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

Heart Health Hub virtual care program for newly diagnosed heart failure patients

BackgroundThe Heart Health Hub (HHH) is a virtual model of care for patients with newly diagnosed heart failure. A program pilot commenced in April 2020 and aimed to achieve acceptable titration rates for heart failure medications while improving patient access to services. This study aimed to investigate whether the virtual HHH service could deliver feasible, safe and acceptable titration outcomes.MethodsA single-arm observational cohort study design was adopted. Eligible heart failure patients currently receiving care could consent to be enrolled in the pilot virtual HHH program based on pre-defined inclusion and exclusion criteria. Data on patient demographics, clinical characteristics and heart failure medication titration rates were obtained from routine health system databases and patient notes. Patient satisfaction data were collected using a Likert-scale questionnaire. Overall health service use and costs for each patient were obtained from health system databases for a period of 12 months following enrolment in the virtual HHH program.ResultsA total of 89 heart failure patients were included in the evaluation. Of these, 95% reached titration to either guideline-recommended target doses or maximum tolerated doses for both angiotensin-converting enzyme inhibitor/angiotensin receptor blockers/angiotensin and angiotensin receptor-neprilysin inhibitor (ACEI/ARB/ARNI) and beta-blockers combined. The mean number of days to achieve titration ranged from 20.2 days for mineralocorticoid receptor antagonist drugs, between 27.5 to 32.3 days for ACEI/ARB/ARNI drugs and 41.0 days for beta-blockers; 70 (79%) patients completed the satisfaction survey at least once, with more than 98% of survey questions receiving a positive response. The average monthly equipment and consumables cost per patient was $277 in year 2021/22.ConclusionThis study provides evidence that a virtual model of care for newly diagnosed heart failure patients was feasible, safe and acceptable, with high titration rates, relatively rapid times to titration, strong patient satisfaction outcomes and relatively low equipment costs.

Family Physicians' Use of, Barriers to, and Attitudes Toward Remote Diagnosis and Treatment in China: A National Web-Based Survey

Background/Objectives: China has introduced a series of policies to encourage family physicians (FPs) to provide remote diagnosis and treatment (RDT) services, with the ultimate goal of providing more continuous, convenient, and efficient medical services for all residents, especially elderly patients and patients with chronic diseases. However, few studies have focused on this important issue. The aim of this study was to provide a comprehensive description of FPs' use of, barriers to, and attitudes toward RDT in China. Methods: A cross-sectional survey was implemented for this study. The data were analyzed via basic descriptive statistics and are expressed as percentages. Additionally, a single-factor logistic regression was used to compare groups in terms of outcome measures. Results: Among the 682 respondents, 63.8% had participated in RDT, and 36.2% had never participated in RDT. Among the 435 respondents who participated in RDT, 19.1% were high-frequency users, and 80.9% were low-frequency users. The results of the single-factor logistic regression revealed that there were significant differences in the use of RDT among FPs in terms of age (p = 0.034), educational background (p < 0.001), hospital type (p = 0.008), income as a result of their work as an FP (p = 0.002), form of employment (p = 0.001), and general practitioner status (p < 0.001). Moreover, there were significant differences in the use frequency of RDT among FPs in terms of age (p = 0.009), years of practice as a health service provider (p = 0.001), years of practice as an FP (p = 0.003), educational background (p = 0.048), and working hours as an FP (p = 0.014). However, a lack of policy support (58.5%), technology support (55.3%), and information support (52.5%) were the top three factors hindering FPs from participating in RDT. Overall, FPs had positive attitudes toward RDT services, with more than half of the respondents expressing that they could benefit from such services and showing increasing interest in using them. Conclusions: The findings of this research can improve policymakers' understanding of FPs' use of, barriers to, and attitudes toward RDT. Our findings also provide suggestions, such as those for improving the promotion of RDT, optimizing relevant laws, and providing technical support for FPs to use RDT, which may help optimize related policies. There are also some limitations in our study; for example, the sample in this study included provincial administrative regions across China, but not all provinces were covered. In the future, research covering all provinces of the country could be carried out to make the research more nationally representative.

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).

Remote management in patients with heart failure (from new onset to advanced): A practical guide

Heart failure is a chronic condition that affects millions of people worldwide and is associated with high morbidity and mortality. Remote monitoring, which includes the use of non-invasive connected devices, cardiac implantable electronic devices and haemodynamic monitoring systems, has the potential to improve outcomes for patients with heart failure. Despite the conceptual and clinical advantages, there are still limitations in the widespread use of these technologies. Moreover, a significant proportion of studies evaluating the benefit of remote monitoring in heart failure have focused on the limited area of prevention of rehospitalization after an episode of acute heart failure. A group of experts in the fields of heart failure and digital health worked on this topic in order to provide a practical paper for the use of remote monitoring in clinical practice at the different stages of the heart failure syndrome: (1) discovery of heart failure; (2) acute decompensation of chronic heart failure; (3) heart failure in stable period; and (4) advanced heart failure. A careful and critical analysis of the available literature was performed with the aim of providing caregivers with some recommendations on when and how to use remote monitoring in these different situations, specifying which variables are essential, optional or useless.

