Evidenze cliniche ed economiche dei miglioramenti prodotti dall’uso dell’IT:l’IT realmente riduce i costi e migliora la cura?

FORUM PA 201329 Maggio 2013 - Roma – Palazzo dei Congressi

How to deliver high-specialty care at home after liver transplantation: a sustainable approachGiovanni Vizzini, MD

Department of Medicine - Transplant Hepatology Unit

ISMETT-UPMC

Palermo - Italy

Agenda• A clinical perspective

1. ISMETT-UPMC: a multi-organ transplant center in Palermo (Italy)

2. The clinical patient’s needs after discharge from hospital

3. The limited resources

4. The challenge: Best care at the lower cost

5. The innovative use of available (and simple) technology

6. Clinical Results and Sustainability

ISMETT-UPMC in Palermo (Italy)

• ISMETT is a public-private partnership (The Sicilian Region -The University of Pittsburgh Medical Center) situated in Palermo, Sicily. It is the only multiorgan (liver, heart, lung, kidney and pancreas) transplant centre in Southern Italy.

• We provide high specialty surgical and non-surgical procedures to the entire regional population (approximately 5 million people living in the Sicilian Region).

• More than 1.300 patients have had transplants at ISMETT in the last 10 years.

78-bed hospital

Solid organs transplant recipients: a growing population

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49 4058

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ISMETT: 1378 transplants from July 1999 to Dec 2012

Solid organs transplant recipients: a growing population

1227

49 4058

91104

150 146127 131

118135 133

0

20

40

60

80

100

120

140

16019

9920

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0120

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ISMETT: 1378 transplants from July 1999 to Dec 2012

Every year, 120-130 new patients in follow up

At present, more than one thousand of transplant recipients in follow up at ISMETT

Patients’ Needs

• In the early post-transplant period, the need to maintain tight clinical follow up results in prolonged time of hospitalization or, alternatively, forces patients (still in not optimal conditions) to travel frequently

BUT• approximately one third of patients live in the city area (about one million

inhabitants), while two third of them live in other areas of the Sicilian Region or outside Sicily. The distances between Palermo and other Sicilian cities vary from 100 to more than 250 Km.

and

• the state of the road network and other communication routes is not optimal and it represents a problem in maintaining a strict and continuous follow-up in the post-transplant period

Patients’ Needs

Liver transplantation at ISMETT- PalermoPatients survival curve

Patients’ Needs

Liver transplantation at ISMETT- PalermoPatients survival curve

Patients’ Needs What we usually do in the early post-operative course

The early post-transplant period is crucial due to:

High risk of rejectionHigh risk of infectionsHigh risk of drug toxicity

The rigid clinical surveillance is mandatory, in order to obtain: • early diagnosis of clinical complications• correct dosage of immunosuppressive medications • best compliance with therapy

Liver transplantation at ISMETT- Palermo

Patients survival curve

Patients’ Needs What we usually do in the early post-operative course

Patients’ Needs What we usually do in the early post-operative course

For these reasons, the usual approach of the Transplant Centers is to force patients to stay in hospital or in residences near the hospital for a long time after

transplant or, alternatively, to travel frequently (back and forth from home)

Patients’ Needs

• In the early post-transplant period, the need to maintain tight clinical follow up results in prolonged time of hospitalization or, alternatively, forces patients (still in not optimal conditions) to travel frequently

BUT• approximately one third of patients live in the city area (about one million

inhabitants), while two third of them live in other areas of the Sicilian Region or outside Sicily. The distances between Palermo and other Sicilian cities vary from 100 to more than 250 Km.

and

• the state of the road network and other communication routes is not optimal and it represents a problem in maintaining a strict and continuous follow-up in the post-transplant period

Distance (Km of highway) between the ISMETT venue (Palermo)and the major sicilian cities

Palermo to:

Trapani 107 Km

Agrigento 126 Km

Caltanissetta 127 Km

Enna 136 Km

Palermo to:

Catania 207 Km

Messina 237 Km

Ragusa 248 Km

Siracusa 259 Km

Distance (Km of highway) between the ISMETT venue (Palermo)and the major sicilian cities

Best care at the lower cost:

Recommendations of Institute of Medicine

Best care at the lower cost:

Recommendations of Institute of Medicine

Best care at the lower cost:

Recommendations of Institute of Medicine

The innovative use of available (and simple) technologyPost liver transplant “Home-monitoring”.

The solution: Progetti Obiettivo- PSN 2010 (A Grant from the Assessorato della Salute, Regione Sicilia)

we teamed-up with Intel-GE Care Innovations TM to design a study using its tele-health technology with the aims ofspeeding up hospital discharge of post-liver transplant patientsenabling uninterrupted recovery at homemaintaining close contact with our medical teams

The technology allows nurses and physiciansto monitor and support transplant patients from their homesto check their general conditionto collect biometric data to manage their treatment to offer face to face appointments via video conferencing.

