University of Groningen Echocardiographic characterization of heart failure Nauta, Jan F

(1)

University of Groningen

Echocardiographic characterization of heart failure

Nauta, Jan F

DOI:

10.33612/diss.165627336

IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from

it. Please check the document version below.

Document Version

Publisher's PDF, also known as Version of record

Publication date:

2021

Link to publication in University of Groningen/UMCG research database

Citation for published version (APA):

Nauta, J. F. (2021). Echocardiographic characterization of heart failure. University of Groningen.

https://doi.org/10.33612/diss.165627336

Copyright

Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).

Take-down policy

If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim.

Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum.

(2)

553433-L-sub01-bw-Jonker 553433-L-sub01-bw-Jonker 553433-L-sub01-bw-Jonker 553433-L-sub01-bw-Jonker Processed on: 28-1-2021 Processed on: 28-1-2021 Processed on: 28-1-2021

(3)

Processed on: 28-1-2021 PDF page: 9PDF page: 9PDF page: 9PDF page: 9

1. General introduction

and outline of this thesis

(4)

(5)

General introduction | 11

1 GENERAL INTRODUCTION

Cancer is a global concern with an incidence of 17 million cases in 2018, excluding non-melanoma skin cancer.1_{The cancer incidence will continue to increase as the} population ages worldwide, with the majority of cancer patients being aged 65 years and older in 2018.2_{In 2035, approximately 14 million older adults will be newly diagnosed} with cancer.2_{Surgery is required for curative treatment in more than 80% of cancer} cases, and this is true for older cancer patients as well.3_{As a result, a considerable} number of older patients will undergo oncologic surgery.

Over the past decades, the length of hospital stay after oncologic surgery has significantly decreased.4,5_{Minimally invasive surgery and enhanced recovery after} surgery programs have reduced complications and shortened the length of hospital stays at reduced costs.6,7 _{However, older patients remain vulnerable in the first few} weeks after hospital discharge, and currently receive limited guidance and monitoring in their recovery at home.8,9 _{As a consequence, the majority of older patients experience} problems after hospital discharge, including difficulties with self-management of their disease, coping with the transition from hospital to home, and obtaining community services such as home care.10_{In addition, late postoperative complications may occur} in the period following hospital discharge,8,11_{which may lead to unplanned hospital} readmissions with considerable impact on the patients’ functional recovery, quality of life, and mortality.12,13_{Most post-discharge complications and unplanned readmissions} result from infections, cardiovascular disease, immobility, or malnutrition.11,14,15 Transitional care programs and home health services have been implemented to support and guide older adults after hospital discharge.10_{Another potential solution} to bridge the gap in guidance and monitoring after discharge is the use of digital technologies to enable monitoring of patients at a distance (i.e., telemonitoring, remote home monitoring).16-18

Through the use of new digital technologies, it is possible to support, replace, or improve care-as-usual.19_{Because of this, the use of eHealth—defined as “health} services and information delivered or enhanced through the internet and related technologies”20_{—has increased.}19_{EHealth interventions have been used to increase} patient engagement, promote self-care and monitor health status in patients with chronic diseases such as cancer, diabetes, or cardiac failure.21,22 _{In 2016, Van der Meij} et al. demonstrated that various eHealth interventions could also improve clinical outcomes for patients who undergo surgery.18 _{However, the quality of evidence in the} included studies was low and the number of studies that used telemonitoring was limited. The number of scientific publications on telemonitoring has rapidly increased

(6)

12 | Chapter 1

in recent years.23_{To evaluate the effectiveness of the current state of perioperative} telemonitoring, we performed a systematic literature study to investigate its effect on clinical, patient-reported, and financial outcomes in patients undergoing major surgery (Chapter 2).

