A Multicenter Randomized Controlled Comparison of Telephonic Disease Management vs. Automated Home Monitoring in Patients Recently Hospitalized with Heart Failure: Span-CHF II Trial

Structured telephone support or non-invasive telemonitoring for patients with heart failure

BACKGROUND

Specialised disease management programmes for heart failure aim to improve care, clinical outcomes and/or reduce healthcare utilisation. Since the last version of this review in 2010, several new trials of structured telephone support and non-invasive home telemonitoring have been published which have raised questions about their effectiveness.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure, in order to quantify the effects of these interventions over and above usual care.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology AsseFssment Database (HTA) on the Cochrane Library; MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index- Science (CPCI-S) on Web of Science (Thomson Reuters), AMED, Proquest Theses and Dissertations, IEEE Xplore and TROVE in January 2015. We handsearched bibliographies of relevant studies and systematic reviews and abstract conference proceedings. We applied no language limits.

SELECTION CRITERIA

We included only peer-reviewed, published RCTs comparing structured telephone support or non-invasive home telemonitoring to usual care of people with chronic heart failure. The intervention or usual care could not include protocol-driven home visits or more intensive than usual (typically four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

We present data as risk ratios (RRs) with 95% confidence intervals (CIs). Primary outcomes included all-cause mortality, all-cause and heart failure-related hospitalisations, which we analysed using a fixed-effect model. Other outcomes included length of stay, health-related quality of life, heart failure knowledge and self care, acceptability and cost; we described and tabulated these. We performed meta-regression to assess homogeneity (the null hypothesis) in each subgroup analysis and to see if the effect of the intervention varied according to some quantitative variable (such as year of publication or median age).

MAIN RESULTS

We include 41 studies of either structured telephone support or non-invasive home telemonitoring for people with heart failure, of which 17 were new and 24 had been included in the previous Cochrane review. In the current review, 25 studies evaluated structured telephone support (eight new studies, plus one study previously included but classified as telemonitoring; total of 9332 participants), 18 evaluated telemonitoring (nine new studies; total of 3860 participants). Two of the included studies trialled both structured telephone support and telemonitoring compared to usual care, therefore 43 comparisons are evident.Non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94; participants = 3740; studies = 17; I² = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I² = 20%, GRADE: moderate-quality evidence). Structured telephone support reduced all-cause mortality (RR 0.87, 95% CI 0.77 to 0.98; participants = 9222; studies = 22; I² = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I² = 27%, GRADE: moderate-quality evidence).Neither structured telephone support nor telemonitoring demonstrated effectiveness in reducing the risk of all-cause hospitalisations (structured telephone support: RR 0.95, 95% CI 0.90 to 1.00; participants = 7216; studies = 16; I² = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I² = 71%, GRADE: very low-quality evidence).Seven structured telephone support studies reported length of stay, with one reporting a significant reduction in length of stay in hospital. Nine telemonitoring studies reported length of stay outcome, with one study reporting a significant reduction in the length of stay with the intervention. One telemonitoring study reported a large difference in the total number of hospitalisations for more than three days, but this was not an analysis of length of stay per hospitalisation. Nine of 11 structured telephone support studies and five of 11 telemonitoring studies reported significant improvements in health-related quality of life. Nine structured telephone support studies and six telemonitoring studies reported costs of the intervention or cost effectiveness. Three structured telephone support studies and one telemonitoring study reported a decrease in costs and two telemonitoring studies reported increases in cost, due both to the cost of the intervention and to increased medical management. Adherence was rated between 55.1% and 98.5% for those structured telephone support and telemonitoring studies which reported this outcome. Participant acceptance of the intervention was reported in the range of 76% to 97% for studies which evaluated this outcome. Seven of nine studies that measured these outcomes reported significant improvements in heart failure knowledge and self-care behaviours.

AUTHORS' CONCLUSIONS

For people with heart failure, structured telephone support and non-invasive home telemonitoring reduce the risk of all-cause mortality and heart failure-related hospitalisations; these interventions also demonstrated improvements in health-related quality of life and heart failure knowledge and self-care behaviours. Studies also demonstrated participant satisfaction with the majority of the interventions which assessed this outcome.

Pilot testing of a multicomponent home care intervention for older adults with heart failure: an academic clinical partnership

BACKGROUND

Heart failure (HF) has clinically significant psychological and physical consequences for older persons, and hospitalization for HF is frequent and costly to the Medicare program. As HF is the most common primary Medicare home care diagnosis, there is a critical need to develop home care services that improve heath-related outcomes for this population. The primary aim of this pilot study was to develop, implement, and test the initial feasibility and potential efficacy of the Home-Care Education, Assessment, Remote-Monitoring, and Therapeutic Activities (HEART) trial, a nurse-directed multicomponent home care intervention. Observed outcomes were quality of life (QOL), depressive symptoms, and 90-day hospitalization.

