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Masotta V, Dante A, Caponnetto V, Marcotullio A, Ferraiuolo F, Bertocchi L, Camero F, Lancia L, Petrucci C. Telehealth care and remote monitoring strategies in heart failure patients: A systematic review and meta-analysis. Heart Lung 2024; 64:149-167. [PMID: 38241978 DOI: 10.1016/j.hrtlng.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/30/2023] [Accepted: 01/09/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Heart failure (HF) is a cardiac clinical syndrome that involves complex pathological aetiologies. It represents a growing public health issue and affects a significant number of people worldwide. OBJECTIVES To synthesize evidence related to the impact of telemonitoring strategies on mortality and hospital readmissions of heart failure patients. METHODS A systematic literature review was conducted using PubMed, Scopus, CINAHL, IEEE Xplore Digital Library, Engineering Source, and INSPEC. To be included, studies had to be in English or Italian and involve heart failure patients of any NYHA class, receiving care through any telecare, remote monitoring, telemonitoring, or telehealth programmes. Articles had to contain data on both mortality and number of patients who underwent rehospitalizations during follow-ups. To explore the effectiveness of telemonitoring strategies in reducing both one-year all-cause mortality and one-year rehospitalizations, studies were synthesized through meta-analyses, while those excluded from meta-analyses were summarized narratively. RESULTS Sixty-one studies were included in the review. Narrative synthesis of data suggests a trend towards a reduction in deaths among monitored patients, but the number of rehospitalized patients was higher in this group. Meta-analysis of studies reporting one-year all-cause mortality outlined the protective power of care models based on telemonitoring in reducing one-year all-cause mortality. Meta-analysis of studies reporting the number of rehospitalized patients in one-year outlined that telemonitoring is effective in reducing the number of rehospitalized patients when compared with usual care strategies. CONCLUSION Evidence from this review confirms the benefits of telemonitoring in reducing mortality and rehospitalizations of HF patients. Further research is needed to reduce the heterogeneity of the studies.
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Affiliation(s)
- Vittorio Masotta
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
| | - Angelo Dante
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy.
| | - Valeria Caponnetto
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
| | - Alessia Marcotullio
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
| | - Fabio Ferraiuolo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
| | - Luca Bertocchi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
| | - Francesco Camero
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
| | - Loreto Lancia
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
| | - Cristina Petrucci
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Via Giuseppe Petrini, L'Aquila 67100, Italy
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Lee KCS, Breznen B, Ukhova A, Martin SS, Koehler F. Virtual healthcare solutions in heart failure: a literature review. Front Cardiovasc Med 2023; 10:1231000. [PMID: 37745104 PMCID: PMC10513031 DOI: 10.3389/fcvm.2023.1231000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
The widespread adoption of mobile technologies offers an opportunity for a new approach to post-discharge care for patients with heart failure (HF). By enabling non-invasive remote monitoring and two-way, real-time communication between the clinic and home-based patients, as well as a host of other capabilities, mobile technologies have a potential to significantly improve remote patient care. This literature review summarizes clinical evidence related to virtual healthcare (VHC), defined as a care team + connected devices + a digital solution in post-release care of patients with HF. Searches were conducted on Embase (06/12/2020). A total of 171 studies were included for data extraction and evidence synthesis: 96 studies related to VHC efficacy, and 75 studies related to AI in HF. In addition, 15 publications were included from the search on studies scaling up VHC solutions in HF within the real-world setting. The most successful VHC interventions, as measured by the number of reported significant results, were those targeting reduction in rehospitalization rates. In terms of relative success rate, the two most effective interventions targeted patient self-care and all-cause hospital visits in their primary endpoint. Among the three categories of VHC identified in this review (telemonitoring, remote patient management, and patient self-empowerment) the integrated approach in remote patient management solutions performs the best in decreasing HF patients' re-admission rates and overall hospital visits. Given the increased amount of data generated by VHC technologies, artificial intelligence (AI) is being investigated as a tool to aid decision making in the context of primary diagnostics, identifying disease phenotypes, and predicting treatment outcomes. Currently, most AI algorithms are developed using data gathered in clinic and only a few studies deploy AI in the context of VHC. Most successes have been reported in predicting HF outcomes. Since the field of VHC in HF is relatively new and still in flux, this is not a typical systematic review capturing all published studies within this domain. Although the standard methodology for this type of reviews was followed, the nature of this review is qualitative. The main objective was to summarize the most promising results and identify potential research directions.
