Effective technologies for noninvasive remote monitoring in heart failure

Accurate Modeling of Ejection Fraction and Stroke Volume With Mobile Phone Auscultation: Prospective Case-Control Study

BACKGROUND

Heart failure (HF) contributes greatly to morbidity, mortality, and health care costs worldwide. Hospital readmission rates are tracked closely and determine federal reimbursement dollars. No current modality or technology allows for accurate measurement of relevant HF parameters in ambulatory, rural, or underserved settings. This limits the use of telehealth to diagnose or monitor HF in ambulatory patients.

OBJECTIVE

This study describes a novel HF diagnostic technology using audio recordings from a standard mobile phone.

METHODS

This prospective study of acoustic microphone recordings enrolled convenience samples of patients from 2 different clinical sites in 2 separate areas of the United States. Recordings were obtained at the aortic (second intercostal) site with the patient sitting upright. The team used recordings to create predictive algorithms using physics-based (not neural networks) models. The analysis matched mobile phone acoustic data to ejection fraction (EF) and stroke volume (SV) as evaluated by echocardiograms. Using the physics-based approach to determine features eliminates the need for neural networks and overfitting strategies entirely, potentially offering advantages in data efficiency, model stability, regulatory visibility, and physical insightfulness.

RESULTS

Recordings were obtained from 113 participants. No recordings were excluded due to background noise or for any other reason. Participants had diverse racial backgrounds and body surface areas. Reliable echocardiogram data were available for EF from 113 patients and for SV from 65 patients. The mean age of the EF cohort was 66.3 (SD 13.3) years, with female patients comprising 38.3% (43/113) of the group. Using an EF cutoff of ≤40% versus >40%, the model (using 4 features) had an area under the receiver operating curve (AUROC) of 0.955, sensitivity of 0.952, specificity of 0.958, and accuracy of 0.956. The mean age of the SV cohort was 65.5 (SD 12.7) years, with female patients comprising 34% (38/65) of the group. Using a clinically relevant SV cutoff of <50 mL versus >50 mL, the model (using 3 features) had an AUROC of 0.922, sensitivity of 1.000, specificity of 0.844, and accuracy of 0.923. Acoustics frequencies associated with SV were observed to be higher than those associated with EF and, therefore, were less likely to pass through the tissue without distortion.

CONCLUSIONS

This work describes the use of mobile phone auscultation recordings obtained with unaltered cellular microphones. The analysis reproduced the estimates of EF and SV with impressive accuracy. This technology will be further developed into a mobile app that could bring screening and monitoring of HF to several clinical settings, such as home or telehealth, rural, remote, and underserved areas across the globe. This would bring high-quality diagnostic methods to patients with HF using equipment they already own and in situations where no other diagnostic and monitoring options exist.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based and technology-supported cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation, especially during the SARS-CoV-2 pandemic. This is an update of a review previously published in 2009, 2015, and 2017.

OBJECTIVES

To compare the effect of home-based (which may include digital/telehealth interventions) and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease SEARCH METHODS: We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 16 September 2022. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials that compared centre-based cardiac rehabilitation (e.g. hospital, sports/community centre) with home-based programmes (± digital/telehealth platforms) in adults with myocardial infarction, angina, heart failure, or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on predefined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE.

MAIN RESULTS

We included three new trials in this update, bringing a total of 24 trials that have randomised a total of 3046 participants undergoing cardiac rehabilitation. A further nine studies were identified and are awaiting classification. Manual searching of trial registers until 16 September 2022 revealed a further 14 clinical trial registrations - these are ongoing. Participants had a history of acute myocardial infarction, revascularisation, or heart failure. Although there was little evidence of high risk of bias, a number of studies provided insufficient detail to enable assessment of potential risk of bias; in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported. No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in our primary outcomes up to 12 months of follow-up: total mortality (risk ratio [RR] = 1.19, 95% confidence interval [CI] 0.65 to 2.16; participants = 1647; studies = 12/comparisons = 14; low-certainty evidence) or exercise capacity (standardised mean difference (SMD) = -0.10, 95% CI -0.24 to 0.04; participants = 2343; studies = 24/comparisons = 28; low-certainty evidence). The majority of evidence (N=71 / 77 comparisons of either total or domain scores) showed no significant difference in health-related quality of life up to 24 months follow-up between home- and centre-based cardiac rehabilitation. Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate-certainty evidence). There was a similar level of trial completion (RR 1.03, 95% CI 0.99 to 1.08; participants = 2638; studies = 22/comparisons = 26; low-certainty evidence) between home-based and centre-based participants. The cost per patient of centre- and home-based programmes was similar.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- (± digital/telehealth platforms) and centre-based forms of cardiac rehabilitation formally supported by healthcare staff seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction, or revascularisation, or with heart failure. This finding supports the continued expansion of healthcare professional supervised home-based cardiac rehabilitation programmes (± digital/telehealth platforms), especially important in the context of the ongoing global SARS-CoV-2 pandemic that has much limited patients in face-to-face access of hospital and community health services. Where settings are able to provide both supervised centre- and home-based programmes, consideration of the preference of the individual patient would seem appropriate. Although not included in the scope of this review, there is an increasing evidence base supporting the use of hybrid models that combine elements of both centre-based and home-based cardiac rehabilitation delivery. Further data are needed to determine: (1) whether the short-term effects of home/digital-telehealth and centre-based cardiac rehabilitation models of delivery can be confirmed in the longer term; (2) the relative clinical effectiveness and safety of home-based programmes for other heart patients, e.g. post-valve surgery and atrial fibrillation.

