Use of home telemonitoring to support multidisciplinary care of heart failure patients in Finland: randomized controlled trial

Anna-Leena Vuorinen, Juha Leppänen, Hannu Kaijanranta, Minna Kulju, Tiina Heliö, Mark van Gils, Jaakko Lähteenmäki, Anna-Leena Vuorinen, Juha Leppänen, Hannu Kaijanranta, Minna Kulju, Tiina Heliö, Mark van Gils, Jaakko Lähteenmäki

Abstract

Background: Heart failure (HF) patients suffer from frequent and repeated hospitalizations, causing a substantial economic burden on society. Hospitalizations can be reduced considerably by better compliance with self-care. Home telemonitoring has the potential to boost patients' compliance with self-care, although the results are still contradictory.

Objective: A randomized controlled trial was conducted in order to study whether the multidisciplinary care of heart failure patients promoted with telemonitoring leads to decreased HF-related hospitalization.

Methods: HF patients were eligible whose left ventricular ejection fraction was lower than 35%, NYHA functional class ≥2, and who needed regular follow-up. Patients in the telemonitoring group (n=47) measured their body weight, blood pressure, and pulse and answered symptom-related questions on a weekly basis, reporting their values to the heart failure nurse using a mobile phone app. The heart failure nurse followed the status of patients weekly and if necessary contacted the patient. The primary outcome was the number of HF-related hospital days. Control patients (n=47) received multidisciplinary treatment according to standard practices. Patients' clinical status, use of health care resources, adherence, and user experience from the patients' and the health care professionals' perspective were studied.

Results: Adherence, calculated as a proportion of weekly submitted self-measurements, was close to 90%. No difference was found in the number of HF-related hospital days (incidence rate ratio [IRR]=0.812, P=.351), which was the primary outcome. The intervention group used more health care resources: they paid an increased number of visits to the nurse (IRR=1.73, P<.001), spent more time at the nurse reception (mean difference of 48.7 minutes, P<.001), and there was a greater number of telephone contacts between the nurse and intervention patients (IRR=3.82, P<.001 for nurse-induced contacts and IRR=1.63, P=.049 for patient-induced contacts). There were no statistically significant differences in patients' clinical health status or in their self-care behavior. The technology received excellent feedback from the patient and professional side with a high adherence rate throughout the study.

Conclusions: Home telemonitoring did not reduce the number of patients' HF-related hospital days and did not improve the patients' clinical condition. Patients in the telemonitoring group contacted the Cardiology Outpatient Clinic more frequently, and on this way increased the use of health care resources.

Trial registration: Clinicaltrials.gov NCT01759368; https://ichgcp.net/clinical-trials-registry/NCT01759368 (Archived by WebCite at http://www.webcitation.org/6UFxiCk8Z).

Keywords: EHFSBS; clinical outcomes; health care resources; heart failure; hospitalization; telemonitoring; user experience.

Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
Overall architecture for remote patient monitoring.
Figure 2
Figure 2
Screenshots of the reporting process with the mobile app.
Figure 3
Figure 3
Screening, randomization, and follow-up of patients.

