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Heart failure disease management programmes are now well established and their role in facilitating self care and improving outcome is recognised in international guidelines.1 Despite this, only 20% of patients in the UK are offered specialist follow-up on hospital discharge,2 and it is unclear how many patients actually enter such management programmes.
Heart failure typically affects the elderly and very elderly, and their limited mobility and lack of social support may make hospital clinic attendance problematic. Home visits may bridge this gap, but are costly in terms of travel time for the health professional, thus limiting the case load that a specialist heart failure nurse can take on.
Health care resources are therefore often unable to match the demands of recommended optimal care in heart failure. This problem is set to increase as the world population ages at an unprecedented rate. In response, policymakers have promoted the use of telehealth (“health care at a distance”), with the aim of widening access to high quality care and providing such care closer to home. As part of this broader concept of telehealth, telemonitoring has the potential to extend the reach of heart failure management programmes and provide care at a time and place more convenient to the patient.
What is telemonitoring?
Remote monitoring using telephone support or patient initiated electronic monitoring has developed rapidly in the past 10 years, and can take many forms. There are key differences between the models: telephone support relies upon the patient’s interpretation of signs and symptoms and reporting of these during structured telephone contact, while patient initiated electronic monitoring (telemonitoring) transfers physiological data from the patient in their home to the health care provider.
More recently, data from implanted devices, such as from a pacemaker or defibrillator, can also be monitored remotely, often without the need for a patient to trigger the transmission of data.
This article focuses on remote monitoring using equipment external to the patient in order to facilitate the earlier detection of clinical deterioration and better disease management.
The rationale for telemonitoring
Telemonitoring uses remote electronic monitoring, with geographical distance separating the patient and professional—at least during the initial monitoring, assessment and intervention. It enables more frequent (usually daily) assessment of clinical parameters than is possible in conventional practice.
Retrospective studies suggest that a patient typically notices change to their symptoms for several days before seeking help.3 There are many reasons for this delay including the complex interplay between patients’ knowledge, health beliefs, family support, and their past experience of health care.
The premise for telemonitoring is that frequent monitoring by a health professional may enable earlier intervention to treat deterioration in the level of control of heart failure. Such intervention may take several forms: reminders about lifestyle and diet, advice to alter medication, recall for early clinic review, a home visit, or urgent hospitalisation. In addition, the telephone contact with the patient resulting from the abnormal telemonitoring data provides feedback that may assist the patient to relate their feelings of breathlessness or fatigue with their vital signs and any recent activity. In this way their understanding of heart failure increases, as does their confidence in identifying appropriate actions to avert or manage any symptoms.
Although telemonitoring has predominantly been used for the early detection of clinical deterioration, it can also be used to ensure more efficient up-titration of drug treatment, such as angiotensin converting enzyme (ACE) inhibitors or β-blockers.
What can be monitored?
External telemonitoring units enable a range of clinical measurements to be monitored. Consideration needs to be given to the balance of accurate patient assessment without overburdening the patient. Equally important, the collection of excessive amounts of physiological data will overcomplicate the process of deciding when or if action is required. This is often a problem in the early phase of the introduction of telemonitoring to a clinical service.
In conventional practice, patients are taught to monitor weight and symptoms or signs of fluid overload as part of self care.1 These measurements can easily be made remotely, alongside blood pressure and heart rate (fig 1). Questions commonly asked during patient assessment can often be included in telemonitoring systems. For example, to the question “did you sleep with extra pillows last night” the patient can answer using a “yes/no” response button.
Where studies have reported health care professionals’ actions as a result of monitoring data, the most frequent response relates to volume overload presenting as dyspnoea or weight gain.4 5 In the absence of clear guidance, it seems appropriate to consider monitoring weight alongside key disease related symptoms as the minimum dataset.
The privacy and security of personal data are of concern to patients and to regulators. It is important that the daily monitoring data are encrypted before being transferred through the normal home telephone line or other connection to the monitoring “base” station at the hospital or clinic. Such a station should also be secure, with access restricted to those with a legitimate interest in the data and the patient’s management.
