention groups.

Although 59 practices eventually did not supply participants

for the trial, sites assessed 15 171 patients for eligibility and

sent data sharing consent forms

• Sites recruited 1625 control patients and 1605 intervention

patients from 179 general practices with each practice

recruiting an average of 18 patients.

• Recruitment started in May 2008 and was planned to finish

in September 2009

Effect of telehealth on use of secondary care and mortality: findings from the

Whole System Demonstrator cluster randomised trial BMJ 2012;344:e3874

Results

Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster

randomised trial BMJ 2012;344:e3874

Results

Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster

randomised trial BMJ 2012;344:e3874

L’intelligence artificielle va t’elle

tout solutionner ?

Qu’est ce que l’IA ?

• L'Intelligence Artificielle (IA) est la science dont le but est

de faire faire par une machine des taches que l'homme

accomplit en utilisant son intelligence.

• L'Informatique est la science du traitement de

l'Information, l'IA s'intéresse à tous les cas ou ce

traitement ne peut etre ramene à une méthode simple,

précise, algorithmique. Un algorithme est une suite

d'opérations ordonnées, bien définies, exécutables sur

un ordinateur actuel, et qui permet d'arriver à la solution

en un temps raisonnable

Que comprend l’IA ?

• L’intelligence artificielle est une branche de

l’informatique qui vise à créer des machines intelligentes

• Les problèmes centraux de l’intelligence artificielle

incluent la programmation d’ordinateurs pour certains

traits tels que :

– Connaissances

– Raisonnement

– Résolution de problèmes

– Perception

– Apprendre

– Planification

– Capacité de manipuler et de déplacer des objets

L’IA c’est d’abord donner à la machine

une capacité d’apprentissage

• L’IA doit avoir accès aux objets, catégories, propriétés et

relations entre eux pour mettre en œuvre l’ingénierie de la

connaissance.

• L’initiation au bon sens, au raisonnement et au pouvoir de

résolution de problèmes dans les machines est une tâche

difficile et fastidieuse.

• L’apprentissage machine est également au cœur de l’IA.

• L’analyse mathématique des algorithmes d’apprentissage

machine et de leurs performances est une branche bien

définie de l’informatique théorique, souvent appelée théorie

de l’apprentissage computationnel.

L’IA ce sont de multiples facettes

Le grand fantasme ?

• les systèmes d’I.A. d’aujourd’hui ne sont que des

logiciels d’apprentissage machine avancés avec des

algorithmes comportementaux étendus qui s’adaptent à

nos goûts et à nos aversions.

• Ces machines ne deviennent pas plus intelligentes au

sens existentiel, mais elles améliorent leurs

compétences et leur utilité à partir d’un vaste ensemble

de données.

Why do not we propose to the

cardiologist

ONE STANDARDIZED SYSTEM ?

Alert systems:

Depending on your risk acceptation

Data

PATIENTMachine

learning

algorythms

Multiple

algorythms

Unique

algorythm

Doctors

Nurses

Cardiologist

Nothing

Relatives

Medical portofolio for optimizing

medical reactivity

Home nurse

Confirmed

alert

Others

cardiologists

GP

ED

Heart failure out

patient structure

Consultation

Patient ?

Industry based

healthcare

professionals

complementary services

EducationMedical

appointement

agenda

Patient

agenda

Medical

agenda

training

Medical

software

Other connected

devices

MaintenanceB to C

Identify your needs, create the

tools… adapt and overcome the

burden of cardiovascular diseases.