An overview of the effect of telehealth on mortality: A systematic review of meta-analyses

INTRODUCTION

Telehealth is recognised as a viable way of providing health care over distance, and an effective way to increase access for individuals with transport difficulties or those living in rural and remote areas. While telehealth has many positives for patients, clinicians and the health system, it is important that changes in the delivery of health care (e.g. in-person to telehealth) do not result in inferior or unsafe care. In this review, we collate existing meta-analyses of mortality rates to provide a holistic view of the current evidence regarding telehealth safety.

METHODS

In November 2020, a search of Pretty Darn Quick Evidence portal was conducted in order to locate systematic reviews published between 2010 and 2019, examining and meta-analysing the effect of telehealth interventions on mortality compared to usual care.

RESULTS

This review summarises evidence from 24 meta-analyses. Five overarching medical disciplines were represented (cardiovascular, neurology, pulmonary, obstetrics and intensive care). Overall, telehealth did not increase mortality rates.

DISCUSSION

The evidence from this review can be used by decision makers, in conjunction with other disease-specific and health economic evidences, to support and guide telehealth implementation plans.

"Digital biomarkers" in preclinical heart failure models - a further step towards improved translational research

Innovations in the development of novel heart failure therapies are essential to further increase the predictive value of early research findings. Animal models are still playing a pivotal role in 'translational research'. In recent years, the transferability from animal studies has been more and more critically discussed due to persistent high attrition rates in clinical trials. However, there is an increasing trend to implement mobile health devices in preclinical studies. These devices can increase the predictive value of animal models by providing more accurate and translatable data and protect from confounding factors. This review outlines the current prevalence and opportunities of these techniques in preclinical heart failure research studies to accelerate the integration of these important tools. A literature screening for preclinical heart failure studies in large animals implementing telemetry devices over the last decade was performed. Twelve out of 43 publications were included. A variety of different hemodynamic and cardiac parameters can be recorded in conscious state by means of telemetry devices in both, the animal model and the patient. The measurement quality is consistently rated as valid and robust. Mobile health technologies functioning as digital biomarkers represent a more predictive approach compared to the traditionally used invasive measurement techniques, due to the possibility of continuous data collection in the conscious animal. Furthermore, they help to implement the 3R concept (reduction, refinement, replacement) in animal research. Despite this, the use of these techniques in preclinical research has been restrained to date.

Evidence and User Considerations of Home Health Monitoring for Older Adults: Scoping Review

BACKGROUND

Home health monitoring shows promise in improving health outcomes; however, navigating the literature remains challenging given the breadth of evidence. There is a need to summarize the effectiveness of monitoring across health domains and identify gaps in the literature. In addition, ethical and user-centered frameworks are important to maximize the acceptability of health monitoring technologies.

OBJECTIVE

This review aimed to summarize the clinical evidence on home-based health monitoring through a scoping review and outline ethical and user concerns and discuss the challenges of the current user-oriented conceptual frameworks.

METHODS

A total of 2 literature reviews were conducted. We conducted a scoping review of systematic reviews in Scopus, MEDLINE, Embase, and CINAHL in July 2021. We included reviews examining the effectiveness of home-based health monitoring in older adults. The exclusion criteria included reviews with no clinical outcomes and lack of monitoring interventions (mobile health, telephone, video interventions, virtual reality, and robots). We conducted a quality assessment using the Assessment of Multiple Systematic Reviews (AMSTAR-2). We organized the outcomes by disease and summarized the type of outcomes as positive, inconclusive, or negative. Second, we conducted a literature review including both systematic reviews and original articles to identify ethical concerns and user-centered frameworks for smart home technology. The search was halted after saturation of the basic themes presented.

RESULTS

The scoping review found 822 systematic reviews, of which 94 (11%) were included and of those, 23 (24%) were of medium or high quality. Of these 23 studies, monitoring for heart failure or chronic obstructive pulmonary disease reduced exacerbations (4/7, 57%) and hospitalizations (5/6, 83%); improved hemoglobin A1c (1/2, 50%); improved safety for older adults at home and detected changing cognitive status (2/3, 66%) reviews; and improved physical activity, motor control in stroke, and pain in arthritis in (3/3, 100%) rehabilitation studies. The second literature review on ethics and user-centered frameworks found 19 papers focused on ethical concerns, with privacy (12/19, 63%), autonomy (12/19, 63%), and control (10/19, 53%) being the most common. An additional 7 user-centered frameworks were studied.

CONCLUSIONS

Home health monitoring can improve health outcomes in heart failure, chronic obstructive pulmonary disease, and diabetes and increase physical activity, although review quality and consistency were limited. Long-term generalized monitoring has the least amount of evidence and requires further study. The concept of trade-offs between technology usefulness and acceptability is critical to consider, as older adults have a hierarchy of concerns. Implementing user-oriented frameworks can allow long-term and larger studies to be conducted to improve the evidence base for monitoring and increase the receptiveness of clinicians, policy makers, and end users.

Post-ST-Segment Elevation Myocardial Infarction Follow-Up Care During the COVID-19 Pandemic and the Possible Benefit of Telemedicine: An Observational Study

Background: Infectious control measures during the COVID-19 pandemic have led to the propensity toward telemedicine. This study examined the impact of telemedicine during the pandemic on the long-term outcomes of ST-segment elevation myocardial infarction (STEMI) patients.