Triage of remotely collected data
The remotely transmitted data are typically compared against preset “limits”, often tailored to the patient’s physiology. Initial response to data that may represent clinical deterioration (such as increase in weight or symptoms) is usually telephone advice from a trained heart failure healthcare professional, often a specialist nurse. Only when the patient’s condition cannot be resolved remotely through telephone advice about medication or lifestyle is early review or a planned hospital admission necessary. In some North American settings, the initial triage of data occurs at a call centre, with contact with the patient’s usual healthcare provider only if required.
Where the likely cause of change in condition is non-heart failure related then referral should be made to the appropriate medical service, such as the primary care physician.
In our experience only a small proportion of the telemonitoring data requires a response and the majority of this can be responded to remotely. In the Home-HF study, a randomised trial of home telemonitoring in West London, UK, only 64% of the monitored patients had telemonitoring data-triggered contact that required triage in the 6 month period after discharge from hospital. This was an average of one phone call to a patient each month during the first 3 months of monitoring. In only 19% of occasions was an early review in secondary care necessary6 (fig 2).
What is the clinical benefit of telemonitoring?
Despite growing interest in telemonitoring in heart failure, and a growing number of service providers, there is no clear guidance on its use. The evidence base remains relatively modest, although an increasing number of randomised trials assessing clinical and cost effectiveness have been reported. International guidelines indicate the developments in this area, but do not provide clear guidance on the role of this technology.1
Early studies of telemonitoring were observational, with before-and-after comparisons potentially inflating the estimates of clinical effectiveness.4 5 7 More recently, several randomised trials have been conducted in a variety of healthcare settings. A meta-analysis of data from five randomised trials, with a total of around 800 patients, reported a 38% reduction in all cause mortality (95% confidence interval (CI) 15% to 55%; p = 0.03) (fig 3). In addition, there was a statistically non-significant trend towards a reduction in all cause hospitalisation. While considerable clinical heterogeneity exists between the studies there is statistical homogeneity between the results.8
Two of the largest randomised trials comparing telemonitoring with usual care provide important insights into the potential benefits of this technology.
The Weight Monitoring in Heart Failure (WHARF) study,9 a multicentre study undertaken in the USA, randomised 280 patients with a mean age of 59 years to daily telemonitoring of weight and symptoms or standard, cardiologist led care. All patients had severe left ventricular (LV) systolic dysfunction (LV ejection fraction (LVEF) ⩽35%) and were in New York Heart Association (NYHA) functional classes III (75%) and IV (25%) at time of entry into the study. Despite no difference in the primary end point of all cause readmission rate, during 6 months follow-up they demonstrated a trend towards an increased time to rehospitalisation with telemonitoring. This study also reported a 60% (95% CI 8% to 82%) relative risk reduction in the secondary end point of mortality (p<0.03).
The Trans-European Network-Home-Care Management System (TEN-HMS) study10 randomised 426 patients (mean age 67 years) with LV systolic dysfunction (LVEF <40%) and in NYHA II–IV (class II 64%, III 27%, IV, 7%). The study recruited patients from 16 hospitals in the UK, Netherlands and Germany. The telemonitoring was more complex than in the WHARF Study, with monitoring of ECG and blood pressure, in addition to weight. They reported a modest, but statistically non-significant, reduction in heart failure related hospitalisation and a reduction in the average length of stay for such admissions. Although not a primary outcome, a statistically significant reduction in mortality between the telemonitoring group and usual care resulted in the study being halted early. A greater number of patients were ultimately on optimal drug treatment for heart failure in the telemonitored group than in the control group.
There are therefore data from high quality randomised trials in both North America and Europe that suggest telemonitoring can reduce mortality in heart failure patients, albeit those with relatively severe symptoms, systolic dysfunction, and perhaps 10 years younger than the typical patient with heart failure.
