Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis

The impact of different perspectives on the cost-effectiveness of remote patient monitoring for patients with heart failure in different European countries

BACKGROUND AND OBJECTIVE

Heart failure (HF) is a complex clinical syndrome with high mortality and hospitalization rates. Non-invasive remote patient monitoring (RPM) interventions have the potential to prevent disease worsening. However, the long-term cost-effectiveness of RPM remains unclear. This study aimed to assess the cost-effectiveness of RPM in the Netherlands (NL), the United Kingdom (UK), and Germany (DE) highlighting the differences between cost-effectiveness from a societal and healthcare perspective.

METHODS

We developed a Markov model with a lifetime horizon to assess the cost-effectiveness of RPM compared with usual care. We included HF-related hospitalization and non-hospitalization costs, intervention costs, other medical costs, informal care costs, and costs of non-medical consumption. A probabilistic sensitivity analysis and scenario analyses were performed.

RESULTS

RPM led to reductions in HF-related hospitalization costs, but total lifetime costs were higher in all three countries compared to usual care. The estimated incremental cost-effectiveness ratios (ICERs), from a societal perspective, were €27,921, €32,263, and €35,258 in NL, UK, and DE respectively. The lower ICER in the Netherlands was mainly explained by lower costs of non-medical consumption and HF-related costs outside of the hospital. ICERs, from a healthcare perspective, were €12,977, €11,432, and €11,546 in NL, the UK, and DE, respectively. The ICER was most sensitive to the effectiveness of RPM and utility values.

CONCLUSIONS

This study demonstrates that RPM for HF can be cost-effective from both healthcare and societal perspective. Including costs of living longer, such as informal care and non-medical consumption during life years gained, increased the ICER.

Heart failure outpatient clinics resources in Italy: a viewpoint of Italian Society of Cardiology organization

The current paper reports the model organization, level of health care, and type of medical and research activities related to the existing heart failure centers of the Italian Society of Cardiology. Of note, we conduced an internal survey among the members of heart failure working group and related hospital and territorial sites about the quality of care and assistance levels according to the local hospital resources and type of diagnostic therapeutic and management resources. Thirty-two hospital ambulatorial structures have been identified, the centers were equally distributed within the national ground, with similar concentration between north and south regions of the Italian country. We distinguished three different levels of organization: (1) basal territorial clinics in which patients with suspected or already diagnosed heart failure (HF) are initially identified and screened; (2) intermediate clinics in which HF patients can be routinary followed by HF specialists supported by a dedicated staff including imaging and arrythmologist experts, and interventional cardiologist; (3) advanced clinics composed by all the technical and staff resources capable of guarantying repetitive invasive assessment, continuous invasive monitoring, dedicated telemedicine structures focused on more advanced HF management integrated by heart transplantation or mechanical assistance programs. Different type of assistance is supported by a relevant number of research activity primarily conducted by the Italian Society of Cardiology or spontaneous studies arranged by HF specialist members. The number of HF centers has increased over the past few decades in proportion to the progressive rise in HF diagnoses and associated hospitalization. The expansion of ambulatory structures has been facilitated by an increasing socioeconomic and research influence. The quality of HF services in Italy could be raised by improving the network and connections between HF specialists, general practitioners (GPs), caregivers, and other specialists frequently working in this field.

Non-invasive telemonitoring programs for patients with chronic heart failure: A systematic review and meta-analysis of randomized controlled trials

AIMS

To assess whether telemonitoring improves outcomes in patients with chronic heart failure.

METHODS AND RESULTS

A literature search was conducted on studies of randomized controlled trials involving non-invasive telemonitoring and heart failure using Medline, Embase, and Cochrane Library. The primary outcomes were all-cause mortality, all-cause hospitalization, and hospitalization for heart failure. Secondary outcomes were length of stay, health-related quality of life as assessed by validated questionnaires, healthcare costs and cost-effectiveness, and self-care behaviors. We performed a meta-analysis using a random effects model for the primary outcomes. The effect measure was odds ratio with corresponding 95% confidence interval, and heterogeneity among studies was assessed using the Higgins I2 value. We screened 212 references, and 34 randomized controlled trials were included in this review. A total of 16179 participants with heart failure were included. Non-invasive telemonitoring reduced all-cause mortality by 18% (OR 0.82, 95% CI 0.71 to 0.95; participants = 15,211; studies = 28; I2 = 34%; GRADE: moderate-quality evidence) and heart failure hospitalization by 20% (OR 0.80, 95% CI 0.69 to 0.94; participants = 7491; studies = 18; I2 = 31%; GRADE: moderate-quality evidence). Non-invasive telemonitoring didn't demonstrate significant benefit on all-cause hospitalization (OR 0.93, 95% CI 0.82 to 1.05; participants = 11,565; studies = 25; I2 = 49%).

CONCLUSION

Telemonitoring programs in patients with heart failure were associated with a reduction in all-cause mortality and heart failure hospitalization without harmful events.

A nurse-led coaching intervention with home telemonitoring for patients with heart failure: Protocol for a feasibility randomized clinical trial

Poor treatment adherence and lack of self-care behaviors are significant contributors to hospital readmissions of people with heart failure (HF). A transitional program with non-invasive telemonitoring may help sustain patients and their caregivers to timely recognize signs and symptoms of exacerbation. We will conduct a Randomized Clinical Trial (RCT) to evaluate the feasibility and acceptability of a 6-month supportive intervention for patients discharged home after cardiac decompensation. Forty-five people aged 65 years and over will be randomized to either receive a supportive intervention in addition to standard care, which combines nurse-led telephone coaching and a home-based self-monitoring vital signs program, or standard care alone. Four aspects of the feasibility will be assessed using a mixed-methods approach: process outcomes (e.g., recruitment rate), resources required (e.g., adherence to the intervention), management data (e.g., completeness of data collection), and scientific value (e.g. 90- and 180-day all-cause and HF-related readmissions, self-care capacity, quality of life, psychological well-being, mortality, etc.). Participants will be interviewed to explore preferences and satisfaction with the intervention. The study is expected to provide valuable insight into the design of a definitive RCT.

A roadmap for empowering cardiovascular disease patients: a 5P-Medicine approach and technological integration

This article explores the multifaceted concept of cardiovascular disease (CVD) patients' empowerment, emphasizing a shift from compliance-oriented models to active patient participation. In recognizing that cardiovascular disease is a paramount global health challenge, this study illuminates the pressing need for empowering patients, underscoring their role as active participants in their healthcare journey. Grounded in 5P-Medicine principles-Predictive, Preventive, Participatory, Personalized, and Precision Medicine-the importance of empowering CVD patients through analytics, prevention, participatory decision making, and personalized treatments is highlighted. Incorporating a comprehensive overview of patient empowerment strategies, including self-management, health literacy, patient involvement, and shared decision making, the article advocates for tailored approaches aligned with individual needs, cultural contexts, and healthcare systems. Technological integration is examined to enhance patient engagement and personalized healthcare experiences. The critical role of patient-centered design in integrating digital tools for CVD management is emphasized, ensuring successful adoption and meaningful impact on healthcare outcomes. The conclusion proposes vital research questions addressing challenges and opportunities in CVD patient empowerment. These questions stress the importance of medical community research, understanding user expectations, evaluating existing technologies, defining ideal empowerment scenarios, and conducting a literature review for informed advancements. This article lays the foundation for future research, contributing to ongoing patient-centered healthcare evolution, especially in empowering individuals with a 5P-Medicine approach to cardiovascular diseases.

Usability of a digital health platform to support home hospitalization in heart failure patients: a multicentre feasibility study among healthcare professionals

AIMS

Heart failure (HF) is a common cause of mortality and (re)hospitalizations. The NWE-Chance project explored the feasibility of providing hospitalizations at home (HH) supported by a newly developed digital health platform. The aim of this study was to explore the perceived usability by healthcare professionals (HCPs) of a digital platform in addition to HH for HF patients.

METHODS AND RESULTS

A prospective, international, multicentre, single-arm interventional study was conducted. Sixty-three patients and 22 HCPs participated. The HH consisted of daily home visits by the nurse and use of the platform, consisting of a portable blood pressure device, weight scale, pulse oximeter, a wearable chest patch to measure vital signs (heart rate, respiratory rate, activity level, and posture), and an eCoach for the patient. Primary outcome was usability of the platform measured by the System Usability Scale halfway and at the end of the study. Overall usability was rated as sufficient (mean score 72.1 ± 8.9) and did not differ between the measurements moments (P = 0.690). The HCPs reported positive experiences (n = 7), negative experiences (n = 13), and recommendations (n = 6) for the future. Actual use of the platform was 79% of the HH days.

