Infrastructural needs and expected benefits of telemonitoring in left ventricular assist device therapy: Results of a qualitative study using expert interviews and focus group discussions with patients

Monitoring left ventricular assist device parameters to detect flow- and power-impacting complications: a proof of concept

Aims

The number of patients on left ventricular assist device (LVAD) support increases due to the growing number of patients with end-stage heart failure and the limited number of donor hearts. Despite improving survival rates, patients frequently suffer from adverse events such as cardiac arrhythmia and major bleeding. Telemonitoring is a potentially powerful tool to early detect deteriorations and may further improve outcome after LVAD implantation. Hence, we developed a personalized algorithm to remotely monitor HeartMate3 (HM3) pump parameters aiming to early detect unscheduled admissions due to cardiac arrhythmia or major bleeding.

Methods and results

The source code of the algorithm is published in an open repository. The algorithm was optimized and tested retrospectively using HeartMate 3 (HM3) power and flow data of 120 patients, including 29 admissions due to cardiac arrhythmia and 14 admissions due to major bleeding. Using a true alarm window of 14 days prior to the admission date, the algorithm detected 59 and 79% of unscheduled admissions due to cardiac arrhythmia and major bleeding, respectively, with a false alarm rate of 2%.

Conclusion

The proposed algorithm showed that the personalized algorithm is a viable approach to early identify cardiac arrhythmia and major bleeding by monitoring HM3 pump parameters. External validation is needed and integration with other clinical parameters could potentially improve the predictive value. In addition, the algorithm can be further enhanced using continuous data.

Innovations and Implementation of Telemedicine in Surgical Clinics Beyond COVID-19: A Narrative Review

Introduction: Telemedicine has emerged as a powerful tool in the delivery of health care to surgical patients and innovations are developing to address challenges in the technology, enhancing consumer-provider encounters while located remotely. Our study aims at collating and commenting on the published evidence for how current challenges in telemedicine for surgical clinics are met by innovations currently in development. We also comment on the implementation and monitoring strategies for telemedicine. Methods: Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science, and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient"; and "surgical clinic." For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting, and if they had a focus during the COVID-19 pandemic. Results: Three hundred forty-five articles were identified and screened, so that 73 articles were included in the review. Almost all articles were from Western countries (n = 69), mostly in surgical journals (n = 39) and from a range of sub-specialties, but pre-dominantly orthopedics (n = 12) and general surgery (n = 9). The majority were original comparative studies, with 31 studies directly comparing telemedicine with in-person appointments and 22 articles focused on implementation during COVID-19. Discussion/Conclusion: Advanced telecommunication technology has enabled telemedicine to become an effective and safe form of health care delivery, with high consumer and provider satisfaction. Innovative protocol and technology developments have addressed the limitations of telemedicine. Sophisticated and familiar medical software integrates with electronic medical records to automate and streamline documentation, consent, and billing processes. Surgical clinics are investing in telehealth workflow co-ordination and information technology support to troubleshoot any technical difficulties as well as education for providers and consumers to address technology illiteracy. As health care services continue to transition their systems to an online network, further research is required to understand the ability and assess the feasibility of telemedicine to fully integrate.

Does the distance between residency and implanting center affect the outcome of patients supported by left ventricular assist devices? A multicenter Italian study on radial mechanically assisted circulatory support (MIRAMACS) analysis

BACKGROUND

Patients with LVAD require continuous monitoring and care, and since Implanting Centers (ICs) are more experienced in managing LVAD patients than other healthcare facilities, the distance between patient residency and IC could negatively affect the outcomes.

METHODS

Data of patients discharged after receiving an LVAD implantation between 2010 and 2021 collected from the MIRAMACS database were retrospectively analyzed. The population was divided into two groups: A (n = 175) and B (n = 141), according to the distance between patient residency and IC ≤ or >90 miles. The primary endpoint was freedom from Adverse Events (AEs), a composite outcome composed of death, cerebrovascular accident, hospital admission because of GI bleeding, infection, pump thrombosis, and right ventricular failure. Secondary endpoints were incidences of mortality and complications. All patients were followed-up regularly, according to participating center protocols.

RESULTS

Baseline clinical characteristics and indications for LVAD did not differ between the two groups. The mean duration of support was 25.5 ± 21 months for Group A and 25.7 ± 20 months for Group B (p = 0.79). At 3 years, freedom from AEs was similar between Group A and Group B (p = 0.36), and there were no differences in rates of mortality and LVAD-related complications.

CONCLUSIONS

Distance from the IC does not represent a barrier to successful outcomes as long as regular and continuous follow-up is provided.

Systematic Review of Telemedicine and eHealth Systems Applied to Vascular Surgery

OBJECTIVE

The objective of this paper is to review and analyze the current state of telemedicine and ehealth in the field of vascular surgery.

METHODS

This paper collects the relevant information obtained after reviewing the articles related to telemedicine in vascular surgery, published from 2012 to 2022 contained in scientific databases. In addition, the results obtained are statistically studied based on various factors, such as the year of publication or the search engine. In this way, we obtain a complete vision of the current state of telemedicine in the field of vascular surgery.

