Outcomes of a Heart Failure Telemonitoring Program Implemented as the Standard of Care in an Outpatient Heart Function Clinic: Pretest-Posttest Pragmatic Study

A Remote Management-Centric Postdischarge Pathway for Patients Admitted to GIM with Heart Failure

BACKGROUND

Few GIM-specific heart failure transition of care (TOC) programs exist. We thus piloted a TOC program for heart failure patients discharged from GIM that incorporates a remote patient management program, Medly.

METHODS

This single-centre, prospective proof-of-concept study described sociodemographic and medical characteristics of included patients, and computed summary statistics to describe clinical and workload outcomes.

RESULTS

Ten patients (median age: 85) enrolled. There were no heart failure-related deaths, re-hospitalizations, or ED visits within 90 days of hospital discharge. One urgent GIM clinic visit was needed.

CONCLUSION

This post-GIM TOC pathway appears to effectively support heart failure patients. Further studies should assess this innovation's scalability.

Quality of Life Among Patients with Heart Failure with Reduced Ejection Fraction Receiving Telemedicine Care in Vietnam

Background: Telemedicine is an effective method to monitor patients at home and improve outcomes of heart failure (HF), especially HF with reduced ejection fraction (HFrEF). However, little is known about the impact of telemedicine on the quality of life (QoL) among outpatients with HFrEF in lower-middle-income countries (LMICs). Methods: In this single-center, prospective, randomized, controlled, open, and parallel-group clinical trial in northern Vietnam, patients with HFrEF were allocated to either telemedicine or control groups. Participants in the experimental arm underwent a home-based telemedicine program with regular telephone follow-ups and consultations. Participants in the control group received usual care. Both groups were followed for 6 months. The primary outcome was the change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score from baseline. The analysis was conducted on an intention-to-treat basis. Results: A total of 223 participants were randomized into two groups-the telemedicine group and the usual care group. Of the 223, 170 patients [mean age: 61.5 ± 15.0 years; female: 122 (71.8%)] completed follow-up and were included in the final analysis (87 in the telemedicine group and 83 in the usual care group). At baseline, the MLHFQ scores were equivalent between the two groups (median [interquartile range]: 81 [73-92] vs. 81 [74-92]; p = 0.992). After 6-month follow-up, the telemedicine group showed greater improvement in MLHFQ total scores than the usual care group (mean change in MLHFQ score: -15.5 ± 14.0 vs. -1.3 ± 6.2; difference in change: -14.2 [95% confidence interval, CI: -17.5, -11.0]; p < 0.0001). Similar results were found for the MLHFQ physical dimension score (difference in change: -5.8 [95% CI: -7.4, -4.1]; p < 0.0001) and the MLHFQ emotional dimension score (difference in change: -3.2 [95% CI: -4.2, -2.2]; p < 0.0001). Conclusions: In this study, a telemedicine intervention significantly improved QoL compared with usual care among patients with HFrEF in an LMIC.

From fragmentation to functionality: Enhancing coherence of digital health integration in health systems

Digital health programs continue to be implemented within Canadian health systems at a steady pace. The effectiveness of digital health initiatives has been rigorously analyzed, with both benefits and drawbacks extensively commented on. While the discussion about digital health continues, both positive and negative perspectives of it are approaching saturation in their themes. Accepting that digital health is here to stay post-pandemic, the focus should shift to strategies and supports needed to avoid the fragmentation of care through digital health implementation. This short article poses three questions which policy-makers and decision-makers should explore as part of a level-setting exercise with involved stakeholders at the outset of a digital health program's consideration. An implementation team should design the digital health program to have equity as its foundational focus, conduct value-based evaluations, and position the program in a learning health system framework to guard against the fragmentation of care.

Patient participation in self-monitoring regarding healthcare of heart failure: an integrated systematic review

BACKGROUND

Self-monitoring in cases of heart failure (HF) can lead to improved health and early detection of states of illness, potentially avoiding unnecessary hospitalisation. Legislation emphasizes the importance of patient participation in health care. This is possible and simplified due to the ongoing digitalisation within the healthcare system. The aim of this study was therefore to describe existing research knowledge on patient participation in self-monitoring regarding healthcare of HF, in the context of digitalisation of healthcare.

METHODS

A systematic literature review with an integrative approach was conducted February 2021 (6 years) and April 2024 (9 years). The review consisted of 12 articles accumulated from four databases. The review was performed in line with the standards of the PRISMA statement, registration number: PROSPERO 2021:244,252.

RESULTS

A total of twelve studies were included, both quantitative and qualitative research. The studies had a wide international spread and included a total of n = 1393 patients aged between 52-77 years, predominantly men. Various aspects of patient participation are the three themes: 'Self-care ability', 'Interaction with healthcare professionals', and 'Empowerment and Individual preferences'. The results indicate that self-monitoring has a predominantly positive effect on self-care behavior and satisfaction with care. Increased awareness and confidence in patients´ own self-care abilities were reported especially in qualitative studies. Through the use of self-monitoring, information and knowledge about HF led to increased control of the disease. Additionally, differences between qualitative and quantitative studies are demonstrated even in this partial result. The qualitative studies showed an increased understanding of disease situations, but corresponding conformity is not shown in quantitative research, and an increased level of knowledge is not yet proven.

CONCLUSIONS

The fact that there is a lack of empirical data in this field of research and that the available data is not coherent indicates that additional studies are required. In step with increased digitalisation and that great responsibility is placed on patient participation, there is a demand for patient studies that embrace a pronounced patient perspective with individual components of self-monitoring.

Wearable Devices for Supporting Chronic Disease Self-Management: Scoping Review

BACKGROUND

People with chronic diseases can benefit from wearable devices in managing their health and encouraging healthy lifestyle habits. Wearables such as activity trackers or blood glucose monitoring devices can lead to positive health impacts, including improved physical activity adherence or better management of type 2 diabetes. Few literature reviews have focused on the intersection of various chronic diseases, the wearable devices used, and the outcomes evaluated in intervention studies, particularly in the context of primary health care.

OBJECTIVE

This study aims to identify and describe (1) the chronic diseases represented in intervention studies, (2) the types or combinations of wearables used, and (3) the health or health care outcomes assessed and measured.

METHODS

We conducted a scoping review following the Joanna Briggs Institute guidelines, searching the MEDLINE and Web of Science databases for studies published between 2012 and 2022. Pairs of reviewers independently screened titles and abstracts, applied the selection criteria, and performed full-text screening. We included interventions using wearables that automatically collected and transmitted data to adult populations with at least one chronic disease. We excluded studies with participants with only a predisposition to develop a chronic disease, hospitalized patients, patients with acute diseases, patients with active cancer, and cancer survivors. We included randomized controlled trials and cohort, pretest-posttest, observational, mixed methods, and qualitative studies.

RESULTS

After the removal of 1987 duplicates, we screened 4540 titles and abstracts. Of the remaining 304 articles after exclusions, we excluded 215 (70.7%) full texts and included 89 (29.3%). Of these 89 texts, 10 (11%) were related to the same interventions as those in the included studies, resulting in 79 studies being included. We structured the results according to chronic disease clusters: (1) diabetes, (2) heart failure, (3) other cardiovascular conditions, (4) hypertension, (5) multimorbidity and other combinations of chronic conditions, (6) chronic obstructive pulmonary disease, (7) chronic pain, (8) musculoskeletal conditions, and (9) asthma. Diabetes was the most frequent health condition (18/79, 23% of the studies), and wearable activity trackers were the most used (42/79, 53% of the studies). In the 79 included studies, 74 clinical, 73 behavioral, 36 patient technology experience, 28 health care system, and 25 holistic or biopsychosocial outcomes were reported.

CONCLUSIONS

This scoping review provides an overview of the wearable devices used in chronic disease self-management intervention studies, revealing disparities in both the range of chronic diseases studied and the variety of wearable devices used. These findings offer researchers valuable insights to further explore health care outcomes, validate the impact of concomitant device use, and expand their use to other chronic diseases.

TRIAL REGISTRATION

Open Science Framework Registries (OSF) s4wfm; https://osf.io/s4wfm.

Bringing Care Close to Home: Remote Management of Heart Failure In Partnership with Indigenous Communities In Northern Ontario, Canada

Background

The Weeneebayko Area Health Authority (WAHA) is a regional, community-based Indigenous health authority in Northern Ontario, Canada. From September 2022 to March 2023, the WAHA and University Health Network engaged in a partnership that designed a collaborative model of care to address inequities in cardiology specialist access in Northern Ontario. This model implemented a digital therapeutic for heart failure, (the Medly program) and in-person cardiology clinics in the region.

Methods

A WAHA-based Medly program clinical coordinator worked closely with the University Health Network team to deliver care and support patient self-management of HF. The use and effectiveness of the Medly program were tracked through app usage and rules-based algorithm alerts, based on patient self-reported data. Distribution of relevant equipment (a scale, a blood pressure cuff, and a mobile device) for the Medly program was recorded. Surveys to assess patient and provider satisfaction with the Medly program also were administered. A retrospective chart audit of electronic medical records and administrative databases was conducted.

Results

A total of 33 patients in the WAHA were enrolled in the Medly program during a 7-month period, surpassing the enrollment goal of 25 patients. A total of 93% of eligible patients were on optimized guideline-directed medical therapy or were being titrated for it. Of 15 surveyed patients, 100% agreed or strongly agreed that the Medly program facilitated delivery of care close to home, and 86% of surveyed clinicians (n = 7) agreed or strongly agreed that the Medly program addresses a gap in available care in the region.