CONCLUSION

A digital health platform to support HH was considered usable by HCPs, although actual use of the platform was limited. Therefore, several improvements in the integration of the digital platform into clinical workflows and in defining the precise role of the digital platform and its use are needed to add value before full implementation.

REGISTRATION

clinicaltrials.gov NCT04084964.

Knowledge mapping of digital medicine in cardiovascular diseases from 2004 to 2022: A bibliometric analysis

Objective

To review studies on digital medicine in cardiovascular diseases (CVD), discuss its development process, knowledge structure and research hotspots, and provide a perspective for researchers in this field.

Methods

The relevant literature in recent 20 years (January 2004 to October 2022) were retrieved from the Web of Science Core Collection (WoSCC). CiteSpace was used to demonstrate our knowledge of keywords, co-references and speculative frontiers. VOSviewer was used to chart the contributions of authors, institutions and countries and incorporates their link strength into the table.

Results

A total of 5265 English articles in set timespan were included. The number of publications increased steadily annually. The United States (US) produced the highest number of publications, followed by England. Most publications were from Harvard Medicine School, followed by Massachusetts General Hospital and Brigham Women's Hospital. The most authoritative academic journal was JMIR mHealth and uHealth. Noseworthy PA may have the highest influence in this intersected field with the highest number of citations and total link strength. The utilization of wearable mobile devices in the context of CVD, encompassing the identification of risk factors, diagnosis and prevention of diseases, as well as early intervention and remote management of diseases, has been widely acknowledged as a knowledge base and an area of current interest. To investigate the impact of various digital medicine interventions on chronic care and assess their clinical effectiveness, examine the potential of machine learning (ML) in delivering clinical care for atrial fibrillation (AF) and identifying early disease risk factors, as well as explore the development of disease prediction models using neural networks (NNs), ML and unsupervised learning in CVD prognosis, may emerge as future trends and areas of focus.

Conclusion

Recently, there has been a significant surge of interest in the investigation of digital medicine in CVD. This initial bibliometric study offers a comprehensive analysis of the research landscape pertaining to digital medicine in CVD, thereby furnishing related scholars with a dependable reference to facilitate further progress in this domain.

Expert Recommendations to Bridge Gaps in Heart Failure Patient Support in the Middle East and Africa Region

Heart failure (HF) remains a serious health and socioeconomic problem in the Middle East and Africa (MEA). The age-standardized prevalence rate for HF in the MEA region is higher compared to countries in Eastern Europe, Latin America, and Southeast Asia. Also cardiovascular-related deaths remain high compared to their global counterparts. Moreover, in MEA, 66% of HF readmissions are elicited by potentially preventable factors, including delay in seeking medical attention, nonadherence to HF medication, suboptimal discharge planning, inadequate follow-up, and poor social support. Patient support in the form of activation, counseling, and caregiver education has been shown to improve outcomes in patients with HF. A multidisciplinary meeting with experts from different countries across the MEA region was convened to identify the current gaps and unmet needs for patient support for HF in the region. The panel provided insights into the real-world challenges in HF patient support and contributed strategic recommendations for optimizing HF care.

Travel burden for patients with multimorbidity - Proof of concept study in a Dutch tertiary care center

Objectives

To explore travel burden in patients with multimorbidity and analyze patients with high travel burden, to stimulate actions towards adequate access and (remote) care coordination for these patients.

Design

A retrospective, cross-sectional, explorative proof of concept study.

Setting and Participants

Electronic health record data of all patients who visited our academic hospital in 2017 were used. Patients with a valid 4-digit postal code, aged ≥18 years, had >1 chronic or oncological condition and had >1 outpatient visits with >1 specialties were included.

Methods

Travel burden (hours/year) was calculated as: travel time in hours × number of outpatient visit days per patient in one year × 2. Baseline variables were analyzed using univariate statistics. Patients were stratified into two groups by the median travel burden. The contribution of travel time (dichotomized) and the number of outpatient clinic visits days (dichotomized) to the travel burden was examined with binary logistic regression by adding these variables consecutively to a crude model with age, sex and number of diagnosis. National maps exploring the geographic variation of multimorbidity and travel burden were built. Furthermore, maps showing the distribution of socioeconomic status (SES) and proportion of older age (≥65 years) of the general population were built.

Results

A total of 14 476 patients were included (54.4% female, mean age 57.3 years ([± standard deviation] = ± 16.6 years). Patients travelled an average of 0.42 (± 0.33) hours to the hospital per (one-way) visit with a median travel burden of 3.19 hours/year (interquartile range (IQR) 1.68 - 6.20). Care consumption variables, such as higher number of diagnosis and treating specialties in the outpatient clinic were more frequent in patients with higher travel burden. High travel time showed a higher Odds Ratio (OR = 578 (95% Confidence Interval (CI) = 353 - 947), p < 0.01) than having high number of outpatient clinic visit days (OR = 237, 95% CI = 144 - 338), p < 0.01) to having a high travel burden in the final regression model.

Conclusions and implications

The geographic representation of patients with multimorbidity and their travel burden varied but coincided locally with lower SES and older age in the general population. Future studies should aim on identifying patients with high travel burden and low SES, creating opportunity for adequate (remote) care coordination.

Exploring the Need and Benefits of Digital Therapeutics (DTx) for the Management of Heart Failure in India

Indian heart failure (HF) registries consistently indicate high hospital readmissions and increased mortality rates after HF diagnosis. The challenges of Indian cardiologists in HF management include limited longitudinal data, frequent readmissions, low medication adherence, inadequate monitoring and follow-up, insufficient patient education, and lack of standard guidelines on cardiac rehabilitation. This article outlines the adoption of digital therapeutics (DTx) in HF management as a potential solution to address these challenges. DTx services offer improved medication adherence, early symptom identification, remote vital monitoring, timely intervention, patient education on symptoms, self-awareness, and lifestyle. Overall, DTx for HF comprises a dedicated team of cardiologists, health coaches, care managers, and globally certified connected devices to provide comprehensive and proactive monitoring, personalized coaching and support, behavioral engagement to improve adherence, emergency response system, delivery of medications and diagnostic tests at home, and a dedicated application for caregivers. DTx has the potential to enhance HF management in India.

The Promise and Risks of mHealth in Heart Failure Care

Mobile health (mHealth) is an emerging approach to health care. It involves wearable, connected technologies that facilitate patient-symptom or physiological monitoring, support clinical feedback to patients and physicians, and promote patients' education and self-care. Evolving algorithms may involve artificial intelligence and can assist in data aggregation and health care teams' interpretations. Ultimately, the goal is not merely to collect data; rather, it is to increase actionability. mHealth technology holds particular promise for patients with heart failure, especially those with frequently changing clinical status. mHealth, ideally, can identify care opportunities, anticipate clinical courses and augment providers' capacity to implement, titrate and monitor interventions safely, including evidence-based therapies. Although there have been marked advancements in the past decade, uncertainties remain for mHealth, including questions regarding optimal indications and acceptable payment models. In regard to mHealth capability, a better understanding is needed of the incremental benefit of mHealth data over usual care, the accuracy of specific mHealth data points in making clinical care decisions, and the efficiency and precision of algorithms used to dictate actions. Importantly, emerging regulations in the wake of COVID-19, and now the end of the federal public health emergency, offer both opportunity and risks to the broader adoption of mHealth-enabled services. In this review, we explore the current state of mHealth in heart failure, with particular attention to the opportunities and challenges this technology creates for patients, health care providers and other stakeholders.

An evidence map of systematic reviews on models of outpatient care for patients with chronic heart diseases

BACKGROUND

Chronic heart disease affects millions of people worldwide and the prevalence is increasing. By now, there is an extensive literature on outpatient care of people with chronic heart disease. We aimed to systematically identify and map models of outpatient care for people with chronic heart disease in terms of the interventions included and the outcomes measured and reported to determine areas in need of further research.

METHODS

We created an evidence map of published systematic reviews. PubMed, Cochrane Library (Wiley), Web of Science, and Scopus were searched to identify all relevant articles from January 2000 to June 2021 published in English or German language. From each included systematic review, we abstracted search dates, number and type of included studies, objectives, populations, interventions, and outcomes. Models of care were categorised into six approaches: cardiac rehabilitation, chronic disease management, home-based care, outpatient clinic, telemedicine, and transitional care. Intervention categories were developed inductively. Outcomes were mapped onto the taxonomy developed by the COMET initiative.

