The evidence base … telehealth and heart failure
Professor John Cleland, University of Hull
This article was prepared by Mike Clark, co-project lead for WSDAN, and is based on the presentation made by Professor Cleland to the WSDAN regional event on the 11 June 2009 at the Leeds Marriott Hotel. The presentation can be accessed on our past events archive.
Professor Cleland reviewed the progress and evidence being made on heart failure and telemonitoring.
National Heart Failure Audit – Evidence from Hull and East Yorkshire
In Hull and East Yorkshire (population around 600,000), the national heart failure audit figures collected over 18 months to March 2008 indicated that there were 5,607 patients with around 8,000 discharges where people were spending on average 10 days in hospital. Altogether this group spent 70–80,000 bed days in hospital and their average age was around 76–77 years old. For the 75 and over age group, patient mortality (with diuretic) was 50 per cent (30 per cent mortality for under 75s). Heart failure is a very expensive condition.
There is a lot of inaccuracy in the data collected and even in the diagnosis of heart failure. However, It is now easier to predict with a new blood test.
Hull benefits from a collaborative approach from the University, NHS and City Council along with many international groups. The third sector has an important role to play in supporting people at home with heart failure.
Technology still in the ‘Stone Age’
Professor Cleland took the view that the telemonitoring approach was still in the ‘stone age’ and that we had not yet really started to explore the potential benefits. Technology will work better when it is not just monitoring what is happening but when it is trying to alter the outcome. Delivering care using the technology will be a big thing for the future. If the current technology had been available 20 years ago in the NHS, it would have been readily accepted and adopted.
Hull has around 400 local users of telemonitoring and links with international groups monitoring around 1,000 people in total. As well as heart failure there is coverage of stroke, myocardial infarction, COPD and, to some extent, hypertension in the patients involved.
Professor Cleland considered that some people worry about big brother and isolation, but having the technology and support may become a reason to visit a patient (eg, by a friend or relative) and can promote social inclusion. In terms of acceptance of the technology, if you show people how to take a blood pressure a few times they can do it. Sometimes they may need help, but the third sector and family can assist. By carrying out these simple activities, patients can improve their health. Only patients can provide personalised one-to-one health care.
Telemonitoring does require investment in awareness – health professionals can be a barrier. Patients may ask more awkward questions.
Taking new technologies forward
Moving forwards, Professor Cleland argued that there is the potential for improved monitoring with improved treatment plans and added convenience for everyone involved. There is patient preference for the place of care and reduced environmental impact. Instead of managing caseloads of 50 of which 45 may generally be OK, clinicians could potentially manage up to 400 of which 50 need additional support at any one time. This could lead to the possibility of reduced overall costs.
He considered that a secret weapon of telehealth is better record keeping. Patients have the ability to see a large part of their health record and can make sure it is accurate compared to the current fragmented system.
The evidence base
Professor Cleland reviewed some of the telehealth studies.1–7
Early studies showed how technology had been used with no real feedback to the patient that could provide education and awareness of their condition.1
In a study set in Hull,2 patients randomised to home telemonitoring were more likely to improve but there is not necessarily a reduction in hospital admissions. In fact, a slight increase in hospital admissions was seen – probably due to patients being more aware of their condition and when to get expert attention. This meant getting the right patient to hospital at the right time which saved lives. It was possible to reduce hospital days through telemonitoring (compared with the usual care and telephone support group), and there was a significant reduction in all cause mortality with telemonitoring. When comparing the nurse telephone monitoring versus home telemonitoring, there was not much difference in mortality but there was a significant additional cost for nurse support.
In a meta-analysis on telemonitoring or structured telephone support programmes for patients with chronic heart failure,3 the research did not report a reduction in hospital admissions, but did report a 40 per cent reduction in mortality across three trials. In the largest of all studies, there was a 36 per cent reduction in cardiovascular readmissions and almost 60 per cent reduction in mortality. A further informal update on the meta-analysis suggests that the evidence is getting stronger for its positive impact.