Methods: This study included 288 patients admitted 1 year before the pandemic (October 2018–December 2018) and during the pandemic (January 2020–March 2020) eras, and survived their index STEMI admission. The follow-up period was 1 year. One-year primary safety endpoint was all-cause mortality. Secondary safety endpoints were cardiac readmissions for unplanned revascularisation, non-fatal myocardial infarction, heart failure, arrythmia, unstable angina. Major adverse cardiovascular events (MACE) was defined as the composite outcome of each individual safety endpoint.

Results: Despite unfavorable in-hospital outcomes among patients admitted during the pandemic compared to pre-pandemic era, both groups had similar 1-year all-cause mortality (11.2 vs. 8.5%, respectively, p = 0.454) but higher cardiac-related (14.1 vs. 5.1%, p < 0.001) and heart failure readmissions in the pandemic vs. pre-pandemic groups (7.1 vs. 1.7%, p = 0.037). Follow-up was more frequently conducted via teleconsultations (1.2 vs. 0.2 per patient/year, p = 0.001), with reduction in physical consultations (2.1 vs. 2.6 per patient/year, p = 0.043), during the pandemic vs. pre-pandemic era. Majority achieved guideline-directed medical therapy (GDMT) during pandemic vs. pre-pandemic era (75.9 vs. 61.6%, p = 0.010). Multivariable Cox regression demonstrated achieving medication target doses (HR 0.387, 95% CI 0.164–0.915, p = 0.031) and GDMT (HR 0.271, 95% CI 0.134–0.548, p < 0.001) were independent predictors of lower 1-year MACE after adjustment.

Conclusion: The pandemic has led to the wider application of teleconsultation, with increased adherence to GDMT, enhanced medication target dosing. Achieving GDMT was associated with favorable long-term prognosis.

Health information technology to improve care for people with multiple chronic conditions

OBJECTIVE

To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps.

DATA SOURCES

We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010 and 2020.

STUDY DESIGN

We identified studies of health IT interventions for PLWMCC across three domains as follows: self-management support, care coordination, and algorithms to support clinical decision making.

DATA COLLECTION/EXTRACTION METHODS

Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data were extracted independently by two reviewers.

PRINCIPAL FINDINGS

The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models were included. Five RCTs had positive results, and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality.

CONCLUSIONS

Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC.

Effects of a diuretic adjustment algorithm protocol on heart failure admissions: A randomized clinical trial

INTRODUCTION

The aim of this study was to evaluate the effectiveness of a diuretic adjustment algorithm (DAA) in maintaining clinical stability and reducing HF readmissions using telemonitoring technologies.

METHODS

Randomized clinical trial of patients with an indication for furosemide dose adjustment during routine outpatient visits. In the intervention group (IG), the diuretic dose was adjusted according to the DAA and the patients received telephone calls for 30 days. In the control group (CG), the diuretic dose was adjusted by a physician at baseline only. Co-primary outcomes were hospital readmission and/or emergency department visits due to decompensated HF within 90 days, and a 2-point change in the Clinical Congestion Score and/or a deterioration in New York Heart Association functional class within 30 days.

RESULTS

A total of 206 patients were included. Most patients were male (n=119; 58%), with a mean age of 62 (SD 13) years. Four patients (2%) in the IG and 14 (7%) in the CG were hospitalized for HF (odds ratio (OR) 0.31 (0.10-0.91); p=0.04). Multivariate analysis showed a reduction of 67% in readmissions and/or emergency department visits due to decompensated HF in the IG compared with the CG (95% CI 0.13-0.88; p=0.027). Regarding the combined outcome of HF readmission and/or emergency department visits or clinical instability, the IG had 20% fewer events than the CG within 30 days (IG: n=48 (23%), CG: n=70 (34%); OR 0.80 (0.63-0.93); p=0.03).

DISCUSSION

Using DAA improved the combined outcome in these outpatients, with favorable and significant results that included a reduction in HF admissions and in clinical instability. (NCT02068937).

Effects of Different Telemonitoring Strategies on Chronic Heart Failure Care: Systematic Review and Subgroup Meta-Analysis

BACKGROUND

Telemonitoring studies in chronic heart failure are characterized by mixed mortality and hospitalization outcomes, which have deterred the uptake of telemonitoring in clinical practice. These mixed outcomes may reflect the diverse range of patient management strategies incorporated in telemonitoring. To address this, we compared the effects of different telemonitoring strategies on clinical outcomes.

OBJECTIVE

The aim of this systematic review and subgroup meta-analysis was to identify noninvasive telemonitoring strategies attributing to improvements in all-cause mortality or hospitalization outcomes for patients with chronic heart failure.

METHODS

We reviewed and analyzed telemonitoring strategies from randomized controlled trials (RCTs) comparing telemonitoring intervention with usual care. For each strategy, we examined whether RCTs that applied the strategy in the telemonitoring intervention (subgroup 1) resulted in a significantly lower risk ratio (RR) of all-cause mortality or incidence rate ratio (IRR) of all-cause hospitalization compared with RCTs that did not apply this strategy (subgroup 2).

RESULTS

We included 26 RCTs (N=11,450) incorporating 18 different telemonitoring strategies. RCTs that provided medication support were found to be associated with a significantly lower IRR value than RCTs that did not provide this type of support (P=.01; subgroup 1 IRR=0.83, 95% CI 0.72-0.95 vs subgroup 2 IRR=1.02, 95% CI 0.93-1.12). RCTs that applied mobile health were associated with a significantly lower IRR (P=.03; IRR=0.79, 95% CI 0.64-0.96 vs IRR=1.00, 95% CI 0.94-1.06) and RR (P=.01; RR=0.67, 95% CI 0.53-0.85 vs RR=0.95, 95% CI 0.84-1.07).

