ABDUCENS INDONESIAN MEDICAL STUDENTS' TRAINING & COMPETITION (IMSTC) 2022 by AMSA-Unhas

INDONESIAN MEDICAL STUDENTS TRAINING AND COMPETITION 2022 TELETHON: Telemedicine Towards a Healthier Indonesia DOES TELEMEDICINE REALLY WORTH IT? MAYBE IF YOU USE IT WISELY! Akhmad Zani Tasir M., Karen Kurnia, Cindy Marsela [Correspondence E-mail: wolesyoo@gmail.com] Background : Telemedicine signifies the use of ICT (Information, Communication, Technologies) to improve patient outcomes by increasing access to care and medical information.(1) Study has shown that during the pandemic of COVID-19, people in Indonesia are becoming more aware of telemedicine. As of March 2020, Indonesia’s telemedicine app users increased by 101% compared to 2019 averages.(2) Considering that telemedicine has its own benefits and disadvantages, we believe that the increasing usage of telemedicine should be followed by increased knowledge about telemedicine, and how to use them wisely. Objective : We aim to maximize the advantages and minimize the disadvantages of telemedicine by educating people on how to use it wisely. Description : Therefore, we made WISELY as the mnemonic to make it easier for the public to memorize. WISELY stands for : W Write down everything that you want to say to your doctor. I If the telemedicine company is not trustworthy, don’t use it. S Search for a good environment so no one can disturb you while you're consulting. E Equipment should be prepared before the appointment. L Let your doctor know the details of your condition. Y You still may have to meet your doctor in person in case you need your blood drawn, X-ray, or other tests.(3) Impact : We hope for better health outcomes in the society especially in this pandemic where social distancing made telemedicine a safe form of doctor-patient interaction. Conclusion : Telemedicine has it’s own advantages and disadvantages. It could improve health outcomes if it is used wisely. Keywords : COVID-19, Indonesia, Telemedicine, Wisely Reference : https://docs.google.com/document/d/1mue2XA4GOUPNJ_a8eTV0sBweM0hifJKzmgVMIEuFY0/edit?usp=sharing

Video link : https://drive.google.com/file/d/1njAe_enMifbmpzD77xFOkmMAVnSii36/view?usp=sharing

Warkes (Warung Kesehatan)

Indonesia merupakan negara dengan segundang heterogenitas termasuk dalam bidang pembanguan daerah. Heterogenitas pembangunan ini kemudian menyebabkan ketertinggalan pembangunan di beberapa daerah yang kemudian disebut sebagai daerah tertinggal. Menurut Perpres No 63 Tahun 2020, terdapat 62 Kabupaten yang berstatus daerah tertinggal. Beberapa masalah yang ada di daerah tertinggal di antaranya masalah pada bidang teknologi informasi dan komunikasi dan masalah pada bidang pelayanan kesehatan. Berdasarkan data BPS, Kemenkominfo, dan penelitian yang telah dilakukan, tingkat kepemilikan gadget di daerah rural hanya 50%. Akses jaringan internet juga baru menjangkau sebanyak 56.307 desa/kelurahan dari total 83.820 desa/kelurahan di Indonesia. Selain itu, data juga menunjukkan bahwa banyak terjadi kekosongan dokter di wilayah dengan status ekonomi yang rendah. Dengan kondisi ini, masyarakat daerah terpencil tentunya akan kesulitan mendapatkan layanan kesehatan baik konvensional (luring) maupun melalui telemedicine. Untuk itu solusi harus dibuat. Solusi yang saya berikan adalah “Warkes (Warung kesehatan)”. Warkes merupakan fasilitas kesehatan yang memungkinkan pasien mendapatkan layanan kesehatan melalui sistem telehealth tanpa keharusan pasien untuk memiliki fasilitas gadget pribadi dan jaringan yang mendukung. Warkes terdiri dari komputer yang terhubung dengan router, printer, dan alat-alat pemeriksaan TTV digital sederhana yaitu termometer dan tensimeter digital. Sistem Warkes juga memungkinkan dokter untuk terhubungan dengan apotek dan puskesmas apabila pasien memerlukan pelayanan kesehatan lebih lanjut misalnya rujukan dan pembelian serta pengantaran obat. Selain itu, tersedia juga jasa transportasi online yang dapat digunakan oleh pasien apabila pasien mengalami kendala transportasi jika dokter membuat rujukan ke puskesmas. Warkes tidak memerlukan peralatan yang banyak sehingga dapat dibangun di banyak tempat seperti di balai desa dan sekolah. Dengan adanya Warkes, masyarakat daerah terpencil yang mengalami kendala sarana dan prasarana yang berkaitan dengan teknologi informasi dan komunikasi dan juga kendala ketiadaan dokter dalam suatu daerah. Dengan Warkes kita juga dapat memperluas jangkuan telemedicine dan mewujudkan Universal Health Coverage (UHC) untuk Indonesia.

TELEMEDICINE AND THE PEACE IT PROVIDES Muhammad Peyrouzi Isyraqi

Background We can’t deny the fact that healthcare are one of the main human needs. With health services, humans can fulfill one of the needs of living organism. These days, health services are starting to grow even better. Technology’s getting more sophisticated, and so are the health service. Basically, human primary needs need to keep up with the times to make it easier for humans to get a better life.

Description & Philosophy Nowadays, digital-based health services are very efficient in limiting contact between individuals. An example is illustrated here. An elderly person can now have a health consultation in peace from his home, when some people out there still have to get in line for health services as reported on the television. Their immune system is no longer as strong as other adults, therefore it’s an important thing to take care of our parents. Our efforts to maintain health can actually be the entrance of diseases, hence let's introduce “the power of technology” to them, because this can be a form of prevention too.