Conclusions

The implementation of the Medly program in partnership with the WAHA has demonstrated success in terms of the volume of referrals, the quality of care, adherence to evidence-based best-practice guidelines, and satisfaction with the program.

Digital solutions to optimize guideline-directed medical therapy prescription rates in patients with heart failure: a clinical consensus statement from the ESC Working Group on e-Cardiology, the Heart Failure Association of the European Society of Cardiology, the Association of Cardiovascular Nursing & Allied Professions of the European Society of Cardiology, the ESC Digital Health Committee, the ESC Council of Cardio-Oncology, and the ESC Patient Forum

The 2021 European Society of Cardiology guideline on diagnosis and treatment of acute and chronic heart failure (HF) and the 2023 Focused Update include recommendations on the pharmacotherapy for patients with New York Heart Association (NYHA) class II-IV HF with reduced ejection fraction. However, multinational data from the EVOLUTION HF study found substantial prescribing inertia of guideline-directed medical therapy (GDMT) in clinical practice. The cause was multifactorial and included limitations in organizational resources. Digital solutions like digital consultation, digital remote monitoring, digital interrogation of cardiac implantable electronic devices, clinical decision support systems, and multifaceted interventions are increasingly available worldwide. The objectives of this Clinical Consensus Statement are to provide (i) examples of digital solutions that can aid the optimization of prescription of GDMT, (ii) evidence-based insights on the optimization of prescription of GDMT using digital solutions, (iii) current evidence gaps and implementation barriers that limit the adoption of digital solutions in clinical practice, and (iv) critically discuss strategies to achieve equality of access, with reference to patient subgroups. Embracing digital solutions through the use of digital consults and digital remote monitoring will future-proof, for example alerts to clinicians, informing them of patients on suboptimal GDMT. Researchers should consider employing multifaceted digital solutions to optimize effectiveness and use study designs that fit the unique sociotechnical aspects of digital solutions. Artificial intelligence solutions can handle larger data sets and relieve medical professionals' workloads, but as the data on the use of artificial intelligence in HF are limited, further investigation is warranted.

Noninvasive biometric monitoring technologies for patients with heart failure

Heart failure remains one of the leading causes of mortality and hospitalizations in the US that not only impacts quality of life but also poses a significant public health burden. The majority of affected patients are admitted with signs and symptoms of congestion. Despite the initial enthusiasm, traditional remote monitoring strategies focusing primarily on weight gain failed to improve clinical outcomes. Implantable pulmonary artery pressure sensors provide earlier and actionable data, but most patients would favor forgoing an invasive procedure in favor of an alternative, non-invasive monitoring platform. Several devices utilizing different combinations of multiparameter monitoring to reliably detect congestion have recently been developed and are undergoing testing in the clinical setting. Combining these sensors with the power of artificial intelligence and machine learning has the potential to revolutionize remote patient monitoring and early congestion detection and to facilitate timely interventions by the care team to prevent hospitalization. This manuscript provides an objective review of novel, noninvasive, multiparameter remote monitoring platforms that may be tailored to individual heart failure phenotypes, aiming to improve quality of life and survival.

The Emerging and Important Role of Artificial Intelligence in Cardiac Surgery

Artificial Intelligence (AI) has greatly affected our everyday lives and holds great promise to change the landscape of medicine. AI is particularly positioned to improve care for the increasingly complex patients undergoing cardiac surgery using the immense amount of data generated in the course of their care. When deployed, AI can be used to analyze this information at the patient's bedside more expediently and accurately, all while providing new insights. This review summarizes the current applications of AI in cardiac surgery from the vantage point of a patient's journey. Applications of AI include preoperative risk assessment, intraoperative planning, postoperative patient care, and outpatient telemonitoring, encompassing the spectrum of cardiac surgical care. Offloading of administrative processes and enhanced experience with information gathering also represent a unique and under-represented avenue for future use of AI. As clinicians, understanding the nomenclature and applications of AI is important to contextualize issues, to ensure problem-driven solutions, and for clinical benefit. Precision medicine, and thus clinically relevant AI, remains dependent on data curation and warehousing to gather insights from large multicentre repositories while treating privacy with the utmost importance. AI tasks should not be siloed but rather holistically integrated into clinical workflow to retain context and relevance. As cardiac surgeons, AI allows us to look forward to a bright future of more efficient use of our clinical expertise toward high-level decision making and technical prowess.

Proceedings of the 2024 Transplant AI Symposium

With recent advancements in deep learning (DL) techniques, the use of artificial intelligence (AI) has become increasingly prevalent in all fields. Currently valued at 9.01 billion USD, it is a rapidly growing market, projected to increase by 40% per annum. There has been great interest in how AI could transform the practice of medicine, with the potential to improve all healthcare spheres from workflow management, accessibility, and cost efficiency to enhanced diagnostics with improved prognostic accuracy, allowing the practice of precision medicine. The applicability of AI is particularly promising for transplant medicine, in which it can help navigate the complex interplay of a myriad of variables and improve patient care. However, caution must be exercised when developing DL models, ensuring they are trained with large, reliable, and diverse datasets to minimize bias and increase generalizability. There must be transparency in the methodology and extensive validation of the model, including randomized controlled trials to demonstrate performance and cultivate trust among physicians and patients. Furthermore, there is a need to regulate this rapidly evolving field, with updated policies for the governance of AI-based technologies. Taking this in consideration, we summarize the latest transplant AI developments from the Ajmera Transplant Center's inaugural symposium.

Unlocking Continuous Improvement in Heart Failure Remote Monitoring: A Participatory Approach to Unveil Value Dimensions and Performance Indicators

Introduction: Heart failure (HF) constitutes a public health concern affecting quality of life, survival, and costs. Remote patient monitoring (RPM) can enhance HF management, involving patients actively and improving follow-up. While current HF RPM assessments emphasise cost-effectiveness analysis, there is a need to consider wider RPM impacts and integrate stakeholders' perspectives into assessments for better comprehensiveness. Methods: We developed a four-stage participatory approach to select value dimensions and indicators for continuous HF RPM assessment: Stage 1 involved building a literature-informed initial list; Stage 2 utilized expert interviews for validation and list expansion; Stage 3 involved a web-Delphi process with Portuguese stakeholders and experts for agreement assessment; and Stage 4 included a conclusive expert interview. Results: A literature review identified fourteen studies on telehealth, RPM, and HF, informing an initial list of four value dimensions (Access, Clinical aspects, Acceptability, and Costs) and 22 indicators. Seven semistructured interviews validated and further adjusted the list to 38 indicators. Subsequently, the web-Delphi process engaged 29 stakeholders, giving their opinions regarding assessment aspects' relevance and proposing additional elements - 1 dimension and 12 indicators. Five value dimensions and 38 indicators (76.0%) reached group agreement for selection, while 12 did not reach an agreement. Upon expert appreciation, 5 dimensions, 43 indicators, and 6 case-mix parameters were considered relevant. Discussion: This comprehensive social approach captured diverse stakeholder perspectives, achieving agreement on pertinent HF RPM monitoring and evaluation indicators. Findings can inform visualization and management tool development, aiding day-to-day RPM evaluation and identification of improvement opportunities.

The role of patient-oriented mHealth interventions in improving heart failure outcomes: A systematic review of the literature

Heart failure (HF) is a debilitating disease with 26 million patients worldwide. Consistent and complex self-care is required on the part of patients to adequately adhere to medication and to the lifestyle changes that the disease necessitates. Mobile health (mHealth) is being increasingly incorporated in patient interventions in HF, as smartphones prove to be ideal platforms for patient education and self-help assistance. This systematic review aims to summarize and report on all studies that have tested the effect of mHealth on HF patient outcomes. Our search yielded 17 studies, namely 11 randomized controlled trials and six non-randomized prospective studies. In these, patients with the assistance of an mHealth intervention regularly measured their blood pressure and/or body weight and assessed their symptoms. The outcomes were mostly related to hospitalizations, clinical biomarkers, patients' knowledge about HF, quality of life (QoL) and quality of self-care. QoL consistently increased in patients who received mHealth interventions, while study results on all other outcomes were not as ubiquitously positive. The first mHealth interventions in HF were not universally successful in improving patient outcomes but provided valuable insights for patient-oriented application development. Future trials are expected to build on these insights and deploy applications that measurably assist HF patients.

Construction of the Digital Health Equity-Focused Implementation Research Conceptual Model - Bridging the Divide Between Equity-focused Digital Health and Implementation Research

Digital health implementations and investments continue to expand. As the reliance on digital health increases, it is imperative to implement technologies with inclusive and accessible approaches. A conceptual model can be used to guide equity-focused digital health implementations to improve suitability and uptake in diverse populations. The objective of this study is expand an implementation model with recommendations on the equitable implementation of new digital health technologies. The Digital Health Equity-Focused Implementation Research (DH-EquIR) conceptual model was developed based on a rigorous review of digital health implementation and health equity literature. The Equity-Focused Implementation Research for Health Programs (EquIR) model was used as a starting point and merged with digital equity and digital health implementation models. Existing theoretical frameworks and models were appraised as well as individual equity-sensitive implementation studies. Patient and program-related concepts related to digital equity, digital health implementation, and assessment of social/digital determinants of health were included. Sixty-two articles were analyzed to inform the adaption of the EquIR model for digital health. These articles included digital health equity models and frameworks, digital health implementation models and frameworks, research articles, guidelines, and concept analyses. Concepts were organized into EquIR conceptual groupings, including population health status, planning the program, designing the program, implementing the program, and equity-focused implementation outcomes. The adapted DH-EquIR conceptual model diagram was created as well as detailed tables displaying related equity concepts, evidence gaps in source articles, and analysis of existing equity-related models and tools. The DH-EquIR model serves to guide digital health developers and implementation specialists to promote the inclusion of health-equity planning in every phase of implementation. In addition, it can assist researchers and product developers to avoid repeating the mistakes that have led to inequities in the implementation of digital health across populations.