CONCLUSIONS

Telemonitoring strategies involving medication support and mobile health were associated with improvements in all-cause mortality or hospitalization outcomes. These strategies should be prioritized in telemonitoring interventions for the management of patients with chronic heart failure.

Patients' experiences regarding self-monitoring of the disease course: an observational pilot study in patients with inflammatory rheumatic diseases at a rheumatology outpatient clinic in The Netherlands

OBJECTIVES

Self-monitoring the disease course is a relatively new concept in the management of patients with inflammatory rheumatic diseases (IRDs). The aims of this pilot study were to obtain patients' experiences with online self-monitoring, to assess information about the agreement between the disease course assessed with patient-reported outcome measures (PROMs) and an objectively measured Disease Activity Score 28 (DAS28) by the rheumatologist, and to assess adherence to predetermined PROM frequency intervals.

DESIGN

Observational study using qualitative and quantitative methods.

SETTING

The rheumatology outpatient clinic of a teaching hospital in The Netherlands (secondary care).

PARTICIPANTS

47 patients with an IRD who regularly attended the outpatient clinic.

METHODS

Patients completed PROMs by using an online self-monitoring program. Their experiences regarding self-monitoring were qualitatively assessed through a focus group discussion and telephone interviews using a thematic analysis approach. Adherence to the predefined PROM frequency (completed PROM assessments within the predetermined frequency) and the agreement between the DAS28 course and PROM values (Rheumatoid Arthritis Disease Activity Index-5 and the Rheumatoid Arthritis Impact of Disease (RAID)) were quantitatively assessed using descriptives.

RESULTS

Forty-seven patients participated, most of them diagnosed with rheumatoid arthritis (n=38, 80.9%). Three themes were identified: knowledge about and insight into the disease (activity), patient-professional interaction and functionality of the program. Mean adherence to the predetermined PROM frequency was 68.1%. The RAID showed the best agreement with the DAS28 course. Mean participation time was 350 days.

CONCLUSION

Patients were predominantly positive about online self-monitoring. They indicated that they gained more knowledge about their disease, felt less dependent on the healthcare professional and valued the insight into their long-term disease course. Barriers were mostly related to technical factors. Patients were able to and willing to self-monitor their disease, which could contribute to a more efficient allocation of outpatient consultations in the future.

Impact on Readmission Reduction Among Heart Failure Patients Using Digital Health Monitoring: Feasibility and Adoptability Study

Background

Heart failure (HF) is a condition that affects approximately 6.2 million people in the United States and has a 5-year mortality rate of approximately 42%. With the prevalence expected to exceed 8 million cases by 2030, projections estimate that total annual HF costs will increase to nearly US $70 billion. Recently, the advent of remote monitoring technology has significantly broadened the scope of the physician’s reach in chronic disease management.

Objective

The goal of our program, named the Heart Health Program, was to examine the feasibility of using digital health monitoring in real-world home settings, ascertain patient adoption, and evaluate impact on 30-day readmission rate.

Methods

A digital medicine software platform developed at Mount Sinai Health System, called RxUniverse, was used to prescribe a digital care pathway including the HealthPROMISE digital therapeutic and iHealth mobile apps to patients’ personal smartphones. Vital sign data, including blood pressure (BP) and weight, were collected through an ambulatory remote monitoring system that comprised a mobile app and complementary consumer-grade Bluetooth-connected smart devices (BP cuff and digital scale) that send data to the provider care teams. Care teams were alerted via a Web-based dashboard of abnormal patient BP and weight change readings, and further action was taken at the clinicians’ discretion. We used statistical analyses to determine risk factors associated with 30-day all-cause readmission.

Results

Overall, the Heart Health Program included 58 patients admitted to the Mount Sinai Hospital for HF. The 30-day hospital readmission rate was 10% (6/58), compared with the national readmission rates of approximately 25% and the Mount Sinai Hospital’s average of approximately 23%. Single marital status (P=.06) and history of percutaneous coronary intervention (P=.08) were associated with readmission. Readmitted patients were also less likely to have been previously prescribed angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (P=.02). Notably, readmitted patients utilized the BP and weight monitors less than nonreadmitted patients, and patients aged younger than 70 years used the monitors more frequently on average than those aged over 70 years, though these trends did not reach statistical significance. The percentage of the 58 patients using the monitors at least once dropped from 83% (42/58) in the first week after discharge to 46% (23/58) in the fourth week.

Conclusions

Given the increasing burden of HF, there is a need for an effective and sustainable remote monitoring system for HF patients following hospital discharge. We identified clinical and social factors as well as remote monitoring usage trends that identify targetable patient populations that could benefit most from integration of daily remote monitoring. In addition, we demonstrated that interventions driven by real-time vital sign data may greatly aid in reducing hospital readmissions and costs while improving patient outcomes.

Improving geriatric care and reducing hospitalisations in regional and remote areas: The benefits of telehealth

INTRODUCTION

The aim of this study was to compare the effectiveness of two geriatrician models of care, the telegeriatric service (TGS) and visiting geriatrician (VG), in regional and remote settings in terms of potential cost-savings to the health system and impact on health service use (HSU). Furthermore, to establish whether longer wait-times for clinic appointments led to increased HSU by study participants.