More recently, we have reported the result of an additional randomised trial of home telemonitoring (Home-HF)6 in a typical elderly heart failure population (mean age 71 years, 45% >75 years), which included those with either preserved or impaired LV systolic function. We compared 6 months of daily telemonitoring with specialist heart failure care in 182 patients discharged from three district hospitals in west London, UK. We found no difference in the primary outcome of all cause hospitalisation, but we demonstrated a significant decrease in the proportion of hospitalisations for heart failure that were an emergency (usual care 13/16 (81%) vs telemonitoring 8/22 (36%); p = 0.01). Alongside this we noted a reduction in the number of emergency room attendances and secondary care clinic visits with telemonitoring. The study was not powered to detect (and did not find) a difference in overall mortality.
Taken together, these randomised studies demonstrate that telemonitoring has the potential to reduce mortality compared to conventional “usual” care in advanced heart failure. This technology can enable specialist services to care for more patients, with greater scheduling of care and consequent reduction in emergency room visits and urgent hospital admissions.
Important questions remain about the optimal model of monitoring, and the patients most likely to benefit.
What is the cost of telemonitoring?
Despite the inclusion of cost savings as a political rationale for telecare, there are few reports of the cost of telemonitoring. Where studies do report this it varies considerably according to the components of both “usual” care and telemonitoring, and the healthcare setting.6 11
Our own experience of telemonitoring in the Home-HF Study suggests a mean incremental cost of approximately £1600 (€1800, US$2600) per patient for a period of 6 months’ telemonitoring, although the overall costs were not statistically significantly different between the telemonitoring and usual care arms of the study.6
Where an infrastructure already exists to support telemonitoring the incremental cost will decrease. Identifying the optimum time period and most useful parameters for monitoring may decrease this cost further.
Cost alone is unlikely to be the primary driver in the delivery of heart failure care using telemonitoring—the driver will be the desire to meet the need for monitoring of a rapidly increasing number of people with heart failure without a large expansion in the number of healthcare professionals.
What do patients think of telemonitoring?
Patients with heart failure indicate that a major issue in their care is the need for better access to specialist advice, including an identified contact for support who is familiar with their medical condition.12 13 This wish can be at least partially addressed through telemonitoring, which both directly and indirectly increases contact with the health professional, and leaves the patient and their family less isolated. When help is sought the professional has easy access to up-to-date clinical information upon which to base their advice. In addition, the patient gains confidence that if there is a medical problem the healthcare professional is likely to contact them, rather than the other way around.
Despite concern about the feasibility of home based technology to monitor chronic conditions, particularly in the elderly, patients generally find the equipment easy to use with studies reporting more than 80% usage6 10 Our experience suggests that this is consistent regardless of age, gender or ethnicity.
Familiarity with information and computer technology through mobile phones and everyday household appliances means that patients are not necessarily daunted by equipment, particularly if it is designed with their needs and potential disabilities in mind. In most developed countries access to a telephone line is almost universal and does not often limit the introduction of home telemonitoring.
The practicalities of telemonitoring
International guidelines for heart failure care suggest early face-to-face follow-up following a hospitalisation, education to facilitate self care, and ongoing support from a multiprofessional team that is responsive to the patient’s need.1 The highest risk period for rehospitalisation is in the first few weeks after discharge from hospital. Telemonitoring should therefore be installed and the patient instructed in its use as soon as possible following hospital discharge.
The optimum time period for telemonitoring is unclear. The follow-up in telemonitoring studies has ranged from 90 days to more than 12 months10 11 while managed care organisations in the USA largely use telemonitoring for the first 30 days following discharge home. It is our experience that the greatest amount of telemonitoring data outside preset parameters occurs during the first 90 days of monitoring, reducing by around 50% over subsequent months. However, it is particularly during these latter months that the telemonitoring supports patients to understand more about their heart failure and the actions required for self care. As evidence accumulates it is likely that services will provide telemonitoring for at least 6 months following discharge home with its usefulness evaluated at 30 day intervals thereafter.