Digital Solutions to Optimize Guideline-Directed Medical Therapy Prescriptions in Heart Failure Patients: Current Applications and Future Directions

PURPOSEOF REVIEW

Guideline-directed medical therapy (GDMT) underuse is common in heart failure (HF) patients. Digital solutions have the potential to support medical professionals to optimize GDMT prescriptions in a growing HF population. We aimed to review current literature on the effectiveness of digital solutions on optimization of GDMT prescriptions in patients with HF.

RECENT FINDINGS

We report on the efficacy, characteristics of the study, and population of published digital solutions for GDMT optimization. The following digital solutions are discussed: teleconsultation, telemonitoring, cardiac implantable electronic devices, clinical decision support embedded within electronic health records, and multifaceted interventions. Effect of digital solutions is reported in dedicated studies, retrospective studies, or larger studies with another focus that also commented on GDMT use. Overall, we see more studies on digital solutions that report a significant increase in GDMT use. However, there is a large heterogeneity in study design, outcomes used, and populations studied, which hampers comparison of the different digital solutions. Barriers, facilitators, study designs, and future directions are discussed. There remains a need for well-designed evaluation studies to determine safety and effectiveness of digital solutions for GDMT optimization in patients with HF. Based on this review, measuring and controlling vital signs in telemedicine studies should be encouraged, professionals should be actively alerted about suboptimal GDMT, the researchers should consider employing multifaceted digital solutions to optimize effectiveness, and use study designs that fit the unique sociotechnical aspects of digital solutions. Future directions are expected to include artificial intelligence solutions to handle larger datasets and relieve medical professional's workload.

The Effect of Using a Remote Patient Management Platform in Optimizing Guideline-Directed Medical Therapy in Heart Failure Patients: A Randomized Controlled Trial

BACKGROUND

Guideline-directed medical therapy (GDMT) remains underutilized in patients with heart failure with reduced ejection fraction, leading to morbidity and mortality.

OBJECTIVES

The Medly Titrate (Use of Telemonitoring to Facilitate Heart Failure Mediation Titration) study was an open-label, randomized controlled trial to determine whether remote medication titration for patients with heart failure with reduced ejection fraction was more effective than usual care (UC).

METHODS

In this study, 108 patients were randomized to remote GDMT titration through the Medly heart failure program (n = 56) vs UC (n = 52). The primary outcome was the proportion of patients completing GDMT titration at 6 months. Secondary outcomes included the number of clinic visits and time required to achieve titration, patient health outcomes, and health care utilization, including urgent clinic/emergency department visits and hospitalization.

RESULTS

At 6 months, GDMT titration was completed in 82.1% (95% CI: 71.2%-90.8%) of patients in the intervention arm vs 53.8% in UC (95% CI: 41.1%-67.7%; P = 0.001). Remote titration required fewer in-person (1.62 ± 1.09 vs 2.42 ± 1.65; P = 0.004) and virtual clinic visits (0.50 ± 1.08 vs 1.29 ± 1.86; P = 0.009) to complete titration. Median time to optimization was shorter with remote titration (3.42 months [Q1-Q3: 2.99-4.04 months] vs 5.47 months [Q1-Q3: 4.14-7.33 months]; P < 0.001). The number of urgent clinic/emergency department visits (incidence rate ratio of remote vs control groups: 0.90 [95% CI: 0.53-1.56]; P = 0.70) were similar between groups, with a reduction in all-cause hospitalization with remote titration (incidence rate ratio: 0.55 [95% CI: 0.31-0.97]; P = 0.042).

CONCLUSIONS

Remote titration of GDMT in heart failure with reduced ejection fraction was effective, safe, feasible, and increased the proportion of patients achieving target doses, in a shorter period of time with no excess adverse events compared with UC. (Use of Telemonitoring to Facilitate Heart Failure Mediation Titration [Medly Titrate]; NCT04205513).

Feasibility of a noninvasive heart failure telemonitoring system: A mixed methods study

Objective

The aim of this study was to examine the feasibility of a noninvasive telemonitoring system used by heart failure patients and nurses in a pilot program of the Heart Hospital unit in Tampere, Finland.

Methods

This cross-sectional observational study used a mixed methods design. Quantitative data were collected with one self-generated questionnaire for patients, and qualitative data were collected with a questionnaire for patients and semi-structured focus group interviews for patients and nurses. The questionnaire was sent to 47 patients who were in the pilot program, and 29 patients (61.7%) responded. Purposefully selected 8 patients and 8 nurses attended the interviews. We used descriptive statistics to assess the quantitative data from the questionnaire and inductive thematic analysis to identify themes deriving from the focus group interviews. We categorized the themes into facilitators and barriers to telemonitoring.

Results

Both the quantitative and qualitative data show that the telemonitoring system is easy to use, supports self-care and self-monitoring, and increases the feeling of safety. The chat tool of the system facilitated communication. The patients and nurses considered the system reliable despite some technical problems. The focus group interviews addressed technical challenges, nurses' increased workload, and patients' engagement with daily follow-up as possible barriers to telemonitoring.

Conclusions

The noninvasive heart failure telemonitoring system used in the pilot program is feasible. We found facilitators and barriers to telemonitoring that should be considered when developing the noninvasive telemonitoring of heart failure in the future.

The German version of the mHealth App Usability Questionnaire (GER-MAUQ): Translation and validation study in patients with cardiovascular disease

Objective

In Germany, only a few standardized evaluation tools for assessing the usability of mobile Health apps exist so far. This study aimed to translate and validate the English patient version for standalone apps of the mHealth App Usability Questionnaire (MAUQ) into a German version.

Methods

Following scientific guidelines for translation and cross-cultural adaptation, the patient version for standalone apps was forward and back-translated from English into German by an expert panel. In total, 53 participants who were recruited as part of the beta testing process of the recently developed mHealth app HerzFit, answered the questions of the German version of the MAUQ (GER-MAUQ) and the System Usability Scale. Subsequently, a descriptive as well as a psychometric analysis was performed to test validity and reliability.

Results

After conducting three cognitive interviews, five items were modified. The values for Cronbach alpha for the entire questionnaire and the three subscales (0.966, 0.814, 0.910, and 0.909) indicate strong internal consistency. The correlation analysis revealed that the scores of the GER-MAUQ, the subscales and the SUS were strongly correlated with each other. The correlation coefficient of the SUS and the GER-MAUQ overall score was r = 0.854, P < 0.001 and the coefficients of the subscales and the SUS were r = 0.642, P < 0.001; r = 0.866, P < 0.001 and r = 0.643, P < 0.001.

Conclusions

We have developed a novel German version of the MAUQ and demonstrated it as a reliable and valid measurement tool for assessing the usability of standalone mHealth apps from the patients' perspective. The GER-MAUQ allows a new form of standardized assessment of usability of mHealth apps for patients with cardiovascular disease in Germany. Further research with a larger sample and other samples is recommended.

Design of a Dyadic Digital Health Module for Chronic Disease Shared Care: Development Study

BACKGROUND

The COVID-19 pandemic forced the spread of digital health tools to address limited clinical resources for chronic health management. It also illuminated a population of older patients requiring an informal caregiver (IC) to access this care due to accessibility, technological literacy, or English proficiency concerns. For patients with heart failure (HF), this rapid transition exacerbated the demand on ICs and pushed Canadians toward a dyadic care model where patients and ICs comanage care. Our previous work identified an opportunity to improve this dyadic HF experience through a shared model of dyadic digital health. We call this alternative model of care "Caretown for Medly," which empowers ICs to concurrently expand patients' self-care abilities while acknowledging ICs' eagerness to provide greater support.

OBJECTIVE

We present the systematic design and development of the Caretown for Medly dyadic management module. While HF is the outlined use case, we outline our design methodology and report on 6 core disease-invariant features applied to dyadic shared care for HF management. This work lays the foundation for future usability assessments of Caretown for Medly.

METHODS

We conducted a qualitative, human-centered design study based on 25 semistructured interviews with self-identified ICs of loved ones living with HF. Interviews underwent thematic content analysis by 2 coders independently for themes derived deductively (eg, based on the interview guide) and inductively refined. To build the Caretown for Medly model, we (1) leveraged the Knowledge to Action (KTA) framework to translate knowledge into action and (2) borrowed Google Sprint's ability to quickly "solve big problems and test new ideas," which has been effective in the medical and digital health spaces. Specifically, we blended these 2 concepts into a new framework called the "KTA Sprint."

RESULTS

We identified 6 core disease-invariant features to support ICs in care dyads to provide more effective care while capitalizing on dyadic care's synergistic benefits. Features were designed for customizability to suit the patient's condition, informed by stakeholder analysis, corroborated with literature, and vetted through user needs assessments. These features include (1) live reports to enhance data sharing and facilitate appropriate IC support, (2) care cards to enhance guidance on the caregiving role, (3) direct messaging to dissolve the disconnect across the circle of care, (4) medication wallet to improve guidance on managing complex medication regimens, (5) medical events timeline to improve and consolidate management and organization, and (6) caregiver resources to provide disease-specific education and support their self-care.