METHODS

Trends in patient emergency department presentations, hospitalisations and bed-days (HSU) were compared from 18 months before to 12 months after geriatrician appointment for the two services in the Western Australian Midwest region. The relationships between wait times, patient triage level and HSU were modelled. The costs of providing the services were offset against reductions in HSU after appointments.

RESULTS

The sample comprised consecutive patients using the TGS (n = 84) and VG service (n = 124). Patient characteristics were similar, although patients using the VG service had longer wait-times, were triaged as more urgent and demonstrated the highest levels of HSU. Both models were effective with similar rates of reduced HSU following appointments. Increased wait-times and higher patient triage urgency were associated with increased HSU.

DISCUSSION

Although TGS and VG showed similar reduced rates of HSU, TGS had the capacity to see a higher volume of patients, a broader geographical reach and improved waitlist management. Consequently, TGS was more effective at reducing avoidable hospitalisations and subsequent health deterioration due to shorter wait-times. Whilst face-to-face consultations are recognised as 'gold standard' a combination of the two models is most efficient.

Engaging telehealth to drive value-based urology

PURPOSE OF REVIEW

Telehealth, or the remote delivery of healthcare services using telecommunications technology, has the potential to revolutionize the delivery of healthcare and contribute to ongoing efforts to provide high-value care.

RECENT FINDINGS

We discuss several categories of telehealth that have been applied to healthcare. Several of these approaches, in particular video visits and teleconsultations, have promising early data demonstrating the significant benefits of telehealth technology with respect to the quality of care, access, cost savings, and patient experience. Nonetheless, considerable knowledge gaps still exist regarding how and for which patients and diseases telehealth modalities should be applied. Finally, we discuss the barriers to widespread adoption at the institutional, state, and federal levels.

SUMMARY

Maximizing the value of healthcare is an important goal for hospitals, physicians, and policymakers. Telehealth leverages advances in technology and the widespread availability of telecommunications devices to make healthcare communication more available, more convenient, and more efficient for patients and providers. With appropriate policies and incentives, telehealth initiatives can improve the value of urologic care and smooth the transition to a value-based healthcare system.

Effectiveness of telemonitoring-enhanced support over structured telephone support in reducing heart failure-related healthcare utilization in a multi-ethnic Asian setting

Aims

Our study aimed to compare the effectiveness of telemonitoring over structured telephone support in reducing heart failure-related healthcare utilization.

Methods

This was a non-randomised controlled study comparing 150 recently discharged heart failure patients enrolled into telemonitoring and 55 patients who only received structured telephone support after rejecting telemonitoring. Patient activation, knowledge and self-management levels were measured at baseline and the one year upon programme completion using the Patient Activation Measure, the Dutch Heart Failure Knowledge Scale and the Self-Care of Heart Failure Index respectively. Differences in heart failure-related and all-cause hospitalization rates, total bed days and mortality rates at 180 days and at one year, knowledge and self-management scores and total cost of care between groups at one year were analysed.

Results

Average age of telemonitoring was 57.9 years and 63.9 years for structured telephone support. Significant difference in adjusted 180-day all-cause bed days (telemonitoring: five days versus structured telephone support: 9.8 days), heart failure-related bed days (telemonitoring: 1.2 days versus structured telephone support: six days) and adjusted one-year heart failure-related bed days (telemonitoring: 2.2 days versus structured telephone support: 6.6 days) were observed. Telemonitoring was associated with reduced all-cause one-year mortality (hazard ratio 0.32, p = 0.02). Estimated mean maintenance and confidence scores were significantly higher in the telemonitoring group at one year. No differences in all-cause and HF-related readmission rates and knowledge levels were observed. The one-year total cost of care was predicted to be Singapore dollars (SG$) 2774.4 lower ( p = 0.07) in telemonitoring.

Conclusion

In conclusion, telemonitoring was associated with lower all-cause and heart failure-related total bed days at 180 days, lower heart failure-related total bed days and total cost of care at one year as compared with structured telephone support.

Internet videoconferencing for patient-clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations

BACKGROUND

The use of internet videoconferencing in healthcare settings is widespread, reflecting the normalisation of this mode of communication in society and current healthcare policy. As the use of internet videoconferencing is growing, increasing numbers of reviews of literature are published.

METHODS

The authors conducted a review of the existing reviews of literature relating to the use of internet videoconferencing for consultations between healthcare professionals and patients with long-term conditions in their own home. The review was followed with an assessment of United Kingdom National Institute for Health and Clinical Excellence guidelines for patient care in the context of common long-term illnesses to examine where videoconferencing could be implemented in line with these recommendations.

RESULTS

The review of reviews found no formal evidence in favour of or against the use of internet videoconferencing. Patients were satisfied with the use of videoconferencing but there was limited evidence that it led to a change in health outcomes. Evidence of healthcare professional satisfaction when using this mode of communication with patients was limited. The review of guidelines suggested a number of opportunities for adoption and expansion of internet videoconferencing. Implementing videoconferencing in line with current evidence for patient care could offer support and provide information on using a communication channel that suits individual patient needs and circumstances. The evidence base for videoconferencing is growing, but there is still a lack of data relating to cost, ethics and safety.

CONCLUSIONS

While the current evidence base for internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published. With more videoconferencing services added in more contexts, research needs to explore how internet videoconferencing can be implemented in ways that it is valued by patients and clinicians, and how it can fit within organisational and technical infrastructure of the healthcare services.

