Heart failure study evaluates whether patients can help monitor themselves

Meredith Cohn - The Baltimore Sun

Derek Scott and his wife had just dropped off two of their three children at school one day last fall when he started having trouble breathing. By the time the Pikesville father arrived at Sinai Hospital emergency room he was gasping for air.

I didn't know what was going on," Scott said. "And I couldn't even talk well enough to tell anyone what was wrong.

It turned out that Scott, 44, was among the 6 million Americans suffering from heart failure, a complex condition that keeps the heart from pumping normally. The condition is often poorly managed, sending about a quarter of patients back to the hospital within a month of their initial treatment.

When Scott returned to the emergency room two weeks later, again short of breath, he was enrolled in a study assessing the effectiveness of a new home monitoring program overseen by Dr. Mauro Moscucci, medical director of the LifeBridge Health Cardiovascular Institute and chairman of Sinai's department of medicine.

The program is one of many efforts by health care providers to find the best method of engaging patients in their care at home so they stay out of the hospital.

Sinai's program, in partnership with the American Heart Association, is testing intensive education and Internet-connected scales and blood pressure cuffs that automatically send data to a team of clinicians who can interpret changes and intervene while there is still time.

One of the challenges with telemonitoring has been getting patients to measure their blood pressure and weight consistently and report their results," Moscucci said. "We are interested to see if this remote wireless technology will make it simpler and easier for them to be more consistent.

Perhaps the most essential element of the program, however, is personal care plans that involve daily emails with reminders to take medications and tailored advice on diets and activity. Patients also can report how much they exercise, what they eat and whether they experience symptoms such as lethargy, shortness of breath or fluid retention that might indicate a brewing problem not captured by data.

Tonja Howell, clinical research manager for the study, checks patients' vital signs remotely and answers questions via email or phone in concert with Moscucci. Doctors also look for trends. Howell said the goal is to enroll 50 patients in the study.

She and the doctor have responded when, for example, a patient's blood pressure was dangerously high. They discovered that the man's wife was out of town and he forgot his medication. They got him back on track in two days. Another patient with well-controlled glucose levels during the day was having spikes at night after his caretakers left, so they referred him for dietary education.

Not one of the 15 patients enrolled in the study has returned to the hospital this year, which is a relief to patients and to Sinai, as hospitals are penalized financially by federal and state regulators for unnecessary readmissions. Moscucci said 15 percent to 20 percent usually would be readmitted during that time span.

Patients will be followed intensively for six months with the aim of ingraining better habits in those with moderate to severe heart failure. If successful, the program could be rolled out to those with less severe heart failure, Moscucci said.

We need to determine what can work for patients," he said. "They may have gotten themselves into trouble, and not all patients will easily change their behavior. They need motivation and teaching.

Moscucci said finding a program that works for patients can be a challenge. Studies have found home monitoring programs lacking when patients do not change their habits, take their medications properly or routinely report problems.

Other local hospitals are experimenting with home monitoring programs to better engage patients. For the past year and a half, some of the most difficult cases from MedStar Health's Union Memorial and Good Samaritan hospitals and Washington Hospital Center have been going home from the hospital with a tablet that allows face-to-face time with a social worker and pharmacist who ensure that they are taking medication properly and coping with their disease.

Many patients find their situation depressing, and frequently other health issues or problems in their homes distract them from their own care, said Kathryn Walker, senior clinical director of palliative care for MedStar Health. She said the ability to talk live, at regular intervals, seems to build trust and gain cooperation in a way that phone calls don't.

In the month before the first 31 patients were enrolled in MedStar's program, there were about 10 hospitalizations and in the month after the number dropped to four. Dozens of medication errors were averted.

We're saying with this program that some patients need more," she said. "It's clear patients need a lot of education and someone to help walk them through some things.

Janet Bettger, a health services researcher at the Duke Clinical Research Institute who helped craft Sinai's program, agreed that patients need education and often intensive communication, at least at first.

A lot of self-management is related to behavior change," she said. "It needs to become routine and stick. In so many cases the patients don't get to that point. We need to be involved and track them and empower them.

Bettger said a technology-based method might not work for everyone. Some patients won't take their vital signs daily and medications properly no matter the kind of remote prompting and will need to come to the doctor for regular monitoring, though that can be burdensome for heart failure patients who easily get out of breath.