Impact The development of technology in the health sector really make a difference. The elderly who are vulnerable to exposure to disease, have now been greatly facilitated by health service applications. They’re no longer need to get in line at the healthcare centre. They can just sit at home, take out their phones, and look for their needs. This is what technology should be, easing access to public facilities.

Conclusion Everything is limited these days. What used to be offline is now online. Works and schools are now done virtually using various technology. Whether we like it or not, we have to adapt to these changes in order to survive.

Keywords: elderly, health services, pandemic, technology.

INDONESIAN MEDICAL STUDENTS TRAINING AND COMPETITION 2022 TELETHON: Telemedicine Towards a Healthier Indonesia

Symptoms Improvement of Heart Failure Patients With the Intervention of Telemedicine: A Systematic Review Ismail, Indira Putri D. Sanusi, Nabilah Puteri Larassaphira [Correspondence E-mail: ismail20c@student.unhas.ac.id] Abstract Introduction: Heart failure (HF) is a fast expanding public health problem, with an estimated prevalence of more than 37.7 million people worldwide. This cardiovascular disease causes shortness of and fluid retention and breath (SOB) or dyspnea almost 80 percent of the time. The diagnosis of HF is associated with higher mortality and loss of quality of life. However, in evidence-based medicines and telemedicine considered as methods to significantly improved patient outcomes. Methods: Systematic review was conducted based criteria on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). In literature search, the authors applied in 4 databases, such as PubMed, ScienceDirect, Cochrane, and ProQuest. In risk of bias, the authors used Cochrane Risk of Bias for Randomized Trial (RoB 2.0). Results: Among 5123 studies from 4 databases, 11 studies included for qualitative synthesis. The studies were published between 2012 and 2022. All of the studies then assessed for risk of bias using Risk of Bias for Randomized Trial (RoB 2.0). The result show mostly low and unclear risk of bias category. Discussion: Patients with heart failure who received telemedicine intervention have a higher score of Kansas City Cardiomyopathy Questionnaire (KCCQ), Functional Assessment of Chronic Illness Therapy–Palliative-14 [FACIT-Pal-14], and Minnesota Living with Heart Failure Questionnaire (MLHFQ). Besides that, the level of BNP and LVEF, which are markers of heart failure, also decrease at HF patient who receive telemedicine. However, in other publications, there are no significant changes found. Conclusion: Telemedicine is considered as solution in remote health services. Telemedicine intervention can slightly improve symptoms compared with patient without telemedicine intervention. Keywords: Symptoms Improvement, Heart Failure, Telemedicine

Introduction Heart failure (HF) is a cardiovascular disease that almost 80 percent of the time causes shortness of breath (SOB)/dyspnea and fluid retention. HF caused by anatomical and functional abnormalities in the myocardium that limit ventricular filling and blood ejection. Reduced left ventricular myocardial function is the most prevalent cause of HF. Besides that, HF can also be caused by dysfunction of the pericardium, myocardium, endocardium, heart valves, or great vessels (1). Heart failure (HF) is a fast expanding public health problem, with an estimated global prevalence of more than 37.7 million people. The elderly have a larger amount of the HF burden. Over half of HF patients admitted to health facilities are over 75 years old. For each decade of life, the prevalence of HF doubles. Although a diagnosis of HF is associated with higher mortality and loss of quality of life, breakthroughs in evidence-based medicines and telemedicine have significantly improved patient outcomes in the contemporary period (2). Telemedicine is the solution of healthcare services over distance when the healthcare provider and its patients are not at the same locations. Healthcare services offered via telemedicine can include consultations (teleconsultation), case reviews, monitoring (telemonitoring), and direct patient care using synchronous videoconferencing, as well as asynchronous interpretation of forwarded images, such as dermatology photos, ophthalmology retinal images, x-rays, ultrasound, and pathology micrographs (3). Telemedicine in heart failure is one of the digital tools currently developing. Several studies explain the effectiveness and safety of telemedicine compared to face-to-face doctor-patient interactions in the diagnosis to treatment of heart failure. The main objective of implementing telemedicine in heart failure is prevention of rehospitalization and more effective treatment (4). To achieve the goals of handling heart failure through telemedicine is to reduce symptoms and also reduce the costs (5).

Methods Search Method Three reviewers (I, I.P, and N.P.) conducted systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) (6). The reviewers conducted a search on four online- database PubMed, ProQuest, Cochrane, and ScienceDirect using keyword as follow: “patient” AND “heart failure” AND “telemedicine” OR “telehealth” AND “symptom improvement”. Only studies in English, ranging from 20122022, and publication type Randomized Control Trial are included in this systematic review. Eligibility criteria Studies were considered eligible for systematic review based on the following criteria: 1) all randomized control trials published in English or Indonesian; 2)The population under consideration are all adult patient of heart failure >18 years old with or without receiving

telemedicine treatment; 3)The main focus of the studies had to be the use of telemedicine on patients with heart failure; 4) The studies had to be published from 2012 until 2022. Data Collection First, The reviewers screened the studies based on the titles and abstracts to identify eligible studies. Studies that did not meet the criteria were excluded. Studies that met the criteria would be further assessed. We discussed the studies that have incomplete data and exclude if it's not possible based on the agreement of the reviewers. Data Extraction The following data is extracted from the included studies: first author, publication tear, study design, sample size, intervention type, study population, measures, and found in each of these studies. Risk of Bias Assessment Risk of bias assesment was done according to the Cochrane risk of bias tool for randomized trial (7) which include selection bias, measurement of exposure, confounding variables, blinding of participants and personnel, incomplete outcome data, and reporting bias. Any disagreements by the three authors were resolved through discussions. Synthesis of result Data that was considered eligible were collected and inputted by three authors to the table. Meta-analysis will be conducted if the data collection supports it. The data will be summarized in a narrative synthesis If the data collection has high heterogeneity. Results Study Selection After conducting searches in four international databases using the aformentioned keyword, we acquired 5123 studies. After screening for duplicates and ineligible study by automatication tools, 4551 studies were left. A total of two studies were excluded for another reason and two other studies were exclude due to not getting access to full-text articles. The three authors discussed the eligibility of the remaining studies and decided to exclude 302 studies that not Randomized Control Studies publication type, 213 that had populations other than heart failure patients, and 26 studies that did not use telemedicine as an intervention. Finally, a total of 11 studies were included in the review. The result of the study selection process is shown in Figure 1.