Reflecting on two recent trials,6,7 Professor Cleland considered that if you put enough human resources in place you can be as good as telehealth so the choice could be another dozen nurses or telehealth. Home visits are very expensive on a routine basis compared to telehealth with an occasional visit. Telehealth is generally installed for up to four months – long-term monitoring cannot be justified currently for heart failure.
A major limitation of the trials to date is that nobody has completed any health economics analysis of the outcomes.
The future of new technologies in care to heart failure patients
Moving forwards, Professor Cleland looked at the development of supporting services. To date the focus has been on the technology and not the services. This would include interactive TV, implanted devices with feedback (there is already extensive remote monitoring of pacemakers and defibrillators which is cheaper, smarter and safer than traditional approaches), the importance of patient education and setting goals, sending timely messages and reminders, and ensuring that people take their medication. It is important to target where specialist nurses can do the most good – who needs attention. Telehealth is what patients do for themselves with the help of family and voluntary organisations.
In the future, there is also the potential for mobile phone technology, which has advantages in terms of portability and ease of use (but also some disadvantages in terms of battery life and lost devices). There are already examples of wearable devices (eg, plasters that can monitor temperature, heart rate, heart rhythm, bio-impedance to indicate fluid in the chest) and even tablets that can provide monitoring information as they pass through the body. An interesting development is a stent located in the pulmonary artery that can monitor cardiac measurements.
Cost will be an issue but there are opportunities for communication and decision support technology with a more patient-centred approach. This can lead to more effective delivery of more effective care.
 EurekAlert! (2009). ‘Individualised treatment for heart failure is rarely available outside hospital’. EurekAlert! website. Available at:
http://www.eurekalert.org/pub_releases/2009-05/esoc-itf052809.php (accessed on 27 July 2009).
 Empirica (2001). ‘Evaluating Telehealth Home Care Services – the Ten-HMS-Project: Medical, Quality of Life and Economic Efficiency Aspects. Empirica website. Available at: http://www.empirica.com/themen/telemedizin/documents/TEN-HMSUlm_2001.pdf (accessed on 27 July 2009).
 Clark RA, Cleland JG, Inglis SC, McAlister FA, Stewart S (2007). ‘Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis’. British Medical Journal, vol 334, pp 942. Available at: http://www.bmj.com/cgi/content/full/334/7600/942 (accessed on 27 July 2009).
 Ignaszewski A, Lear SA, Maric B, Kaan A, (2009). ‘A systematic review of telemonitoring technologies in heart failure’. European Journal of Heart Failure, vol 11, no5, pp 506–17. Available at: http://eurjhf.oxfordjournals.org/cgi/content/abstract/11/5/506 (accessed on 27 July 2009).
 Capomolla S, Johnson P, La Rovere MT, Maestri R, Mortara A, Pinna GA, Ponikowski P, Sleight P, Tavazzi L (2009). ‘Home telemonitoring in heart failure patients: the HHH study (Home or Hospital in Heart Failure)’. European Journal of Heart Failure, vol 11, pp 312–18. Available at: http://eurjhf.oxfordjournals.org/cgi/content/abstract/11/3/312 (accessed on 27 July 2009).
 Chapman C, Cowie MR, Dar O, Dubrey SW, Morris S, Riley J, Rosen SD, Roughton M (2009). ‘A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home-HF study’. European Journal of Heart Failure, vol 11, pp 319–25. Available at: http://eurjhf.oxfordjournals.org/cgi/content/abstract/11/3/319 (accessed on 27 July 2009).
 Cleland J, Lewinter C, Goode K (2009). ‘Telemonitoring for heart failure: the only feasible option for good universal care?’ European Journal of Heart Failure, vol 11, pp 227–8. Available at: http://eurjhf.oxfordjournals.org/cgi/content/extract/11/3/227 (accessed on 27 July 2009).