RESULTS

The systematic literature search identified 8043 potentially relevant publications on models of outpatient care for patients with chronic heart diseases. Finally, 47 systematic reviews met the inclusion criteria, covering 1206 primary studies (including double counting). We identified six different models of care and described which interventions were used and what outcomes were included to measure their effectiveness. Education-related and telemedicine interventions were described in more than 50% of the models of outpatient care. The most frequently used outcome domains were death and life impact.

CONCLUSION

Evidence on outpatient care for people with chronic heart diseases is broad. However, comparability is limited due to differences in interventions and outcome measures. Outpatient care for people with coronary heart disease and atrial fibrillation is a less well-studied area compared to heart failure. Our evidence mapping demonstrates the need for a core outcome set and further studies to examine the effects of models of outpatient care or different interventions with adjusted outcome parameters.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42020166330).

Efficacy of disease management program used among patients with chronic heart failure: protocol for a systematic review and network meta-analysis

BACKGROUND

A large number of studies have provided a variety of heart failure management program (HF-MP) intervention modes. It is generally believed that HF-MP is effective, but the question of which type of program works best, what level of support is needed for an intervention to be effective, and whether different subgroups of patients are best served by different types of programs is still confusing.

METHODS

This study will search for published and unpublished randomized clinical trials in English examining HF-MP interventions in comparison with usual care. MEDLINE, Medlin In-Process and Non-Indexed, CENTRAL, CINAHL, EMBASE, and PsycINFO will be the databases. We will calibrate our eligibility criteria among the team. Each literature will be screened by at least two reviewers. Conflicts will be resolved through team discussion. A similar process will be used for data abstraction and quality appraisal. The results will be synthesized descriptively, and a network meta-analysis will be conducted if the studies are deemed methodologically, clinically, and statistically acceptable (e.g., I² < 50%). Moreover, potential moderators of efficacy will be analyzed using a meta-regression.

DISCUSSION

This study will reduce the clinical heterogeneity and statistical heterogeneity of review and meta-analysis through a more scientific classification method to determine the most effective HF-MP in different subgroups of heart failure patients with different human resource investments and different intervention methods, providing high-quality evidence and guidance for clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021258521.

Telemonitoring in heart failure patients: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Home telemonitoring has been used as a modality to prevent readmission and improve outcomes for patients with heart failure. However, studies have produced conflicting outcomes over the years.

AIM

To determine the aggregate effect of telemonitoring on all-cause mortality, heart failure-related mortality, all-cause hospitalization, and heart failure-related hospitalization in heart failure patients.

METHODS

We conducted a systematic review and meta-analysis of 38 home telemonitoring randomized controlled trials involving 14993 patients. We also conducted a sensitivity analysis to examine the effect of telemonitoring duration, recent heart failure hospitalization, and age on telemonitoring outcomes.

RESULTS

Our study demonstrated that home telemonitoring in heart failure patients was associated with reduced all-cause [relative risk (RR) = 0.83, 95% confidence interval (CI): 0.75-0.92, P = 0.001] and cardiovascular mortality (RR = 0.66, 95%CI: 0.54-0.81, P < 0.001). Additionally, telemonitoring decreased the all-cause hospitalization (RR = 0.87, 95%CI: 0.80-0.94, P = 0.002) but did not decrease heart failure-related hospitalization (RR = 0.88, 95%CI: 0.77-1.01, P = 0.066). However, prolonged home telemonitoring (12 mo or more) was associated with both decreased all-cause and heart failure hospitalization, unlike shorter duration (6 mo or less) telemonitoring.

CONCLUSION

Home telemonitoring using digital/broadband/satellite/wireless or blue-tooth transmission of physiological data reduces all-cause and cardiovascular mortality in heart failure patients. In addition, prolonged telemonitoring (≥ 12 mo) reduces all-cause and heart failure-related hospitalization. The implication for practice is that hospitals considering telemonitoring to reduce heart failure readmission rates may need to plan for prolonged telemonitoring to see the effect they are looking for.

Quality of Life in Heart Patients Receiving Telerehabilitation: An Overview with Meta-Analyses

Background

This overview is conducted to evaluate the effect of telerehabilitation on Health-Related Quality of Life (HRQOL) in patients with cardiovascular diseases (CVDs).

Methods

A comprehensive search was performed through the [MeSH] keywords (heart diseases, coronary disease, coronary artery disease, myocardial infarction, coronary artery bypass, heart failure, cardiac rehabilitation and telemedicine) until January 20, 2021 in databases of Science Direct, Medline/PubMed, Web of Science, Scopus, ProQuest, Google Scholar and Cochrane library. Finally, 20 reviews were entered into the analysis.

Results

The results of meta-analyses showed that receiving telerehabilitation program by telemedicine method has a positive effect on the physical dimension and changing the mental status of patients following this intervention depends on age so that the use of these technologies in heart patients with younger ages promotes mental status. On the other hand, increasing the duration of the intervention 18 months or more affects the physical dimension and 12 months or more affects promoting overall HRQOL. Among the various types of Telemedicine methods, telephone support has a greater effect on promoting the physical dimension.

Conclusion

The ability to use virtual technology is less at older ages, so age conditions of patients should be considered in choosing this type of intervention. The living place of the people and the level of access to advanced care, seem to play an important role in changing outcomes and choosing this type of intervention because the main purpose of telerehabilitation is to provide treatment care in areas with low access levels.

A maturity model framework for integrated virtual care

Purpose

Remote patient monitoring (RPM) and virtual visits have the potential to transform care delivery and outcomes but require intentional planning around how these technologies contribute to integrated care. Since maturity models are useful frameworks for understanding current performance and motivating progress, the authors developed a model describing the features of RPM that can advance integrated care.

Design/methodology/approach

This work was led by St. Joseph's Health System Centre for Integrated Care in collaboration with clinical and programme leads and frontline staff offering RPM services as part of Connected Health Hamilton in Ontario, Canada. Development of the maturity model was informed by a review of existing telehealth maturity models, online stakeholder meetings, and online interviews with clinical leads, programme leads, and staff.

Findings

The maturity model comprises 4 maturity levels and 17 sub-domains organised into 5 domains: Technology, Team Organisation, Programme Support, Integrated Information Systems, and Performance and Quality. An implementation pillars checklist identifies additional considerations for sustaining programmes at any maturity level. Finally, the authors apply one of Connected Health Hamilton's RPM programmes to the Team Organisation domain as an example of the maturity model in action.

Originality/value

This work extends previous telehealth maturity models by focussing on the arrangement of resources, teams, and processes needed to support the delivery of integrated care. Although the model is inspired by local programmes, the model is highly transferable to other RPM programmes.

Heart failure disease management program: A review

Disease management programs (DMPs) have shown great potential for optimizing care of chronically ill patients, thereby improving health outcomes and patient satisfaction. This had led to an overall reduction in healthcare costs. Longer life expectancy has led to increased utilization of healthcare facilities, which may lead to a rise in costs. DMPs are an effective means of improving care and compliance and ultimately curbing inappropriate resource utilization. The present study reviews different definitions proposed for disease management, its components, the evidence behind it, and the conditions for success. It also examines heart failure management as an example of a DMP, exploring the complexity surrounding implementation of guideline-based approaches in patient care. A literature search on DMPs was conducted using PubMed, MEDLINE, and Google Scholar, including heart failure management programs from articles published from 2000 to 2020. This reviewed emphasized on the management of important biomarkers and cardiovascular indicators such as glycemic levels, urine output to improve efficacy of disease management programme during patient treatment. The review concluded that diseases like heart failure can be combat by improving the quality of care for patients and reducing the burden on the public healthcare system. Moreover, DMPs have proved to be an effective way of improving care and compliance with treatment.

Impact of a nurse-led teleconsultation strategy for cardiovascular disease management during COVID-19 pandemic in India: a pyramid model feasibility study

OBJECTIVE

The COVID-19 pandemic necessitated the use of telemedicine to maintain continuity of care for patients with cardiovascular diseases (CVDs). This study aimed to demonstrate the feasibility of implementing a nurse-led teleconsultation strategy for CVD management during the COVID-19 pandemic in India and evaluated the impact of nurse-led teleconsultations on patient treatment satisfaction.