Figure 1. PRISMA Flow Diagram Study Characteristics After rigorous screening and rechecking to maintain uniformity and relevancy to inclusion and exclusion criteria, a total of 11 randomized controlled studies are included. The included studies are shown in Table 1. There are 3 studies were conducted in United Kingdom, 2 studies were conducted in Australia, 2 studies were conducted in United States, and 1 study each were conducted in Canada, China, Poland, and France. All study were published between 2012 until 2022. Due to the objective of this review being assesing symptoms improvement of heart failure patients with telemedicine, subject of the studies include adult patient of heart failure >18 years old with or without receiving telemedicine treatment.

Risk of Bias Assesment

Figure 2. Risk of Bias Summary The studies acquired were examined with the Cochrane Risk of Bias Tool. The risk for bias in both human and animal studies are mostly in the low and unclear risk of bias category, and some are classified as having high risk of bias. The detail of risk of bias in individual studies were displayed in Figure 2. Discussion Telemedicine to diagnose and treat patients with heart failure is currently multiplying. However, few articles are still reviewing the results of telemedicine interventions in terms of symptom improvement. Each randomized control trial's outcome and main findings are still very heterogeneous, so it is unfeasible to conduct any numerical statistical analysis such as

meta-analysis. Replicability testing is also essential to seek similar outcomes and main findings. Based on the data obtained from various publication, only two publications have similar measures and main findings that is Kansas City Cardiomyopathy Questionnaire (KCCQ). KCCQ provides an effective and sensitive view of the impact of heart failure on a patient's life and is strongly associated with long-term clinical events, a high KCCQ score indicate better perceived health status and quality of life. With the intervention of telemedicine, the score on KCCQ is higher if we compare it with patients that received usual care. The same thing happen with a different measuring instrument, which is the Functional Assessment of Chronic Illness Therapy–Palliative-14 [FACIT-Pal-14]. Patients who received the intervention of telemedicine got a higher score than patients who dont. Another publications uses Minnesota Living with Heart Failure Questionnaire (MLHFQ) to determine whether a treatment for heart failure is effective for improving patients’ quality of life by reducing the adverse impact of heart failure. Patients who received the intervention of telemedicine through 8-week of home-based telehealth exercise training program have a significant improvement regarding quality of life (measured by MLHFQ) and 6-Minute Walking Distance (6MWD) test compared to the control group post-test. This significant improvements were sustained for 4 months post-test. But on the other hand, there are no significant improvements regarding the NYHA classification. The New York Heart Association (NYHA) functional classification of heart failure is widely used in practice and in clinical studies. It is based on symptom severity and the amount of exertion needed to provoke symptoms. Besides KCCQ, FACIT-Pal-14, and MLHFQ, Packer Clinical composite score also used as measures and mind finding on another publication. Packer clinical composite score is often use to measure clinical outcome, heart failure status, and patient symptoms. In this study, there are no significant changes compared with usual care and heart failure hospitalization risk. However, there is significantly reduced on heart failure patient hospitalized in this study. It still needed further evaluation because it is unclear due to an insufficient number of general practitioners in the study. BNP and LVEF, which are markers of heart failure, showed that patients with telemonitoring showed more decreased BNP and LVEF. This could happen because changes in BNP and LVEF levels were also associated with improvement in symptoms of heart failure. The heart's ventricles produce BNP in response to an increase in ventricular wall pressure. An increase in ventricular wall pressure occurs due to the amount of blood the heart cannot pump throughout the body, commonly known as heart failure. Telemonitoring that is carried out can control the increase in ventricular heart pressure and control the increase in BNP biomarkers. In terms of mental health, patients with telemedicine intervention and without telemedicine had a significant improvement in quality of life. This becomes very interesting because remote treatment and in-hospital treatment have the same ability to maintain patients' mental health. Questionnaires that carry out assessments need to be reviewed for validity and

reliability. The number of patients who are not balanced and much different would cause the uniqueness of the results of the analysis. Standard cardiac rehabilitation also needs to be analyzed regarding the criteria or the need for guidelines to determine which patients are the standard for becoming controls. The literature on the cost-effectiveness of treating heart failure through telemonitoring is still lacking. However, several review articles indicate that there are still shortcomings in the implementation of telemedicine in heart failure patients, so the effectiveness of the costs incurred is still highly debated. This cost-effectiveness analysis still requires comprehensive economic analysis. Conclusion Telemedicine is a solution in remote health services. From the results of the review above, telemedicine interventions in the treatment of patients with heart failure are harmless and have a positive but less significant effect and even have similarities in symptoms improvement changes compared to patients without telemedicine intervention. Conflict of Interest The authors declared that there are no conflict of interest in this study.

