Cost-Utility Analysis of 3-Month Telemedical Intervention for Heart Failure Patients: A Preliminary Study from Poland

Heart failure (HF) is a common clinical syndrome in which the cardiac systolic and/or diastolic functions are significantly insufficient, resulting in an inadequate pump function. Currently, it is one of the leading causes of human death and/or hospitalization, and it has become a serious global public health problem. Approximately 1.2 million people in Poland suffer from HF, and approximately 140,000 of them die every year. In this article, we present the result of telemedicine intervention and its cost-effectiveness in a group of patients from a pilot program on telemedicine and e-health solutions reducing social inequalities in the field of cardiology. Based on the EQ-5D-5L questionnaire administered in the beginning of the project and after approximately 3 months, used for the health state utility values calculation, cost estimates of the project, and inclusion of supplementary data, the economic rationale behind telemedical intervention in HF patients using a cost-utility analysis was corroborated. The choice of a 3-month project duration was due to the top-down project assumptions approved by the bioethics committee. The average improvement in health state utility values was statistically significant, implying a 0.01 QALY improvement per patient. The cost of the telemedical intervention per QALY was well within the official limit adopted as a cost-effective therapy measure in Poland.

Sustainable adoption of noninvasive telemonitoring for chronic heart failure: A qualitative study in the Netherlands

Objective

Noninvasive telemonitoring aims to improve healthcare for patients with chronic heart failure (HF) by reducing hospitalizations and improving patient experiences. Yet, sustainable adoption seems to be limited. Therefore, the goal of our study is to gain insight in the processes that support sustainable adoption of telemonitoring for patients with HF.

Methods

We conducted semi-structured interviews with 25 stakeholders that were involved with the adoption of telemonitoring, such as healthcare professionals, policymakers and healthcare insurers. We analyzed the interviews by using a combination of open-coding and the themes of the Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability framework.

Results

We found that telemonitoring projects have moved beyond initial pilot phases despite a high level of complexity on multiple topics. The patient selection, the business case, the evidence, the aims of telemonitoring, integration of telemonitoring in the care pathway, reimbursement, and future centralization were items that yielded different and sometimes contradictory opinions.

Conclusions

This study showed that the sustainable adoption of telemonitoring for HF is a complex endeavor. Different aims and perspectives play an important role in the patient selection, design, evaluations and envisioned futures of telemonitoring. High conviction among participants of the added value that telemonitoring may support further adoption of telemonitoring. Structural evaluations will be needed to guide cyclical improvement and adapt programs to employ telemonitoring in such a manner that it contributes to collectively supported aims.

Device-based remote monitoring strategies for congestion-guided management of patients with heart failure: a systematic review and meta-analysis

AIMS

Pre-clinical congestion markers of worsening heart failure (HF) can be monitored by devices and may support the management of patients with HF. We aimed to assess whether congestion-guided HF management according to device-based remote monitoring strategies is more effective than standard therapy.

METHODS AND RESULTS

A comprehensive literature research for randomized controlled trials (RCTs) comparing device-based remote monitoring strategies for congestion-guided HF management versus standard therapy was performed on PubMed, Embase, and CENTRAL databases. Incidence rate ratios (IRRs) and associated 95% confidence intervals (CIs) were calculated using the Poisson regression model with random study effects. The primary outcome was a composite of all-cause death and HF hospitalizations. Secondary endpoints included the individual components of the primary outcome. A total of 4347 patients from eight RCTs were included. Findings varied according to the type of parameters monitored. Compared with standard therapy, haemodynamic-guided strategy (4 trials, 2224 patients, 12-month follow-up) reduced the risk of the primary composite outcome (IRR 0.79, 95% CI 0.70-0.89) and HF hospitalizations (IRR 0.76, 95% CI 0.67-0.86), without a significant impact on all-cause death (IRR 0.93, 95% CI 0.72-1.21). In contrast, impedance-guided strategy (4 trials, 2123 patients, 19-month follow-up) did not provide significant benefits.

CONCLUSION

Haemodynamic-guided HF management is associated with better clinical outcomes as compared to standard clinical care.

Dapagliflozin attenuates residual cardiac remodeling after surgical ventricular reconstruction in mice with an enlarged heart after myocardial infarction

BACKGROUND

Severe heart failure refractory to conventional therapy requires alternative treatment modalities. Surgical ventricular reconstruction (SVR) has been used to reverse cardiac remodeling in post-myocardial infarction (MI) patients with large left ventricular (LV) aneurysm, however, residual LV remodeling and dysfunction remain postoperatively. It is unclear whether SVR recovers response to drug treatment and whether the sodium-glucose co-transporter 2 inhibitor dapagliflozin (DAPA) reverses residual LV remodeling after SVR.