DESIGN, SETTING AND PARTICIPANTS

We developed a two-stage teleconsultation strategy and tested the feasibility of implementing a nurse-led teleconsultation strategy to manage CVD in a northern state (Punjab) in India. A multidisciplinary team of experts developed the treatment protocol used for teleconsultations to manage CVD. Nurses were trained to provide teleconsultation, triaging of patients and referrals to the physicians. Patients with CVD who had an outpatient visit or hospitalisation between September 2019 and March 2020 at the Dayanand Medical College Hospital, Ludhiana, India, were contacted by phone and offered teleconsultations. Telemedicine strategy comprised: stage 1 nurse-led teleconsultations and stage 2 physician-led teleconsultations. Descriptive analysis was performed to report the proportion of patients triaged by the two-stage telemedicine strategy, and patient's clinical characteristics, and treatment satisfaction between the nurse-led versus physician-led teleconsultations.

RESULTS

Overall, nurse-led stage 1 teleconsultations were provided to 12 042 patients with CVD. The mean (SD) age of the participants was 58.9 years (12.8), and men were 65.4%. A relatively small proportion of patients (6.3%) were referred for the stage-2 physician-led teleconsultations and of these only 8.4% required hospitalisations. During stage 1 nurse-led teleconsultations, patients were referred to the physicians due to uncontrolled diabetes (24.9%), uncontrolled hypertension (18.7%) and congestive heart failure (16.2%). The patient's treatment satisfaction was similar between the nurse-led versus physician-led teleconsultations (p=0.07).

CONCLUSION

This study showed that a nurse-led telemedicine strategy is feasible to implement in a resource-constraint setting for triaging patients with CVD and reduces physician's burden.

Implementation and Evaluation of COVIDCare@Home, a Family Medicine Led Remote Monitoring Program for COVID-19 Patients: a multi-method cross-sectional study

Background

COVIDCare@Home (CC@H) is a multifaceted, interprofessional team-based remote monitoring program led by family medicine for patients diagnosed with COVID-19, based at Women’s College Hospital (WCH), an ambulatory academic center in Toronto, Canada. CC@H offers virtual visits (phone and video) to address the clinical needs and broader social determinants of the health of patients during the acute phase of COVID-19 infection, including finding a primary care provider (PCP) and support for food insecurity.

Objective

The objective of this evaluation is to understand the implementation and quality outcomes of CC@H within the Quadruple Aim framework of patient experience, provider experience, cost, and population health.

Methods

This multimethod cross-sectional evaluation follows the Quadruple Aim framework to focus on implementation and service quality outcomes, including feasibility, adoption, safety, effectiveness, equity, and patient centeredness. These measures were explored using clinical and service utilization data, patient experience data (an online survey and a postdischarge questionnaire), provider experience data (surveys, interviews, and focus groups), and stakeholder interviews. Descriptive analysis was conducted for surveys and utilization data. Deductive analysis was conducted for interviews and focus groups, mapping to implementation and quality domains. The Ontario Marginalization Index (ON-Marg) measured the proportion of underserved patients accessing CC@H.

Results

In total, 3412 visits were conducted in the first 8 months of the program (April 8-December 8, 2020) for 616 discrete patients, including 2114 (62.0%) visits with family physician staff/residents and 149 (4.4%) visits with social workers/mental health professionals. There was a median of 5 (IQR 4) visits per patient, with a median follow-up of 7 days (IQR 27). The net promoter score was 77. In addition, 144 (23.3%) of the patients were in the most marginalized populations based on the residential postal code (as per ON-Marg). Interviews with providers and stakeholders indicated that the program continued to adapt to meet the needs of patients and the health care system.

Conclusions

Future remote monitoring should integrate support for addressing the social determinants of health and ensure patient-centered care through comprehensive care teams.

Tele-clinics in palliative care during the COVID-19 outbreak: Tertiary care cancer center experience

OBJECTIVES

To investigate the effect of tele-clinics on palliative care patients during the COVID-19 pandemic.

METHODS

This is a retrospective cross-sectional study (chart review) carried out from March 17, 2020, to September 16, 2020, included all patients who were booked into the palliative care clinic. Patients were assessed by the palliative nurse specialist for COVID-19 symptoms using the acute respiratory illness screening form and Edmonton Symptoms Assessment System, also identifies the needs of the patient. Data were analyzed to investigate the effect of tele-clinics on the patients regarding ER visits and admission.

RESULTS

A total of 167 individuals were analyzed and the results showed that 234 of 447 visits were virtual, supporting the increasing value of telemedicine. The number of virtual patients' visits dropped slightly at the beginning of the pandemic (46.4% in March to 39.8% in July). Subsequently, it increased steadily to 72.2% in September. The choice of virtual/non-virtual visits for individuals with cancer diagnosis significantly depends on other factors. Code status, palliative patients or follow-up service, and the frequency of oncology center visits, admissions, or ER visits were crucial in explaining the means of receiving treatment.

CONCLUSION

Virtual visits in palliative care are efficient means of decreasing the threat of COVID-19 contagion. It is recommended to increase the palliative care patients' awareness of tele-clinics and their positive outcomes, particularly during the pandemic.

Implantable cardioverter defibrillators and devices for cardiac resynchronization therapy: what perspective for patients' apps combined with remote monitoring?

INTRODUCTION

Remote monitoring (RM) of cardiac implantable electronic devices (CIED) allows rapid detection of clinical and electrical events. Recently, several smartphone applications have been developed with the aim of improving patient compliance and better interpreting and integrating data deriving from remote control for the management of heart failure (HF).

AREAS COVERED

Studies investigating the role of CIEDs' RM in HF patients to predict and early treat acute decompensation. The importance of new technologies and applications developed to provide crucial information to clinicians, to better manage HF patients.

EXPERT OPINION

New medical technologies and smartphone applications for CIEDs' RM were developed to help clinicians in the management of CIED carriers. Indeed, the accessibility of technological devices (e.g. smartphones) and the improvements in medical technology provide the opportunity to optimize HF patients' monitoring by the transmission of device-related data, and with direct involvement of patients themselves. Thanks to these advancements, physicians have the possibility to recognize worsening signs of HF and promptly optimize treatments to potentially avoid hospitalization. The great value of this approach is its potential of reducing scheduled in-office visits or unnecessary medical contacts and optimizing healthcare resources management.

Challenges of Telemonitoring Programs for Complex Chronic Conditions: Randomized Controlled Trial With an Embedded Qualitative Study

Background

Despite the growing prevalence of people with complex conditions and evidence of the positive impact of telemonitoring for single conditions, little research exists on telemonitoring for this population.

Objective

This randomized controlled trial and embedded qualitative study aims to evaluate the impact on and experiences of patients and health care providers (HCPs) using a telemonitoring system with decision support to manage patients with complex conditions, including those with multiple chronic conditions, compared with the standard of care.

Methods

A pragmatic, unblinded, 6-month randomized controlled trial sought to recruit 146 patients with ≥1 diagnosis of heart failure (HF), uncontrolled hypertension (HT), and insulin-requiring diabetes mellitus (DM) from outpatient specialty settings in Toronto, Ontario, Canada. Participants were randomized into the control and telemonitoring groups, with the latter being instructed to take readings relevant to their conditions. The telemonitoring system contained an algorithm that generated decision support in the form of actionable self-care directives to patients and alerts to HCPs. The primary outcome was health status (36-Item Short Form Health Survey questionnaire). Secondary outcomes included anxiety and depression, self-efficacy in chronic disease management, and self-reported health service use. HF-related quality of life and self-care measures were also collected from patients followed for HF. Within- and between-group change scores were analyzed for statistical significance (P<.05). A convenience sample of HCPs and patients in the intervention group was interviewed about their experiences.

Results

A total of 96 patients were recruited and randomized. Recruitment was terminated early because of implementation challenges and the onset of the COVID-19 pandemic. No significant within- and between-group differences were found for the main primary and secondary outcomes. However, a within-group analysis of patients with HF found improvements in self-care maintenance (P=.04) and physical quality of life (P=.046). Opinions expressed by the 5 HCPs and 13 patients who were interviewed differed based on the monitored conditions. Although patients with HF reported benefitting from actionable self-care guidance and meaningful interactions with their HCPs, patient and HCP users of the DM and HT modules did not think telemonitoring improved the clinical management of those conditions to the same degree. These differing experiences were largely attributed to the siloed nature of specialty care and the design of the decision support, whereby fluctuations in the status of HT and DM typically required less urgent interventions compared with patients with HF.

Conclusions

We recommend that future research conceive telemonitoring as a program and that self-management and clinical decision support are necessary but not sufficient components of such programs for patients with complex conditions and lower acuity. We conclude that telemonitoring for patients with complex conditions or within multidisciplinary care settings may be best operationalized through nurse-led models of care.