CONCLUSIONS

These disease-invariant features were designed to address ICs' needs in supporting their care partner. We anticipate that the implementation of these features will empower a shared model of care for chronic disease management through digital health and will improve outcomes for care dyads.

Review and content analysis of mobile apps for inflammatory bowel disease management using the mobile application rating scale (MARS): Systematic search in app stores

BACKGROUND

People with inflammatory bowel disease (IBD) need tools for self-management of their disease with the ultimate goal of improving medication adherence and health outcomes. Mobile apps represent a novel opportunity to provide self-management for patients with IBD. Many mobile apps have been developed for IBD self-management, but more evidence is needed about the quality of these mobile apps.

OBJECTIVE

This study evaluated mobile apps developed for the IBD community and rated the quality of these apps to provide a roadmap for future development.

MATERIALS AND METHODS

The Apple App Store and Google Play Store were systematically searched to identify IBD mobile apps for patients and physicians based on the IBD-related keywords. We included mobile apps that focus on IBD, are in the English language, and are free. The related app quality was evaluated independently by two reviewers using the Mobile Application Rating Scale (MARS).

RESULTS

We identified 401 mobile apps. After removing duplicates and unrelated apps, 44 apps were included in the review. Overall, the mean MARS scores were 3.5 (SD = 0.5) on a scale from 1.00 to 5.00, which was the acceptable range.; 12 apps got scores ≥ 4.00. The highest mean domain score belonged to the functionality dimension (mean = 3.9, SD = 0.6) and the lowest belonged to the engagement dimension (mean = 3.2, SD = 0.8).

CONCLUSION

The MARS ratings showed that the IBD mobile apps quality meet acceptable criteria. However, more attention must be paid to design features that improve user interest and engagement, especially among children and adolescents. Healthcare professional involvement is crucial for designing mobile health apps.

Cost-effectiveness analysis of digital therapeutics for home-based cardiac rehabilitation for patients with chronic heart failure: model development and data analysis

BACKGROUND

In recent years, numerous guidelines and expert consensus have recommended the inclusion of digital technologies and products in cardiac rehabilitation. Digital therapeutics (DTx) is an evidence-based medicine that uses digital means for data collection and monitoring of indicators to control and optimize the treatment, management, and prevention of disease.

OBJECTIVE

This study collected and reviewed real-world data and built a model using health economics assessment methods to analyze the potential cost-effectiveness of DTx applied to home-based cardiac rehabilitation for patients with chronic heart failure. From the perspective of medical and health decision-makers, the economic value of DTx is evaluated prospectively to provide the basis and reference for the application decision and promotion of DTx.

METHODS

Markov models were constructed to simulate the outcomes of DTx for home-based cardiac rehabilitation (DT group) compared to conventional home-based cardiac rehabilitation (CH group) in patients with chronic heart failure. The model input parameters were clinical indicators and cost data. Outcome indicators were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). The robustness of the evaluation methods and results was tested using sensitivity analyses. Clinical indicators, cost data, and health utility values were obtained from real-world data, including clinical study data, published literature, and public website information.

RESULTS

The Markov model simulated a time span of 10 years, with a cycle set at one month, for 120 cycles. The results showed that the per capita cost of the CH group was 38,442.11 CNY/year, with a QALY of 0.7196 per person per year. The per capita cost of the DT group was 42,300.26 CNY/year, with a QALY of 0.81687 per person per year. The ICER per person was 39,663.5 CNY/QALY each year, which was below the willingness-to-pay threshold of 85,698 CNY (China's GDP per capita in 2022).

CONCLUSIONS

DTx for home-based cardiac rehabilitation is an extremely cost-effective rehabilitation option compared with conventional home-based cardiac rehabilitation. DTx for home-based cardiac rehabilitation is potentially valuable from the perspective of healthcare decision-makers.

Virtual healthcare solutions in heart failure: a literature review

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.

Telemonitoring for heart failure: a meta-analysis

AIMS

Telemonitoring modalities in heart failure (HF) have been proposed as being essential for future organization and transition of HF care, however, efficacy has not been proven. A comprehensive meta-analysis of studies on home telemonitoring systems (hTMS) in HF and the effect on clinical outcomes are provided.

METHODS AND RESULTS

A systematic literature search was performed in four bibliographic databases, including randomized trials and observational studies that were published during January 1996-July 2022. A random-effects meta-analysis was carried out comparing hTMS with standard of care. All-cause mortality, first HF hospitalization, and total HF hospitalizations were evaluated as study endpoints. Sixty-five non-invasive hTMS studies and 27 invasive hTMS studies enrolled 36 549 HF patients, with a mean follow-up of 11.5 months. In patients using hTMS compared with standard of care, a significant 16% reduction in all-cause mortality was observed [pooled odds ratio (OR): 0.84, 95% confidence interval (CI): 0.77-0.93, I2: 24%], as well as a significant 19% reduction in first HF hospitalization (OR: 0.81, 95% CI 0.74-0.88, I2: 22%) and a 15% reduction in total HF hospitalizations (pooled incidence rate ratio: 0.85, 95% CI 0.76-0.96, I2: 70%).

CONCLUSION

These results are an advocacy for the use of hTMS in HF patients to reduce all-cause mortality and HF-related hospitalizations. Still, the methods of hTMS remain diverse, so future research should strive to standardize modes of effective hTMS.

The Complexity of Transferring Remote Monitoring and Virtual Care Technology Between Countries: Lessons From an International Workshop

International deployment of remote monitoring and virtual care (RMVC) technologies would efficiently harness their positive impact on outcomes. Since Canada and the United Kingdom have similar populations, health care systems, and digital health landscapes, transferring digital health innovations between them should be relatively straightforward. Yet examples of successful attempts are scarce. In a workshop, we identified 6 differences that may complicate RMVC transfer between Canada and the United Kingdom and provided recommendations for addressing them. These key differences include (1) minority groups, (2) physical geography, (3) clinical pathways, (4) value propositions, (5) governmental priorities and support for digital innovation, and (6) regulatory pathways. We detail 4 broad recommendations to plan for sustainability, including the need to formally consider how highlighted country-specific recommendations may impact RMVC and contingency planning to overcome challenges; the need to map which pathways are available as an innovator to support cross-country transfer; the need to report on and apply learnings from regulatory barriers and facilitators so that everyone may benefit; and the need to explore existing guidance to successfully transfer digital health solutions while developing further guidance (eg, extending the nonadoption, abandonment, scale-up, spread, sustainability framework for cross-country transfer). Finally, we present an ecosystem readiness checklist. Considering these recommendations will contribute to successful international deployment and an increased positive impact of RMVC technologies. Future directions should consider characterizing additional complexities associated with global transfer.

Bridging community and clinic through digital health: Community-based adaptation of a mobile phone-based heart failure program for remote communities in Uganda

Background

In Uganda, limited healthcare access has created a significant burden for patients living with heart failure. With the increasing use of mobile phones, digital health tools could offer an accessible platform for individualized care support. In 2016, our multi-national team adapted a mobile phone-based program for heart failure self-care to the Ugandan context and found that patients using the system showed improvements in their symptoms and quality of life. With approximately 84% of Ugandans residing in rural communities, the Medly Uganda program can provide greater benefit for communities in rural areas with limited access to care. To support the implementation of this program within rural communities, this study worked in partnership with two remote clinics in Northern Uganda to identify the cultural and service level requirements for the program.

Methods

Using the principles from community-based research and user-centered design, we conducted a mixed-methods study composed of 4 participatory consensus cycles, 60 semi-structured interviews (SSI) and 8 iterative co-design meetings at two remote cardiac clinics. Patient surveys were also completed during each SSI to collect data related to cell phone access, community support, and geographic barriers. Qualitative data was analyzed using inductive thematic analysis. The Indigenous method of two-eyed seeing was also embedded within the analysis to help promote local perspectives regarding community care.

Results

Five themes were identified. The burden of travel was recognized as the largest barrier for care, as patients were travelling up to 19 km by motorbike for clinic visits. Despite mixed views on traditional medicine, patients often turned to healers due to the cost of medication and transport. With most patients owning a non-smartphone (n = 29), all participants valued the use of a digital tool to improve equitable access to care. However, to sustain program usage, integrating the role of village health teams (VHTs) to support in-community follow-ups and medication delivery was recognized as pivotal.

Conclusion

The use of a mobile phone-based digital health program can help to reduce the barrier of geography, while empowering remote HF self-care. By leveraging the trusted role of VHTs within the delivery of the program, this will help enable more culturally informed care closer to home.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44247-023-00020-5.

Examining standardized tools used for the evaluation of mobile health applications for cardiovascular disease

Cardiovascular disease is one of the leading causes of death worldwide. Scarce resources and rising costs are pushing healthcare systems to their limits. There is an urgency to develop, optimize and evaluate technologies that provide more effective care for patients. Modern technologies, such as mobile health (mHealth) applications, can provide relief as a key strategy. To integrate digital interventions into care structures, a detailed impact assessment of all professional mHealth applications is needed. The aim of this study is to analyze the standardized tools used in the field of cardiovascular disease. The results show that questionnaires, usage logs, and key indicators are predominantly used. Although the identified mHealth interventions are specific to cardiovascular disease and thus require particular questions to evaluate apps, the user readiness, usability, or quality of life criteria are non-specific. Therefore, the results contribute to understanding how different mHealth interventions can be assessed, categorized, evaluated, and accepted.