The role of digital communication in patient–clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Background

Young people (aged 16–24 years) with long-term health conditions tend to disengage from health services, resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK NHS clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely.

Objectives

To explore how health-care engagement can be improved using digital clinical communication (DCC); understand effects, impacts, costs and necessary safeguards; and provide critical analysis of its use, monitoring and evaluation.

Design

Observational mixed-methods case studies; systematic scoping literature reviews; assessment of patient-reported outcome measures (PROMs); public and patient involvement; and consensus development through focus groups.

Setting

Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long-term physical or mental health conditions.

Participants

One hundred and sixty-five young people aged 16–24 years living with a long-term health condition; 13 parents; 173 clinical team members; and 16 information governance specialists.

Interventions

Clinical teams and young people variously used mobile phone calls, text messages, e-mail and voice over internet protocol.

Main outcome measures

Empirical work – thematic and ethical analysis of qualitative data; annual direct costs; did not attend, accident and emergency attendance and hospital admission rates plus clinic-specific clinical outcomes. Scoping reviews–patient, health professional and service delivery outcomes and technical problems. PROMs: scale validity, relevance and credibility.

Data sources

Observation, interview, structured survey, routinely collected data, focus groups and peer-reviewed publications.

Results

Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships, but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases and the main cost is staff time. Clinical teams had not evaluated the impact of their intervention and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures, but the Patient Activation Measure and the Physicians’ Humanistic Behaviours Questionnaire are promising. Scoping reviews suggest DCC is acceptable to young people, but with no clear evidence of benefit except for mental health.

Limitations

Qualitative data were mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available.

Conclusions

Timely DCC is perceived as making a difference to health care and health outcomes for young people with long-term conditions, but this is not supported by evidence that measures health outcomes. Such communication is challenging and costly to provide, but valued by young people.

Future work

Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes.

Study registration

Two of the reviews in this study are registered as PROSPERO CRD42016035467 and CRD42016038792.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Understanding heart failure; explaining telehealth - a hermeneutic systematic review

BACKGROUND

Enthusiasts for telehealth extol its potential for supporting heart failure management. But randomised trials have been slow to recruit and produced conflicting findings; real-world roll-out has been slow. We sought to inform policy by making sense of a complex literature on heart failure and its remote management.

METHODS

Through database searching and citation tracking, we identified 7 systematic reviews of systematic reviews, 32 systematic reviews (including 17 meta-analyses and 8 qualitative reviews); six mega-trials and over 60 additional relevant empirical studies and commentaries. We synthesised these using Boell's hermeneutic methodology for systematic review, which emphasises the quest for understanding.

RESULTS

Heart failure is a complex and serious condition with frequent co-morbidity and diverse manifestations including severe tiredness. Patients are often frightened, bewildered, socially isolated and variably able to self-manage. Remote monitoring technologies are many and varied; they create new forms of knowledge and new possibilities for care but require fundamental changes to clinical roles and service models and place substantial burdens on patients, carers and staff. The policy innovation of remote biomarker monitoring enabling timely adjustment of medication, mediated by "activated" patients, is based on a modernist vision of efficient, rational, technology-mediated and guideline-driven ("cold") care. It contrasts with relationship-based ("warm") care valued by some clinicians and by patients who are older, sicker and less technically savvy. Limited uptake of telehealth can be analysed in terms of key tensions: between tidy, "textbook" heart failure and the reality of multiple comorbidities; between basic and intensive telehealth; between activated, well-supported patients and vulnerable, unsupported ones; between "cold" and "warm" telehealth; and between fixed and agile care programmes.

CONCLUSION

The limited adoption of telehealth for heart failure has complex clinical, professional and institutional causes, which are unlikely to be elucidated by adding more randomised trials of technology-on versus technology-off to an already-crowded literature. An alternative approach is proposed, based on naturalistic study designs, application of social and organisational theory, and co-design of new service models based on socio-technical principles. Conventional systematic reviews (whose goal is synthesising data) can be usefully supplemented by hermeneutic reviews (whose goal is deepening understanding).

Old-and With Severe Heart Failure: Telemonitoring by Using Digital Pen Technology in Specialized Homecare: System Description, Implementation, and Early Results

Telehealth programs for heart failure have been studied using a variety of techniques. Because currently a majority of the elderly are nonusers of computers and Internet, we developed a home telehealth system based on digital pen technology. Fourteen patients (mean age, 84 years [median, 83 years]) with severe heart failure participated in a 13-month pilot study in specialized homecare. Participants communicated patient-reported outcome measures daily using the digital pen and health diary forms, submitting a total of 3 520 reports. The reports generated a total of 632 notifications when reports indicated worsening health. Healthcare professionals reviewed reports frequently, more than 4700 times throughout the study, and acted on the information provided. Patients answered questionnaires and were observed in their home environment when using the system. Results showed that the technology was accepted by participants: patients experienced an improved contact with clinicians; they felt more compliant with healthcare professionals' advice, and they felt more secure and more involved in their own care. Via the system, the healthcare professionals detected heart failure-related deteriorations at an earlier stage, and as a consequence, none of the patients were admitted into hospital care during the study.

The effectiveness of telemedicine in the management of chronic heart disease - a systematic review

OBJECTIVE

The primary objective of this systematic review is to assess the effectiveness of telemedicine in managing chronic heart disease patients concerning improvement in varied health attributes.

DESIGN

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard.