In order to assess the effectiveness of telemonitoring in surgical patients, it is important to also evaluate patients’ perceptions of its usability and acceptability. This is especially true for older adults, as they tend to use digital health solutions less often24_{and have lower digital literacy than their younger counterparts.}25 Moreover, eHealth interventions developed specifically for older adults, are often limited to patients with chronic diseases rather than patients undergoing surgery.21,26 Therefore, Chapter 3 evaluates the feasibility of eHealth interventions in the older surgical population. The objective of this second systematic review is to assess patients’ perceptions of the usability and acceptability of perioperative eHealth interventions as well as their satisfaction and compliance with the interventions. While Chapters 2 and 3 explore perioperative telemonitoring used for several aims, the focus of the study described in this thesis is the use of telemonitoring for early detection of complications after hospital discharge, as previously discussed. The majority of post-discharge complications result from infections, cardiovascular causes, immobility, malnutrition, or conditions less precisely defined as “failure to thrive”.11,14,15_{Therefore, we intended to monitor older patients for signs of these} complications. For this, we collaborated with the European consortium Connecare (founded in 2015, European Union’s Horizon 2020 Research & Innovation Program, project grant no. 689802). The objective of the Connecare project was to integrate complex care for older patients with chronic long-term conditions, including older patients undergoing cancer surgery. Multiple European technical and clinical partners co-designed an information technology (IT) system that included a smart adaptive case management system (SACM) for the health care professional and an application for patients’ use called a self-management system (SMS). The system was adapted to meet the clinical and technical possibilities, needs, and aims of the local setting. As one of the clinical partners of Connecare in the Department of Surgery at the University Medical Center Groningen (UMCG), we were mainly interested in deviations in postoperative recovery of older patients after hospital discharge. To this end, patients aged 65 years and older undergoing oncologic surgery in the UMCG were asked to participate in an observational cohort study. We hypothesized that remote home monitoring could result in early detection of complications and other deviations in recovery. Eventually, this could lead to early management of complications, preventing more invasive treatment or even readmission.

(7)

1

However, in clinical practice the implementation of the Connecare telemonitoring study proved challenging. Important questions were raised regarding feasibility and inclusion of the target population. First, the issues regarding implementation and feasibility are presented in Chapter 4. This chapter provides a perspective on challenges and solutions during the step-wise development and implementation of the Connecare system. The feasibility of Connecare was evaluated in the first 50 patients from the cohort by assessing study completion rate, compliance, and usability and acceptability of the patients’ mobile application (the SMS) with additional devices. Next, the barriers to study participation during the recruitment process for Connecare are studied in Chapter 5. In general, older patients are underrepresented in clinical cancer trials as well as in eHealth intervention studies.27_{This might lead to biased reporting of study outcomes, non-generalizable} results, and ultimately, unequal provision of healthcare.28 _{Older patients who are} at a high risk of developing complications might therefore not benefit from new digital solutions. Notably, in the Connecare study including only patients aged 65 years and older, approximately half of the identified patients could not be included. Therefore, possible technological and patient-related barriers to participation in our cohort are investigated in a retrospective analysis. We analyze reasons for ineligibility and compare characteristics and postoperative outcomes between participants and non-participants.

Next, we analyze the telemonitoring data from the Connecare cohort. Chapter 6 aims to objectively quantify physical activity using a commercially available wearable activity tracker (Fitbit) and to assess the recovery of physical activity at three months postoperative. Recovery of physical activity is an important functional outcome measure after cancer surgery.29,30_{Traditionally, functional recovery is assessed} using self-reported functional recovery questionnaires or physical function tests.29 Objective measures of physical activity might provide more accurate and detailed information on physical recovery. In addition to quantifying physical activity and assessing recovery, this chapter characterizes older patients who returned to their preoperative level of physical activity. Finally, Chapter 7 analyzes the postoperative telemonitoring parameters two weeks after hospital discharge to objectively quantify deviations in recovery at home. Physical activity, vital signs, and patient-reported symptoms are evaluated in relation to post-discharge complications and hospital readmissions.

(8)

14 | Chapter 1

In summary, this thesis aims to explore the possibilities of perioperative telemonitoring, especially in older patients undergoing cancer surgery. It starts with an overview of the effectiveness of perioperative telemonitoring in general, continues with the challenges of telemonitoring regarding feasibility, study implementation, and inclusion of older surgical patients, and ends with the analyses of monitored parameters. An overview of the main findings of the two systematic reviews and the prospective observational cohort study (Connecare) and future perspectives on telemonitoring and eHealth in this aging population are discussed in Chapter 8.

(9)

1 REFERENCES

1. Ferlay J, Ervik M, Lam F, et al. Global cancer observatory: Cancer today. Lyon, france: International agency for research on cancer. available from: https://gco.iarc.fr/today. Updated 2018. Accessed July 6, 2020. 2. Pilleron S, Sarfati D, Janssen-Heijnen M, et

al. Global cancer incidence in older adults, 2012 and 2035: A population-based study. Int

J Cancer. 2019;144(1):49-58.

3. Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: Delivering safe, affordable, and timely cancer surgery. The

Lancet Oncology. 2015;16(11):1193-1224.

4. Aravani A, Samy EF, Thomas JD, et al. A retrospective observational study of length of stay in hospital after colorectal cancer surgery in England (1998–2010). Medicine. 2016;95(47).

5. Downing A, Lansdown M, West RM, et al. Changes in and predictors of length of stay in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of england: A population-based study. BMC

Health Serv Res. 2009;9:202-6963-9-202.