Remote Monitoring for Heart Failure Management at Home

Early telemonitoring of weights and symptoms did not decrease heart failure hospitalizations but helped identify steps toward effective monitoring programs. A signal that is accurate and actionable with response kinetics for early re-assessment is required for the treatment of patients at high risk, while signal specifications differ for surveillance of low-risk patients. Tracking of congestion with cardiac filling pressures or lung water content has shown most impact to decrease hospitalizations, while multiparameter scores from implanted rhythm devices have identified patients at increased risk. Algorithms require better personalization of signal thresholds and interventions. The COVID-19 epidemic accelerated transition to remote care away from clinics, preparing for new digital health care platforms to accommodate multiple technologies and empower patients. Addressing inequities will require bridging the digital divide and the deep gap in access to HF care teams, who will not be replaced by technology but by care teams who can embrace it.

Clinical Pathways Guided by Remotely Monitoring Cardiac Device Data: The Future of Device Heart Failure Management?

Research examining the utility of cardiac device data to manage patients with heart failure (HF) is rapidly evolving. COVID-19 has reignited interest in remote monitoring, with manufacturers each developing and testing new ways to detect acute HF episodes, risk stratify patients and support self-care. As standalone diagnostic tools, individual physiological metrics and algorithm-based systems have demonstrated utility in predicting future events, but the integration of remote monitoring data with existing clinical care pathways for device HF patients is not well described. This narrative review provides an overview of device-based HF diagnostics available to care providers in the UK, and describes the current state of play with regard to how these systems fit in with current HF management.

Effectiveness of mobile telemonitoring applications in heart failure patients: systematic review of literature and meta-analysis

Close and frequent follow-up of heart failure (HF) patients improves clinical outcomes. Mobile telemonitoring applications are advantageous alternatives due to their wide availability, portability, low cost, computing power, and interconnectivity. This study aims to evaluate the impact of telemonitoring apps on mortality, hospitalization, and quality of life (QoL) in HF patients. We conducted a registered (PROSPERO CRD42022299516) systematic review of randomized clinical trials (RCTs) evaluating mobile-based telemonitoring strategies in patients with HF, published between January 2000 and December 2021 in 4 databases (PubMed, EMBASE, BVSalud/LILACS, Cochrane Reviews). We assessed the risk of bias using the RoB2 tool. The outcome of interest was the effect on mortality, hospitalization risk, and/or QoL. We performed meta-analysis when appropriate; heterogeneity and risk of publication bias were evaluated. Otherwise, descriptive analyses are offered. We screened 900 references and 19 RCTs were included for review. The risk of bias for mortality and hospitalization was mostly low, whereas for QoL was high. We observed a reduced risk of hospitalization due to HF with the use of mobile-based telemonitoring strategies (RR 0.77 [0.67; 0.89]; I2 7%). Non-statistically significant reduction in mortality risk was observed. The impact on QoL was variable between studies, with different scores and reporting measures used, thus limiting data pooling. The use of mobile-based telemonitoring strategies in patients with HF reduces risk of hospitalization due to HF. As smartphones and wirelessly connected devices are increasingly available, further research on this topic is warranted, particularly in the foundational therapy.

A Voice App Design for Heart Failure Self-management: Proof-of-Concept Implementation Study

BACKGROUND

Voice user interfaces are becoming more prevalent in health care and are commonly being used for patient engagement. There is a growing interest in identifying the potential this form of interface has on patient engagement with digital therapeutics (DTx) in chronic disease management. Making DTx accessible through an alternative interaction model also has the potential to better meet the needs of some patients, such as older adults and those with physical and cognitive impairments, based on existing research.

OBJECTIVE

This study aimed to evaluate how participants with heart failure interacted with a voice app version of a DTx, Medly, through a proof-of-concept implementation study design. The objective was to understand whether the voice app would enable the participants to successfully interact with the DTx, with a focus on acceptability and feasibility.

METHODS

A mixed methods concurrent triangulation design was used to better understand the acceptability and feasibility of the use of the Medly voice app with the study participants (N=20) over a 4-week period. Quantitative data included engagement levels, accuracy rates, and questionnaires, which were analyzed using descriptive statistics. Qualitative data included semistructured interviews and were analyzed using a qualitative descriptive approach.

RESULTS

The overall average engagement level was 73% (SD 9.5%), with a 14% decline between results of weeks 1 and 4. The biggest difference was between the average engagement levels of the oldest and youngest demographics, 84% and 43%, respectively, but these results were not significant-Kruskal-Wallis test, H(2)=3.8 (P=.14). The Medly voice app had an overall accuracy rate of 97.8% and was successful in sending data to the clinic. From an acceptability perspective, the voice app was ranked in the 80th percentile, and overall, the users felt that the voice app was not a lot of work (average of 2.1 on a 7-point Likert scale). However, the overall average score for whether users would use it in the future declined by 13%. Thematic analysis revealed the following: the theme feasibility of clinical integration had 2 subthemes, namely users adapted to the voice app's conversational style and device unreliability, and the theme voice app acceptability had 3 subthemes, namely the device integrated well within household and users' lives, users blamed themselves when problems arose with the voice app, and voice app was missing specific, desirable user features.

CONCLUSIONS

In conclusion, participants were largely successful in using the Medly voice app despite some of the barriers faced, proving that an app such as this could be feasible to be deployed in the clinic. Our data begin to piece together the patient profile this technology may be most suitable for, namely those who are older, have flexible schedules, are confident in using technology, and are experiencing other medical conditions.

Design of a Patient Voice App Experience for Heart Failure Management: Usability Study

BACKGROUND

The use of digital therapeutics (DTx) in the prevention and management of medical conditions has increased through the years, with an estimated 44 million people using one as part of their treatment plan in 2021, nearly double the number from the previous year. DTx are commonly accessed through smartphone apps, but offering these treatments through additional platforms can improve the accessibility of these interventions. Voice apps are an emerging technology in the digital health field; not only do they have the potential to improve DTx adherence, but they can also create a better user experience for some user groups.

OBJECTIVE

This research aimed to identify the acceptability and feasibility of offering a voice app for a chronic disease self-management program. The objective of this project was to design, develop, and evaluate a voice app of an already-existing smartphone-based heart failure self-management program, Medly, to be used as a case study.

METHODS

A voice app version of Medly was designed and developed through a user-centered design process. We conducted a usability study and semistructured interviews with patients with heart failure (N=8) at the Peter Munk Cardiac Clinic in Toronto General Hospital to better understand the user experience. A Medly voice app prototype was built using a software development kit in tandem with a cloud computing platform and was verified and validated before the usability study. Data collection and analysis were guided by a mixed methods triangulation convergence design.

RESULTS

Common themes were identified in the results of the usability study, which involved 8 participants with heart failure. Almost all participants (7/8, 88%) were satisfied with the voice app and felt confident using it, although half of the participants (4/8, 50%) were unsure about using it in the future. Six main themes were identified: changes in physical behavior, preference between voice app and smartphone, importance of music during voice app interaction, lack of privacy concerns, desired reassurances during voice app interaction, and helpful aids during voice app interaction. These findings were triangulated with the quantitative data, and it concluded that the main area for improvement was related to the ease of use; design changes were then implemented to better improve the user experience.

CONCLUSIONS

This work offered preliminary insight into the acceptability and feasibility of a Medly voice app. Given the recent emergence of voice apps in health care, we believe that this research offered invaluable insight into successfully deploying DTx for chronic disease self-management using this technology.

Characteristics of Smart Health Ecosystems That Support Self-care Among People With Heart Failure: Scoping Review

BACKGROUND

The management of heart failure is complex. Innovative solutions are required to support health care providers and people with heart failure with decision-making and self-care behaviors. In recent years, more sophisticated technologies have enabled new health care models, such as smart health ecosystems. Smart health ecosystems use data collection, intelligent data processing, and communication to support the diagnosis, management, and primary and secondary prevention of chronic conditions. Currently, there is little information on the characteristics of smart health ecosystems for people with heart failure.

OBJECTIVE

We aimed to identify and describe the characteristics of smart health ecosystems that support heart failure self-care.

METHODS

We conducted a scoping review using the Joanna Briggs Institute methodology. The MEDLINE, Embase, CINAHL, PsycINFO, IEEE Xplore, and ACM Digital Library databases were searched from January 2008 to September 2021. The search strategy focused on identifying articles describing smart health ecosystems that support heart failure self-care. A total of 2 reviewers screened the articles and extracted relevant data from the included full texts.

RESULTS

After removing duplicates, 1543 articles were screened, and 34 articles representing 13 interventions were included in this review. To support self-care, the interventions used sensors and questionnaires to collect data and used tailoring methods to provide personalized support. The interventions used a total of 34 behavior change techniques, which were facilitated by a combination of 8 features for people with heart failure: automated feedback, monitoring (integrated and manual input), presentation of data, education, reminders, communication with a health care provider, and psychological support. Furthermore, features to support health care providers included data presentation, alarms, alerts, communication tools, remote care plan modification, and health record integration.

CONCLUSIONS

This scoping review identified that there are few reports of smart health ecosystems that support heart failure self-care, and those that have been reported do not provide comprehensive support across all domains of self-care. This review describes the technical and behavioral components of the identified interventions, providing information that can be used as a starting point for designing and testing future smart health ecosystems.