References

    1. McMurray JJV, Stewart S. The burden of heart failure. Eur Heart J Suppl. 2002;4(suppleD):307–333.
    1. Lang CC, Mancini DM. Non-cardiac comorbidities in chronic heart failure. Heart. 2007 Jun;93(6):665–71. doi: 10.1136/hrt.2005.068296.
    1. Chen J, Normand SL, Wang Y, Krumholz HM. National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998-2008. JAMA. 2011 Oct 19;306(15):1669–78. doi: 10.1001/jama.2011.1474.
    1. Krumholz HM, Merrill AR, Schone EM, Schreiner GC, Chen J, Bradley EH, Wang Y, Wang Y, Lin Z, Straube BM, Rapp MT, Normand SL, Drye EE. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009 Sep;2(5):407–13. doi: 10.1161/CIRCOUTCOMES.109.883256.
    1. Desai AS, Stevenson LW. Rehospitalization for heart failure: predict or prevent? Circulation. 2012 Jul 24;126(4):501–6. doi: 10.1161/CIRCULATIONAHA.112.125435.
    1. Stewart S. Financial aspects of heart failure programs of care. Eur J Heart Fail. 2005 Mar 16;7(3):423–8. doi: 10.1016/j.ejheart.2005.01.001.
    1. Stewart S, MacIntyre K, Hole DJ, Capewell S, McMurray JJ. More 'malignant' than cancer? Five-year survival following a first admission for heart failure. Eur J Heart Fail. 2001 Jun;3(3):315–22.
    1. McAlister FA, Stewart S, Ferrua S, McMurray JJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004 Aug 18;44(4):810–9. doi: 10.1016/j.jacc.2004.05.055.
    1. van der Wal MH, Jaarsma T, van Veldhuisen DJ. Non-compliance in patients with heart failure; how can we manage it? Eur J Heart Fail. 2005 Jan;7(1):5–17. doi: 10.1016/j.ejheart.2004.04.007.
    1. Michalsen A, König G, Thimme W. Preventable causative factors leading to hospital admission with decompensated heart failure. Heart. 1998 Nov;80(5):437–41.
    1. Klersy C, De Silvestri A, Gabutti G, Regoli F, Auricchio A. A meta-analysis of remote monitoring of heart failure patients. J Am Coll Cardiol. 2009 Oct 27;54(18):1683–94. doi: 10.1016/j.jacc.2009.08.017.
    1. Inglis SC, Clark RA, McAlister FA, Stewart S, Cleland JG. Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: Abridged Cochrane Review. Eur J Heart Fail. 2011 Sep;13(9):1028–40. doi: 10.1093/eurjhf/hfr039.
    1. Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JG. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010;(8):CD007228. doi: 10.1002/14651858.CD007228.pub2.
    1. Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, Phillips CO, Hodshon BV, Cooper LS, Krumholz HM. Telemonitoring in patients with heart failure. N Engl J Med. 2010 Dec 9;363(24):2301–9. doi: 10.1056/NEJMoa1010029.
    1. Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Böhm M, Boll H, Baumann G, Honold M, Koehler K, Gelbrich G, Kirwan BA, Anker SD, Telemedical Interventional Monitoring in Heart Failure Investigators Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation. 2011 May 3;123(17):1873–80. doi: 10.1161/CIRCULATIONAHA.111.018473.
    1. Cleland JG, Louis AA, Rigby AS, Janssens U, Balk AH, TEN-HMS Investigators Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the Trans-European Network-Home-Care Management System (TEN-HMS) study. J Am Coll Cardiol. 2005 May 17;45(10):1654–64. doi: 10.1016/j.jacc.2005.01.050.
    1. Mortara A, Pinna GD, Johnson P, Maestri R, Capomolla S, La Rovere MT, Ponikowski P, Tavazzi L, Sleight P, Investigators HHH. Home telemonitoring in heart failure patients: the HHH study (Home or Hospital in Heart Failure) Eur J Heart Fail. 2009 Mar;11(3):312–8. doi: 10.1093/eurjhf/hfp022.
    1. Takahashi PY, Pecina JL, Upatising B, Chaudhry R, Shah ND, Van Houten H, Cha S, Croghan I, Naessens JM, Hanson GJ. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med. 2012 May 28;172(10):773–9. doi: 10.1001/archinternmed.2012.256.
    1. Wade MJ, Desai AS, Spettell CM, Snyder AD, McGowan-Stackewicz V, Kummer PJ, Maccoy MC, Krakauer RS. Telemonitoring with case management for seniors with heart failure. Am J Manag Care. 2011 Mar;17(3):e71–9.
    1. Seto E, Leonard KJ, Cafazzo JA, Barnsley J, Masino C, Ross HJ. Mobile phone-based telemonitoring for heart failure management: a randomized controlled trial. J Med Internet Res. 2012;14(1):e31. doi: 10.2196/jmir.1909.
    1. Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S, Cartwright M, Rixon L, Knapp M, Henderson C, Rogers A, Fitzpatrick R, Hendy J, Newman S, Whole System Demonstrator Evaluation Team Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ. 2012;344:e3874.
    1. Cartwright M, Hirani SP, Rixon L, Beynon M, Doll H, Bower P, Bardsley M, Steventon A, Knapp M, Henderson C, Rogers A, Sanders C, Fitzpatrick R, Barlow J, Newman SP, Whole Systems Demonstrator Evaluation Team Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial. BMJ. 2013;346:f653.
    1. Henderson C, Knapp M, Fernández Jl, Beecham J, Hirani SP, Cartwright M, Rixon L, Beynon M, Rogers A, Bower P, Doll H, Fitzpatrick R, Steventon A, Bardsley M, Hendy J, Newman SP, Whole System Demonstrator evaluation team Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial. BMJ. 2013;346:f1035.
    1. Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Beynon M, Hirani S, Cartwright M, Rixon L, Knapp M, Henderson C, Rogers A, Hendy J, Fitzpatrick R, Newman S. Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial. Age Ageing. 2013 Jul;42(4):501–8. doi: 10.1093/ageing/aft008.
    1. Eysenbach G, CONSORT-EHEALTH Group CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res. 2011;13(4):e126. doi: 10.2196/jmir.1923.
    1. Vuong Q. Likelihood ratio tests for model selection and non-nested hypotheses. Econometrica. 1989;57:307–333. doi: 10.2307/191255.
    1. Bueno H, Ross JS, Wang Y, Chen J, Vidán MT, Normand SL, Curtis JP, Drye EE, Lichtman JH, Keenan PS, Kosiborod M, Krumholz HM. Trends in length of stay and short-term outcomes among Medicare patients hospitalized for heart failure, 1993-2006. JAMA. 2010 Jun 2;303(21):2141–7. doi: 10.1001/jama.2010.748.
    1. Orsama AL, Lähteenmäki J, Harno K, Kulju M, Wintergerst E, Schachner H, Stenger P, Leppänen J, Kaijanranta H, Salaspuro V, Fisher WA. Active assistance technology reduces glycosylated hemoglobin and weight in individuals with type 2 diabetes: results of a theory-based randomized trial. Diabetes Technol Ther. 2013 Aug;15(8):662–9. doi: 10.1089/dia.2013.0056.
    1. Troughton RW, Frampton CM, Yandle TG, Espiner EA, Nicholls MG, Richards AM. Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations. Lancet. 2000 Apr 1;355(9210):1126–30.
    1. Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Böhm M, de Brouwer S, Perrin E, Baumann G, Gelbrich G, Boll H, Honold M, Koehler K, Kirwan BA, Anker SD. Telemedicine in heart failure: pre-specified and exploratory subgroup analyses from the TIM-HF trial. Int J Cardiol. 2012 Nov 29;161(3):143–50. doi: 10.1016/j.ijcard.2011.09.007.
    1. Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients with heart failure. Lancet. 2011 Aug 20;378(9792):731–9. doi: 10.1016/S0140-6736(11)61229-4.
    1. Paré G, Jaana M, Sicotte C. Systematic review of home telemonitoring for chronic diseases: the evidence base. J Am Med Inform Assoc. 2007;14(3):269–77. doi: 10.1197/jamia.M2270.

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