Decentralization of Care: What Role Does Remote Patient Monitoring Play?
Bijan Nafafi, PhD, began his discussion by sharing a study that found that individuals who live more than 50 miles from an experienced hospital have a higher likelihood of amputation.1 Statistics like this, he said, are leading to a movement to decentralize the health care model away from the traditional hospital and more towards a patient-centered/home-centered point of view. Dr. Najafi shared that technology plays a role in implementation of such a model, including concepts like telehealth, smart hospital referral, empowerment of home care nurses, mobile care services, and “smart home” devices. He added that this will benefit from a multidisciplinary approach.
He then discussed the 2023 Phillips Future Health Index Report, which stated that 40 percent of hospitals are expected to shift 20 percent of beds to patients’ homes by 2025.2 Additionally, 60 percent of patients find virtual care more convenient, and 80 percent of patients are willing to seek care for minor illnesses at retail clinics. Dr. Najafi urged clinicians to be ready.
In a 2021 publication with Mishra, Dr. Najafi outlined the pathway to a decentralized care model for diabetic foot syndrome.3 He said this includes examining practices for triage, patient empowerment, and remote care. In triage, one should consider both prevention and intervention points of view. Traditionally, he pointed out, stratification of visit frequency is based on risk level; however, what if something happens between those prescribed visits? Leveraging remote patient monitoring may allow for continuous monitoring of risk factors and smarter referrals.
The key question then becomes, said Dr. Najafi, what can we measure easily and reliably through technology, and what is actionable? He presented the idea of digital biomarkers that one can measure by things like watches, furniture, or socks. In 1975, Bergholdt and Brand4 asserted that “wounds heat up before they break down,” leading to temperature being a key metric to assess. In 2007, Lavery and team advocated for capturing inflammation, and since some of the cardinal signs of inflammation are difficult to measure, temperature monitoring provides a promising option.5
Over the past several decades, research has shown a nearly 10-fold reduction in incidence of diabetic foot ulcer when using temperature monitoring.5,6 However, Dr. Najafi noted there was some challenges associated with the simplicity of the process. He pointed out that the color of the device mattered to patients, the time necessary for use, and if the patient had access to WiFi.
Frykberg and team in 2017 looked at a temperature monitoring mat and found that its use led to a lead time prediction of diabetic foot ulcer of 37 +/- 18 days, with 97 percent sensitivity.7 Although specificity was low at 43 percent, Dr. Najafi pointed out that even a false alert to the patient had value, as it reinforced that the system was doing something for the patient.
Dr. Najafi went on to discuss even more data on remote monitoring, diving into offloading evidence, gamification of exercise and personalizing patient care. Be sure to read Podiatry Today’s January 2024 Diabetes Watch for more details on the latter part of Dr. Najafi’s presentation at Great Debates and Updates in Diabetic Foot 2023.
References
1. Barshes NR, Uribe-Gomez A, Sharath SE, Mills JL Sr, Rogers SO Jr. Leg amputations among Texans remote from experienced surgical care. J Surg Res. 2020;250:232-238.
2. Future Health Index 2023. Accessed December 1, 2023.
3. Najafi B, Mishra R. Harnessing digital health technologies to remotely manage diabetic foot syndrome: a narrative review. Medicina (Kaunas). 2021 Apr;57(4):377.
4. Bergtholdt HT, Brand PW (1975). Thermography: an aid in the management of insensitive feet and stumps. Arch Phys Med Rehabil. 1975;56:205-209.
5. Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007;30(1):14-20.
6. Armstrong DG, Lavery LA, Liswood PJ, Todd WF, Tredwell JA. Infrared dermal thermometry for the high-risk diabetic foot. Phys Ther. 1997;77(2):169-175; discussion 176-7.
7. Frykberg RG, Gordon IL, Reyzelman AM, et al. Feasibility and efficacy of a smart mat technology to predict development of diabetic plantar ulcers. Diabetes Care. 2017;40(7):973-980.