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Affiliation(s)
| | - Boris Breznen
- Evidence Synthesis, Evidinno Outcomes Research Inc., Vancouver, BC, Canada
| | | | - Seth Shay Martin
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Friedrich Koehler
- Deutsches Herzzentrum der Charité (DHZC), Centre for Cardiovascular Telemedicine, Campus Charité Mitte, Berlin, Germany
- Division of Cardiology and Angiology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Auener SL, Remers TEP, van Dulmen SA, Westert GP, Kool RB, Jeurissen PPT. The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review. J Med Internet Res 2021; 23:e26744. [PMID: 34586072 PMCID: PMC8515232 DOI: 10.2196/26744] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/18/2021] [Accepted: 06/30/2021] [Indexed: 12/20/2022] Open
Abstract
Background Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear. Objective This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs. Methods We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant. Results We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization. Conclusions Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.
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Affiliation(s)
- Stefan L Auener
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Toine E P Remers
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Simone A van Dulmen
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gert P Westert
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rudolf B Kool
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Patrick P T Jeurissen
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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Brons M, Rutten FH, Zuithoff NPA, Oerlemans MIFJ, Asselbergs FW, Koudstaal S. Disease management with home telemonitoring aimed at substitution of usual care in the Netherlands: Post-hoc analyses of the e-Vita HF study. J Cardiol 2021; 79:1-5. [PMID: 34454810 DOI: 10.1016/j.jjcc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Home telemonitoring in heart failure (HF) patients may reduce workload of HF nurses by reducing face-to-face contacts. The aim of this study is to assess whether telemonitoring as a substitution could have negative effects as expressed by less reduction in circulating natriuretic peptide levels between baseline and one-year of follow up compared to usual care. METHODS A post-hoc analysis of the e-Vita HF trial, a three-arm parallel randomized trial conducted in stable HF patients. Patients were randomized into three arms: (i) usual HF outpatient care, (ii) usual care combined with the use of the website heartfailurematters.org, and (iii) telemonitoring (e-Vita HF platform) instead of face-to-face consultations. Mixed linear model analyses were applied to assess differences in the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels between the three arms over a year. RESULTS A total of 223 participants could be included (mean age 67.1 ± 10.1 years, 27% women, New York Heart Association class I-IV; 39%, 38%, 14%, and 9%). The mean left ventricular ejection fraction was 35 ± 10%. The median of routine face-to-face contacts over a year was 1.0 lower (2.0 vs. 3.0) in the third arm compared with usual care. Median NT-proBNP levels did not significantly differ between the three arms. CONCLUSION In stable and optimally treated HF patients, telemonitoring causing a reduction of routine face-to-face contacts seems not to negatively affect hemodynamic status as measured by NT-proBNP levels over time.
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Affiliation(s)
- Maaike Brons
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, P.O. Box 85500, Utrecht, GA 3508, the Netherlands.
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Nicolaas P A Zuithoff
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Marish I F J Oerlemans
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, P.O. Box 85500, Utrecht, GA 3508, the Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, P.O. Box 85500, Utrecht, GA 3508, the Netherlands; Faculty of Population Health Sciences, Institute of Cardiovascular Science, University College London, London, UK; Institute of Health Informatics, University College London, London, UK
| | - Stefan Koudstaal
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, P.O. Box 85500, Utrecht, GA 3508, the Netherlands
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Koole MAC, Kauw D, Winter MM, Dohmen DAJ, Tulevski II, de Haan R, Somsen GA, Schijven MP, Robbers-Visser D, Mulder BJM, Bouma BJ, Schuuring MJ. First real-world experience with mobile health telemonitoring in adult patients with congenital heart disease. Neth Heart J 2019; 27:30-37. [PMID: 30488380 PMCID: PMC6311159 DOI: 10.1007/s12471-018-1201-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Arrhythmias and heart failure are common and invalidating sequelae in adult patients with congenital heart disease (CHD). Mobile health (m-Health) enables daily monitoring and a timely response that might prevent deterioration. We present an observational prospective registry to evaluate feasibility of an m‑Health telemonitoring program for managing arrhythmia, heart failure and blood pressure in symptomatic adults with CHD. METHODS Symptomatic adult patients with CHD are enrolled in an m‑Health telemonitoring program, which evaluates single-lead ECG, blood pressure and weight measurements. In case of symptoms extra measurements could be performed. Data are collected by mobile apps, matched with individualised thresholds. Patients are contacted if thresholds were exceeded or if arrhythmias were found, for treatment adjustments or reassurance. Data on emergency care utilisation, hospitalisation and patient-reported outcome measures are used to assess quality of life and self-management. RESULTS 129 symptomatic CHD patients were invited to participate, 55 participated. Reasons for refusing consent included too time consuming to participate in research (30) and to monitor vital signs (14). At baseline 22 patients were in New York Heart Association class ≥ II heart failure, 43 patients had palpitations or documented arrhythmias, and 8 had hypertension. Mean follow-up was 3.0 months, one patient dropped out, and adherence was 97%. CONCLUSION The first results indicate that this program is feasible with high adherence.