METHODS

Twenty-four patients with a primary diagnosis of HF were assigned to the intervention (n = 12) or control group (n = 12) according to geographical location in a large multibranch Medicare-certified home health agency. Intervention group patients received 8 structured nurse education visits using evidence-based protocols designed in previous trials to teach HF self-management and to prevent/reduce depression, as well as a telemonitoring system. Control group patients received usual care and telemonitoring. Quality of life was assessed using the Minnesota Living With Heart Failure questionnaire. Depressive symptoms were assed using the Patient Health Questionnaire 9 at baseline and 90-day study end point.

RESULTS

Study protocols and instrumentation were found to be feasible and effective. Examination of enrollment data led to a reevaluation of eligibility criteria. Patients participating in the HEART intervention demonstrated significantly improved QOL (F = 8.99, P = .007) and significantly reduced depressive symptoms (F = 35.10, P = .001) in comparison to control group patients at the study end point. There was a trend toward lower hospital readmission rates in the intervention group (16% vs 25%), but this was not statistically significant.

CONCLUSION

This pilot study suggests that a full-scale trial of the HEART intervention is feasible.

Structured telephone support or telemonitoring programmes for patients with chronic heart failure

BACKGROUND

Specialised disease management programmes for chronic heart failure (CHF) improve survival, quality of life and reduce healthcare utilisation. The overall efficacy of structured telephone support or telemonitoring as an individual component of a CHF disease management strategy remains inconclusive.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or telemonitoring compared to standard practice for patients with CHF in order to quantify the effects of these interventions over and above usual care for these patients.

SEARCH STRATEGY

Databases (the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database (HTA) on The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED and Science Citation Index Expanded and Conference Citation Index on ISI Web of Knowledge) and various search engines were searched from 2006 to November 2008 to update a previously published non-Cochrane review. Bibliographies of relevant studies and systematic reviews and abstract conference proceedings were handsearched. No language limits were applied.

SELECTION CRITERIA

Only peer reviewed, published RCTs comparing structured telephone support or telemonitoring to usual care of CHF patients were included. Unpublished abstract data was included in sensitivity analyses. The intervention or usual care could not include a home visit or more than the usual (four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

Data were presented as risk ratio (RR) with 95% confidence intervals (CI). Primary outcomes included all-cause mortality, all-cause and CHF-related hospitalisations which were meta-analysed using fixed effects models. Other outcomes included length of stay, quality of life, acceptability and cost and these were described and tabulated.

MAIN RESULTS

Twenty-five studies and five published abstracts were included. Of the 25 full peer-reviewed studies meta-analysed, 16 evaluated structured telephone support (5613 participants), 11 evaluated telemonitoring (2710 participants), and two tested both interventions (included in counts). Telemonitoring reduced all-cause mortality (RR 0.66, 95% CI 0.54 to 0.81, P < 0.0001) with structured telephone support demonstrating a non-significant positive effect (RR 0.88, 95% CI 0.76 to 1.01, P = 0.08). Both structured telephone support (RR 0.77, 95% CI 0.68 to 0.87, P < 0.0001) and telemonitoring (RR 0.79, 95% CI 0.67 to 0.94, P = 0.008) reduced CHF-related hospitalisations. For both interventions, several studies improved quality of life, reduced healthcare costs and were acceptable to patients. Improvements in prescribing, patient knowledge and self-care, and New York Heart Association (NYHA) functional class were observed.

AUTHORS' CONCLUSIONS

Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and CHF-related hospitalisations in patients with CHF; they improve quality of life, reduce costs, and evidence-based prescribing.

Patient self-management by telehealth using the Bosch model of care

A telehealth system that can transmit vital signs data, and also empowers patients to maintain their autonomy and learn how to manage their disease better, can improve patients' quality of life. Such a system can form part of a high-quality and efficient health-care service. The Bosch telehealth system, which focuses on self-management, has been used by thousands of patients with long-term conditions in the USA and Europe. The efficiency of the programmes, as well as their positive effects on quality of life and compliance, have been proven for a number of chronic conditions, as well as for patients with multiple co-morbidities.

Situation, motivation, implementation and results of telehealth-enabled health care

Well-implemented telehealth systems can reduce the total costs of care by reducing emergency hospital visits and unnecessary treatment. Telehealth is especially well-suited to supporting patients with chronic, complex or co-morbid conditions. A substantial body of research – much from the USA – documents the value of a commercially-available system which supplements remote monitoring with daily questions about the patient's health and behaviours. However, there are still very few large scale deployments of telehealth because the best practices needed to implement it are still being developed.

Integration of diagnostic and communication technologies

Three key areas in diagnostics will drive the convergence of diagnostic and communication technologies: point-of-care testing, micro-electromechanical systems and biomarker discovery. In addition, the communications revolution means that increasing numbers of people will be able to send data from their home to their doctor using the Internet. Also, the widespread availability of broadband opens up the possibly of realtime videoconferencing with clinicians. It is already possible for patients at home to monitor simple variables, such as heart rate and blood pressure, and send their results using communication technologies to their doctors, who can promptly review the information to diagnose problems. As diagnostic and communication technologies converge, it will be feasible for patients to transmit more complex health-care data periodically to their doctor, who will be able to identify problems early on and thus modify disease management to prevent exacerbations of patients' medical conditions. This will allow improved patient care in a wide range of health-care situations, from acute medical conditions to chronic disease.