Digital Solutions to Optimize Guideline-Directed Medical Therapy Prescriptions in Heart Failure Patients: Current Applications and Future Directions

PURPOSEOF REVIEW

Guideline-directed medical therapy (GDMT) underuse is common in heart failure (HF) patients. Digital solutions have the potential to support medical professionals to optimize GDMT prescriptions in a growing HF population. We aimed to review current literature on the effectiveness of digital solutions on optimization of GDMT prescriptions in patients with HF.

RECENT FINDINGS

We report on the efficacy, characteristics of the study, and population of published digital solutions for GDMT optimization. The following digital solutions are discussed: teleconsultation, telemonitoring, cardiac implantable electronic devices, clinical decision support embedded within electronic health records, and multifaceted interventions. Effect of digital solutions is reported in dedicated studies, retrospective studies, or larger studies with another focus that also commented on GDMT use. Overall, we see more studies on digital solutions that report a significant increase in GDMT use. However, there is a large heterogeneity in study design, outcomes used, and populations studied, which hampers comparison of the different digital solutions. Barriers, facilitators, study designs, and future directions are discussed. There remains a need for well-designed evaluation studies to determine safety and effectiveness of digital solutions for GDMT optimization in patients with HF. Based on this review, measuring and controlling vital signs in telemedicine studies should be encouraged, professionals should be actively alerted about suboptimal GDMT, the researchers should consider employing multifaceted digital solutions to optimize effectiveness, and use study designs that fit the unique sociotechnical aspects of digital solutions. Future directions are expected to include artificial intelligence solutions to handle larger datasets and relieve medical professional's workload.

Telehealth care and remote monitoring strategies in heart failure patients: A systematic review and meta-analysis

BACKGROUND

Heart failure (HF) is a cardiac clinical syndrome that involves complex pathological aetiologies. It represents a growing public health issue and affects a significant number of people worldwide.

OBJECTIVES

To synthesize evidence related to the impact of telemonitoring strategies on mortality and hospital readmissions of heart failure patients.

METHODS

A systematic literature review was conducted using PubMed, Scopus, CINAHL, IEEE Xplore Digital Library, Engineering Source, and INSPEC. To be included, studies had to be in English or Italian and involve heart failure patients of any NYHA class, receiving care through any telecare, remote monitoring, telemonitoring, or telehealth programmes. Articles had to contain data on both mortality and number of patients who underwent rehospitalizations during follow-ups. To explore the effectiveness of telemonitoring strategies in reducing both one-year all-cause mortality and one-year rehospitalizations, studies were synthesized through meta-analyses, while those excluded from meta-analyses were summarized narratively.

RESULTS

Sixty-one studies were included in the review. Narrative synthesis of data suggests a trend towards a reduction in deaths among monitored patients, but the number of rehospitalized patients was higher in this group. Meta-analysis of studies reporting one-year all-cause mortality outlined the protective power of care models based on telemonitoring in reducing one-year all-cause mortality. Meta-analysis of studies reporting the number of rehospitalized patients in one-year outlined that telemonitoring is effective in reducing the number of rehospitalized patients when compared with usual care strategies.

CONCLUSION

Evidence from this review confirms the benefits of telemonitoring in reducing mortality and rehospitalizations of HF patients. Further research is needed to reduce the heterogeneity of the studies.

Interactive Remote Patient Monitoring Devices for Managing Chronic Health Conditions: Systematic Review and Meta-analysis

BACKGROUND

Telemedicine is an expanding and feasible approach to improve medical care for patients with long-term conditions. However, there is a poor understanding of patients' acceptability of this technology and their rate of uptake.

OBJECTIVE

The aim of this study was to systematically review the current evidence on telemonitoring in the management of patients with long-term conditions and evaluate the patients' uptake and acceptability of this technology.

METHODS

MEDLINE, Scopus, and CENTRAL (the Cochrane Central Register of Controlled Trials) were searched from the date of inception to February 5, 2021, with no language restrictions. Studies were eligible for inclusion if they reported any of the following outcomes: intervention uptake and adherence; study retention; patient acceptability, satisfaction, and experience using the intervention; changes in physiological values; all-cause and cardiovascular-related hospitalization; all-cause and disease-specific mortality; patient-reported outcome measures; and quality of life. In total, 2 reviewers independently assessed the articles for eligibility.

RESULTS

A total of 96 studies were included, and 58 (60%) were pooled for the meta-analyses. Meta-analyses showed a reduction in mortality (risk ratio=0.71, 95% CI 0.56-0.89; P=.003; I2=0%) and improvements in blood pressure (mean difference [MD]=-3.85 mm Hg, 95% CI -7.03 to -0.68; P=.02; I2=100%) and glycated hemoglobin (MD=-0.33, 95% CI -0.57 to -0.09; P=.008; I2=99%) but no significant improvements in quality of life (MD=1.45, 95% CI -0.10 to 3; P=.07; I2=80%) and an increased risk of hospitalization (risk ratio=1.02, 95% CI 0.85-1.23; P=.81; I2=79%) with telemonitoring compared with usual care. A total of 12% (12/96) of the studies reported adherence outcomes, and 9% (9/96) reported on satisfaction and acceptance outcomes; however, heterogeneity in the assessment methods meant that a meta-analysis could not be performed.