METHODS

Adult male C57 mice were subjected to MI or sham surgery. Four-week later, MI mice with LV aneurysm underwent modified SVR or second open-chest sham operation and were randomized to DAPA or vehicle for four-week. Cardiac remodeling, LV function, and the underlying mechanisms were evaluated by echocardiography, invasive LV hemodynamic measurements, mRNA sequencing, and bioinformatics analysis.

RESULTS

SVR significantly decreased LV volume; increased myocardial strain, LV pressure change rates and end-systolic elastance; and decreased heart-to-body weight ratio and myocardial fibrosis. However, significant residual cardiac remodeling remained. DAPA significantly attenuated residual cardiac remodeling and improved LV function in SVR mice but did not have curative effects in non-SVR mice. Of the 1532 genes differentially expressed in SVR and MI mice, 1037 were associated with cardiac metabolism; Src, Crebbp, Fn1, Grb2, and Mapk14 were the top 5 hub genes. Unlike sham surgery, MI upregulated those 5 genes, and treatment with SVR + DAPA normalized their expression.

CONCLUSIONS

SVR restores therapeutic response in the post-MI heart with large LV aneurysm, and DAPA attenuates residual cardiac remodeling after SVR by normalizing some cardiac metabolism-related hub genes.

Impact of hospitalisation on health-related quality of life in patients with chronic heart failure

BACKGROUND

Empirical identification of the direct impact of hospitalisation in the change in utility could provide an interpretation for some of the unexplained variance in quality of life responses in clinical practice and clinical trials and provide assistance to researchers in assessing the impact of a hospitalisation in the context of economic evaluations. This study had the goal of determining the impact of nonfatal hospitalisations on the quality of life of a cohort of patients previously diagnosed with heart failure by using their quality of life measurements before and after hospitalisation.

METHODS

The impact of hospitalisation on health-related quality of life was estimated by calculating the difference in utility measured using the EQ-5D-3L in patients that were hospitalised and had records of utility before and after hospitalisation. The variation in differences between the utilities pre and post hospitalisation was explained through two multiple linear regression models using (1) the individual patient characteristics and (2) the hospitalisation characteristics as explanatory variables.

RESULTS

The mean difference between health-related quality of life measurement pre and post hospitalisation was found to be 0.020 [95% CI: - 0.020, 0.059] when measured with the EQ-5D index, while there was a mean decrease of - 0.012 [95% CI: - 0.043, 0.020] in the utility measured with the visual analogue scale. Differences in utility variation according to the primary cause for hospitalisation were found. Regression models showed a statistically significant impact of body mass index and serum creatinine in the index utility differences and of serum creatinine for utilities measured with the visual analogue scale.

CONCLUSIONS

Knowing the impact of hospitalisation on health-related quality of life is particularly relevant for informing cost-effectiveness studies designed to assess health technologies aimed at reducing hospital admissions. Through using patient-level data it was possible to estimate the variation in utilities before and after the average hospitalisation and for hospitalisations due to the most common causes for hospital admission. These estimates for (dis) utility could be used in the calculations of effectiveness on economic evaluations, especially when discrete event simulations are the employed modelling technique.

Enhancing the Sustainable Goal of Access to Healthcare: Findings from a Literature Review on Telemedicine Employment in Rural Areas

Fighting health inequalities is a challenge addressed by the United Nations Strategic Development Goals (UN-SDGs). Particularly, people living in rural areas suffer from a lack of health infrastructure, which would jeopardize their inclusion in universal coverage for specialist care. Delivering valuable healthcare in underserved areas can be achieved through the employment of new technical innovations, such as telemedicine, which improves service delivery processes. Accordingly, this paper discusses how telemedicine strategies have enhanced the sustainability of right of “access to healthcare” in rural areas. Once we derived the sustainability pillars for healthcare from the UN-SDGs 3 and 10 according to the WHO innovation assessment metrics, a PRISMA-based literature review was conducted using the Scopus database. English, peer-reviewed articles/reviews from 1973 to 2019 were considered. The enquiry covers two analyses: (i) quantitative-bibliometric on 2267 papers; and (ii) qualitative-narrative on the 30 most significant papers. Interest about the topic has increased in the last decade following digitalization diffusion. The most productive and collaborative countries are those with huge dimensions and under financial restrictions. From a sustainability-oriented standpoint, telemedicine enhances both emergency and diagnostic healthcare in rural areas by decreasing the cost of services, expanding coverage of specialist cares, and increasing the quality of the outcomes. For health policies, telemedicine can be considered a suitable solution for providing cost-effective and sustainable healthcare.