REFERENCES 1. Inamdar AA, Inamdar AC. Heart failure: Diagnosis, management and utilization. J Clin Med. 2016;5(7). 2. Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol. 2016;13(6):368–78. 3. Latifi R, Doarn CR, Merrell RC. Telehealth and Telepresence. 2021. 4. Gensini GF, et al. Value of Telemonitoring and Telemedicine in Heart Failure Management. Card Fail Rev. 2017;3(2):1. 5. Eurlings CGMJ, Boyne JJ, de Boer RA, Brunner-La Rocca HP. Telemedicine in heart failure— more than nice to have? Netherlands Hear J. 2019;27(1):5–15. 6. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372. doi:10.1136/bmj.n71 7. Risk of bias tools - Current version of RoB 2. Accessed January 30, 2022. https://www.riskofbias.info/welcome/rob-2-0-tool/current-version-of-rob-2

Comparation

Intervention Type

Sample Size

Study Country Study Design

usual care

an 8-week home-based telehealth exercise training program,

- Experimental group (n=49) - Control group (n=49)

Peng et al., 2018 China Randomized Control Trial

Kansas City Cardiomyopathy Questionnaire [KCCQ]: score range, 0100; higher scores indicate better perceived health status and clinical summary scores 50 are considered “fairly good” quality of life; and the Functional Assessment of Chronic Illness Therapy– Palliative-14 [FACIT-Pal-14]: score range, 0-56; higher scores indicate better quality of life).

usual care

in-person palliative care consultation and 6 weekly nurse-coach telephonic sessions (20-40 minutes) and monthly follow-up for 48 weeks.

Bakitas et al., 2020 United Kingdom Randomized Control Trial - Experimental group (n = 208) - Control group (n = 207)

The average KCCQ overall summary score for those receiving telemonitoring was 2.5 points higher than usual care, driven primarily by improvements in symptoms (3.5 points) and social function (3.1 points).

Kansas City Cardiomyopathy Questionnaire (KCCQ) within 2 weeks of discharge and at 3 and 6 months. Repeated measures linear regression models were used to assess differences in KCCQ scores between patients assigned to telemonitoring and usual care over 6 months.

usual care

Received Tele-HF trial (Telemonitoring to Improve Heart Failure Outcomes),

Jayaram et al., 2017 United States Randomized Control Trial - Experimental group (n = 756) - Control group (n = 756)

TABLES

Measures

The outcome variables in this study were QOL, 6minute walking distance (6MWD), resting heart rate (HR), left ventricular ejection fraction (LVEF), NYHA classification, anxiety, and depression. The primary outcome was quality of life, which was measured by the MLHFQ.

At week 16, the mean (SE) KCCQ score improved 3.9 points in the intervention group vs 2.3 in the usual care group (difference, 1.6) and the mean (SE) FACIT-Pal-14 score improved 1.4 points in the intervention group vs 0.2 points in the usual care group (difference, 1.2).

Main Findings

Statistically significant improvements were observed in the experimental group regarding quality of life (QOL) and 6MWD compared to the control group post-test. Significant improvements in QOL, 6MWD, and resting HR were sustained for 4 months post-test. However, no significant improvements were observed regarding the NYHA classification, LVEF, anxiety, and depression at either the post-test or 4month post-test follow-ups. No patients experienced any significant complications or adverse outcomes during the program.

Nosignificant difference was seen in the rate of the primary end point, which occurred in 349 patients (42.4%) in the RM group and in 347 patients (408%) in the UC group. Cumulative incidence curves for the composite primary endpoint of death from any cause and hospital-ization for cardiovascular reasons, as well as for both components separately, did not reveal a significant difference between the two groups. No significant differences were seen between the two groups with respect to the secondary endpoints.

Primary end point, all cause mortality, and unplanned CV rehospitalization.

usual care

Remote management of heart failure using implantable electronic devices (REM-HF)

Morgan et al., 2017 United Kingdom Randomized Control Trial - Experimental group (n = 826) - Control group (n = 824)

Time to all-cause death or first unplanned hospitalisation was 105 days in the telemonitoring group and 84 days in the SC group.

The rate of all-cause deaths or unplanned hospitalisations in HF patients.

standard care

18-month telemonitoring (daily body weight measurement, daily recording of HF symptoms, and personalised education)

Galinier et al., 2020 France Randomized Control Trial - Experimental group (n = 482) - Control group (n = 455)

Piette et al., 2015 United States Randomized Control Trial - Experimental group (n = 166) - Control group (n = 165) 12 months of weekly interactive voice response (IVR) calls including questions about their health and selfmanagement and automated emails sent to their CarePartner after each IVR call, including feedback about the patient’s status and suggestions for how the CarePartner (= caregiver outside the household) could support disease care (“mHealth+CP”). Self-care and symptoms were measured via 6- and 12-month telephone surveys standard care (12 months of weekly interactive voice response (IVR) calls including questions about their health and self-management) Minnesota Living with Heart Failure Questionnaire (MLHFQ) for HF quality and Revised Heart Failure Self-Care Behavior Scale for HF self-care behaviors. Compared to a relatively intensive model of IVR monitoring, self-management assistance, and clinician alerts, a model including automated feedback to an informal caregiver outside the household improved HF patients’medication adherence and caregiver communication. mHealth+CP may also decrease patients’ risk of HF exacerbations related to shortness of breath and sudden weight gains. mHealth+CP may improve quality of life among patients with greater depressive symptoms. Weekly health and self-care monitoring via mHealth tools may identify intervention effects in mHealth trials that go undetected using typical, infrequent retrospective surveys.

The primary endpoint was the Packer clinical composite score. Secondary endpoints included hospitalization for any cause, death or hospitalization, as well as HF hospitalization.

usual care

12 month of Usual Care and telephone support Intervention (UC+I) for an ongoing support using a cluster design involving 143 GPs using the TeleWatchTM system throughout Australia.

Krum et al., 2013 Australia Randomized Control Trial - Experimental group (n = 188) - Control group (n = 217)

Quality of life

Standard care (visiting the clinic between once every 2 weeks to once every 3 to 6 months, depending on the severity of the patient’s heart failure condition and the need for optimizing their medication.)

The telemonitoring group took daily weight and blood pressure readings and weekly single-lead ECGs, and answered daily symptom questions on a mobile phone over 6 months.