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Affiliation(s)
- M A C Koole
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cardiology Centers of the Netherlands, Amsterdam, The Netherlands.
- Department of Cardiology, Red Cross Hospital, Beverwijk, The Netherlands.
| | - D Kauw
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - M M Winter
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cardiology Centers of the Netherlands, Amsterdam, The Netherlands
| | - D A J Dohmen
- FocusCura, Driebergen-Rijsenburg, The Netherlands
| | - I I Tulevski
- Cardiology Centers of the Netherlands, Amsterdam, The Netherlands
| | - R de Haan
- Cardiology Centers of the Netherlands, Amsterdam, The Netherlands
| | - G A Somsen
- Cardiology Centers of the Netherlands, Amsterdam, The Netherlands
| | - M P Schijven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - D Robbers-Visser
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B J M Mulder
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M J Schuuring
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
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Abstract
Telemedicine in chronic diseases like heart failure is rapidly evolving and has two important goals: improving and individualising care as well as reducing costs. In this paper, we provide a critical and an updated review of the current evidence by discussing the most important trials, meta-analyses and systematic reviews. So far, evidence for the CardioMEMS device is most convincing. Other trials regarding invasive and non-invasive telemonitoring and telephone support show divergent results, but several meta-analyses and systematic reviews uniformly reported a beneficial effect. Voice-over systems and ECG monitoring had neutral results. Lack of direct comparison between different modalities makes it impossible to determine the most effective method. Dutch studies showed predominantly non-significant results, mainly due to underpowered studies or because of a high standard of usual care. There are no conclusive results on cost-effectiveness of telemedicine because of the above shortcomings. The adherence of elderly patients was good in the trials, being essential for the compliance of telemedicine in the entire heart failure population. In the future perspective, telemedicine should be better standardised and evolve to be more than an addition to standard care to improve care and reduce costs.
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Gingele AJ, Brunner-la Rocca H, Ramaekers B, Gorgels A, De Weerd G, Kragten J, van Empel V, Brandenburg V, Vrijhoef H, Cleuren G, Knackstedt C, Boyne JJ. Telemonitoring in patients with heart failure: Is there a long-term effect? J Telemed Telecare 2017; 25:158-166. [PMID: 29251245 DOI: 10.1177/1357633x17747641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Evidence suggests that telemonitoring decreases mortality and heart failure (HF)-related hospital admission in patients with HF. However, most studies follow their patients for only several months. Little is known about the long-term effects of telemonitoring after a period of application. METHODS In 2007, the TEHAF study was initiated to compare tailored telemonitoring with usual care with respect to time until first HF-related hospital admission. In total, 301 patients completed the study after a follow-up period of one year. No differences could be found in time to first HF-related admission between intervention and control groups. Here, we performed a retrospective analysis in order to investigate potential long-term effects of telemonitoring. The primary endpoint was time to first HF-related hospital admission. Secondary endpoints were, amongst others, all-cause mortality, hospital admission due to HF and days alive and out of hospital (DAOOH). Electronic files of all included patients were reviewed between October 2007 and September 2015. RESULT Mean follow-up duration was 1652 days (standard deviation: 1055 days). No significant difference in time to first HF-related hospital admission (log-rank test, p = 0.15), all-cause mortality (log-rank test, p = 0.43), or DAOOH (two-sample t-test, p = 0.87) could be found. However, patients that underwent telemonitoring had significantly fewer HF-related hospital admissions (incident rate ratio 0.54, 95% confidence interval 0.31-0.88). DISCUSSION Telemonitoring did not significantly influence the long-term outcome in our study. Therefore, extending the follow-up period of telemonitoring studies in HF patients is probably not beneficial.
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Affiliation(s)
- Arno J Gingele
- 1 Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Bram Ramaekers
- 2 Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anton Gorgels
- 1 Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Gerjan De Weerd
- 3 Department of Cardiology, Zuyderland Hospital, Sittard, The Netherlands
| | - Johannes Kragten
- 4 Department of Cardiology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Vanessa van Empel
- 1 Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Hubertus Vrijhoef
- 6 Department of Family Medicine, Vrije Universiteit Brussels, Brussels, Belgium.,7 Panaxea BV, Amsterdam, The Netherlands
| | - Ger Cleuren
- 8 Department of Patient and Care, Maastricht University Medical Centre, Maastricht, The Netherlands.,9 CAPHRI, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Christian Knackstedt
- 1 Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Josiane Jj Boyne
- 8 Department of Patient and Care, Maastricht University Medical Centre, Maastricht, The Netherlands.,9 CAPHRI, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands
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