Prevention, Monitoring, and Management of Cardiac Dysfunction in Patients with Metastatic Breast Cancer

Cardiac monitoring is becoming an important part of breast cancer care. Breast cancer and cardiovascular disease (CVD) share many common risk factors, and it is estimated that by the median age of diagnosis, many patients with breast cancer will have established or subclinical CVD. In addition, a number of treatments for metastatic breast cancer are known to have cardiac effects. As such, there is a clear need to prevent, identify, and effectively manage cardiovascular events in patients with breast cancer. Current clinical practice for patients with metastatic breast cancer involves a comprehensive set of assessments to ensure efficacy and safety of treatment. Adding cardiac monitoring to the assessments already required for patients with breast cancer may improve survival and quality of life. Currently, cardiac monitoring is recommended for several breast cancer treatments, and guidelines related to cardiac monitoring are available. Here, we review the risk of CVD in patients with breast cancer, providing an overview of the cardiac events associated with standard therapies for metastatic breast cancer. We also assess the current clinical recommendations relating to cardiac monitoring, and practical management strategies for oncologists. Cardio-oncology is a growing medical subspecialty that promotes the need for effective cancer therapy while minimizing cardiac effects. Integrating cardiac monitoring into routine clinical practice may safeguard patients with metastatic breast cancer against adverse cardiac effects. IMPLICATIONS FOR PRACTICE: This review details the common risk factors associated with cardiovascular disease that are frequently observed in patients with metastatic breast cancer, as well as the adverse cardiac effects of many therapies that are commonly prescribed. The review also provides a rationale for routine and comprehensive cardiovascular assessment of all patients at baseline, and during and after therapy depending on the treatment and presence of risk factors for cardiovascular disease. The medical discipline of cardio-oncology is increasingly being recognized as an important part of clinical practice to ensure effective cancer therapy while maintaining cardiac health.

Noise-robust bioimpedance approach for cardiac output measurement

OBJECTIVE

Congestive heart failure is a problem affecting millions of Americans. A continuous, non-invasive, telemonitoring device that can accurately monitor cardiac metrics could greatly help this population, reducing unnecessary hospitalizations and cost.

APPROACH

Machine learning (ML) algorithms trained on electrical-impedance tomography (EIT) data are presented for portable cardiac monitoring. The approach was validated on a simulated thorax and a measured tank experiment. A highly detailed 4D chest model (finite element method mesh and conductivity profiles) was developed utilizing the 4D XCAT phantom to provide realistic data. The ML algorithms were trained using databases that assumed the presence of poorly contacting electrodes without any assumptions of knowing which electrodes would be bad in the experiment. The trained ML algorithms were compared to EIT evaluated with and without removing bad electrodes.

MAIN RESULTS

A regression support vector machine and a deep neural network (DNN) were found to be the most accurate and robust to poorly contacting electrodes while not needing to know which electrodes were in poor contact in the simulated and measured experiments, respectively.

SIGNIFICANCE

Although the ML algorithms are not always better than EIT (with bad electrodes removed), the comparable results without needing a priori knowledge of which electrodes are bad is seen as a very promising feature. An evaluation of computational costs showed that the DNN required comparable computational power to the other methods while requiring less memory, which could make the DNNs an attractive algorithm for a low-power, portable system. This work represents an important validation of the method using measured data, and model development, which is needed to apply this method on real clinical data. Additionally, the developed 4D simulated thorax model could be an important tool within the EIT community.

Willingness to pay for pharmacist-provided home telemonitoring among patients with chronic diseases in Enugu metropolis

Home telemonitoring is a promising approach in the management of patients with chronic diseases. However, no study has assessed its acceptability and possible service charge in Nigeria. Therefore, this study aimed to evaluate willingness to pay for pharmacist-provided telemonitoring among patients with chronic diseases and to explore its determinants. Hence, using the contingent valuation method, a cross-sectional study was conducted among eligible patients visiting 15 selected community pharmacies in Enugu metropolis, over a period of 3 months. Of the 335 patients who participated in the study, about 40 percent (i.e. 39.4%) were willing to pay an average monthly fee of ₦915.91 ± 485.49 (US$2.99 ± 1.59) for home telemonitoring services. Significant predictors of willingness to pay for home telemonitoring were perceived insufficient income (odds ratio = 0.20, 95% confidence interval = 0.07-0.60, p = 0.040) and health insurance status (odds ratio = 0.39, 95% confidence interval = 0.18-0.86, p = 0.019). Our findings suggest a promising potential for adopting home telemonitoring services among patients with chronic diseases in Enugu metropolis.

Implant-based multi-parameter telemonitoring of patients with heart failure and a defibrillator with vs. without cardiac resynchronization therapy option: a subanalysis of the IN-TIME trial

Aims

In the IN-TIME trial, automatic daily implant-based multiparameter telemonitoring significantly improved clinical outcomes in patients with chronic systolic heart failure and implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D). We compared IN-TIME results for ICD and CRT-D subgroups.

