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JAMA Intern Med:远程监控对心衰患者“然并卵”(BEAT-HF研究)

2016-03-15 MedSci MedSci原创

以移动医疗为手段的干预并不能改善和提升病人的健康,也不能为支付方进行真正有效的控费。那么,这样的僵局该如何打破?    近日,JAMA Internal Medicine刊登了Better Effectiveness After Transition–Heart Failure (BEAT-HF)的研究结果,该研究主要集中在对因心脏病出院的病人干预的效果分析上。一共1400个病人被分为两组,一

以移动医疗为手段的干预并不能改善和提升病人的健康,也不能为支付方进行真正有效的控费。那么,这样的僵局该如何打破?

  

近日,JAMA Internal Medicine刊登了Better Effectiveness After Transition–Heart Failure (BEAT-HF)的研究结果,该研究主要集中在对因心脏病出院的病人干预的效果分析上。一共1400个病人被分为两组,一组是具有强干预,另一组没有任何干预措施。这些病人都是在2011-2013年因心脏病入院后出院的50岁以上人群随机选取。具体的干预措施包括电话指导,血压、心跳和体重等一系列数据的监测,主要由护士长期监测数据并据此对病人进行干预。实验结果显示,两组人群出院后180天内的再入院率是一致的,都是50%,30天的再入院率和180天的死亡率也是没有区别的。

近期公布于BEAT-HF研究结果显示,远程监控与常规治疗相比并未减少心衰患者6个月时的再入院率,而且这一策略(包括出院前心衰教育、定期电话辅导、体重、血压及心率远程监控)对30天再入院率及6个月死亡率也无影响。主要研究者Michael Ong(加利福尼亚大学洛杉矶分校)认为这一结果可能与患者依从性有关,因为他们曾在小型试验中发现该策略带来的获益,也许它并不适用于全部患者。

BEAT-HF研究

研究纳入了1437例≥50岁失代偿性心衰患者,平均年龄73岁,60%以上为NYHA3级或4级心衰。在接受远程监控治疗的715例患者中,83%使用电话远程监控,共记录221211个远程监控结果,每个受试者在6个月间平均接到6个电话,但是研究者未发现该组患者的180天再入院率降低。死亡率方面,远程监控组的30天死亡率(校正后)明显降低,但对照组患者死亡主要发生于住院期间,因此该结果与远程监控无关;两组间180天死亡率无差异。

与监控天数不足一半的患者相比,依从性较好(监控天数达50%以上)患者的180天再入院率明显降低(41.3% vs 61.1%,P<0.001),而且完成通话次数较多者及风险因素监控更频繁者的180天死亡率也明显降低。Ong认为很多因素都会影响患者依从性,而科技进步(例如使用智能腕表监测心衰)将有助人们更深入的研究电话监控的优势。Ong承认目前多数心衰患者未形成自我护理意识(例如体重及血压测量),因此研究者还需更好的理解如何影响患者行为改变。


Mariell Jessup(宾夕法尼亚大学)对此表示赞同,她认为促进患者改变自身行为这项工作并不简单,这将是Ong教授带头研究的另一个方向;当然,远程管理患者也许就是一种天方夜谭。


移动医疗在蓬勃发展后数年,由于在短期内并没有取得立竿见影的效果,市场自身的反思开始日益明显。同时,作为最主要的买单者,支付方对移动医疗的支持力度始终保持在一个较小的规模,整个市场正在从密集投资期向平稳发展过渡,试图去寻找更为有效的服务模式。


这样的研究显示以移动医疗为手段的干预并不能改善和提升病人的健康,也不能为支付方进行真正有效的控费。无独有偶,Scripps Translational Science Institute在近日宣布的一项调研也显示,可穿戴设备的短期监测对健康效果和医疗成本的控制都难以体现效果。


这类研究并不是第一次公布,虽然可以从样本和研究时长对其提出质疑,但移动医疗的效果还不是非常明确是毋庸置疑的,这也是为什么与远程医疗相比,移动医疗的发展相对较为缓慢。这就对移动医疗到底能提供什么样的价值提出了挑战。一般来说,移动医疗的价值是可以干预病人的病情、药企研发新药和支付方控制医疗费用。但从上述的研究来看,效果都并不明显,无法在短期创造足够的价值,这严重影响了市场对移动医疗未来发展的预期。

因此,移动医疗以及由此带动的大数据业务在短期无法量化,也无法获得规模性的增长。未来最可能的脱困路径在于将其融合进传统的医疗服务中,通过长时段的实践来真正发挥其价值,带动医疗服务的转型和提升。

原始出处:

Ong MK, Romano PS, Edgington S, Aronow HU, Auerbach AD, Black JT, De Marco T, Escarce JJ, Evangelista LS, Hanna B, Ganiats TG, Greenberg BH, Greenfield S, Kaplan SH, Kimchi A, Liu H, Lombardo D, Mangione CM, Sadeghi B, Sadeghi B, Sarrafzadeh M, Tong K, Fonarow GC; Better Effectiveness After Transition–Heart Failure (BEAT-HF) Research Group. Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure: The Better Effectiveness After Transition-Heart Failure (BEAT-HF) Randomized Clinical Trial. JAMA Intern Med. 2016 Mar 1;176(3):310-8

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    2016-03-22 1de304d2m86(暂无匿称)

    值得深思

    0

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    2016-03-16 任然

    需要进一步改善

    0

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据7月3日发表在JAMA(《美国医学会杂志》)上的一则研究披露,与常规治疗相比,由药剂师进行管理的居家血压(BP)远程监控组成的一种干预治疗在12个月的时间段内达到了改善血压控制和血压下降的效果,并且在该干预之后血压的改善维持了6个月的时间。 根据文章的背景资料:“高血压是最常见的慢性疾病,病人会因为该疾病病而到初级保健医生处就诊;该疾病对美国30%的成年人造成影响;据估计每年在高血压上所花费的

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