Ambio Health, which donated the equipment and software costing up to $500 per patient for the first year, has been selling such monitoring systems since 2012 to medical groups and health systems that are managing patients with various chronic conditions. Ambio CEO Kevin Jones said he believes the technology works best when combined with a coaching element.

Scott said he needed the coaching support when he was first discharged from the hospital and contacted Howell at Sinai frequently with questions about medications and diet. Howell said Scott is now a "rock star" patient and they have much less interaction.

He checks his vitals and keeps tabs on them through a website he accesses on his cellphone. He goes to cardiac rehabilitation three times a week at Northwest Hospital. And the biggest change has been paying attention to what he eats.

Meals are made at home more frequently and include more fresh vegetables and fruit. Scott reads labels, checking for sodium that can worsen his condition. When the broad-shouldered, 6-foot-5-inch Scott goes to a fast-food restaurant, he eats one hamburger and not three. He has an implantable defibrillator to regulate his heartbeat if needed.

Scott said he has influenced the health habits of the rest of his family.

"My scare got their attention," he said. "We're all trying to get in better routines."

Meredith Cohn - The Baltimore Sun

Simply Being Connected Can Keep You Healthier


Whether you or your loved one has high blood pressure, heart disease, diabetes, or is taking any medications, staying connected to your health care provider and or your loved can improve your health, and give all of you peace of mind.

As a health care provider, I take care of a lot of people who monitor their blood sugars, blood pressure, and weight at home. Most of my patients don’t like keeping a written record to bring to me. Many of them don’t know the numbers that should concern them, or if the numbers are as they should be. Over the last few months, I have been recommending they use a system from Ambio Health, called Ambio. Ambio is a wireless remote health monitoring system that effortlessly allows you to take readings at home, which then goes to whoever you choose to receive the information. Don’t let the description scare you. It is so simple, you don’t even have to press a button. One of my patients said, “The Ambio set up is pretty slick. Hard to believe everything worked the first time I set it up with no tech intervention required. Impressed!” Here are some examples of people I’ve worked with who have Ambio.

William is a 62-year-old man, who had a stroke three years ago. He has diabetes, high blood pressure, and a family that loves him. Before Ambio, we talked weekly. He wasn’t writing down his blood sugars, he would have to read off every number to me. I was never sure they were correct, and it took a long time to go through them. William was not even checking his blood pressure. Once on Ambio, I got his blood sugar and blood pressure results automatically. The numbers were all high. Ambio gave us a record of all the readings to share with his health care providers. Medication changes were made immediately. One important point here is that William’s blood pressure was only high in the morning, which is the most dangerous time for high blood pressure. A lot of people miss that number if they don’t check at home. Bringing William’s numbers to target range in a timely manner can help him prevent another stroke. He looks forward to his son’s wedding this fall. He, his loved ones, and his health care providers are amazed at the simplicity of this device, and how William’s health can be better cared for.

John, a 35-year-old man was recently diagnosed with type 1 diabetes. He was told to check his blood sugar at least four times a day. He was scared of his numbers going too high and having complications of diabetes. I was concerned about his numbers going too low. It is not unusual for people who have type 1 diabetes to need a larger amount of insulin early on, but then need a lot less. Although high blood sugars can be dangerous, it is the long-term high blood sugars that can cause a problem. On the other hand, low blood sugars can cause more immediate problems, and even death. When we met, I introduced John to Ambio. I started getting his numbers right away. His doctor and I advised him to decrease his insulin, so had avoided any serious low blood sugars. He has been amazed by how easy it is to use, and how it has given him and his family a feeling of safety.

Susan, a 60-year-old patient who has pre-diabetes, thyroid problems, and allergies started using the Ambio system. Since she had not been told she actually has diabetes or high blood pressure, she wasn’t checking her blood sugar or blood pressure. She did know too much thyroid and or her allergy medicine could raise her blood pressure. Once on Ambio, she saw her numbers were rising. She immediately contacted with her health care provider. Together they worked on getting a balance of her medications that worked keep her feeling good and her numbers in her target range.

Patients tell me they are doing better, just knowing someone is watching and someone cares. As a health care provider, I am working towards recommending this simple tool to all of my patients. It’s a relief for all of us: health care providers, caregivers, and most important the patient.

Joy Pape is an internationally known Certified Diabetes Educator in New York City.

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