Methods

Patients with LVEF ≤ 35%, NYHA class II/III, optimized drug treatment, no permanent atrial fibrillation, and a dual-chamber ICD (n = 274) or CRT-D (n = 390) were randomized 1:1 to telemonitoring or no telemonitoring for 12 months. Primary outcome measure was a composite clinical score, classified as worsened if the patient died or had heart failure-related hospitalization, worse NYHA class, or a worse self-reported overall condition.

Results

The prevalence of worsened score at study end was higher in CRT-D than ICD patients (26.4% vs. 18.2%; P = 0.014), as was mortality (7.4% vs. 4.1%; P = 0.069). With telemonitoring, odds ratios (OR) for worsened score and hazard ratios (HR) for mortality were similar in the ICD [OR = 0.55 (P = 0.058), HR = 0.39 (P = 0.17)] and CRT-D [OR = 0.68 (P = 0.10), HR = 0.35 (P = 0.018)] subgroups (insignificant interaction, P = 0.58–0.91).

Conclusion

Daily multiparameter telemonitoring has a potential to reduce clinical endpoints in patients with chronic systolic heart failure both in ICD and CRT-D subgroups. The absolute benefit seems to be higher in higher-risk populations with worse prognosis.

Electronic supplementary material

The online version of this article (10.1007/s00392-019-01447-5) contains supplementary material, which is available to authorized users.

Telemonitoring with an implantable loop recorder in outpatient heart failure care : One year follow-up report from a prospective observational Dutch multicentre study

Introduction

In the care of heart failure patients, telemonitoring is receiving growing attention. The main purpose of this study was to determine the effect of continuous telemonitoring with an implantable loop recorder (ILR, Reveal XT), a novel strategy in the management of stable heart failure patients without a cardiac implantable device. Furthermore, little is known about the incidence of subclinical arrhythmias in this specific group of patients.

Materials and Methods

Stable heart failure patients, New York Heart Association Class II and III, without recent hospitalisation or upcoming intervention, were included. After implantation of the ILR there was regular contact with the research nurse on a pre-specified basis. Clinic visits and telephonic interviews were alternated for a minimum of 1 year. Parallel visits to their treating physician continued according to standard care. The treating physician was blinded for the ILR findings, accept for pre-specified, significant arrhythmic events.

Results

Thirty patients were included and followed for a median duration of 12 months. In 13 patients, data from the loop recorder led to therapeutic changes. One patient received a pacemaker. Eight patients developed atrial fibrillation, all subclinical, with a mean burden of 65.8 ± 173.2 min/day.

Conclusion

The use of an ILR could potentially impact patient management. Additional study is needed in different patient populations (e. g. higher risk groups) to assess if an ILR could also impact on endpoints such as heart failure hospitalisation.

An Analog Front End ASIC for Cardiac Electrical Impedance Tomography

In this paper, an end-to-end CMOS application specific integrated circuit (ASIC) for readout channel in a cardiac electrical impedance tomography system is presented. The ASIC consists of an integrated current driver for current injection, an instrumentation amplifier, variable gain amplifier at the analog front end for voltage readout from electrodes, and an on-chip 10-bit successive approximation register analog to digital converter with serial peripheral interface. The ASIC is fabricated in the CMOS 0.18 $\mu$ m process with a supply voltage of 3.3 V. Amplitude and phase extraction of the voltages is performed in the digital domain with a matched filter. A fully integrated solution for use in multiple electrode system is demonstrated. The readout chain in the ASIC achieves a minimum signal-to-noise ratio of 71 dB over the frequency range of 500 Hz-700 kHz, while maintaining an average accuracy of 99.7 $\%$. Frame rates of 21 frames per second for a 32 electrode system is feasible, and the ASIC has an overall power consumption of 11.8 mW.

Innovative Telemonitoring Enhanced Care Programme for Chronic Heart Failure (ITEC-CHF) to improve guideline compliance and collaborative care: protocol of a multicentre randomised controlled trial

INTRODUCTION

Chronic heart failure (CHF) is a life-threatening chronic disease characterised by periodic exacerbations and recurrent hospitalisations. In the management of CHF, patient compliance with evidence-based clinical guidelines is essential, but remains difficult practically. The objective of this study is to examine whether an Innovative Telemonitoring Enhanced Care Programme for CHF (ITEC-CHF) improves patients' compliance, and associated health and economic outcomes.

