Evidence base update: the management of heart failure
In July 2009, we ran a feature on the evidence base for telehealth and heart failure. This was based on a presentation delivered by Professor John Cleland at a WSDAN regional event. His view was that telemonitoring was still in its infancy, and that one sign of positive progress would be the ability of technology to alter outcomes, in addition to monitoring. It was noted that an increase in home-visiting staff could produce the same effects as telehealth, although this would have cost implications.
Professor Cleland’s review included a specific focus on a meta-analysis of data from Hull and East Yorkshire, gathered as part of the National Heart Failure Audit (PDF, 285 KB). This revealed significant percentage reductions in mortality within a randomised home telemonitoring group, compared with a regular care group and a telephone support group .
To update on Professor Cleland’s presentation, this article focuses on a recently published review of telemonitoring for heart failure (PDF, 293 KB), assessing this evidence in the light of the findings of more than 40 studies in the WSDAN evidence database.
A systematic review of heart failure trials
On 15 March 2010, we reported the publication of a systematic review of telemonitoring and heart failure by Schmidt et al (2010) from Ernst-Moritz-Arndt University, Greifswald. They reviewed articles – particularly randomised controlled trials (RCTs) – that appeared between June 2001 and May 2008. They found that assessing the success of telemonitoring is complex and involves considering a range of criteria, including clinical, patient-related, physician-related, and health-economic issues. They found that telemonitoring offered the possibility of transmitting data or self-reports electronically, and of telephone data transmission.
However, limited data meant it was not possible for them to adequately evaluate multidisciplinary, pre-2005 evidence for some telemonitoring processes such as vital signs transmission. The review also found that telephone monitoring was the most popular area of research undertaken on the remote management of heart failure patients. Relatively few RCTs focused on vital signs monitoring.
Among the research studies that they examined, several showed a significant reduction in morbidity for telemonitoring patients compared with standard care patients, when assessed by rehospitalisation rate. For example, one study showed a 20 per cent reduction in overall mortality for both telephone monitoring and vital signs monitoring in New York Heart Association class I to IV heart failure patients .
Schmidt et al’s review found that patient-related criteria had not been key endpoints in telemonitoring research thus far. While they did find some evidence of improvement in quality of life for telemonitoring patients, the evidence suggested the need for more in-depth analysis to discover precisely what had changed for patients in this regard. Nonetheless, the review found increased patient compliance in those RCTs that evaluated it. For example, electrical implants for heart failure patients were shown to significantly reduce the need for patient visits, and to generate a cost saving of €712.31 per patient per year . Overall, the review concluded that further research was needed to assess improvements in patients’ quality of life and to ascertain whether the impact of telemonitoring was predominantly patient-related or physician-related.
Evidence around the costs of interventions was also inconclusive, as the majority of RCTs reviewed omitted cost analyses. Of those that incorporated this information, Chaudhry et al (2007) cited intervention costs ranging from US$1,600 to US$8,000, depending on the technology used, thus making it difficult to judge cost benefits or drawbacks. ‘No incremental benefit’ was noted between the technologies, although the sample size was admittedly small .
The review found that most studies showed high patient acceptance of telemonitoring. However, one study registered just 50 to 60 per cent participation willingness. Data from controlled studies had yet to be examined in terms of physicians’ acceptance of telemonitoring, though there was some evidence to suggest that physicians may be fearful of its potential to upset traditional doctor/patient relationships. Also, physicians were worried about the implications of the technological aspect of telemonitoring on their clinical work .
The WSDAN evidence database
The WSDAN evidence database currently includes over 40 heart failure entries, many of which focus on the (re)hospitalisation and cost effects of telemonitoring. Numerous studies have found reduced rates of hospitalisation for heart failure patients who received the intervention, compared with control groups. One US RCT found a 47.8 per cent lower rehospitalisation rate for patients receiving ‘telephonic case management’, compared with a control group .
The same study also recorded cost savings among the telephone care group, even after the costs of intervention were factored in.
Findings from a 2005 Italian study also highlight significant percentage reductions in hospitalisation, and considerable cost reductions for a patient group receiving ‘home-based telecardiology’: €107,494 compared with €140,874 for the control group . A non-invasive telemonitoring system for congestive heart failure was found to reduce rehospitalisation, but not length of stay .
Other studies have indicated less disparity between telemonitoring groups and those receiving regular care in terms of hospitalisation rates. A 2004 RCT found that nurse co-ordinated telecare had little impact on heart failure rehospitalisation rates for elderly participants, compared with a control group .
Outcomes such as patients’ quality of life and patient completion are evaluated in other studies. For example, the Home or Hospital in Heart Failure research recorded between 81 and 92 per cent completion using home telemonitoring .
Two recent systematic reviews found evidence of an increase in quality of life among heart failure patients who received interventions  .
Schmidt et al’s recent review and the evidence contained in the WSDAN database enable us to draw some broad conclusions. In terms of patient care, there is clear evidence of improvements in quality of life and a high level of patient acceptance in the use of telemonitoring. Hence, available research generally presents telemonitoring as a positive method of care, from both clinical and patient perspectives. However, further studies are needed to elicit more clearly the tangible benefits for patients, and how these weigh up against the costs.
Susan Royer is WSDAN Network Manager, The King’s Fund
 Cleland J. Telehealth and Heart Failure: Overview and recent progress – presentation to WSDAN Event June 2009
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