Seto et al., 2012 Canada Randomized Control Trial - Experimental group (n = 50) - Control group (n = 50)

Rahimi et al., 2020 United Kingdom Randomized Control Trial - Experimental group (n = 101) - Control group (n = 101) active self-monitoring and IT-supported specialist management for about 6 months with collection of home monitoring data, blood tests, patient-repored outcomes and clinical events.

Use of guideline-recommended medical therapy for chronic HF and major comorbidities, measured as a composite opportunity score. Co-primary outcome was change in physical score of Minnesota Living with Heart Failure questionnaire.

UC+I significantly reduced the number of HF patients hospitalized among a rural and remote cohort. These data suggest that telephone support may be an efficacious approach to improve clinical outcomes in rural and remote HF patients.

The results from our trial suggest mobile phonebased telemonitoring improves quality of life through improved self-care and clinical management. A subgroup analysis using only the participants who had attended clinic for more than 6 months showed only the telemonitoring group had significant improvements in BNP and LVEF from baseline to post-study.

self monitoring (with collection of home monitoring data, blood tests, patient-repored outcomes and clinical events)

Central provision of tailored specialist management in a multi-morbid HF population was feasible. However, there was no strong evidence for improvement in use of evidencebased treatment nor health-related quality of life.

After rehabilitation, both groups achieved a significant QoL improvement, both physically and mentally. HTCR Group patients improved in QoL physical categories in one subscale (physical function), and in two subscales in the mental categories (mental health, vitality). In SCR Group, three physical subscales improved (physical function, role limitation caused by physical problems, bodily pain). In the mental categories, also three subscales improved (social function, mental health, vitality).

The Polish version of the Medical Outcome Survey Short Form 36 (SF36) questionnaire was used to assess patients’ QoL related to participating in cardiac rehabilitation. The questionnaire is designed for a subjective assessment of a patient’s health condition. It consists of 11 items containing 36 statements that allow eight subscales to be defined.

Standard Cartiac Rehabilitation (SCR)

home-based rehabilitation supervised telemedically based on walking training.

- Experimental Group (n=75) - Control Group (n=56)

Piotrowicz et al., 2015 Poland Randomized Control Trial

In 53 participants (mean age 67 years, 75% males), there were no significant between group differences on 6-minute walk distance gains, with a mean difference of 15 m (95% CI –28 to 59) at Week 12. The confidence intervals were within the predetermined non-inferiority range. The secondary outcomes indicated that the experimental intervention was at least as effective as traditional rehabilitation. Significantly higher attendance rates were observed in the telerehabilitation group.

Participants were assessed by independent assessors at baseline (Week 0), at the end of the intervention (Week 12) and at follow-up (Week 24). The primary outcome was a between-group comparison of the change in 6 minute walk distance, with a non-inferiority margin of 28 m. Scondary outcome included the other functional measures, quality of life, patient satisfaction, program attendance rates and adverse event.

traditional hospital outpatient-based program

The experimental group received a 12-week, real-time exercise and education intervention delivered into the participant's home twice weekly, using online videoconferenceing software.

- Experimental Group (n = 24), - Control Group (n=29)

Hwang et al., 2017 Australia Randomized Control Trial

Table 1. Table summary of studies collected

INDONESIAN MEDICAL STUDENTS TRAINING AND COMPETITION 2022 TELETHON: Telemedicine Towards a Healthier Indonesia

HOME BLOOD PRESSURE TELEMONITORING FOR HYPERTENSIVE DIAGNOSED PATIENTS: A SYSTEMATIC REVIEW Muhammad Azka Al atsari, Jessica Ho, Mohammad Reyza Junus [Correspondence E-mail: azka2alatsary@gmail.com]

ABSTRACT Introduction: Hypertension defined as systolic blood pressure and/or diastolic blood pressure values which elevated above normal levels. Hypertensive patients should be treated for both nonpharmacologic and pharmacologically. Only less than half of those who were treated by usual care successfully achieved hypertension control. Hypertensive adults who were either untreated or treated but uncontrolled hypertension were at increased risk of all-cause and CVD-specific mortality. Today’s era of technology has provided our healthcare services the use of telemedicine to assist the monitoring and controlling patient’s blood pressure. However, despite the wide use of telemedicine, more recent studies need to clarify its significance. Methods: This systematic review generate the evidence collection on applying blood pressure telemonitoring in the control of hypertension (PubMed, Science Direct, 2017–2022). Results and Discussion: Blood pressure levels in patients with uncontrolled hypertension has shown to be effectively reduced by the use of telemonitoring intervention, which shows significant in studies included (P<0.05). Conclusion: In order to combat hypertension in the future, especially for those who were untreated or treated but still have uncontrolled blood pressure, the application of telemedicine indicates as a very promising tools. Keywords: blood pressure, hypertension, telemonitoring

HOME BLOOD PRESSURE TELEMONITORING FOR HYPERTENSIVE DIAGNOSED PATIENTS: A SYSTEMATIC REVIEW Indonesian Medical Students’ Training and Competition 2022