Trial Registration

ClinicalTrials.gov NCT03127852; https://clinicaltrials.gov/ct2/show/NCT03127852

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.8367

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

BACKGROUND

Guideline-directed medical therapy (GDMT), optimized to target doses, improves health outcomes in patients with heart failure. However, GDMT remains underused, with <25% of patients receiving target doses in clinical practice. A randomized controlled trial was conducted at the Peter Munk Cardiac Centre in Toronto to compare a remote GDMT titration intervention with standard in-office titration. This randomized controlled trial found that remote titration increased the proportion of patients who achieved optimal GDMT doses, decreased the time to dose optimization, and reduced the number of essential clinic visits. This paper presents findings from the qualitative component of the mixed methods study, which evaluated the implementation of the remote titration intervention.

OBJECTIVE

The objective of the qualitative component is to assess the perceptions and experiences of clinicians and patients with heart failure who participated in the remote titration intervention to identify factors that affected the implementation of the intervention.

METHODS

We conducted semistructured interviews with clinicians (n=5) and patients (n=11) who participated in the remote titration intervention. Questions probed the experiences of the participants to identify factors that can serve as barriers and facilitators to its implementation. Conventional content analysis was first used to analyze the interviews and gain direct information based on the participants' unique perspectives. Subsequently, the generated themes were delineated and mapped following a multilevel framework.

RESULTS

Patients and clinicians indicated that the intervention was easy to use, integrated well into their routines, and removed practical barriers to titration. Key implementation facilitators from the patients' perspective included the reduction in clinic visits and daily monitoring of their condition, whereas clinicians emphasized the benefits of rapid drug titration and efficient patient management. Key implementation barriers included the resources necessary to support the intervention and lack of physician remuneration.

CONCLUSIONS

This study presents results from a real-world implementation assessment of remote titration facilitated by telemonitoring. It is among the first to provide insight into the perception of the remote titration process by clinicians and patients. Our findings indicate that the relative advantages that remote titration presents over standard care strongly appeal to both clinicians and patients. However, to ensure uptake and adherence, it is important to ensure that suitable patients are enrolled and the impact on the physicians' workload is minimized. The implementation of remote titration is now more critical than ever, as it can help provide access to care for patients during times when physical distancing is required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19705.

Web-Based Training and Telephone Follow-up of Patients With Heart Failure: Randomized Controlled Trial

This study was carried out to determine the effect of Web-based training and telephone follow-up on symptom burden and health status in patients with heart failure. Patient training and postdischarge follow-up are necessary to improve symptom management and quality of life in patients with heart failure. In Turkey, Web-based education and phone monitoring are not very common yet. In this parallel randomized controlled trial, patients were allocated to a control group (n = 32) or an intervention group (n = 32). The control group received routine care, and the intervention group was administered the following interventions in addition to routine care: Web-based training, four-session telephone follow-up, and one text message weekly. All results regarding symptom management and quality of life were assessed beginning and at the 12th week. The Consolidated Standards of Reporting Trials checklist was used. In the 12th week after discharge, patients in the intervention group showed a significant improvement in terms of symptom burden and health status compared with the control group.

Factors Associated with Telemedicine Use for Chronic Disease Specialty Care in the Alaska Tribal Health System, 2015-2019

Background: There are disparities in access to specialty care for chronic diseases in rural and minority populations. Telemedicine has been proposed to improve access. Introduction: The objective of this study was to identify predictors of telemedicine use for chronic disease specialty care in the Alaska Tribal Health System (ATHS) in the setting of usual care. Materials and Methods: We utilized data from the electronic health record (EHR) of patients from four regions in the ATHS. We queried the EHR to identify cases (ever users of telemedicine) and controls (never users), both of whom had chronic diseases requiring specialty care. Data were collected from 2015 through mid-2019. Results: We included 3,075 patients (799 ever users and 2,276 never users). In univariate analysis, ever users were older, more likely to be male, had more chronic conditions and higher encounter rates. There were differences by region, community, and type of specialty clinic. In our simple multivariate model, factors associated with telemedicine use included age, male gender, region, and outpatient visit rate per year. Having at least one cardiology clinic visit was also associated with telemedicine use, with the highest estimated odds ratio (5.27, p < 0.01). Discussion: This study describes factors associated with telemedicine use in the ATHS before the COVID-19 pandemic. We anticipate monitoring changes in these predictors over time, as we expect them to evolve. Conclusions: We found among factors associated with telemedicine use were age, gender, region, outpatient visit rate, and visits to a specific specialty clinic.

Factors influencing the effectiveness of remote patient monitoring interventions: a realist review

OBJECTIVES

Our recent systematic review determined that remote patient monitoring (RPM) interventions can reduce acute care use. However, effectiveness varied within and between populations. Clinicians, researchers, and policymakers require more than evidence of effect; they need guidance on how best to design and implement RPM interventions. Therefore, this study aimed to explore these results further to (1) identify factors of RPM interventions that relate to increased and decreased acute care use and (2) develop recommendations for future RPM interventions.

DESIGN

Realist review-a qualitative systematic review method which aims to identify and explain why intervention results vary in different situations. We analysed secondarily 91 studies included in our previous systematic review that reported on RPM interventions and the impact on acute care use. Online databases PubMed, EMBASE and CINAHL were searched in October 2020. Included studies were published in English during 2015-2020 and used RPM to monitor an individual's biometric data (eg, heart rate, blood pressure) from a distance.

PRIMARY AND SECONDARY OUTCOME MEASURES

Contextual factors and potential mechanisms that led to variation in acute care use (hospitalisations, length of stay or emergency department presentations).

RESULTS

Across a range of RPM interventions 31 factors emerged that impact the effectiveness of RPM innovations on acute care use. These were synthesised into six theories of intervention success: (1) targeting populations at high risk; (2) accurately detecting a decline in health; (3) providing responsive and timely care; (4) personalising care; (5) enhancing self-management, and (6) ensuring collaborative and coordinated care.

CONCLUSION

While RPM interventions are complex, if they are designed with patients, providers and the implementation setting in mind and incorporate the key variables identified within this review, it is more likely that they will be effective at reducing acute hospital events.

PROSPERO REGISTRATION NUMBER

CRD42020142523.

Same same-but different: using qualitative studies to inform concept elicitation for quality of life assessment in telemedical care: a request for an extended working model

Background

Although telemedical applications are increasingly used in the area of both mental and physical illness, there is no quality of life (QoL) instrument that takes into account the specific context of the healthcare setting. Therefore, the aim of this study was to determine a concept of quality of life in telemedical care to inform the development of a setting-sensitive patient-reported outcome measure.

Methods

Overall, 63 semi-structured single interviews and 15 focus groups with 68 participants have been conducted to determine the impact of telemedical care on QoL. Participants were patients with chronic physical or mental illnesses, with or without telemedicine supported healthcare as well as telemedical professionals. Mayring's content analysis approach was used to encode the qualitative data using MAXQDA software.

Results

The majority of aspects that influence the QoL of patients dealing with chronic conditions or mental illnesses could be assigned to an established working model of QoL. However, some aspects that were considered important (e. g. perceived safety) were not covered by the pre-existing domains. For that reason, we re-conceptualized the working model of QoL and added a sixth domain, referred to as healthcare-related domain.

Conclusion

Interviewing patients and healthcare professionals brought forth specific aspects of QoL evolving in telemedical contexts. These results reinforce the assumption that existing QoL measurements lack sensitivity to assess the intended outcomes of telemedical applications. We will address this deficiency by a telemedicine-related re-conceptualization of the assessment of QoL and the development of a suitable add-on instrument based on the resulting category system of this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01807-8.

Ambulatory Management of Worsening Heart Failure: Current Strategies and Future Directions

Heart failure (HF) is a highly prevalent and morbid disease in the USA. The chronic, progressive course of HF is defined by periodic exacerbations of symptoms, described as 'worsening heart failure' (WHF). Previously, episodes of WHF have required hospitalization for intravenous diuretics; however, recent innovations in care delivery models for patients with HF have allowed a transition from the acute care setting to the ambulatory setting. The development of remote monitoring strategies, including device-based algorithms and implantable haemodynamic monitoring systems, has facilitated more advanced surveillance of patients, aiming to prevent the clinical deterioration that leads to hospitalization. Additionally, the establishment of multidisciplinary HF clinics has provided the setting and resources for the outpatient treatment of WHF, specifically the administration of intravenous diuretics. Here we review the current state of ambulatory HF management, including mechanisms for patient monitoring and treatment, and outline future opportunities for outpatient management of this patient population.