The value of technology to support dyadic caregiving for individuals living with heart failure: A qualitative descriptive study (Preprint)

Background

The demand for health services to meet the chronic health needs of the aging population is significant and remains unmet because of the limited supply of clinical resources. Specifically, in managing heart failure (HF), digital health sought to address this gap during the COVID-19 pandemic but highlighted an access issue for those who could not use technology-mediated health care services without the support of their informal caregivers (ICs). The complexity of managing HF symptoms and recurrent exacerbations requires many patients to comanage their illness with their ICs in a care dyad, working together to optimize patient outcomes and health-related quality of life. However, most HF programs have missed the opportunity to consider the dyadic perspective despite interdependencies on HF outcomes.

Objective

This study aims to characterize the value of technology in supporting caregiving for individuals living with HF.

Methods

Motivated by an observed unique pattern of engagement in patients enrolled in our Medly HF management program at the Peter Munk Cardiac Centre in Toronto, Canada, we conducted 20 semistructured interviews with a convenience sample of ICs. All interviews were analyzed using the iterative refinement of a codeveloped codebook. The team maintained reflexivity journals to reflect the impact of their positionality on their coding. Themes were first derived deductively using HF typologies (patient-oriented dyads, caregiver-oriented dyads, and collaboratively oriented dyads) and then inductively refined and recategorized based on concepts from the van Houtven et al framework.

Results

We believe that there is a need to formally and intentionally expand HF technologies to include dyadic needs and goals. We suggest defining 3 opportunities in which value can be added to technological design. First, identify how technology may be leveraged to increase psychological bandwidth by reducing uncertainty and providing peace of mind. We found that actionable feedback was highly desired by both partners. Second, develop technology that can serve as a member of the dyad’s support system. In our experience, automated prompts for patients to take measurements can mimic the support typically provided by ICs and ease their workload. Third, consider how technology can mitigate the dyad’s clinical knowledge requirements and learning curve. Our approach includes real-time actionable feedback paired with a human-in-the-loop, nurse-led model of care.

Conclusions

Our findings identified a need to focus on improving the dyadic experience as a whole by building IC functionality into digital health self-management interventions. Through a shared model of care that supports the role of the patient in their own HF management, includes ICs to expand and enhance the patient’s capacity to care, and acknowledges the need of ICs to care for themselves, we anticipate improved outcomes for both partners.

Risk Factors for Hospital Readmission Post-Transcatheter Aortic Valve Implantation in the Contemporary Era: A Systematic Review

Background

Despite transcatheter aortic valve implantation (TAVI) becoming a widely accepted therapeutic option for the management of aortic stenosis, post-procedure readmission rates remain high. Rehospitalization is associated with negative patient outcomes, as well as increased healthcare costs, and has therefore been identified as an important target for quality improvement. Strategies to reduce the post-TAVI readmission rate are needed but require the identification of patients at high risk for rehospitalization. Our systematic review aims to identify predictors of post-procedure readmission in patients eligible for TAVI.

Methods

We conducted a comprehensive search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases for the time period from 2015 to the present for articles evaluating risk factors for rehospitalization post-TAVI with a follow-up period of at least 30 days in adults age ≥ 70 years with aortic stenosis. The quality of included studies was evaluated using the Newcastle-Ottawa Scale. We present the results as a qualitative narrative review.

Results

We identified 49 studies involving 828,528 patients. Post-TAVI readmission is frequent, and rates vary (14.9% to 54.3% at 1 year). The most-frequent predictors identified for both 30-day and 1-year post-TAVI readmission are atrial fibrillation, lung disease, renal disease, diabetes mellitus, in-hospital life-threatening bleeding, and non-femoral access.

Conclusions

This systematic review identifies the most-common predictors for 30-day and 1-year readmission post-TAVI, including comorbidities and potentially modifiable procedural approaches and complications. These predictors can be used to identify patients at high-risk for readmission who are most likely to benefit from increased support and follow-up post-TAVI.

Voice activated remote monitoring technology for heart failure patients: Study design, feasibility and observations from a pilot randomized control trial

BACKGROUND

Heart failure (HF) is a serious health condition, associated with high health care costs, and poor outcomes. Patient empowerment and self-care are a key component of successful HF management. The emergence of telehealth may enable providers to remotely monitor patients' statuses, support adherence to medical guidelines, improve patient wellbeing, and promote daily awareness of overall patients' health.

OBJECTIVE

To assess the feasibility of a voice activated technology for monitoring of HF patients, and its impact on HF clinical outcomes and health care utilization.

METHODS

We conducted a randomized clinical trial; ambulatory HF patients were randomized to voice activated technology or standard of care (SOC) for 90 days. The system developed for this study monitored patient symptoms using a daily survey and alerted healthcare providers of pre-determined reported symptoms of worsening HF. We used summary statistics and descriptive visualizations to study the alerts generated by the technology and to healthcare utilization outcomes.

RESULTS

The average age of patients was 54 years, the majority were Black and 45% were women. Almost all participants had an annual income below $50,000. Baseline characteristics were not statistically significantly different between the two arms. The technical infrastructure was successfully set up and two thirds of the invited study participants interacted with the technology. Patients reported favorable perception and high comfort level with the use of voice activated technology. The responses from the participants varied widely and higher perceived symptom burden was not associated with hospitalization on qualitative assessment of the data visualization plot. Among patients randomized to the voice activated technology arm, there was one HF emergency department (ED) visit and 2 HF hospitalizations; there were no events in the SOC arm.

CONCLUSIONS

This study demonstrates the feasibility of remote symptom monitoring of HF patients using voice activated technology. The varying HF severity and the wide range of patient responses to the technology indicate that personalized technological approaches are needed to capture the full benefit of the technology. The differences in health care utilization between the two arms call for further study into the impact of remote monitoring on health care utilization and patients' wellbeing.

Review and Analysis of German Mobile Apps for Inflammatory Bowel Disease Management Using the Mobile Application Rating Scale: Systematic Search in App Stores and Content Analysis

Background

Patients suffering from inflammatory bowel disease (IBD) frequently need long-term medical treatment. Mobile apps promise to complement and improve IBD management, but so far there has been no scientific analysis of their quality.

Objective

This study evaluated the quality of German mobile apps targeting IBD patients and physicians treating IBD patients using the Mobile Application Rating Scale (MARS).

Methods

The German Apple App Store and Google Play Store were systematically searched to identify German IBD mobile apps for patient and physician use. MARS was used by 6 physicians (3 using Android smartphones and 3 using iPhones) to independently assess app quality. Apps were randomly assigned so that the 4 apps with the most downloads were rated by all raters and the remaining apps were rated by 1 Android and 1 iOS user.

Results

In total, we identified 1764 apps in the Apple App Store and Google Play Store. After removing apps that were not related to IBD (n=1386) or not available in German (n=317), 61 apps remained. After removing duplicates (n=3) and apps for congresses (n=7), journals (n=4), and clinical studies (n=6), as well as excluding apps that were available in only 1 of the 2 app stores (n=20) and apps that could only be used with an additional device (n=7), we included a total of 14 apps. The app “CED Dokumentation und Tipps” had the highest overall median MARS score at 4.11/5. On the whole, the median MARS scores of the 14 apps ranged between 2.38/5 and 4.11/5. As there was no significant difference between iPhone and Android raters, we used the Wilcoxon comparison test to calculate P values.

Conclusions

The MARS ratings showed that the quality of German IBD apps varied. We also discovered a discrepancy between app store ratings and MARS ratings, highlighting the difficulty of assessing perceived app quality. Despite promising results from international studies, there is little evidence for the clinical benefits of German IBD apps. Clinical studies and patient inclusion in the app development process are needed to effectively implement mobile apps in routine care.

Continuous remote patient monitoring in heart failure patients (CASCADE study): mixed methods feasibility protocol (Preprint)

Background

Heart failure (HF) is a prevalent chronic disease and is associated with increases in mortality and morbidity. HF is a leading cause of hospitalizations and readmissions in the United States. A potentially promising area for preventing HF readmissions is continuous remote patient monitoring (CRPM).

Objective

The primary aim of this study is to determine the feasibility and preliminary efficacy of a CRPM solution in patients with HF at NorthShore University HealthSystem.

Methods

This study is a feasibility study and uses a wearable biosensor to continuously remotely monitor patients with HF for 30 days after discharge. Eligible patients admitted with an HF exacerbation at NorthShore University HealthSystem are being recruited, and the wearable biosensor is placed before discharge. The biosensor collects physiological ambulatory data, which are analyzed for signs of patient deterioration. Participants are also completing a daily survey through a dedicated study smartphone. If prespecified criteria from the physiological data and survey results are met, a notification is triggered, and a predetermined electronic health record–based pathway of telephonic management is completed. In phase 1, which has already been completed, 5 patients were enrolled and monitored for 30 days after discharge. The results of phase 1 were analyzed, and modifications to the program were made to optimize it. After analysis of the phase 1 results, 15 patients are being enrolled for phase 2, which is a calibration and testing period to enable further adjustments to be made. After phase 2, we will enroll 45 patients for phase 3. The combined results of phases 1, 2, and 3 will be analyzed to determine the feasibility of a CRPM program in patients with HF. Semistructured interviews are being conducted with key stakeholders, including patients, and these results will be analyzed using the affective adaptation of the technology acceptance model.