6. Slieker J, Frauche P, Jurt J, et al. Enhanced recovery ERAS for elderly: A safe and beneficial pathway in colorectal surgery. Int

J Colorectal Dis. 2017;32(2):215-221.

7. Johnston ME, Sussman JJ, Patel SH. Surgical oncology and geriatric patients. Clin Geriatr

Med. 2019;35(1):53-63.

8. Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-102. 9. Branowicki PM, Vessey JA, Graham DA, et al.

Meta-analysis of clinical trials that evaluate the effectiveness of hospital-initiated postdischarge interventions on hospital readmission. J Healthc Qual. 2017;39(6):354-366.

10. Altfeld SJ, Shier GE, Rooney M, et al. Effects of an enhanced discharge planning intervention for hospitalized older adults: A randomized trial. Gerontologist. 2012;53(3):430-440. 11. Ommundsen N, Nesbakken A, Wyller TB, et

al. Post-discharge complications in frail older patients after surgery for colorectal cancer.

Eur J Surg Oncol. 2018;44(10):1542-1547.

12. Morris MS, Deierhoi RJ, Richman JS, et al. The relationship between timing of surgical complications and hospital readmission.

JAMA Surg. 2014;149(4):348-354.

13. Weerink LBM, Gant CM, van Leeuwen BL, et al. Long-term survival in octogenarians after surgical treatment for colorectal cancer: Prevention of postoperative complications is key. Ann Surg Oncol. 2018 Dec;25(13):3874–82. 14. Lim SL, Ong KCB, Chan YH, et al. Malnutrition

and its impact on cost of hospitalization, length of stay, readmission, and 3-year mortality. Clin

Nutr Edinb Scotl. 2012;31:345–50.

15. Hughes LD, Witham MD. Causes and correlates of 30-day and 180-day readmission following discharge from a medicine for the elderly rehabilitation unit. BMC Geriatr. 2018;18:1 16. Cleeland CS, Wang XS, Shi Q, et al. Automated

symptom alerts reduce postoperative symptom severity after cancer surgery: A randomized controlled clinical trial. J Clin Oncol. 2011;29(8):994-1000.

17. Lee TC, Kaiser TE, Alloway R, et al. Telemedicine based remote home monitoring after liver transplantation: Results of a randomized prospective trial. Ann Surg. 2019;270(3):564-572. 18. van der Meij E, Anema JR, Otten RH, et al. The

effect of perioperative E-health interventions on the postoperative course: A systematic review of randomised and non-randomised controlled trials. PLoS One. 2016;11(7):e0158612. 19. World Health Organisation. Global strategy on

digital health 2020-2024. Draft 26 March 2019. 20. Eysenbach G. What is e-health? J Med Internet

Res. 2001;3(2):E20.

21. Batsis JA, DiMilia PR, Seo LM, et al. Effectiveness of ambulatory telemedicine care in older adults: A systematic review. J Am Geriatr Soc. 2019. 22. Penedo FJ, Oswald LB, Kronenfeld JP, et al.

The increasing value of eHealth in the delivery of patient-centred cancer care. The Lancet

Oncology. 2020;21(5):e240-e251.

23. Farias FAC, Dagostini CM, Bicca YA, et al. Remote patient monitoring: A systematic review. Telemed J E Health. 2020;26(5):576-583. 24. Levine DM, Lipsitz SR, Linder JA. Trends in

seniors’ use of digital health technology in the united states, 2011-2014 Letters. JAMA. 2016;316(5):538-540.

(10)

16 | Chapter 1

25. Hoogland AI, Mansfield J, Lafranchise EA, et al. eHealth literacy in older adults with cancer. J Geriatr Oncol. 2020. Jan 6. ;S1879-4068(19)30438-12.

26. van den Berg N, Schumann M, Kraft K, et al. Telemedicine and telecare for older patients-a systematic review. Maturitas 2012;73:94e114. 27. Ford JG, Howerton MW, Lai GY, et al. Barriers

to recruiting underrepresented populations to cancer clinical trials: a systematic review. Cancer 2008 Jan 15;112(2):228–42.

28. Downing A, Morris EJ, Corrigan N, et al. High hospital research participation and improved

colorectal cancer survival outcomes: a population-based study. Gut. 2017 Jan;66(1):89–96.

29. Rønning B, Wyller TB, Jordhøy MS, et al. Frailty indicators and functional status in older patients after colorectal cancer surgery.

J Geriatr Oncol. 2014;5(1):26-32.

30. Montroni I, Rostoft S, Spinelli A, et al. GOSAFE - geriatric oncology surgical assessment and functional recovery after surgery: Early analysis on 977 patients. J Geriatr Oncol. 2019. S1879-4068(19)30168-7.

(11)