Darshan Brahmbhatt, Attending in Cardiology and Heart Failure at Mount Sinai Hospital, has an interest in heart failure innovations and remote monitoring. He was awarded a 2021 TRANSFORM HF Trainee Award when he was a Clinical Fellow in Heart Failure and Cardiac Transplantation at the Peter Munk Cardiac Centre for his project “Remote monitoring of patients with LVADs: A safety and feasibility study,” co-supervised by Drs. Phyllis Billia and Emily Seto.
As Darshan’s time as a TRANSFORM HF Trainee comes to a close, we sat down with him to talk about his research over the past year and where he sees the field of digital health heading.
What research did you complete as a TRANSFORM HF Trainee? How did the network support you?
My first project, and the main reason for my funding, was to evaluate how well we could look after patients with mechanical heart support through digital health and through remote monitoring. Never before had this been done. The COVID-19 pandemic provided an opportunity – not one we really wanted – to look after these patients using telehealth. And we were just trying to assess how well we could do it and whether it was safe and effective. We felt it was, but feelings alone are just not good enough, especially when you have complex patients with complicated care needs who are sometimes 1,000 km away from downtown Toronto. The preliminary results look as though it is safe, it is effective, and provides a model for us to expand the care of these patients.
What did TRANSFORM help with? It helped me get connections with different members of the team. So, clinicians, I had lots around me. But working together with people who do health technology assessment, and particularly some of our engineering colleagues, and the collaboration with the Institute of Health Policy, Management and Evaluation at the University of Toronto alongside my base at UHN – that was phenomenal.
The second thing that TRANSFORM was really good at helping me understand was just how much inequity there is, and how that affects our patients’ outcomes. I had always been thinking, “We need a better medicine, we need another medicine – one that is 5% better or 10% better.” But actually, the whole context of delivering care and the collaboration with patients, the collaboration with Indigenous populations, has shown me how inequity can really skew what’s available to patients just based on geography, income, education, digital access – all of these factors which I hadn’t really appreciated before. TRANSFORM really been helpful for my development in understanding those fields.
A key focus of TRANSFORM HF’s Trainee Awards is the translational aspect of research activities. Can you comment on how your research may be translated into practice?
Very few technologies currently exist for patients with LVAD. They’re a small population of patients, and it’s not necessarily commercially lucrative for companies to be chasing this market. So, the amount of work that has been previously done in this space is very little. In fact, our proposition paper came out to much fanfare because we were the first ones who suggested this should be done. Again, there is only one other study that has been done in the same timeframe, and that was again in North America
The lessons that were learned, particularly the framework around how we can implement remote monitoring of these patients, is going to be key to moving forward. Our aim is to actually take this to the International Society of Heart Lung Transplantation to put forward a framework of what you need to do, what bits need to be included, what should technology involve, how do you train patients and caregivers alongside clinicians and the hospital staff in using this. Hopefully we will essentially have a “How to Manual.”
You’re clearly very passionate about this field! What excites you most about digital innovation for heart failure care?
That’s difficult! There are so many to choose from…
I think what excites me the most is that we’ve transitioned from just looking at what’s effective in terms of a clinical trial sense and how we can then actually use digital health to implement those findings for all patients.
An example in cancer care from back in the UK was that the government decreed that no one would wait more than two weeks from suspicion of cancer by a doctor to being assessed, and then a further two weeks until a final diagnosis. That’s great! But the problem was that none of the patients were getting through the front door because they weren’t educated about what symptoms of cancer they should look out for. In this same way, patients were having heart attack but not knowing they were having heart attacks. The systems of care inside hospitals are great, but they hadn’t necessarily been built with patient access in mind – only patient outcomes.
The whole idea of digital technology is that we can flatten the barriers that exist to accessing care. People who work during the daytime when our clinics run may not have the opportunity to spend three to five hours coming to central Toronto, paying $25-30 for parking, and giving up a day’s income to be assessed. Well, digital health technologies can perhaps bridge that, reduce the frequency with which we need to do that.
The second thing that really excites me is getting away from fixed patterns of follow-up. When I started training, I was told: “See when the patient was last seen and double it – If you saw them two weeks go, see them in four weeks; if you saw them four weeks ago, see them in two months. Two months, go to three-four months. Six months, a year. And after a year, you can get them back to their family doctor.” When we do that, we spend a lot of time getting patients to come see us in clinic.
Hopefully we can move away from low-quality, high volume routine care and actually use digital technologies to provide that level of surveillance, so we can free up time and focus our energies more on the patients who are deteriorating. If we can highlight those patients, find them, and then bring them in for longer in-person assessments, I think that will be a paradigm change that is really key. But if we could do that using technology, that would give patients the reassurance that they are still being cared for, because we are still looking after them, but it’s lighter touch. I think that’s the ultimate goal.
What do you enjoy most about being a part of the TRANSFORM HF network?
I think it’s the people I’ve met. It’s given me exposure and access to different groups of people that I wouldn’t normally get the opportunity to interact with. I think that’s one of the tenets of TRANSFORM HF – bringing together like-minded individuals from very different experiences, whether it’s our patient partners, whether its those with lived experience, whether it’s engineers, whether it’s our bio scientists.
At our first in-person event, I met lots of very interesting people who we started talking to, we started collaborating with. One of the summer students we’ve had working in our lab comes from a completely different background, aerospace engineering! And has now learned machine learning and artificial intelligence methods to try and help us understand how we can predict deterioration of heart failure patients. That’s only happened because of TRANSFORM HF.
Sure, the funding was important, but more the bringing like-minded individuals together, getting ideas critiqued by people who are in a different field to yourself, and actually using that as a mode to develop has been amazing.
I think that’s what the secret sauce of TRANSFORM HF really is – getting the right people in the room at the same time.
What’s next for you?
I’ve been a trainee for a long time, and I successfully defended my PhD along the way and had my corrections fixed last month, so should hopefully finally get the degree awarded. The postdoctoral work I am doing I will continue, particularly around the advanced heart failure space – that is where my clinical interest is and where my research interest is. I recently started working at Mount Sinai Hospital and am doing some attending work there whilst doing my research at UHN. Hopefully that will lead to more opportunities for a substantive position as an academic cardiologist.
In addition to important contributions to the fields of cardiovascular care and digital health, Darshan has given much to the TRANSFORM HF network during his time as a Trainee. Darshan, we wish you the best of luck as you continue your work, and thank you very much for your continued enthusiasm and energy!