By: Muhammad Azka Al atsari Jessica Ho Mohammad Reyza Junus

Asian Medical Students’ Association-Indonesia (AMSA-Indonesia) 2022

INTRODUCTION Hypertension defined as systolic blood pressure (hereafter referred to as SBP) and/or diastolic blood pressure (hereafter referred to as DBP) values which elevated above normal levels, current updates and guidelines related hypertension have standardized the classification, stages, treatment option, and management of hypertension.1 An updated study by The Lancet NCD Risk Factor Collaboration in 2021, reported the prevalence and management of hypertension has doubled since 1990, the global agestandardised prevalence of hypertension in adults were 32% and 34 %, respectively in men and women.2 Hypertensive adults who were either untreated or treated but uncontrolled hypertension were at increased risk of all-cause and CVD-specific mortality.3 Hypertensive patients should be treated for both non-pharmacologic and pharmacologic treatment. The initial pharmacological therapy begin when SBP of ≥140 mmHg or DBP of ≥90 mmHg.4 In order to achieve the reduction of BP to recommended levels, 70% of hypertensive patients needs the combination of at least two antihypertensive agents.5 Along with the that, lifestyle changes and targeted dietary approaches also proved effectively reduce blood pressure (BP).6 Besides strong benefit of such treatments, studies results many patient’s BP remain uncontrolled, therefore new advancements, including new technologies needed to improve the quality of screening, detection and control of hypertension.7 To combat hypertension, we need a strategy to make sure that people who suffer from hypertension could control their blood pressure regularly and thus could prevent them to get further complication.8 In the era of technology, studies have proved the use of telemedicine could help patient with hypertension to better monitor their blood pressure compared to usual clinical care monitoring and thus keeping it controlled at the normal range8, recent study also shows it is more cost efficient since most of hypertension patient comes from middle-low class, so the usual care where the patient goes to the hospital is expensive in some countries.9 Here we performed a systematic review to compare the effectiveness between the use of telemedicine versus the usual care to monitoring patients with essential hypertension. This systematic review present some level data of SBP and DBP changes due to both intervention and its significancy. METHODS

This systematic review is based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and organized adhering to previously recommended guidelines for transparent and comprehensice reporting of methodology and result. Data Source and Search Strategy Three reviewers (M.A., J.H., R.J.) search this review using online search engineering with two database including PubMed and Science Direct. The keywords used during the search were “hypertension telemonitoring OR home blood pressure telemonitoring” AND “hypertensive OR hypertension OR high blood pressure” AND patient. Eligibility Criteria Eligible studies are randomized controlled trials (RCTs) that include patients with hypertension, which used BP telemonitoring or other telemedicine to monitor patients’ BP as the intervention, and change in SBP and/or DBP between intervention group and control group for evaluation. The control group receive either usual care or enhanced standard care for hypertension treatment. Only english literatures and last 5-years studies were reviewed for this study. Study Selection Journals are identified using keywords used during the search. After removing duplicates using Rayyan.ai program, three independent reviewers (M.A., J.H., R.J.) screened retrieved studies based on their title and abstracts. Studies without hypertension patients as their population, telemedicine as their method of intervention, and change in SBP and/or DBP as their parameter of outcome were excluded. Thereafter, potentially eligible full-text studies were thoroughly assessed using the eligibility criteria described above. Any emerging discrepancies will be resolved by consensus among the review team. Quality Assessment To evaluate the risk of bias in selection, performance, detection, attrition, and outcome reporting, this study utilizes Review Manager 5.4.1. Results are then classified into high, low, or unclear for risk of bias. Three authors (M.A., J.H., R.J.) evaluate the risk of bias independently and discuss together to form a summary. Data Extraction Data from each journal is collected and then inputted into a table. The following data is extracted from the included studies: 1) first author and publication year; 2) study design; 3) characteristics of participants (sample size and type, as well as age of participants); 4) intervention features; 5) duration of study; 6) control features; 7) assessment period; 8) change in BP between intervention group and control group.

RESULTS A preliminary search in electronic database yielded 1149 articles, 46 duplicate articles were removed. Then, authors read the title and abstract of remaining 1103 articles for preliminary screening, resulted in 213 eligible articles for futher analysis. Finally, author excluded 202 articles for neither published below range of 5 years, using RCTs as study design, using English language for their study, nor having complete data report. A total of 11 studies were included in the systematic review at last.10,11,20,12–19 Search flowchart and selection methods in this systematic review was summarized in Figure 1.

Figure 1. PRISMA flow chart of study selection

Characteristics of included studies Full details of each study are displayed in Table 1. Outcome data were available from 11 studies with randomized controlled trials (RCTs) with telemonitoring as their method of intervention, usual care as comparison, and change in BP between two groups as their outcome parameter. Mean sample ages ranged from 18 to 79 years. Subject included in those studies are patients with uncontrolled hypertension10,11,14,17,19,20, subjects with primary hypertension15,16, subjects with hypertension confirmed13,18, and subjects with uncomplicated hypertension.12 Total of participants included in those studies were 3690 participants (1684 participants as intervention group and 2006 participants as control group). Eight studies showed significant difference in BP change between telemonitoring intervention compared to usual care statistically using P-value data10–12,14–16,19,20, one study didn’t show significant difference statistically13, one study showed significant difference without P-value data18, and one study showed significant difference statistically at 6, 12, and 18 months post-intervention but not significant at 54 months follow-up.17 Risk of bias assessment Result from Review Manager 5.4.1 for risk of bias assessment are displayed in Figure 2A & Figure 2B. More than 75% of the studies clearly described the method used to generate random allocation sequence and allocation concealment. Less than 25% of the studies did blinding of participants and personnel as well as blinding of outcome assessment. About 10% of the studies deal with the incomplete outcome data, while none of the studies had reporting bias. As a summary, three studies had good quality10,15,20, six studies had moderate quality11,13,14,17–19, and two studies had low level of methodological quality.12,16

Figure 2. Quality assessment of RCTs. (A) Risk of bias graph: review of authors’ judgements regarding the risk of bias item presented as percentage for all included studies. (B) Risk of bias summary: review of authors’ judgements regarding the risk of bias for each included study.