METHODS AND ANALYSIS

An open multicentre randomised controlled trial has been designed. Patients will be recruited and randomised to receive either ITEC-CHF (n=150) or usual care CHF (n=150) for at least 6 months. ITEC-CHF combines usual care and an additional telemonitoring service including remote weight monitoring, structured telephone support and nurse-led collaborative care. The primary outcomes are the compliance rates with the best-practice guidelines for daily weight monitoring. The secondary outcomes include the compliance with other guideline recommendations (health maintenance, medication, diet and exercise), health (health-related quality of life, risk factors, functional capacity and psychological states) and economic outcomes related to the use of healthcare resources such as hospital readmissions and general practitioner/emergency department visits.

ETHICS AND DISSEMINATION

The clinical trial has been approved by Peninsula Health Human Research Ethics Committee (HREC Reference: HREC/14/PH/27), Royal Perth Hospital Human Research Ethics Committee (Reference: 15-081) and the Curtin University Human Research Ethics Committee (Reference: HR 181/2014). We will disseminate the final results to the public via conferences and journal publications. A final study report will also be provided to the ethics committees.

TRIAL REGISTRATION NUMBER

Registered with Australian New Zealand Clinical Trial Registry (ACTRN12614000916640).

The management of patients with chronic heart failure: the growing role of e-Health

INTRODUCTION

The increasing pandemic of heart failure is becoming a serious challenge for the health care system. The medical world is searching for solutions which could decrease its scale and improve patients' quality of life and prognosis. Telemanagement of heart failure patients is a new promising option. Technical and technological platforms to perform e-Health management in heart failure patients' homes have become available. This paper's aims are to present different forms of e-Health including telecare, home monitoring of cardiovascular implantable electronic devices, remote monitoring of hemodynamic implantable devices and telerehabilitation in providing optimal long term management for heart failure patients. Areas covered: E-education and self-monitoring, structured telephone support and telemonitoring, remote monitoring of cardiovascular implantable electronics devices and hemodynamic implantable electronic devices and telerehabilitation. Expert commentary: The data analyzed in the paper suggests that remote monitoring is capable of identifying life-threatening deterioration and helps heart failure patients avoid seeking medical assistance in hospitals and that home-based telerehabilitation is well accepted, safe, effective and has high adherence among HF patients.

The effectiveness of the use of consumer health information technology in patients with heart failure: A meta-analysis and narrative review of randomized controlled trials

Purpose The purpose of this study was to examine whether the use of consumer health information technologies (CHITs) has an impact on outcomes of patients in the self-management of heart failure (HF). Methods A literature search of six electronic databases was conducted to identify relevant reports of randomized controlled trials (RCTs) for the analysis. Mortality, hospitalization and length of hospital stay were meta-analyzed and other patient outcomes were synthesized using a narrative approach. Results The literature search identified 50 studies, representing 43 RCTs, comparing the use of CHITs with usual care for HF patients. The meta-analysis showed that the use of CHITs reduced the risk of HF-caused mortality (relative risk (RR) = 0.70, 95% confidence interval (CI): 0.54-0.91), p = 0.007), lowered the risk of HF-caused hospitalization (RR = 0.80, 95% CI: 0.66-0.96), p = 0.020), and shortened HF-caused length of hospital stay (mean difference = -0.52, 95% CI: -0.77 to -0.27, p < 0.00), but not all-cause mortality, all-cause hospitalization or all-cause length of hospital stay, compared with usual care. The narrative synthesis indicated that only a small proportion of the trials reported positive effects of CHITs over usual care. Conclusions Evidence from RCTs presents mixed results on the impacts of CHITs for HF management. Further studies are required to assess whether and how CHITs would play a role in enhancing health care and patient outcomes and what specific CHIT features and functions are relevant to different HF treatment goals and self-care objectives.

Telemonitoring in heart failure patients treated by cardiac resynchronisation therapy with defibrillator (CRT-D): the TELECART Study

AIM

Telemonitoring (TM) is a safe and efficient monitoring system for internal cardioverter defibrillator device (ICD) recipients. TM has been used to track info on the clinical status of heart failure patients treated by ICD and/or cardiac resynchronisation therapy defibrillator (CRT-D). The aim of this study was to investigate the impact of TM on clinical outcomes in a population of CRT-D patients with heart failure.

METHODS

In a multicentre, randomised study, patients with chronic heart failure, New York Heart Association (NYHA) functional class II or III, left bundle branch block, severe left ventricle ejection fraction reduction (LVEF < 35%) have been identified and screened.