SETTING

We adopted a logical search process used in two main research databases, the Cumulative Index to Nursing and Allied Health Literature and PubMed (MEDLINE). Four reviewers meticulously screened 151 abstracts to determine relevancy and significance to our research objectives. The final sample in the literature review consisted of 20 articles.

MAIN OUTCOME MEASURES

We looked for improved medical outcomes as the main outcome measure.

RESULTS

Our results indicated that telemedicine is highly associated with the reduction in hospitalisations and readmissions (9 of 20 articles, 45%). The other significant attributes most commonly encountered were improved mortality and cost-effectiveness (both 40%) and improved health outcomes (35%). Patient satisfaction occurred the least in the literature, mentioned in only 2 of 20 articles (10%). There was no significant mention of an increase in patient satisfaction because of telemedicine.

CONCLUSIONS

We concluded that telemedicine is considered to be effective in quality measures such as readmissions, moderately effective in health outcomes, only marginally effective in customer satisfaction. Telemedicine shows promise on an alternative modality of care for cardiovascular disease, but additional exploration should continue to quantify the quality measures.

Recent Worldwide Developments in eHealth and mHealth to more Effectively Manage Cancer and other Chronic Diseases - A Systematic Review

OBJECTIVES

This paper is a systematic literature review intended to gain an understanding of the most original, excellent, stateof- the-art research in the application of eHealth (including mHealth) in the management of chronic diseases with a focus on cancer over the past two years.

METHOD

This review looks at peer-reviewed papers published between 2013 and 2015 and examines the background and trends in this area. It systematically searched peer-reviewed journals in databases PubMed, Proquest, Cochrane Library, Elsevier, Sage and the Institute of Electrical and Electronic Engineers (IEEE Digital Library) using a set of pre-defined keywords. It then employed an iterative process to filter out less relevant publications.

RESULTS

From an initial search return of 1,519,682 results returned, twenty nine of the most relevant peer reviewed articles were identified as most relevant.

CONCLUSIONS

Based on the results we conclude that innovative eHealth and its subset mHealth initiatives are rapidly emerging as an important means of managing cancer and other chronic diseases. The adoption is following different paths in the developed and developing worlds. Besides governance and regulatory issues, barriers still exist around information management, interoperability and integration. These include medical records available online information for clinicians and consumers on cancer and other chronic diseases, mobile app bundles that can help manage co-morbidities and the capacity of supporting communication technologies.

Technology-assisted congestive heart failure care

The interface between eHealth technologies and disease management in chronic conditions such as chronic heart failure (CHF) has advanced beyond the research domain. The substantial morbidity, mortality, health resource utilization and costs imposed by chronic disease, accompanied by increasing prevalence, complex comorbidities and changing client and health staff demographics, have pushed the boundaries of eHealth to alleviate costs whilst maintaining services. Whilst the intentions are laudable and the technology is appealing, this nonetheless requires careful scrutiny. This review aims to describe this technology and explore the current evidence and measures to enhance its implementation.

Structured telephone support or non-invasive telemonitoring for patients with heart failure

BACKGROUND

Specialised disease management programmes for heart failure aim to improve care, clinical outcomes and/or reduce healthcare utilisation. Since the last version of this review in 2010, several new trials of structured telephone support and non-invasive home telemonitoring have been published which have raised questions about their effectiveness.

OBJECTIVES

To review randomised controlled trials (RCTs) of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure, in order to quantify the effects of these interventions over and above usual care.

SEARCH METHODS

We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology AsseFssment Database (HTA) on the Cochrane Library; MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index- Science (CPCI-S) on Web of Science (Thomson Reuters), AMED, Proquest Theses and Dissertations, IEEE Xplore and TROVE in January 2015. We handsearched bibliographies of relevant studies and systematic reviews and abstract conference proceedings. We applied no language limits.

SELECTION CRITERIA

We included only peer-reviewed, published RCTs comparing structured telephone support or non-invasive home telemonitoring to usual care of people with chronic heart failure. The intervention or usual care could not include protocol-driven home visits or more intensive than usual (typically four to six weeks) clinic follow-up.

DATA COLLECTION AND ANALYSIS

We present data as risk ratios (RRs) with 95% confidence intervals (CIs). Primary outcomes included all-cause mortality, all-cause and heart failure-related hospitalisations, which we analysed using a fixed-effect model. Other outcomes included length of stay, health-related quality of life, heart failure knowledge and self care, acceptability and cost; we described and tabulated these. We performed meta-regression to assess homogeneity (the null hypothesis) in each subgroup analysis and to see if the effect of the intervention varied according to some quantitative variable (such as year of publication or median age).