RESULTS

After performing this search and applying selection criteria, 29 articles were obtained for subsequent study and discussion, of which 20 were published in the second half of the decade, representing 70% of the results. In the analysis carried out according to the search criteria used, it can be seen that using the word telemedicine we obtained 69% of the articles while with the criteria mHealth and eHealth we only obtained 22% and 9% of the results, respectively. It can be seen that the filter with the most potential content articles was "vascular surgery AND telemedicine". In the analysis performed according to the search engine, it was observed that the Google Scholar database contains 93% of the articles found in the massive search and the relevant articles contained therein represent 52% of the total.

CONCLUSION

An upward trend has been observed in recent years, with a clear increase in the number of publications and much lower figures in the first years. One aspect to highlight is that 47.8% of the articles analyzed focus only on postoperative treatment, which may be due to the help provided by telemedicine in detecting surgical site infections by sending images and videos, this being one of the most common postoperative complications. The analyzed works show the importance of telemedicine in vascular surgery and identify possible future lines of research. In the analysis carried out on the origin of the selected relevant papers, an important interest of the US in this topic is demonstrated since more than 50% of the research contains authors from this country, it is also observed that there is no research from Spain, so this research would be an initial step to determine the weaknesses of telemedicine in this field of medicine and a good opportunity to open a research gap in this branch.

Non-use of telemedicine: A scoping review

Many telemedicine interventions fail to be implemented in medical care with non-use and discontinued use by patients being among the major reasons. The aim of this scoping review was to provide an overview of barriers associated with non-use and discontinued use of telemedicine. An electronic search was conducted in Pubmed in October 2019 and updated in November 2020, followed by a hand search in the beginning of 2021. All potential articles were screened by two independent reviewers based on predefined inclusion and exclusion criteria. A qualitative content analysis according to Mayring was carried out. The topics 'intervention', 'context of use' and 'user' were chosen as overarching themes. Out of 1377 potentially relevant articles, 73 were included. User-related barriers were mentioned in most of the analysed studies, followed by barriers related to the intervention. The analysis provides the basis for overcoming non-use issues in telemedicine.

Telemonitoring and Care Program for Left Ventricular Assist Device Patients During COVID-19 Outbreak: A European Experience

Coronavirus disease 2019 (COVID-19) radically modified the organization of healthcare systems with shutdown of routine activities and outpatient clinics. Herein, we report our institutional experience with a Telemonitoring and Care Program (TC-Program) to monitor and support left ventricular assist device (LVAD) patients during COVID-19 outbreak. This single-arm cohort study analyzed 156 patients who entered the TC-Program at our institution between April and August 2020. The TC-Program was based on routine phone calls to patients and a 24/7 emergency line. In November 2020, patients were asked for feedback on the TC-Program and checked for survival, transplant, or explant. The primary endpoint was the rate of TC-Program-driven interventions. Patients (males: 82.8%) were 61 years old (interquartile range [IQR]: 53.0-67.5) and on LVAD support for 1,266 days (IQR: 475-2,211). Patients were included in the TC-Program for a median time of 99 days (min:15, max:120) and received a median number of six phone calls (min:1, max:14). Twenty-three patients (14.7%) were referred for clinical evaluation after phone contact. Two patients (1.27%) were diagnosed with COVID-19: one of them died after intensive care, and one remained paucisymptomatic and recovered. Three patients asked to exit the program considering it not useful while the others gave high rates in terms of usefulness (median: 9, IQR: 8-10), information (median: 9, IQR: 8-10), good medical care (median: 9, IQR: 8-10), and psychologic support (median: 8, IQR: 7-10). A TC-Program based on the four ICSA principles (Inform, Care, Support, and Adapt) is feasible in LVAD patients and can be rapidly implemented during the COVID-19 pandemic.

Current and future use of telemedicine in surgical clinics during and beyond COVID-19: A narrative review

Introduction

Telemedicine has emerged as a powerful tool in the delivery of healthcare to surgical patients and enhances clinician-patient encounters during all phases of patient care. Our study aims were: to review the current use and applicability of telemedicine; evaluate its suitability, safety and effectiveness in a surgical outpatient setting, particularly in the era of social distancing restrictions and provide insight into future applications.

Methods

Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient" and "surgical clinic". For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting and if they had a focus during the COVID-19 pandemic.

Results

335 articles were identified and screened, so that 63 articles were included in the review. Almost all articles were from Western countries (n = 60), mostly in surgical journals (n = 35) and from a range of sub-specialities, but pre-dominantly orthopaedics (n = 12) and general surgery (n = 7). The majority were original comparative studies where 31 studies directly compared telemedicine to in-person appointments and 14 papers focused on implementation during COVID-19.

Discussion/conclusions

Telemedicine has been safely used across various phases of surgical outpatient care, with its effectiveness evaluated by clinical outcomes, economics and user/provider satisfaction. Telemedicine has multiple accepted benefits including time efficiency, patient/healthcare cost savings and community access, but with reported limitations of clinical uncertainty, technology infrastructure requirements, cybersecurity vulnerabilities and healthcare regulatory restraints. These limitations are being overcome by accelerated implementation during COVID-19 via fast-tracked practice development. Further work is required via development of research protocols to refine the application of emerging telemedicine technologies and their applicability to different surgical sub-specialties.