Towards a unifying caring life-course theory for better self-care and caring solutions: A discussion paper

Aim

To present the first iteration of the caring life‐course theory.

Background

Despite requiring care from birth to death, a person's universal or fundamental care needs and the subsequent care provision, either by self or others, has yet to be presented within a life‐course perspective. Accurately describing the care people require across their lifespan enables us to identify who, what type, how and where this care should be provided. This novel perspective can help to legitimise a person's care needs and the support they require from wider care systems and contexts.

Design

Discussion paper outlines theory development. We adopted an inductive approach to theory development, drawing upon existing literature and the team's diverse experiences. Our theoretical insights were refined through a series of collaborative meetings to define the theory's constructs, until theoretical saturation was reached.

Discussion

Fourteen constructs are identified as essential to the theory. We propose it is possible, using these constructs, to generate caring life‐course trajectories and predict divergences in these trajectories. The novel contribution of the theory is the interplay between understanding a person's care needs and provision within the context of their lifespan and personal histories, termed their care biography, and understanding a person's care needs and provision at specific points in time within a given care network and socio‐political context.

Impact for Nursing

The caring life‐course theory can provide a roadmap to inform nursing and other care industry sectors, providing opportunities to integrate and deliver care from the perspective of the person and their care history, trajectories and networks, with those of professional care teams. It can help to shape health, social and economic policy and involve individuals, families and communities in more constructive ways of talking about the importance of care for improved quality of life and healthy societies.

The Costs and Cardiovascular Benefits in Patients With Peripheral Artery Disease From a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study

BACKGROUND

Patients with peripheral artery disease (PAD) are at high risk for major cardiovascular events, including myocardial infarction, stroke, and hospitalization for heart failure. We have previously shown the clinical efficacy of a fourth-generation synchronous telehealth program for some patients, but the costs and cardiovascular benefits of the program for PAD patients remain unknown.

OBJECTIVE

The telehealth program is now widely used by higher-risk cardiovascular patients to prevent further cardiovascular events. This study investigated whether patients with PAD would also have better cardiovascular outcomes after participating in the fourth-generation synchronous telehealth program.

METHODS

This was a retrospective cohort study. We screened 5062 patients with cardiovascular diseases who were treated at National Taiwan University Hospital and then enrolled 391 patients with a diagnosis of PAD. Of these patients, 162 took part in the telehealth program, while 229 did not and thus served as control patients. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to mitigate possible selection bias. Follow-up outcomes included heart failure hospitalization, acute coronary syndrome, stroke, and all-cause readmission during the 1-year follow-up period and through the last follow-up.

RESULTS

The mean follow-up duration was 3.1 (SD 1.8) years for the patients who participated in the telehealth program and 3.2 (SD 1.8) for the control group. The telehealth program patients exhibited lower risk of ischemic stroke than did the control group in the first year after IPTW (0.9% vs 3.5%; hazard ratio [HR] 0.24; 95% CI 0.07-0.80). The 1-year composite endpoint of vascular accident, including acute coronary syndrome and stroke, was also significantly lower in the telehealth program group after IPTW (2.4% vs 5.2%; HR 0.46; 95% CI 0.21-0.997). At the end of the follow-up, the telehealth program group continued to exhibit a significantly lower rate of ischemic stroke than did the control group after IPTW (0.9% vs 3.5%; HR 0.52, 95% CI 0.28-0.93). Furthermore, the medical costs of the telehealth program patients were not higher than those of the control group, whether in terms of outpatient, emergency department, hospitalization, or total costs.

CONCLUSIONS

The PAD patients who participated in the fourth-generation synchronous telehealth program exhibited lower risk of ischemic stroke events over both mid- and long-term follow-up periods. However, larger-scale and prospective randomized clinical trials are needed to confirm our findings.

Experience of remote monitoring of patients with cardiovascular diseases in the Perm Krai

The first review on the effectiveness of remote monitoring in cardiovascular patients was published in 2007, which is still relevant, reaching the peak during the Coronavirus disease 2019 (COVID-19) pandemic. Reduced availability of elective outpatient care, and sometimes reluctance of patients to visit the office due to the pandemic, required changes in ambulatory follow-up. In order to increase the availability of healthcare and reduce the mortality of Perm Krai population from cardiovascular diseases during the COVID-19 pandemic, a project for remote monitoring of high-cardiovascular-risk patients was developed and implemented.

The developed remote monitoring project represents regular phone contacts with a patient included in the remote monitoring program, according to which the need for further face-to-face consultation, additional diagnostic tests and treatment strategy is determined. The working group of the project identified indications for including patients in remote monitoring, algorithms for phone contacts and management options depending on the responses received from patients.

The project was launched in July 2020. Initially, it included five medical institutions, which selected 3901 patients.

The results will be published as the project moves forward.

Epidemiology of Heart Failure: A Contemporary Perspective

Designated as an emerging epidemic in 1997, heart failure (HF) remains a major clinical and public health problem. This review focuses on the most recent studies identified by searching the Medline database for publications with the subject headings HF, epidemiology, prevalence, incidence, trends between 2010 and present. Publications relevant to epidemiology and population sciences were retained for discussion in this review after reviewing abstracts for relevance to these topics. Studies of the epidemiology of HF over the past decade have improved our understanding of the HF syndrome and of its complexity. Data suggest that the incidence of HF is mostly flat or declining but that the burden of mortality and hospitalization remains mostly unabated despite significant ongoing efforts to treat and manage HF. The evolution of the case mix of HF continues to be characterized by an increasing proportion of cases with preserved ejection fraction, for which established effective treatments are mostly lacking. Major disparities in the occurrence, presentation, and outcome of HF persist particularly among younger Black men and women. These disturbing trends reflect the complexity of the HF syndrome, the insufficient mechanistic understanding of its various manifestations and presentations and the challenges of its management as a chronic disease, often integrated within a context of aging and multimorbidity. Emerging risk factors including omics science offer the promise of discovering new mechanistic pathways that lead to HF. Holistic management approaches must recognize HF as a syndemic and foster the implementation of multidisciplinary approaches to address major contributors to the persisting burden of HF including multimorbidity, aging, and social determinants of health.

Engagement With a Health Information Technology-Augmented Self-Management Support Program in a Population With Limited English Proficiency: Observational Study

Background

Limited English proficiency (LEP) is an important driver of health disparities. Many successful patient-level interventions to prevent chronic disease progression and complications have used automated telephone self-management support, which relies on patient activation and communication to achieve improved health outcomes. It is not clear whether these interventions are similarly applicable to patients with LEP compared to patients with English proficiency.

Objective

The objectives of this study were as follows: (1) To examine the impact of LEP on patient engagement (primary outcome) with a 12-month language-concordant self-management program that included automated telephone self-management support, designed for patients with chronic kidney disease (CKD). (2) To assess the impact of LEP on change in systolic blood pressure (SBP) and albuminuria (secondary outcomes) resulting from the self-management program.

Methods

This was a secondary analysis of the Kidney Awareness Registry and Education (KARE) pilot trial (NCT01530958) which was funded by the National Institutes of Health in August 2011, approved by the University of California Institutional Review Board in October 2011 (No. 11-07399), and executed between 2013 and 2015. Multivariable logistic and linear models were used to examine various facets of patient engagement with the CKD self-management support program by LEP status. Patient engagement was defined by patient’s use of educational materials, completion of a health coaching action plan, and degree of participation with automated telephone self-management support. Changes in SBP and albuminuria at 12 months by LEP status were determined using multivariable linear mixed models.

Results

Of 137 study participants, 53 (38.7%) reported LEP, of which 45 (85%) were Spanish speaking and 8 (15%) Cantonese speaking. While patients with LEP and English proficiency similarly used the program’s educational materials (85% [17/20] vs 88% [30/34], P=.69) and completed an action plan (81% [22/27] vs 74% [35/47], P=.49), those with LEP engaged more with the automated telephone self-management support component. Average call completion was 66% among patients with LEP compared with 57% among those with English proficiency; patients with LEP requested more health coach telephone calls (P=.08) and had a significantly longer average automated call duration (3.3 [SD 1.4] min vs 2.2 [1.1 min], P<.001), indicating higher patient engagement. Patients with LEP randomized to self-management support had a larger, though nonstatistically significant (P=.74), change in SBP (–4.5 mmHg; 95% CI –9.4 to 0.3) and albuminuria (–72.4 mg/dL; 95% CI –208.9 to 64.1) compared with patients with English proficiency randomized to self-management support (–2.1 mmHg; 95% CI –8.6 to 4.3 and –11.1 mg/dL; 95% CI –166.9 to 144.7).