Results

During phase 1, of the 5 patients, 2 (40%) were readmitted during the study period. The study completion rate for phase 1 was 80% (4/5), and the study attrition rate was 20% (1/5). There were 57 protocol deviations out of 150 patient days in phase 1 of the study. The results of phase 1 were analyzed, and the study protocol was adjusted to optimize it for phases 2 and 3. Phase 2 and phase 3 results will be available by the end of 2022.

Conclusions

A CRPM program may offer a low-risk solution to improve care of patients with HF after hospital discharge and may help to decrease readmission of patients with HF to the hospital. This protocol may also lay the groundwork for the use of CRPM solutions in other groups of patients considered to be at high risk.

International Registered Report Identifier (IRRID)

DERR1-10.2196/36741

The Future of Virtual Care for Older Ethnic Adults Beyond the COVID-19 Pandemic

The COVID-19 pandemic has fundamentally changed how Canadians access health care. Although it is undeniable that the rapid adoption of virtual care has played a critical role in reducing viral transmission, the gap in equitable access to virtual care remains pervasive for Canada's aging and ethnocultural minority communities. Existing virtual care solutions are designed for the English-speaking, health-literate, and tech-savvy patient population, excluding older ethnic adults who often do not see themselves reflected in these identities. In acknowledging the permanency of virtual care brought on by the pandemic, we have a collective responsibility to co-design new models that serve our older ethnic patients who have been historically marginalized by the status quo. Building on existing foundations of caregiving within ethnocultural minority communities, one viable strategy to realize culturally equitable virtual care may be to engage the highly motivated and skilled family caregivers of older ethnic adults as partners in the technology-mediated management of their chronic disease. The time is now to build a model of shared virtual care that embraces Canada's diverse cultures, while also providing its older ethnic adults with access to health innovations in partnership with equally invested family caregivers who have their health at heart.

A digital self-care intervention for Ugandan patients with heart failure and their clinicians: User-centred design and usability study

Background

The prevalence of heart failure (HF) is increasing in Uganda. Ugandan patients with HF report receiving limited information about their illness and associated self-care behaviours. Interventions targeted at improving HF self-care have been shown to improve patient quality of life and reduce hospitalizations in high-income countries. However, such interventions remain underutilized in resource-limited settings like Uganda. This study aimed to develop a digital health intervention that enables improved self-care amongst HF patients in Uganda.

Methods

We implemented a user-centred design (UCD) process to develop a self-care intervention entitled Medly Uganda. The ideation phase comprised a scoping review and preliminary data collection amongst HF patients and clinicians in Uganda. An iterative design process was then used to advance an initial prototype into a functional digital health intervention. The evaluation phase involved usability testing of the intervention amongst Ugandan patients with HF and their clinicians.

Results

Medly Uganda is a digital health intervention that allows patients to report daily HF symptoms, receive tailored treatment advice and connect with a clinician when showing signs of decompensation. The system harnesses Unstructured Supplementary Service Data (USSD) technology that is already widely used in Uganda for mobile phone-based financial transactions. Usability testing showed Medly Uganda to be both acceptable and feasible amongst clinicians, patients and caregivers.

Conclusions

Medly Uganda is a functional digital health intervention with demonstrated acceptability and feasibility in enabling Ugandan HF patients to better care for themselves. We are hopeful that the system will improve self-care efficacy amongst HF patients in Uganda.

Continuous Remote Patient Monitoring: Evaluation of the Heart Failure Cascade Soft Launch

OBJECTIVE

We report on our experience of deploying a continuous remote patient monitoring (CRPM) study soft launch with structured cascading and escalation pathways on heart failure (HF) patients post-discharge. The lessons learned from the soft launch are used to modify and fine-tune the workflow process and study protocol.

METHODS

This soft launch was conducted at NorthShore University HealthSystem's Evanston Hospital from December 2020 to March 2021. Patients were provided with non-invasive wearable biosensors that continuously collect ambulatory physiological data, and a study phone that collects patient-reported outcomes. The physiological data are analyzed by machine learning algorithms, potentially identifying physiological perturbation in HF patients. Alerts from this algorithm may be cascaded with other patient status data to inform home health nurses' (HHNs') management via a structured protocol. HHNs review the monitoring platform daily. If the patient's status meets specific criteria, HHNs perform assessments and escalate patient cases to the HF team for further guidance on early intervention.

RESULTS

We enrolled five patients into the soft launch. Four participants adhered to study activities. Two out of five patients were readmitted, one due to HF, one due to infection. Observed miscommunication and protocol gaps were noted for protocol amendment. The study team adopted an organizational development method from change management theory to reconfigure the study protocol.

CONCLUSION

We sought to automate the monitoring aspects of post-discharge care by aligning a new technology that generates streaming data from a wearable device with a complex, multi-provider workflow into a novel protocol using iterative design, implementation, and evaluation methods to monitor post-discharge HF patients. CRPM with structured escalation and telemonitoring protocol shows potential to maintain patients in their home environment and reduce HF-related readmissions. Our results suggest that further education to engage and empower frontline workers using advanced technology is essential to scale up the approach.

Digital Technology Application for Improved Responses to Health Care Challenges: Lessons Learned From COVID-19

While COVID-19 is still ongoing and associated with more than 5 million deaths, the scope and speed of advances over the past year in terms of scientific discovery, data dissemination, and technology have been staggering. It is not a matter of “if” but “when” we will face the next pandemic, and how we leverage technology and data management effectively to create flexible ecosystems that facilitate collaboration, equitable care, and innovation will determine its severity and scale. The aim of this review is to address emerging challenges that came to light during the pandemic in health care and innovations that enabled us to adapt and continue to care for patients. The pandemic highlighted the need for seismic shifts in care paradigms and technology with considerations related to the digital divide and health literacy for digital health interventions to reach full potential and improve health outcomes. We discuss advances in telemedicine, remote patient monitoring, and emerging wearable technologies. Despite the promise of digital health, we emphasise the importance of addressing its limitations, including interpretation challenges, accuracy of findings, and artificial intelligence–driven algorithms. We summarise the most recent recommendation of the Virtual Care Task Force to scaling virtual medical services in Canada. Finally, we propose a model for optimal implementation of health digital innovations with 5 tenets including data management, data security, digital biomarkers, useful artificial intelligence, and clinical integration.

Experiences and Perceptions of Patients and Providers Participating in Remote Titration of Heart Failure Medication Facilitated by Telemonitoring: Qualitative Study

BACKGROUND

Guideline-directed medical therapy (GDMT), optimized to target doses, improves health outcomes in patients with heart failure. However, GDMT remains underused, with <25% of patients receiving target doses in clinical practice. A randomized controlled trial was conducted at the Peter Munk Cardiac Centre in Toronto to compare a remote GDMT titration intervention with standard in-office titration. This randomized controlled trial found that remote titration increased the proportion of patients who achieved optimal GDMT doses, decreased the time to dose optimization, and reduced the number of essential clinic visits. This paper presents findings from the qualitative component of the mixed methods study, which evaluated the implementation of the remote titration intervention.

OBJECTIVE

The objective of the qualitative component is to assess the perceptions and experiences of clinicians and patients with heart failure who participated in the remote titration intervention to identify factors that affected the implementation of the intervention.

METHODS

We conducted semistructured interviews with clinicians (n=5) and patients (n=11) who participated in the remote titration intervention. Questions probed the experiences of the participants to identify factors that can serve as barriers and facilitators to its implementation. Conventional content analysis was first used to analyze the interviews and gain direct information based on the participants' unique perspectives. Subsequently, the generated themes were delineated and mapped following a multilevel framework.

RESULTS

Patients and clinicians indicated that the intervention was easy to use, integrated well into their routines, and removed practical barriers to titration. Key implementation facilitators from the patients' perspective included the reduction in clinic visits and daily monitoring of their condition, whereas clinicians emphasized the benefits of rapid drug titration and efficient patient management. Key implementation barriers included the resources necessary to support the intervention and lack of physician remuneration.

CONCLUSIONS

This study presents results from a real-world implementation assessment of remote titration facilitated by telemonitoring. It is among the first to provide insight into the perception of the remote titration process by clinicians and patients. Our findings indicate that the relative advantages that remote titration presents over standard care strongly appeal to both clinicians and patients. However, to ensure uptake and adherence, it is important to ensure that suitable patients are enrolled and the impact on the physicians' workload is minimized. The implementation of remote titration is now more critical than ever, as it can help provide access to care for patients during times when physical distancing is required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19705.

Methods Used to Evaluate mHealth Applications for Cardiovascular Disease: A Quasi-Systematic Scoping Review

In the face of demographic change and constantly increasing health care costs, health care system decision-makers face ever greater challenges. Mobile health applications (mHealth apps) have the potential to combat this trend. However, in order to integrate mHealth apps into care structures, an evaluation of such apps is needed. In this paper, we focus on the criteria and methods of evaluating mHealth apps for cardiovascular disease and the implications for developing a widely applicable evaluation framework for mHealth interventions. Our aim is to derive substantiated patterns and starting points for future research by conducting a quasi-systematic scoping review of relevant peer-reviewed literature published in English or German between 2000 and 2021. We screened 4066 articles and identified n = 38 studies that met our inclusion criteria. The results of the data derived from these studies show that usability, motivation, and user experience were evaluated primarily using standardized questionnaires. Usage protocols and clinical outcomes were assessed primarily via laboratory diagnostics and quality-of-life questionnaires, and cost effectiveness was tested primarily based on economic measures. Based on these findings, we propose important considerations and elements for the development of a common evaluation framework for professional mHealth apps, including study designs, data collection tools, and perspectives.