RESULTS

One hundred and ninety-one patients have been randomised to receive either a CRT-D with TM or a CRT-D with traditional ambulatory monitoring (control group) and completed the 12-month study follow-up. Primary endpoints were all cause death, cardiac death and hospital admission for heart failure. Secondary endpoints were atrial fibrillation, sustained episodes, non-sustained and self terminated ventricular tachyarrhythmia, sustained ventricular tachycardia, and ventricular fibrillation, ICD shocks and percentage of CRT-D responder patients. Univariate analysis identified the following factors predicting hospitalisation: TM, age, chronic kidney disease, hypercholesterolaemia, LVEF and NYHA class. At multivariate analysis, TM was the only factor predicting heart failure hospitalisation (hazard ratio 0.6, 0.42-0.79, 95% CI, p = 0.002), without affecting overall mortality and cardiac deaths events.

CONCLUSIONS

Taken together, our data indicate the importance of TM in predicting heart failure hospitalisation in patients treated with CRT-D.

Psychological Determinants of Heart Failure Self-Care: Systematic Review and Meta-Analysis

OBJECTIVE

Psychological distress has been associated with poor outcomes in patients with chronic heart failure (HF), which is assumed to be partly due to poor HF self-care behavior. This systematic review and meta-analysis describes the current evidence concerning psychological determinants of self-care in patients with chronic HF.

METHODS

Eligible studies were systematically identified by searching electronic databases PubMed, PsycINFO, and the Conference Proceedings Citation Index (Web of Science) for relevant literature (1980-October 17, 2014). Study quality was assessed according to the level of risk of bias. Quantitative data were pooled using random-effects models.

RESULTS

Sixty-five studies were identified for inclusion that varied considerably with respect to sample and study characteristics. Risk of bias was high in the reviewed studies and most problematic with regard to selection bias (67%). Depression (r = -0.19, p < .001), self-efficacy (r = 0.37, p < .001), and mental well-being (r = 0.14, p = .030) were significantly associated with self-reported self-care. Anxiety was not significantly associated with either self-reported (r = -0.18, p = .24) or objective self-care (r = -0.04, p = .79), neither was depression associated with objectively measured medication adherence (r = -0.05, p = .44).

CONCLUSIONS

Psychological factors (depression, self-efficacy, and mental well-being) were associated with specific self-care facets in patients with chronic HF. These associations were predominantly observed with self-reported indices of self-care and not objective indices. Methodological heterogeneity and limitations preclude definite conclusions about the association between psychological factors and self-care and should be addressed in future research.

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.

Prediction of Heart Failure Decompensation Events by Trend Analysis of Telemonitoring Data

This paper aims to assess the predictive value of physiological data daily collected in a telemonitoring study in the early detection of heart failure (HF) decompensation events. The main hypothesis is that physiological time series with similar progression (trends) may have prognostic value in future clinical states (decompensation or normal condition). The strategy is composed of two main steps: a trend similarity analysis and a predictive procedure. The similarity scheme combines the Haar wavelet decomposition, in which signals are represented as linear combinations of a set of orthogonal bases, with the Karhunen-Loève transform, that allows the selection of the reduced set of bases that capture the fundamental behavior of the time series. The prediction process assumes that future evolution of current condition can be inferred from the progression of past physiological time series. Therefore, founded on the trend similarity measure, a set of time series presenting a progression similar to the current condition is identified in the historical dataset, which is then employed, through a nearest neighbor approach, in the current prediction. The strategy is evaluated using physiological data resulting from the myHeart telemonitoring study, namely blood pressure, respiration rate, heart rate, and body weight collected from 41 patients (15 decompensation events and 26 normal conditions). The obtained results suggest, in general, that the physiological data have predictive value, and in particular, that the proposed scheme is particularly appropriate to address the early detection of HF decompensation.

Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial

BACKGROUND

An increasing number of patients with heart failure receive implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation defibrillators (CRT-Ds) with telemonitoring function. Early detection of worsening heart failure, or upstream factors predisposing to worsening heart failure, by implant-based telemonitoring might enable pre-emptive intervention and improve outcomes, but the evidence is weak. We investigated this possibility in IN-TIME, a clinical trial.

METHODS

We did this randomised, controlled trial at 36 tertiary clinical centres and hospitals in Australia, Europe, and Israel. We enrolled patients with chronic heart failure, NYHA class II-III symptoms, ejection fraction of no more than 35%, optimal drug treatment, no permanent atrial fibrillation, and a recent dual-chamber ICD or CRT-D implantation. After a 1 month run-in phase, patients were randomly assigned (1:1) to either automatic, daily, implant-based, multiparameter telemonitoring in addition to standard care or standard care without telemonitoring. Investigators were not masked to treatment allocation. Patients were masked to allocation unless they were contacted because of telemonitoring findings. Follow-up was 1 year. The primary outcome measure was a composite clinical score combining all-cause death, overnight hospital admission for heart failure, change in NYHA class, and change in patient global self-assessment, for the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT00538356.