Conclusions

Patients with LEP with CKD were equally or more engaged with a language-concordant, culturally appropriate telehealth intervention compared with their English-speaking counterparts. Augmented telehealth may be useful in mitigating communication barriers among patients with LEP.

Trial Registration

ClinicalTrials.gov NCT01530958; https://clinicaltrials.gov/ct2/show/NCT01530958

Impacts of Post-Hospitalization Accessible Health Technology and Caregiver Support on 90-Day Acute Care Use and Self-Care Assistance: A Randomized Clinical Trial

Hospitalized patients often are readmitted soon after discharge, with many hospitalizations being potentially preventable. The authors evaluated a mobile health intervention designed to improve post-hospitalization support for older adults with common chronic conditions. All participants enrolled with an informal caregiver or "CarePartner" (CP). Intervention patients received automated assessment and behavior change calls. CPs received automated, structured feedback following each assessment. Clinicians received alerts about serious problems identified during patient calls. Controls had a 65% greater risk of hospitalization within 90 days post discharge than intervention patients (P = .041). For every 6.8 enrollees, the intervention prevented 1 rehospitalization or emergency department encounter. The intervention improved physical functioning at 90 days (P = .012). The intervention also improved medication adherence and indicators of the quality of communication with CPs (all P < .01). Automated telephone patient monitoring and self-care advice with feedback to primary care teams and CPs reduces readmission rates over 90 days.

Can tele-nursing affect the supportive care needs of patients with cancer undergoing chemotherapy? A randomized controlled trial follow-up study

Purpose

In some countries, telephone-based support is one of the key services used for supporting patients with cancer. However, there is a lack of research on the efficacy of this method in Iran. This study aimed to evaluate the effects of tele-nursing on supportive care needs (SCNs) of patients with cancer undergoing chemotherapy.

Methods

This randomized controlled trial was conducted on 60 patients with cancer undergoing chemotherapy who were randomly assigned and allocated to two groups, an intervention group and a control group. Patients’ SCNs were assessed in the baseline, and 1 and 2 months after commencement of the intervention using the SCNs Survey -Short Form 34. The data were analyzed through descriptive statistics, t-test, and repeated measure test, by SPSS version 16.

Results

There were no significant statistical differences in the mean score of dimensions and total SCNs between the two groups in baseline (p˃0.05). However, the results showed that the mean score of dimensions and total SCNs in the intervention group were significantly less than the control group, after the intervention (p˂0.05).

Conclusions

Telephone-based support is an effective method to address and reduce SCNs of patients with cancer undergoing chemotherapy through increasing access to support for this population especially who may be in rural and remote settings. During the COVID_19 pandemic and given the vulnerability of patients with cancer, telephone support can be used to avoid unnecessary visits to hospitals and reduced the risk of transmitting the virus to the patients.

Trial registration number

IRCT20170404033216N1

Effectiveness of Mobile Health Technology Interventions for Patients With Heart Failure: Systematic Review and Meta-analysis

BACKGROUND

Heart failure (HF) is a complex and serious condition associated with substantial morbidity, mortality, and health care costs. We conducted a systematic review and meta-analysis to evaluate the effects of mobile health (mHealth) interventions compared with usual care in patients with HF.

METHODS

We searched MEDLINE, CENTRAL, CINAHL, and EMBASE databases to identify eligible randomized controlled trials (RCTs) of mHealth interventions. Primary outcomes included: all-cause mortality, cardiovascular mortality, HF-related hospitalizations, and all-cause hospitalizations. Meta-analyses using a random effects model were performed for all outcomes. Risk of bias and quality of evidence were evaluated using the Cochrane Tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RESULTS

Sixteen RCTs involving 4389 patients were included. Compared with usual care, mHealth interventions reduced the risk of all-cause mortality (risk ratio [RR], 0.80; 95% confidence interval [CI], 0.65-0.97; absolute risk reduction [ARR], 2.1%; high-quality evidence), cardiovascular mortality (RR, 0.70; 95% CI, 0.53-0.91; ARR, 2.9%; high-quality evidence), and HF hospitalizations (RR, 0.77; 95% CI, 0.67-0.88; ARR, 5%; high-quality evidence), but had no effect on all-cause hospitalizations. Results were driven by mHealth interventions with remote monitoring and clinical feedback, which were associated with larger reductions than stand-alone mHealth interventions. However, subgroup differences were not statistically significant.

CONCLUSIONS

mHealth interventions with remote monitoring and clinical feedback reduce mortality and HF-related hospitalizations, but might not reduce all-cause hospitalizations in patients with HF. Additional studies are needed to determine the efficacy of stand-alone mHealth interventions as well as active features of mHealth that contribute to efficacy.

Early Detection of Fluid Retention in Patients with Advanced Heart Failure: A Review of a Novel Multisensory Algorithm, HeartLogicTM

Heart failure (HF) hospitalisations due to decompensation are associated with shorter life expectancy and lower quality of life. These hospitalisations pose a significant burden on the patients, doctors and healthcare resources. Early detection of an upcoming episode of decompensation may facilitate timely optimisation of the ambulatory medical treatment and thereby prevent heart-failure-related hospitalisations. The HeartLogic^TM algorithm combines data from five sensors of cardiac implantable electronic devices into a cumulative index value. It has been developed for early detection of fluid retention in heart failure patients. This review aims to provide an overview of the current literature and experience with the HeartLogic^TM algorithm, illustrate how the index can be implemented in daily clinical practice and discuss ongoing studies and potential future developments of interest.

Role of New Technologies in Supporting the Treatment of Complex Patients

Cardiology represents one of the privileged disciplinary areas for the experimentation and validation of the applications of telemedicine. Telemedicine, and the health technologies that go by the name of eHealth, identify the digital exchange of social and health information in order to support and optimize the care process remotely. Telemonitoring applied to cardiovascular diseases is defined as the recording, remote transmission, storage, and interpretation of cardiovascular parameters and diagnostic images. Meta-analyses have shown that telemedicine-supported models of care not only are effective but also cost-effective.

Impact of a telemonitoring intervention in patients with chronic heart failure in Germany: A difference-in-difference matching approach using real-world data

INTRODUCTION

The aim of this study was to evaluate the effects of a non-invasive telemonitoring intervention on mortality, healthcare costs, and hospital and pharmaceutical utilisation in patients with chronic heart failure (CHF) of a large statutory health insurer in Germany.

METHODS

In a retrospective observational cohort study using real-world data, we assessed differences between 635 patients who received a telemonitoring intervention versus 635 receiving usual care covering 36 months after intervention. We used propensity score matching on a set of 102 parameters collected in the 24-month pre-intervention period to correct for observed differences, as well as difference-in-difference (DiD) estimators to account for unobserved differences. We analysed the effect of the intervention for up to three years on (i) all-cause mortality; (ii) costs (i.e. inpatient stays, ambulatory care, pharmaceuticals, and medical aids and appliances); and (iii) healthcare utilisation (i.e. length and number of hospital stays, number of prescriptions).

RESULTS

DiD estimates suggest lower inpatient costs of the telemonitoring group of up to €1160 (95% confidence interval (CI): -2253 to -69) in year three. Ambulatory care costs increased significantly in all three years up to €316 (95% CI: 1267 to 505) per year. Telemonitoring had a positive effect on survival (hazard ratio = 0.71; 95% CI: 0.51 to 0.99) and increased the number of prescriptions for diuretics. Effects were more prominent for patients with severe CHF.

DISCUSSION

The study suggests that the telemonitoring intervention led to a significant decrease in mortality and a shift in costs from the inpatient to the ambulatory care sector 36 months after intervention.

Digital Health Applications in Heart Failure: a Critical Appraisal of Literature

Purpose of the review

Despite advancements in the diagnostic and therapeutic armamentarium, heart failure (HF) remains a major public health concern in the USA and worldwide. Digital health applications hold promise to bridge this gap and improve HF care. This review will provide the reader with a concise overview of the current digital health applications in HF, the main challenges to its use, and discuss the future of digital health for promoting care for HF patients.

Recent findings

Emerging evidence continues to support the potential role of digital health across the continuum of HF disease process including primary prevention, early detection, disease management, and reducing associated morbidity. There is also increasing emphasis on the need to pursue rigorous investigations to validate these promising claims, with some successful stories that have changed clinical practices.