An m-Health intervention to improve education, self-management, and outcomes in patients admitted for acute decompensated heart failure: barriers to effective implementation

Aims

Effective and efficient education and patient engagement are fundamental to improve health outcomes in heart failure (HF). The use of artificial intelligence (AI) to enable more effective delivery of education is becoming more widespread for a range of chronic conditions. We sought to determine whether an avatar-based HF-app could improve outcomes by enhancing HF knowledge and improving patient quality of life and self-care behaviour.

Methods and results

In a randomized controlled trial of patients admitted for acute decompensated HF (ADHF), patients at high risk (≥33%) for 30-day hospital readmission and/or death were randomized to usual care or training with the HF-app. From August 2019 up until December 2020, 200 patients admitted to the hospital for ADHF were enrolled in the Risk-HF study. Of the 72 at high-risk, 36 (25 men; median age 81.5 years; 9.5 years of education; 15 in NYHA Class III at discharge) were randomized into the intervention arm and were offered education involving an HF-app. Whilst 26 (72%) could not use the HF-app, younger patients [odds ratio (OR) 0.89, 95% confidence interval (CI) 0.82-0.97; P < 0.01] and those with a higher education level (OR 1.58, 95% CI 1.09-2.28; P = 0.03) were more likely to enrol. Of those enrolled, only 2 of 10 patients engaged and completed ≥70% of the program, and 6 of the remaining 8 who did not engage were readmitted.

Conclusions

Although AI-based education is promising in chronic conditions, our study provides a note of caution about the barriers to enrolment in critically ill, post-acute, and elderly patients.

Practice Patterns and Patient Outcomes After Widespread Adoption of Remote Heart Failure Care

BACKGROUND

An unprecedented shift to remote heart failure outpatient care occurred during the coronavirus disease 2019 (COVID-19) pandemic. Given challenges inherent to remote care, we studied whether remote visits (video or telephone) were associated with different patient usage, clinician practice patterns, and outcomes.

METHODS

We included all ambulatory cardiology visits for heart failure at a multisite health system from April 1, 2019, to December 31, 2019 (pre-COVID) or April 1, 2020, to December 31, 2020 (COVID era), resulting in 10 591 pre-COVID in-person, 7775 COVID-era in-person, 1009 COVID-era video, and 2322 COVID-era telephone visits. We used multivariable logistic and Cox proportional hazards regressions with propensity weighting and patient clustering to study ordering practices and outcomes.

RESULTS

Compared with in-person visits, video visits were used more often by younger (mean 64.7 years [SD 14.5] versus 74.2 [14.1]), male (68.3% versus 61.4%), and privately insured (45.9% versus 28.9%) individuals (P<0.05 for all). Remote visits were more frequently used by non-White patients (35.8% video, 37.0% telephone versus 33.2% in-person). During remote visits, clinicians were less likely to order diagnostic testing (odds ratio, 0.20 [0.18-0.22] video versus in-person, 0.18 [0.17-0.19] telephone versus in-person) or prescribe β-blockers (0.82 [0.68-0.99], 0.35 [0.26-0.47]), mineralocorticoid receptor antagonists (0.69 [0.50-0.96], 0.48 [0.35-0.66]), or loop diuretics (0.67 [0.53-0.85], 0.45 [0.37-0.55]). During telephone visits, clinicians were less likely to prescribe ACE (angiotensin-converting enzyme) inhibitor/ARB (angiotensin receptor blockers)/ARNIs (angiotensin receptor-neprilysin inhibitors; 0.54 [0.40-0.72]). Telephone visits but not video visits were associated with higher rates of 90-day mortality (1.82 [1.14-2.90]) and nonsignificant trends towards higher rates of 90-day heart failure emergency department visits (1.34 [0.97-1.86]) and hospitalizations (1.36 [0.98-1.89]).

CONCLUSIONS

Remote visits for heart failure care were associated with reduced diagnostic testing and guideline-directed medical therapy prescription. Telephone but not video visits were associated with increased 90-day mortality.

The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review

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.

User-centered design features for digital health applications to support physical activity behaviors in solid organ transplant recipients: A qualitative study

INTRODUCTION

Digital health tools may be effective in engaging solid organ transplant (SOT) recipients in physical activity (PA). This study examined the perspectives of SOT recipients regarding PA, and desired features for digital health tools.

METHODS

Semi-structured interviews were used to explore perspectives of SOT recipients about barriers and motivators to physical activity, and core features of a digital health tool to support PA. Interviews were analyzed via thematic analysis.

RESULTS

Participants included 21 SOT recipients (11 men, 10 women, 21-78 years, 1.5-16 years post-transplant) from various organ groups (four heart, five kidney, five liver, three lung, and four multi-organ). Barriers to PA included risk aversion, managing non-linear health trajectories, physical limitations and lack of access to appropriate fitness training. Facilitators of PA included desire to live long and healthy lives, renewed physical capabilities, access to appropriate fitness guidelines and facilities. Desired features of a digital health tool included a reward system, affordability, integration of multiple functions, and the ability to selectively share information with healthcare professionals and peers.

CONCLUSIONS

SOT recipients identified the desired features of a digital health tool, which may be incorporated into future designs of digital and mobile health applications to support PA in SOT recipients.

Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre-Post Study

Background

Patients with heart failure (HF) can be affected by disabling symptoms and low quality of life. Furthermore, they may frequently need to visit the emergency department or be hospitalized due to their condition deteriorating. Home telemonitoring can play a role in tracking symptoms, reducing hospital visits, and improving quality of life.

Objective

Our objective was to conduct a feasibility study of a home health monitoring (HHM) solution for patients with HF in British Columbia, Canada, to prepare for conducting a randomized controlled trial.

Methods

Patients with HF were recruited from 3 urban hospitals and provided with HHM technology for 60 days of monitoring postdischarge. Participants were asked to monitor their weight, blood pressure, and heart rate and to answer symptomology questions via Bluetooth sensors and a tablet computer each day. A monitoring nurse received this data and monitored the patient’s condition. In our evaluation, the primary outcome was the combination of unscheduled emergency department revisits of discharged participants or death within 90 days. Secondary outcomes included 90-day hospital readmissions, patient quality of life (as measured by Veterans Rand 12-Item Health Survey and Kansas City Cardiomyopathy Scale), self-efficacy (as measured by European Heart Failure Self-Care Behaviour Scale 9), end-user experience, and health system cost-effectiveness including cost reduction and hospital bed capacity. In this feasibility study, we also tested the recruitment strategy, clinical protocols, evaluation framework, and data collection methods.

Results

Seventy participants were enrolled into this trial. Participant engagement to monitoring was measured at 94% (N=70; ie, data submitted 56/60 days on average). Our evaluation framework allowed us to collect sound data, which also showed encouraging trends: a 79% reduction of emergency department revisits post monitoring, an 87% reduction in hospital readmissions, and a 60% reduction in the median hospital length of stay (n=36). Cost of hospitalization for participants decreased by 71%, and emergency department visit costs decreased by 58% (n=30). Overall health system costs for our participants showed a 56% reduction post monitoring (n=30). HF-specific quality of life (Kansas City Cardiomyopathy Scale) scores showed a significant increase of 101% (n=35) post monitoring (P<.001). General quality of life (Veterans Rand 12-Item Health Survey) improved by 19% (n=35) on the mental component score (P<.001) and 19% (n=35) on the physical component score (P=.02). Self-efficacy improved by 6% (n=35). Interviews with participants revealed that they were satisfied overall with the monitoring program and its usability, and participants reported being more engaged, educated, and involved in their self-management.

Conclusions

Results from this small-sample feasibility study suggested that our HHM intervention can be beneficial in supporting patients post discharge. Additionally, key insights from the trial allowed us to refine our methods and procedures, such as shifting our recruitment methods to in-patient wards and increasing our scope of data collection. Although these findings are promising, a more rigorous trial design is required to test the true efficacy of the intervention. The results from this feasibility trial will inform our next step as we proceed with a randomized controlled trial across British Columbia.

Trial Registration

ClinicalTrials.gov NCT03439384; https://clinicaltrials.gov/ct2/show/NCT03439384

Influential Factors in Remote Monitoring of Heart Failure Patients: A Review of the Literature and Direction for Future Research

With new advances in technology, remote monitoring of heart failure (HF) patients has become increasingly prevalent and has the potential to greatly enhance the outcome of care. Many studies have focused on implementing systems for the management of HF by analyzing physiological signals for the early detection of HF decompensation. This paper reviews recent literature exploring significant physiological variables, compares their reliability in predicting HF-related events, and examines the findings according to the monitored variables used such as body weight, bio-impedance, blood pressure, heart rate, and respiration rate. The reviewed studies identified correlations between the monitored variables and the number of alarms, HF-related events, and/or readmission rates. It was observed that the most promising results came from studies that used a combination of multiple parameters, compared to using an individual variable. The main challenges discussed include inaccurate data collection leading to contradictory outcomes from different studies, compliance with daily monitoring, and consideration of additional factors such as physical activity and diet. The findings demonstrate the need for a shared remote monitoring platform which can lead to a significant reduction of false alarms and help in collecting reliable data from the patients for clinical use especially for the prevention of cardiac events.