FINDINGS

We enrolled 716 patients, of whom 664 were randomly assigned (333 to telemonitoring, 331 to control). Mean age was 65·5 years and mean ejection fraction was 26%. 285 (43%) of patients had NYHA functional class II and 378 (57%) had NYHA class III. Most patients received CRT-Ds (390; 58·7%). At 1 year, 63 (18·9%) of 333 patients in the telemonitoring group versus 90 (27·2%) of 331 in the control group (p=0·013) had worsened composite score (odds ratio 0·63, 95% CI 0·43-0·90). Ten versus 27 patients died during follow-up.

INTERPRETATION

Automatic, daily, implant-based, multiparameter telemonitoring can significantly improve clinical outcomes for patients with heart failure. Such telemonitoring is feasible and should be used in clinical practice.

FUNDING

Biotronik SE & Co. KG.

Wireless blood pressure monitoring with a novel implantable device: long-term in vivo results

PURPOSE

Devices constantly tracking the blood pressure (BP) of hypertensive patients are highly desired to facilitate effective patient management and to reduce hospitalization. We report on experiences gathered in a pilot study that was designed to evaluate the prototype of a newly developed, minimally invasive implantable sensor system for long-term BP monitoring.

METHODS

The device was implanted in the femoral artery (FA) of 12 sheep via standard FA catheterization under fluoroscopic control. Accuracy of the recorded blood pressure was determined by comparison with a reference catheter, which was positioned in the contralateral FA immediately after implantation. Regular follow-up included angiography, computed tomography (CT), and control of functionality and position of the BP sensor. Animals were euthanized after 6 months. FA segments with in situ pressure sensor underwent macroscopic and histopathologic examinations.

RESULTS

All implantations of the novel sensor device in the FA were successful and uneventful. High-quality BP recordings were documented. Bland-Altman plots indicate very good agreement. Comparison with measurements taken from the reference sensor revealed mean differences and standard deviations of -0.56 ± 0.85, 0.29 ± 1.44, and 0.85 ± 2.27 mmHg (diastolic, systolic, and pulse pressure, respectively) after exclusion of one outlier. CT uncovered deficiencies in cable stability that were addressed in a redesign. No thrombus formation, necrosis, or apoptosis were detected.

CONCLUSIONS

The pilot study proved the technical feasibility of wireless BP measurement in the FA via a novel miniature sensor device.

Telemonitoring after discharge from hospital with heart failure: cost-effectiveness modelling of alternative service designs

OBJECTIVES

To estimate the cost-effectiveness of remote monitoring strategies versus usual care for adults recently discharged after a heart failure (HF) exacerbation.

DESIGN

Decision analysis modelling of cost-effectiveness using secondary data sources.

SETTING

Acute hospitals in the UK.

PATIENTS

Patients recently discharged (within 28 days) after a HF exacerbation.

INTERVENTIONS

Structured telephone support (STS) via human to machine (STS HM) interface, (2) STS via human to human (STS HH) contact and (3) home telemonitoring (TM), compared with (4) usual care.

MAIN OUTCOME MEASURES

The incremental cost per quality-adjusted life year (QALY) gained by each strategy compared to the next most effective alternative and the probability of each strategy being cost-effective at varying willingness to pay per QALY gained.

RESULTS

TM was the most cost-effective strategy in the scenario using these base case costs. Compared with usual care, TM had an estimated incremental cost effectiveness ratio (ICER) of £11 873/QALY, whereas STS HH had an ICER of £228 035/QALY against TM. STS HM was dominated by usual care. Threshold analysis suggested that the monthly cost of TM has to be higher than £390 to have an ICER greater than £20 000/QALY against STS HH. Scenario analyses performed using higher costs of usual care, higher costs of STS HH and lower costs of TM do not substantially change the conclusions.

CONCLUSIONS

Cost-effectiveness analyses suggest that TM was an optimal strategy in most scenarios, but there is considerable uncertainty in relation to clear descriptions of the interventions and robust estimation of costs.

Remote monitoring of cardiovascular implanted electronic devices: a paradigm shift for the 21st century

Traditional follow-up of cardiac implantable electronic devices involves the intermittent download of largely nonactionable data. Remote monitoring represents a paradigm shift from episodic office-based follow-up to continuous monitoring of device performance and patient and disease state. This lessens device clinical burden and may also lead to cost savings, although data on economic impact are only beginning to emerge. Remote monitoring technology has the potential to improve the outcomes through earlier detection of arrhythmias and compromised device integrity, and possibly predict heart failure hospitalizations through integration of heart failure diagnostics and hemodynamic monitors. Remote monitoring platforms are also huge databases of patients and devices, offering unprecedented opportunities to investigate real-world outcomes. Here, the current status of the field is described and future directions are predicted.