This results indicate that the use of telemedicine tools in order to monitoring BP in patients with uncontrolled hypertension has shown to be effective in reducing BP which shows significant in almost all studies included (P<0.05).10–12,14–20 Home BP Telemonitoring Home BP telemonitoring intervention comprises of digitalized and automatic data transmission of BP from the patient's living place, such as home, to the physician or hospital thus BP measurements are stored in the device memory and then forwarded to a remote device host. Data transmission are encrypted to ensure data privacy and security.21 In the end, whole process results medical report being forwarded to the patient and refer the doctor in charge via the web page, email, or smartphone application.21 The home BP telemonitoring was reported to be used in all included studies with various advancements and methods. In 2019, one of them interestingly utilized WeChat, which commonly used as media social apps, study found that a WeChat-based self-management intervention would be suitable for primary hypertensive patients since the statistic analysis shows the significancy of BP reduction.16 Another utilization of newly mobile application was the SMASH App, this application could paired with the bluetooth of the SMASHers, SMASH user, thus they was to measure their BPs every three days and messages were sent to them as reminder every 3 days. As a results, this intervention compared to usual care was statistically significant (P<0.01).10 Meanwhile, rest of the studies, generally used the same method which implemented telehealth system that transmits the measurement readings to the e-medical record of the patient significantly improves the control of hypertension by P<.05.11–15,17–20 Self-monitoring of BP without Telemonitoring Self-monitoring of BP refers to those who measure their own BP, usually in a home based, that previously being hypothesized could improve BP control and as part of hypertension management.22 Only one study from our review that used the self-monitoring of BP without telemonitoring as intervention group, result found a lower SBP than those receiving treatment adjusted using clinic BP.18 Usual Care of BP Monitoring Usual care is the standardised care that is expected by targeted patient population would receive as part of the standar treatment and in these RCTs also represent the group of population who are not receiving the tested intervention, usually this care reflect locally current practices.23 The usual care term in these studies received the basic services such visit the healthcare facilities for measuring their BP, clinician followed up for future checks, and attend regular health seminar at the community health services. All of our study used usual care group as

comparison group to the telemedicine intervention, and interestingly almost all of the results shows the significant difference with P<.05.10–12,14–20 DISCUSSIONS The study that we reviewed are using randomized controlled trial (RCTs) design study which mostly compared between the BP control on telemedicine versus usual care hypertension management. The subjects are mostly consent toward the study and mostly are being intervened and being follow-up constantly. Telemedicine intervention that are being studied use various methods, such as using 3G network–equipped automatic sphygmomanometer that integrated with a certain website, medicine based application like SMASH application, and using social media application like WeChat. The control group mostly use usual care method which means the patient have to visit the physician in order to get feedback for their BP condition. Most of the study range from 4 weeks up to 12 months, and we find that all of the study show that the telemedicine group able to reach the therapeutic target that are classified based on clinical diagnosis of each study. Based on the paper, the reason that the use of telemedicine is able to reduced SBP and DBP better than the control group is because various factor, like the patient whose becoming more aware of their daily blood pressure and able to report to a group of doctors that are expert in their field, also they tend get earlier access to antihypertensive medication since the doctors can easily give them those medicine when the doctors received report from all of the provided platform that are used in the study. The result of our study find that telemedicine based program make significant difference in control of systolic blood pressure (SBP) and diastolic blood pressure (DBP) by P<.05. This is very promising to combat hypertension in the future. Not only that, other study also found that telemedicine is more cost efficient.9 This is a very good news considering one of the barriers of people, especially in the middle to lower class, is the cost of the treatment that is considerably high in usual care. Based on our findings, we believe that the application of telemedicine could be the future in combating hypertension. CONCLUSIONS In conclusion, we found that across 11 randomized controlled trials with total of 3690 participants, the implementation of home blood pressure telemonitoring significantly reduced the high blood pressure within certain date of follow-up compare with common modality, based on the reduction of blood pressure data and statistical analysis. It promisingly be an acceptable

and effective tool for rapid blood pressure control and its maintenance especially for patient with uncontrolled hypertension. CONFLICT OF INTEREST The authors declare that there were no competing interests in this study. REFERENCES 1.

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APPENDIX

Study

Subject

Study Design

Population (Intervention/ Control) Age (mean)

Intervention Type

Duration

Control Type

Baseline, 1, 3, 6, and 9 months after

Asses Period

Findings (mean SBP(mmHg), DBP(mmHg), and Significacy)

Table 1. Characteristics of included studies in the systematic review

Enchanced standard care

Baseline, 4, and 12 weeks after

9 months

Usual care (UC)

SMASH App

12 weeks

21 – 65 (46,5)

Digital medicine offering (DMO)

54 (26/28)

(58,7)

RCT

119 (80/29)

RCT

Hispanic adult with uncontrolled hypertension

Adults with uncontrolled hypertension

Chandler et al., 2019(10)

Frias et al., 2017(11)

Systolic (baseline: 152.3 vs 150.7 ; month 1: 125.3 vs 140.6 ; month 3: 120.4 vs. 137.5 ; month 6: 121.2 vs. 138.9, and month 9: 121.8 vs 145.7 Diastolic (baseline: 86.8 vs 84.6 ; month 1: 82.1 vs 78.3 ; month 3: 71.3 vs. 75.4 ; month 6: 74.7 vs. 77.5, and month 9: 74.2 vs 79.4 Difference compared to usual care was statistically significant (P<0.01).

Systolic DMO (mmhg) (baseline 4week : 152,2 ; Week 4-4 DMO : 130,7 ; Week 12-4 DMO : 135 ; baseline 12week 146,4; Week 4-12 DMO : 124,3 ; Week 12-12 DMO : 121,8) Systolic UC (mmhg) (baseline UC : 155,4 ; 4-week UC :142,7 ; 12-week UC : 140,2) Diastolic DMO (mmhg) (baseline 4week DMO : 90,5 ; Week 4-4 DMO : 80,4 ; Week 12-4 DMO : 82,6 ; baseline 12-week DMO : 82,0 ; Week 12-4 DMO : 74,2 ; Week 12-12 DMO : 72,8) Diastolic UC (mmhg) (baseline UC : 83,9 ; 4-week UC : 78 ; 12-week UC : 78,1) Difference compared to usual care was statistically significant (P<0.05).