Summary

Digital health technologies have emerged as potentially useful tools to complement HF care in both research and clinical realms. As digital technologies continue to play an increasing role in transforming healthcare delivery, creating the framework for its effective use would be necessary to ensure that digital health applications consistently improve outcomes and enhance care for HF patients.

Use of a Bluetooth tablet-based technology to improve outcomes in lung transplantation: A pilot study

The impact of remote patient monitoring platforms to support the postoperative care of solid organ transplant recipients is evolving. In an observational pilot study, 28 lung transplant recipients were enrolled in a novel postdischarge home monitoring program and compared to 28 matched controls during a 2-year period. Primary endpoints included hospital readmissions and total days readmitted. Secondary endpoints were survival and inflation-adjusted hospital readmission charges. In univariate analyses, monitoring was associated with reduced readmissions (incidence rate ratio [IRR]: 0.56; 95% confidence interval [CI]: 0.41-0.76; P < .001), days readmitted (IRR: 0.46; 95% CI: 0.42-0.51; P < .001), and hospital charges (IRR: 0.52; 95% CI: 0.51-0.54; P < .001). Multivariate analyses also showed that remote monitoring was associated with lower incidence of readmission (IRR: 0.38; 95% CI: 0.23-0.63; P < .001), days readmitted (IRR: 0.14; 95% CI: 0.05-0.37; P < .001), and readmission charges (IRR: 0.11; 95% CI: 0.03-0.46; P = .002). There were 2 deaths among monitored patients compared to 6 for controls; however, this difference was not significant. This pilot study in lung transplant recipients suggests that supplementing postdischarge care with remote monitoring may be useful in preventing readmissions, reducing subsequent inpatient days, and controlling hospital charges. A multicenter, randomized control trial should be conducted to validate these findings.

The Structure and the Outcome of Telephone-Based Cardiac Consultations During Lockdown: A Lesson From COVID-19

Background In response to COVID-19, Saudi Arabia as many countries, implemented "lockdown" to contain the epidemic. This resulted in suspension of all outpatient services. The reliability of the alternative telecommunication cardiac services during that time is not well studied. Accordingly, the objective of this study is to describe the structure of the telephone-based cardiac consultation (TBCC) and to explore its outcome. Methods This is a cross-sectional study that has a prospective follow up on patients who underwent medical intervention. During the period of lockdown, Alre'aiah health care society in Almadinah Almunawwarah, Saudi Arabia, provided a community health service. This was achieved by announcing telephone numbers for consultations in most specialties. This study includes all TBCC of a single cardiologist. Detailed demographic data, medical, social and drug histories of the patients were collected in charts. Individuals were requested to measure blood pressure (BP) and heart rate (HR) at the time of TBCC. Accordingly, cardiovascular assessment and appropriate intervention were executed. Patients who needed medical intervention were followed up in one week. The data were analyzed using appropriate statistical methods. Results From 01 April till 15 June 2020, a total of 168 individuals sought TBCC. Their median age was 51.5 ± 12.7 years, and (57.1%) were females. Healthy individuals constituted (33.9%), and (59.9%) were non-smokers. The most common reported medical illnesses were hypertension (27.3%), diabetes (23.8%), heart failure (16.1%), and coronary artery disease (14.9%). Palpitations were encountered by 58 patients. None of them had high-risk features or cardiac disease. Stress, excessive smoking, and caffeine intake were thought to be responsible for palpitations in 52 individuals who were reassured and educated, and newly diagnosed hypertension was established prospectively in eight patients and they were started on medications. Chest pain was reported by 51 individuals. The diagnosis of typical angina was made in nine patients and they were instructed to seek emergency care. Atypical angina pain was established in 10 cases who were advised to seek formal consultation once lockdown ends. Reassurance was achieved in 32 individuals who had features of non-angina pain. Uncontrolled hypertension was reported by 32 patients. Blood pressure control was achieved prospectively in 70% of these patients who followed up by adjusting their antihypertensive drugs. Twenty-seven patients with heart failure complained of worsening shortness of breath. New York Heart Association (NYHA) class 1-2 was reported by 21 patients, and they were managed by doubling diuretic dose, 19 of them followed back and reported significant improvement. NYHA class 3-4 was established in 6 patients and they were instructed to seek emergency care. Conclusions When standard face-to-face cardiac consultations are compromised, a structured TBCC is considered feasible, seems effective, and promising alternative method of delivering the utmost cardiac care to the community. When conducted properly, it is useful to triage patients.

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.

Impact of Remote Titration Combined With Telemonitoring on the Optimization of Guideline-Directed Medical Therapy for Patients With Heart Failure: Protocol for a Randomized Controlled Trial

BACKGROUND

Guideline-directed medical therapy (GDMT), optimized to maximum tolerated doses, has been shown to improve clinical outcomes in patients with heart failure (HF). Timely use and optimization of GDMT can improve HF symptoms, reduce the burden of hospitalization, and increase survival rates, whereas GDMT deferral may worsen the progression of HF, decrease survival rates, and predispose patients to poor outcomes. However, studies indicate that GDMT remains underused, with less than 25% of patients receiving target doses in clinical practice. Telemonitoring is a potential component in the management of HF that can provide reliable and real-time physiological data for clinical decision support and facilitate remote titration of medication.

OBJECTIVE

The primary objective of this study is to evaluate the impact of remote titration facilitated by telemonitoring on health care outcomes, with a primary outcome measure being the proportion of patients achieving target doses. The secondary objective is to identify the barriers and facilitators that can affect the implementation and effectiveness of the intervention.

METHODS

A mixed methods study of a smartphone-based telemonitoring system is being conducted at the Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto. The study is based on an effectiveness-implementation hybrid design and incorporates process evaluations alongside the assessment of clinical outcomes. The effectiveness research component is assessed by a two-arm randomized controlled trial (RCT) aiming to enroll 108 patients. The RCT compares a remote titration strategy that uses data from a smartphone-based telemonitoring system with a standard titration program consisting of in-office visits. The implementation research component consists of a qualitative study based on semistructured interviews with a purposive sample of clinicians and patients.

RESULTS

Patient recruitment began in January 2019 at PMCC, with a total of 76 participants recruited by February 24, 2020 (39 in the intervention group and 37 in the control group). The final analysis is expected to be completed by the winter of 2021.

CONCLUSIONS

This study will be among the first to provide evidence on the implementation of remote titration facilitated by telemonitoring and its impact on patient health outcomes. The successful use of telemonitoring for this purpose has the potential to alter the existing approach to titration of HF medication and support the development of a care delivery model that combines clinic visits with virtual follow-ups.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04205513; https://clinicaltrials.gov/ct2/show/NCT04205513.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19705.

Remote Patient Monitoring for the Detection of COPD Exacerbations

Background

COPD exacerbations occur more frequently with disease progression and are associated with worse prognosis and higher healthcare expenditure.

Purpose

To utilize a networked system, optimized with statistical process control (SPC), for remote patient monitoring (RPM) and to identify potential predictors of COPD exacerbations.

Methods

Seventeen subjects, mean (SD) age of 69.7 (7.2) years, with moderate to severe COPD received RPM. Over 2618 patient-days (7.17 patient-years) of monitoring, we obtained daily symptom scores, treatment adherence, self-reported activity levels, daily spirometry (SVC, FEV₁, FVC, PEF), inspiratory capacity (IC), and oxygenation (SpO₂). These data were used to identify predictors of exacerbations defined using Anthonisen and other criteria.

Results

After implementation of SPC, concordance analysis showed substantial agreement between FVC (decrease below the 7-day rolling average minus 1.645 SD) and self-reported healthcare utilization events (κ=0.747, P<0.001) as well as between increased use of inhaled short-acting bronchodilators and exacerbations defined by two Anthonisen criteria (κ=0.611, P<0.001) or modified Anthonisen criteria (κ=0.622, P<0.001). There was a moderate agreement between FEV₁ (decrease >1.645 SD below the 7-day rolling average) and self-reported healthcare utilization events (κ=0.475, P<0.001) and between SpO₂ less than 90% and exacerbations defined by two Anthonisen criteria (κ=0.474, P<0.001) or modified Anthonisen criteria (κ=0.564, P<0.001).

Conclusion

Exacerbations were best predicted by FVC and FEV₁ below the one-sided 95% confidence interval derived from SPC but also by increased use of inhaled short-acting bronchodilators and fall in oxygen saturation. An RPM program that captures these parameters may be used to guide appropriate interventions aimed at reducing healthcare utilization in COPD patients.