A three stage ontology-driven solution to provide personalized care to chronic patients at home

PURPOSE

The goal of this work is to contribute to personalized clinical management in home-based telemonitoring scenarios by developing an ontology-driven solution that enables a wide range of remote chronic patients to be monitored at home.

METHODS

Through three stages, the challenges of integration and management were met through the ontology development and evaluation. The first stage dealt with the ontology design and implementation. The second stage dealt with the ontology application study in order to specifically address personalization issues. For both stages, interviews and working sessions were planned with clinicians. Clinical guidelines and MDs (medical device) interoperability were taken into account as well during these stages. Finally the third stage dealt with a software prototype implementation.

RESULTS

An ontology was developed as an outcome of the first stage. The structure, based on the autonomic computing paradigm, provides a clear and simple manner to automate and integrate the data management procedure. During the second stage, the application of the ontology was studied to monitor patients with different and multiple morbidities. After this task, the ontology design was successfully adjusted to provide useful personalized medical care. In the third and final stage, a proof-of-concept on the software required to remote monitor patients by means of the ontology-based solution was developed and evaluated.

CONCLUSIONS

Our proposed ontology provides an understandable and simple solution to address integration and personalized care challenges in home-based telemonitoring scenarios. Furthermore, our three-stage approach contributes to enhance the understanding, re-usability and transferability of our solution.

Can individualized weight monitoring using the HeartPhone algorithm improve sensitivity for clinical deterioration of heart failure?

AIMS

Previous studies have demonstrated poor sensitivity of guideline weight monitoring in predicting clinical deterioration of heart failure (HF). This study aimed to evaluate patterns of remotely transmitted daily weights in a high-risk HF population and also to compare guideline weight monitoring and an individualized weight monitoring algorithm.

METHODS AND RESULTS

Consenting, consecutive, high-risk patients were provided with a mobile phone-based remote weight telemonitoring device. We aimed to evaluate population vs. individual weight variability, weight patterns pre- and post-events of clinical deterioration of HF, and to compare guideline weight thresholds with the HeartPhone algorithm in terms of sensitivity and specificity for such events. Of 87 patients recruited and followed for an average of 23.9 ± 12 weeks, 19 patients experienced 28 evaluable episodes of clinical deterioration of HF. Following a post-discharge decline, the population average weight remained stable for the follow-up period, yet the 7-day moving average of individual patients exceeded 2 kg in three-quarters of patients. Significant increases in weight were observed up to 4 days before HF events. The HeartPhone algorithm was significantly more sensitive (82%) in predicting HF events than guideline weight thresholds of 2 kg over 2-3 days (21%) and a 'rule of thumb' threshold of 1.36 kg over 1 day (46%).

CONCLUSIONS

An individualized approach to weight monitoring in HF with the HeartPhone algorithm improved prediction of HF deterioration. Further evaluation of HeartPhone with and without other biomarkers of HF deterioration is warranted.

Theoretical study for safe and efficient energy transfer to deeply implanted devices using ultrasound

The goal of this paper is to prove that a safe and efficient energy transfer is possible between an external transducer located on the patient's skin and a device deeply implanted in the abdomen. An ultrasound propagation model based on the Rayleigh-Sommerfeld diffraction integral is coupled with the data from the Visible Human Project to account for the geometry of the organs in the body. The model is able to predict the amount of acoustic power received by the device for different acoustic paths. The acoustic model is validated by comparison with measurements in water and in heterogeneous liquid phantoms. Care is taken to minimize adverse bioeffects-mainly temperature rise and cavitation in tissues. Simulations based on the bio-heat transfer equation are performed to check that thermal effects are indeed small.

Home monitoring for heart failure management

With a prevalence of 5.8 million in the United States alone, heart failure (HF) is a common syndrome associated with substantial morbidity, mortality, and healthcare expenditures. Close to 1 million HF hospitalizations occur annually in the United States, with the majority of these resulting from worsening congestion in patients previously diagnosed with HF. An estimated $37.2 billion is spent each year on HF in the United States. These statistics emphasize the need to develop and implement more effective strategies to assess, monitor, and treat HF. It has also become increasingly apparent that interventions geared toward identifying and monitoring subclinical congestion would be of value in the home management of chronic HF. Earlier identification and treatment of congestion together with improved care coordination, management of comorbid conditions, and enhanced patient self-management may help to prevent hospitalizations in patients with chronic HF. Such home monitoring extends from the promotion of self-care and home visitations to telemedicine and remote monitoring of external or implantable devices. This paper discusses the challenges in monitoring patients with HF, reviews clinical trials testing different monitoring strategies in HF, and highlights ongoing investigations into the optimal approaches to home monitoring for HF.