International guidelines for the use of telemonitoring in heart failure have not yet been developed. In their absence it is likely that the heart failure nurse will remain central to the success of this new approach to care, triaging and responding to the data and maintaining contact with the lead clinician for heart failure. In some countries the nurse is also able to prescribe medications, although policies vary between countries. While telemonitoring promises accurate patient monitoring and management, it also relies upon the confidence and ability of the health professional to interpret and use the information. There is likely to be a steep learning curve associated with handling increased amounts of information regarding physiological parameters without visual cues from a face-to-face contact.
Preventing over-dependence on the healthcare professional
Similarly to regular heart failure nurse follow-up, telemonitoring may lead to the patient becoming too dependent on this close professional link, with a reduction in self care and increased anxiety. This can be avoided through managing patients’ expectations, with a clearly defined time period for monitoring and regular review of the need for such monitoring. The confidence and skills gained by the patient during the monitoring period should prepare them for removal of the equipment when it is no longer required.
Telemonitoring in heart failure: key points
Telemonitoring is the process of remote monitoring of clinical status.
Several randomised trials have reported clinical benefit of telemonitoring for patients with heart failure.
Telemonitoring is acceptable and easy to use by patients of all ages.
Close collaboration between professionals involved in management decisions is essential.
Telemonitoring is likely to become part of a modern heart failure management programme.
Organisation of services
Heart failure disease management services, while designed to provide follow-up following hospital discharge, have primarily been led by secondary care. So too have studies of telemonitoring. Such models potentially strengthen the relationship between the patient and the secondary care based specialist, perhaps at the expense of the primary care team. Patients with heart failure are generally elderly with multiple comorbid conditions. They are likely to be under the care of a number of health care professionals simultaneously, and can become confused when they receive care from this broad range of practitioners.
The successful introduction of telemonitoring is likely to depend on a functional multidisciplinary team, with the heart failure nurse playing a pivotal role in patient assessment, triage and management. Ensuring close collaboration between all agencies involved when action is appropriate is likely to be more important than whether the initial triage of data is undertaken in primary or secondary care or even outsourced to a call centre.
However, it is important not to underestimate the impact telemonitoring has on traditional working practices. There is no evidence that telemonitoring consumes more of the health professional’s time than traditional disease management programmes, but the workload is perhaps less predictable and may require working outside the “usual” business hours. Rather than “routine” face-to-face visits, earlier detection of deterioration results in time spent resolving an issue at the point of detection.
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Our experience is that <6% of telemonitoring data require a telephone call for patient assessment and that the majority of this contact occurs in the first 3 months following hospital discharge. This suggests that telemonitoring is likely to increase substantially the number of patients that can be monitored by a specialist heart failure service.
With an increasingly elderly population living with heart failure, the need for high quality disease management programmes to “reach out” to patients in their normal living environment is set to increase dramatically. Telemonitoring offers the opportunity to provide a modern approach to the monitoring of such patients. It enables the patient and professional to adopt a proactive approach to recognising problems and resolving issues together, and reduces unnecessary travel to the hospital. It ensures the patient has close contact with someone who knows their current health status, provides ready access to specialist help and scheduled hospital admission when needed. The benefits extend beyond the early detection of clinical deterioration to optimising medication and facilitating education for self care.
Many questions remain unanswered—such as which patients benefit most, and how long to continue monitoring—but the evidence is accumulating that telemonitoring can reduce mortality and improve access to health care for patients with heart failure, and should be part of the modern multidisciplinary heart failure service.
▸ Updated European guidance for heart failure management developed in collaboration with the Heart Failure Association of the European Society of Cardiology.
▸ A comprehensive meta-analysis of remote monitoring versus usual care.
▸ A landmark multicentre randomised study with three arms: home telemonitoring, telephone support and usual care.
▸ A study of the patients’ view of traditional heart failure care.
Competing interests In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. The authors have no competing interests.
Provenance and peer review Commissioned; not externally peer reviewed.
Patient consent Obtained
▸ Additional references are published online only at http://heart.bmj.com/content/vol95/issue23
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