The innovative use of available (and simple) technologyPost liver transplant “Home-monitoring”.

The solution: Progetti Obiettivo- PSN 2010 (A Grant from the Assessorato della Salute, Regione Sicilia)

we teamed-up with Intel-GE Care Innovations TM to design a study using its tele-health technology with the aims ofspeeding up hospital discharge of post-liver transplant patientsenabling uninterrupted recovery at homemaintaining close contact with our medical teams

The technology allows nurses and physiciansto monitor and support transplant patients from their homesto check their general conditionto collect biometric data to manage their treatment to offer face to face appointments via video conferencing.

The challenges:To remotely manage patients

- in the aftermath of an extremely invasive surgical procedure

- in not complete stable conditions- still suffering of the consequences of a prolonged disease

Post liver transplant “Home-monitoring”Study protocol

Inclusion criteria: All consecutive adults patients who live in Sicily, who received liver transplantation at ISMETT and were discharged from July 15, 2011.

Staff involved:At the patient’s home:

technician for the instalment of the devices

In Tele-Visit (tele-consult):Physician (ISMETT-UPMC)Transplant coordinator (ISMETT)Others(physical th.- psycologist)

Clinical pathway:

• Clinical monitoring during the post-discharge time (first 3 months or until clinical stabilization)

• Verification of the adherence to therapy (immunosuppression, other medications)

• Verification of the adherence to the bio-humoral surveillance after transplant

Post liver transplant “Home-monitoring”.

Main functionalities:Monitoring of vitals signs, according to a pre-defined schedule (that depends on the time from transplantation) or to the patient’s clinical conditions.

Tele-visit (by Videoconference patient home-ISMETT)performed by our specialists:

once a day during the first weekeach other day during the first month every week until conclusion of the study (3 months)whenever considered useful according to the clinical needs

Educational support for patient/family

Post liver transplant “Home-monitoring”at ISMETT-UPMC

Patient information/ education

Phone lineInternet

3G wireless

Transplant PhysicianTransplant Coordinator

HomeTransplant Center

Post liver transplant “Home-monitoring” at ISMETT-UPMC

Post liver transplant “Home-monitoring” at ISMETT-UPMC

Post liver transplant “Home-monitoring” at ISMETT-UPMC

Post liver transplant “Home-monitoring”.Study end-points

In Home-monitoringJuly 2011-April 2013

Hystoric controlsJuly 2009-June 2011

Patients included 74 75

Patients in the analysis (> 3 months of f-up) 66 75

Average length of stay (days) 19.8 25.4Deaths during the 3-month study period 0 1

Patients who needed urgent re-admission during the first 3 months after transplant

0 3

Overall number of urgent re-admissions during the first 3 months after transplant

0 4

Overall length of stay due to urgent re-admissions during the first 3 months after transplant (days)

0 25

Patient/family satisfaction rate (based on questionnaire administered)

98% NA

Economic impact of the home-monitoring system at ISMETT-UPMC

Data:– Length of stay reduction of 6 days (average) in the group of

patients in home-monitoring– Number of liver transplant recipients discharged from our

Centre: 60-70 per year– Cost of hospital stay (no-ICU) in our organization: about 1.000

Euro per day– Cost of home monitoring: 7 Euro per patient/day

SavingSix days of hospital stay x 60 patients = 360 days of hospital stay

360 days x 1000 Euro = 360.000 Euro/year

Cost7 Euro per patient/dayTotal cost of home monitoring per patient: 7 euro x 90 days = 630 Euro630 Euro x 60 patients = 37.800 Euro/year

Follow-up of liver transplant recipients: a “sustainable” approach

Sustainability

Social To guarantee that precious resourses used for the care are used appropriately = Best standard of care for patients

Economic Rational use of high-cost resources (hospital beds/OPC visits by specialists). Reduction of unnecessary assistance-related costs (i.e. work-days of family members)

Environmental Reduction of the impact to the enviroment (i.e. reduction of fuel consumption for travel and related CO2 production)

A possible solution to the challenges we face:

home-monitoring/tele-consult

How to deliver high-specialty care at home after liver transplantation: a sustainable approach

Conclusion- The adoption of this simple technical solution has allowed

us to maintain an effective clinical and therapeutic remote management in a group of patients discharged from the hospital after a liver transplantation

Best care at the lower cost, according to the recommendations of The Institute of Medicine: Partner with patientsUse Information Technology more effectivelyDecrease waste and increase efficiency

- The result can be considered a “proof of concept”: home-monitoring seems to be a safe and effective solution not only in stable “chronic” patients, but also in unstable patients with difficult issues in the clinical and therapeutic management

Thank you

Giovanni Vizzini, MD

Department of Medicine

ISMETT-UPMC

Palermo- Italy

gvizzini@ismett.edu

www.ismett.edu