Factors Influencing the Acceptance and Adoption of Mobile Health Apps by Physicians During the COVID-19 Pandemic: Systematic Review

BACKGROUND

During the COVID-19 pandemic, the provision of and access to health care have been uniquely challenging, particularly during lockdowns or when dealing with COVID-19 cases. Health care professionals have had to provide patients with the necessary health care. However, delivering health care services while reducing face-to-face interaction puts an immense strain on health systems that are already overburdened. Against this backdrop, it is now more critical than ever to ensure the accessibility of health care services. Such access has been made increasingly available through mobile health (mHealth) apps. These apps have the potential to significantly improve health care outcomes and expectations and address some of the challenges confronting health care systems worldwide. Despite the advantages of mHealth, its acceptance and adoption remain low. Hence, health care organizations must consider the perceptions and opinions of physicians if the technology is to be successfully implemented.

OBJECTIVE

The objective of this systematic review was to explore and synthesize the scientific literature on the factors influencing the acceptance and adoption of mHealth among physicians during the COVID-19 pandemic.

METHODS

A systematic review of the studies published between March 2020 and December 2022 was conducted using the MEDLINE, Scopus, Embase, and ProQuest databases. The database search yielded an initial sample of 455 potential publications for analysis, of which 9 (2%) met the inclusion criteria. The methodology of this review was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

RESULTS

The factors influencing mHealth acceptance and adoption by physicians were divided into perceived barriers and perceived facilitators, which were further grouped into the following 3 major thematic categories: technological, individual, and organizational barriers and facilitators, respectively. The technological barriers were accessibility, technical issues, usefulness, and data management; individual barriers were perceived patient barriers, time and workload pressure, technical literacy, knowledge of mHealth, and peer support; and organizational barriers were financial factors, management support and engagement, data security, telemonitoring policy, and collaboration. The technological facilitators of uptake were technical factors, clinical usefulness, and data management; individual facilitators were patient-related care, intrinsic motivation, collaboration, and data sharing (individual); and organizational facilitators were workflow-related determinants, organizational financial support, recommendation of mHealth services, and evidence-based guidelines.

CONCLUSIONS

This review summarized the evidence on the factors influencing mHealth acceptance and adoption by physicians during the COVID-19 pandemic. The main findings highlighted the importance of addressing organizational readiness to support physicians with adequate resources, shifting the focus from technological to patient-centered factors, and the seamless integration of mHealth into routine practice during and beyond the pandemic.

TRIAL REGISTRATION

PROSPERO CRD42022356125; https://tinyurl.com/2mmhn5yu.

Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study

BACKGROUND

Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption.

OBJECTIVE

We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF.

METHODS

We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use.

RESULTS

Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring.

CONCLUSIONS

The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.

Participant and Research Team Perspectives on the Conduct of a Remote Therapeutic COVID-19 Clinical Trial: A Mixed Methods Approach

Background:

Responding to the need to investigate potential treatments of COVID-19, a research team employed a telehealth platform to determine whether niclosamide, an oral anthelmintic drug that had shown antiviral activity, reduced SARS-CoV-2 shedding and duration of symptoms in patients with mild-to-moderate symptoms of COVID-19. To encourage compliance with patient self-quarantine, this randomized placebo-controlled clinical trial was conducted utilizing a remote telehealth design to complete all study visits, monitor symptoms, and coordinate participant self-collected specimens.

Methods:

A mixed methods approach employing surveys and interviews of trial participants and interviews of research team members was used to collect their experiences with and perspectives on the acceptability of the remote clinical trial design and delivery.

Results:

Of the 67 eligible trial participants invited to take part in a study to evaluate the telehealth platform, 46% (n = 31) completed a post-participation survey. While 97% (n = 30) of respondents had not previously participated in a clinical trial, 77% (n = 24) reported they would consider taking part in a future remote research study. The majority of respondents were moderately or very comfortable (93%) with using the technology.

Conclusions:

The COVID-19 crisis was a call to action to expand understanding of the conduct of remote clinical trials, including the experiences of research participants. Our findings showed that this approach can be both effective for the conduct of research and positive for participants. Further research on the use of telehealth research platforms seems warranted in rural, underserved populations, and remote trials of prevention, screening, and treatment.