MAIN RESULTS

We include 41 studies of either structured telephone support or non-invasive home telemonitoring for people with heart failure, of which 17 were new and 24 had been included in the previous Cochrane review. In the current review, 25 studies evaluated structured telephone support (eight new studies, plus one study previously included but classified as telemonitoring; total of 9332 participants), 18 evaluated telemonitoring (nine new studies; total of 3860 participants). Two of the included studies trialled both structured telephone support and telemonitoring compared to usual care, therefore 43 comparisons are evident.Non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94; participants = 3740; studies = 17; I² = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I² = 20%, GRADE: moderate-quality evidence). Structured telephone support reduced all-cause mortality (RR 0.87, 95% CI 0.77 to 0.98; participants = 9222; studies = 22; I² = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I² = 27%, GRADE: moderate-quality evidence).Neither structured telephone support nor telemonitoring demonstrated effectiveness in reducing the risk of all-cause hospitalisations (structured telephone support: RR 0.95, 95% CI 0.90 to 1.00; participants = 7216; studies = 16; I² = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I² = 71%, GRADE: very low-quality evidence).Seven structured telephone support studies reported length of stay, with one reporting a significant reduction in length of stay in hospital. Nine telemonitoring studies reported length of stay outcome, with one study reporting a significant reduction in the length of stay with the intervention. One telemonitoring study reported a large difference in the total number of hospitalisations for more than three days, but this was not an analysis of length of stay per hospitalisation. Nine of 11 structured telephone support studies and five of 11 telemonitoring studies reported significant improvements in health-related quality of life. Nine structured telephone support studies and six telemonitoring studies reported costs of the intervention or cost effectiveness. Three structured telephone support studies and one telemonitoring study reported a decrease in costs and two telemonitoring studies reported increases in cost, due both to the cost of the intervention and to increased medical management. Adherence was rated between 55.1% and 98.5% for those structured telephone support and telemonitoring studies which reported this outcome. Participant acceptance of the intervention was reported in the range of 76% to 97% for studies which evaluated this outcome. Seven of nine studies that measured these outcomes reported significant improvements in heart failure knowledge and self-care behaviours.

AUTHORS' CONCLUSIONS

For people with heart failure, structured telephone support and non-invasive home telemonitoring reduce the risk of all-cause mortality and heart failure-related hospitalisations; these interventions also demonstrated improvements in health-related quality of life and heart failure knowledge and self-care behaviours. Studies also demonstrated participant satisfaction with the majority of the interventions which assessed this outcome.

Effects of home telemonitoring interventions on patients with chronic heart failure: an overview of systematic reviews

BACKGROUND

Growing interest on the effects of home telemonitoring on patients with chronic heart failure (HF) has led to a rise in the number of systematic reviews addressing the same or very similar research questions with a concomitant increase in discordant findings. Differences in the scope, methods of analysis, and methodological quality of systematic reviews can cause great confusion and make it difficult for policy makers and clinicians to access and interpret the available evidence and for researchers to know where knowledge gaps in the extant literature exist.

OBJECTIVE

This overview aims to collect, appraise, and synthesize existing evidence from multiple systematic reviews on the effectiveness of home telemonitoring interventions for patients with chronic heart failure (HF) to inform policy makers, practitioners, and researchers.

METHODS

A comprehensive literature search was performed on MEDLINE, EMBASE, CINAHL, and the Cochrane Library to identify all relevant, peer-reviewed systematic reviews published between January 1996 and December 2013. Reviews were searched and screened using explicit keywords and inclusion criteria. Standardized forms were used to extract data and the methodological quality of included reviews was appraised using the AMSTAR (assessing methodological quality of systematic reviews) instrument. Summary of findings tables were constructed for all primary outcomes of interest, and quality of evidence was graded by outcome using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system. Post-hoc analysis and subgroup meta-analyses were conducted to gain further insights into the various types of home telemonitoring technologies included in the systematic reviews and the impact of these technologies on clinical outcomes.

RESULTS

A total of 15 reviews published between 2003 and 2013 were selected for meta-level synthesis. Evidence from high-quality reviews with meta-analysis indicated that taken collectively, home telemonitoring interventions reduce the relative risk of all-cause mortality (0.60 to 0.85) and heart failure-related hospitalizations (0.64 to 0.86) compared with usual care. Absolute risk reductions ranged from 1.4%-6.5% and 3.7%-8.2%, respectively. Improvements in HF-related hospitalizations appeared to be more pronounced in patients with stable HF: hazard ratio (HR) 0.70 (95% credible interval [Crl] 0.34-1.5]). Risk reductions in mortality and all-cause hospitalizations appeared to be greater in patients who had been recently discharged (≤28 days) from an acute care setting after a recent HF exacerbation: HR 0.62 (95% CrI 0.42-0.89) and HR 0.67 (95% CrI 0.42-0.97), respectively. However, quality of evidence for these outcomes ranged from moderate to low suggesting that further research is very likely to have an important impact on our confidence in the observed estimates of effect and may change these estimates. The post-hoc analysis identified five main types of non-invasive telemonitoring technologies included in the systematic reviews: (1) video-consultation, with or without transmission of vital signs, (2) mobile telemonitoring, (3) automated device-based telemonitoring, (4) interactive voice response, and (5) Web-based telemonitoring. Of these, only automated device-based telemonitoring and mobile telemonitoring were effective in reducing the risk of all-cause mortality and HF-related hospitalizations. More research data are required for interactive voice response systems, video-consultation, and Web-based telemonitoring to provide robust conclusions about their effectiveness.

CONCLUSIONS

Future research should focus on understanding the process by which home telemonitoring works in terms of improving outcomes, identify optimal strategies and the duration of follow-up for which it confers benefits, and further investigate whether there is differential effectiveness between chronic HF patient groups and types of home telemonitoring technologies.

The impact of telemedicine in cardiac critical care

Telemedicine was recognized in the 1970s as a legitimate entity for applying the use of modern information and communications technologies to the delivery of health services. Telecardiology is one of the fastest growing fields in telemedicine. The advancement of technologies and Web-based applications has allowed better transmission of health care delivery. This article discusses current advancements, the scope of telemedicine in cardiology, and its application to the critically ill. The impact of telecardiology consultation continues to evolve and includes many promising applications with potential positive implications for admission rates, morbidity, and mortality.