How to Deliver High-Specialty Care At

How to deliver high-specialty care at home after liver transplantation: a sustainable approach Giovanni Vizzini, MD Department of Medicine - Transplant Hepatology Unit ISMETT-UPMC Palermo - Italy

Evidenze cliniche ed economiche dei miglioramenti prodotti dall’uso dell’IT: l’IT realmente riduce i costi e migliora la cura? FORUM PA 2013 29 Maggio 2013 - Roma – Palazzo dei Congressi 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 78-bed hospital 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. Solid organs transplant recipients: a growing population

ISMETT: 1378 transplants from July 1999 to Dec 2012

160

140

120

100

80 150 146 135 127 131 133 60 118 104 91 40 58 49 20 40 27 12 0 9 0 1 2 3 4 5 6 7 8 9 0 1 2 9 0 0 0 0 0 0 0 0 0 0 1 1 1 9 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 2 2 2 2 2 2 2 2 2 2 2 2 Solid organs transplant recipients: a growing population

ISMETT: 1378 transplants from July 1999 to Dec 2012

160 At present, more than one thousand of transplant 140 recipients in follow up at ISMETT 120

100

80 150 146 135 127 131 133 60 118 104 91 Every year, 120-130 new 40 patients in follow up 58 49 20 40 27 12 0 9 0 1 2 3 4 5 6 7 8 9 0 1 2 9 0 0 0 0 0 0 0 0 0 0 1 1 1 9 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 2 2 2 2 2 2 2 2 2 2 2 2 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

Liver transplantation at ISMETT- Palermo Patients survival curve Patients’ Needs

Liver transplantation at ISMETT- Palermo Patients survival curve Patients’ Needs What we usually do in the early post-operative course

The early post-transplant period is crucial due to: Liver transplantation at ISMETT- Palermo High risk of rejection Patients survival curve High risk of infections High 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 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

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

Palermo to: Catania Æ 207 Km Messina Æ 237 Km Palermo to: Ragusa Æ 248 Km Trapani Æ 107 Km Siracusa Æ 259 Km Agrigento Æ 126 Km Caltanissetta Æ 127 Km Enna Æ 136 Km 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) technology Post 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 of ¾ speeding up hospital discharge of post-liver transplant patients ¾ enabling uninterrupted recovery at home ¾ maintaining close contact with our medical teams

The technology allows nurses and physicians ¾ to monitor and support transplant patients from their homes ¾ to check their general condition ¾ to collect biometric data ¾ to manage their treatment ¾to offer face to face appointments via video conferencing. The innovative use of available (and simple) technology Post 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- Thehealth challenges: technology with the aims of ¾Tospeeding remotely up hospital manage discharge patients of post-liver transplant patients ¾ enabling- uninterrupted in the aftermath recovery of at anhome extremely invasive surgical ¾ maintainingprocedure close contact with our medical teams - in not complete stable conditions The technology- still allows suffering nurses ofand the physicians consequences of a prolonged ¾ to monitordisease and support transplant patients from their homes ¾ to check their general condition ¾ to collect biometric data ¾ to manage their treatment ¾to offer face to face appointments via video conferencing. Post liver transplant “Home-monitoring” Study protocol

Inclusion criteria: Clinical pathway: All consecutive adults patients who live in Sicily, who received • Clinical monitoring during the liver transplantation at ISMETT post-discharge time (first 3 and were discharged from July 15, months or until clinical 2011. stabilization)

Staff involved: • Verification of the adherence to At the patient’s home: therapy (immunosuppression, technician for the instalment of the other medications) devices In Tele-Visit (tele-consult): • Verification of the adherence to Physician (ISMETT-UPMC) the bio-humoral surveillance after transplant Transplant coordinator (ISMETT) Others(physical th.- psycologist) 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 week each 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

Transplant Center Home

Phone line Internet 3G wireless

Transplant Physician Transplant Coordinator

Patient information/ education 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-monitoring Hystoric controls July 2011-April 2013 July 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 25.4

Deaths during the 3-month study period 01

Patients who needed urgent re-admission during the first 03 3 months after transplant Overall number of urgent re-admissions during the first 3 04 months after transplant

Overall length of stay due to urgent re-admissions during 025 the first 3 months after transplant (days)

Patient/family satisfaction rate (based on questionnaire 98% NA administered) 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

Saving Cost Six days of hospital stay x 60 7 Euro per patient/day patients = 360 days of hospital Total cost of home monitoring stay per patient: 7 euro x 90 days = 630 Euro 360 days x 1000 Euro = 630 Euro x 60 patients = 360.000 Euro/year 37.800 Euro/year Follow-up of liver transplant recipients: a “sustainable” approach

A possible solution to the challenges we face: home-monitoring/tele-consult

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) 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 Æ Æ Best care at the lower cost, according to the recommendations of The Institute of Medicine: Partner with patients Use Information Technology more effectively Decrease 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

[email protected] www.ismett.edu