RCT

356 (175/181)

Usual care (UC)

Baseline, 3 and 6 months after

Baseline and 3 months after

3 months

Usual care (UC)

Baseline and 6 months after

Usual care (UC)

BP telemonitoring and remote counselling (BPTM)

6 months

Usual care (UC)

3 months

18 – 78 (48)

Web-Based SelfTitration Program

6 months

55 - 64

20 – 79

WeChat-Based SelfManagement

TBPM (Telemonitoring of home BP measurements)

222 (111/111)

45 – 70 (61,5)

Hypertensive patients

Patients with uncontrolled hypertension

RCT

253 (110/143)

HoffmanPetersen et al., 2016(13)

Ionov et al., 2021(14)

Patients with primary hypertension

RCT

240 (160/80)

Kao et al., 2019(15)

Patients with primary hypertension

RCT

Li et al., 2019(16)

Daytime ABPM, systolic mean (mmhg) Baseline TBPM group : 151 ; Control group : 152 3 Months TBPM group : 142 ; Control group : 144 Daytime ABPM, diastolic mean (mmhg) Baseline TBPM group : 89 ; Control group : 90 3 Months TBPM group : 85 ; Control group : 86 Difference compared to usual care was statistically not significant (P>.05).

BPTM Group (mmHg) Baseline SBP : 157.5 ± 16.5 3 Months SBP : 134.0 ± 13.0 Baseline DBP : 94.4 ± 9.3 3 Months DBP : 80 ± 8 UC Group (mmHg) Baseline office SBP : 164.9 ± 27.3 3 Months office SBP : 156.2 ± 25.6 Baseline office DBP : 98,1 ± 13.1 3 Months office DBP : 91.2 ± 12.3 Difference compared to usual care was statistically significant (P<0.05). Systolic BP (mmHg) Intervention group: 143; 127; 123 Control group: 143; 149; 151 Diastolic BP (mmHg) Intervention group: 84; 77; 75 Control group: 84; 82; 84 Difference compared to usual care was statistically significant (P<0.01). Intervention Group (mmHg) Baseline SBP : 135,8 3 Months SBP : 130,5 Baseline DBP : 83,0 3 Months DBP : 81,9 UC Group (mmHg) Baseline SBP : 135,2

1173 (393/391/389)

450 (228/222)

RCT

Hypertensive patients

622 (305/317)

McManus et al., 2018(18)

RCT

Patients with uncontrolled hypertension

Margolis et al., 2018(17)

McManus et al., 2021(19)

Self-monitoring, with and without telemonitoring

Telemonitoring

60 – 62

18 (66)

Self-monitoring of BP with

Baseline, 6, and 12 months after

54 months

Usual care (UC)

Baseline, 6, 12, 18, and 54 months after

12 months

Baseline, 6, and 12 months after

Usual Care (UC)

12 months

Usual care (UC)

3 Months SBP : 136,8 Baseline DBP : 81,1 3 Months DBP : 83,1 Difference compared to usual care was statistically significant (P<0.05).

Systolic BP (mean, mmHg) Telemonitoring group Baseline : 148,2 6 mo : 126,7 ; 12 mo : 125,7 ; 18 mo : 126,9 ; 54 mo : 130,6 UC group Baseline : 147,7 ; 6 mo : 136,9 ; 12 mo : 134,8 ; 18 mo : 133,0 ; 54 mo : 132,6 Diastolic BP (mean,mmhg) Telemonitoring group Baseline : 84,4 ; 6 mo : 75,0 ; 12 mo : 75,1 ; 18 mo : 75,1 ; 54 mo : 77,5 UC group Baseline : 85,1 ; 6 mo : 81,7 ; 12 mo : 80,8 ; 18 mo : 78,7 ; 54 mo : 79,1

Difference compared to usual care was statistically significant (P<0.05) at 6, 12, and 18 months. But not significant at 54 months follow-up (P>.05) Systolic BP (mmHg) Telemonitoring group: 153,2 ; 139,0 ; 136, 0 Self-monitoring group: 152,9 ; 140,4 ; 137,0 Usual care group: 153,1 ; 142,5 ; 140,4 Diastolic BP (mmHg) Telemonitoring group: 85,5 ; 79,8 ; 78,7 Self-monitoring group: 85,1 ; 80,3 ; 77,8 Usual care group: 86,0 ; 81,1 ; 79,9 Difference compared to usual care was significant (no P-value data) Systolic BP (mm Hg) Usual care: 151.6; 140.9; 141.8 Intervention: 151.7; 138.7; 138.4 Diastolic BP (mm Hg)

11.

Pan et al., 2018(20)

Yatabe et al., 2021(12)

Hypertensive patients with uncontrolled high BP

Patients with uncomplicated hypertension

RCT

107 (52/55)

94 (48/46)

35 – 75

>20

a digital intervention

Home telemonitoring for BP

Telemedicine

3 months

12 months

Usual Care (UC)

Baseline, 30, 90, and 180 days

Baseline and last week of the 12 month period

Usual care: 85.3; 80.2; 79.8 Intervention: 86.4; 79.9; 80.2 Difference compared to usual care was statistically significant (P<0.05) Systolic BP (mm Hg) Usual care: 147,9; 141,7; 138,7; 138,1 Intervention: 148,3; 134.1; 132.2; 131,9 Diastolic BP (mm Hg) Usual care: 87,0; 81,4; 80,9; 82,6 Intervention: 88,0; 82,6; 78,5; 80,6 Difference compared to usual care was statistically significant (P<0.05)

Home systolic BP (mmHg) Usual care group: 136 ; 131 Telemedicine group: 136 ; 125 Home diastolic BP (mmHg) Usual care group: 91 ; 87 Telemedicine group: 90 ; 83 Difference compared to usual care was statistically significant (P<0.05)