CONCLUSIONS

Telemonitoring is a valid alternative to usual care, reducing mortality and improving self-management of the disease, with patients reporting good satisfaction and adherence. Further studies are required to address some potential concerns regarding higher hospitalization rates and a lack of positive impact on patients' quality of life.

TRIAL REGISTRATION

PROSPERO CRD42021236291; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=236291.

Telehealth in palliative care is being described but not evaluated: a systematic review

BACKGROUND

Telehealth is growing and its application in palliative care is seen as a solution to pressures on palliative care services. A 2010 UK review reported growing awareness of telehealth in palliative care but a lack of evidence-based research to support its use. The primary aim of this review was to describe the current use of telehealth in palliative care in the UK and evaluate telehealth initiatives against a digital service standard. The secondary aim was to explore whether telehealth results in a reduction in emergency care access.

METHODS

Systematic review of the literature with thematic synthesis. Records were screened and data extracted by two reviewers. EMBASE, MEDLINE, CINAHL, Psychinfo and Cochrane central register for controlled trials were searched using pre-defined terms. Hand searching of conference literature, thesis databases and citation tracking was also conducted. The protocol for this systematic review was registered with PROSPERO and can be found at http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017080038.

RESULTS

The search identified 3807 titles and 30 studies were included in the review. Telehealth was used to support patients and carers, electronic record keeping and professional education. Notably, the number of home telemonitoring initiatives for patients had increased from the 2010 review. Despite this variety, many studies were small scale, descriptive and provided little evidence of evaluation of the service. Ten papers were sufficiently detailed to allow appraisal against the digital service standard and only one of these met all of the criteria to some extent. Seven studies made reference to emergency care access.

CONCLUSIONS

Although there is growth of telehealth services, there remains a lack of evaluation and robust study design meaning conclusions regarding the clinical application of telehealth in palliative care cannot be drawn. There is insufficient evidence to appreciate any benefit of telehealth on access to emergency care. Future work is needed to evaluate the use of telehealth in palliative care and improve telehealth design in line with digital service standards.

[Telemonitoring in patients with chronic heart failure]

Actuality. High risk of hospitalisation and death in patients with heart failure highlight the importance of developing methods to moni‑ tor weight, diuresis, heart rate and other parameters and provide the physicians with an ability to change the therapy immediately if needed. The aim of this work is an analysis of clinical trials which investigate telemonitoring in patients with heart failure. Discussion. The Cochrane meta-analysis is also discussed in this work. Main conclusions. Our analysis showed that there is no consistency among trials. Not all trials have demonstrated that telemonitoring can reduce the risk of death and heart failure hospitalisations. Potentials explanations are lack of compliance with systems which didn't include the direct contact between the patient and the caregivers, using parameters with low sensitivity in some of the methods and including of stable patients in some of the studies. It is also seeming that effect of telemonitoring is low in regions with existing programs to treat heart failure.

Changes in Daily Measures of Blood Pressure and Heart Rate Improve Weight-Based Detection of Heart Failure Deterioration in Patients on Telemonitoring

Blood pressure (BP) and heart rate (HR) are often captured in conjunction with weight in telemonitoring systems, but the additional prognostic potential of daily measurements of BP and HR in providing information on upcoming hospitalizations for worsening heart failure (HFH) have not been explored thoroughly. We retrospectively analyzed 267 daily home-telemonitored heart failure (HF) subjects. We extracted those episodes of HFHs that had sufficient data entries in the days leading up to hospitalization and tested the prognostic potential of 48 trend features based on weight, systolic BP, diastolic BP, pulse pressure (PP), and HR with a Naïve Bayesian model. The single best-performing trend feature-with a cross-validated estimate of 0.64 for the area under the curve (AUC) with a standard deviation (SD) of 0.01-is based on a 2-day weight trend. The best multivariate feature set (cross-validated [Formula: see text], [Formula: see text]) comprises of 2-day trend features based on weight, systolic BP, and HR. There were large variations in the weight trends preceding hospitalizations and weight change alone had a modest predictive ability. Readily interpretable features capturing trends in BP and HR provided additional prognostic information and can be used for improving classification.

Cost-Effectiveness Analysis in Telehealth: A Comparison between Home Telemonitoring, Nurse Telephone Support, and Usual Care in Chronic Heart Failure Management

OBJECTIVES

To assess the cost effectiveness of home telemonitoring (HTM) and nurse telephone support (NTS) compared with usual care (UC) in the management of patients with chronic heart failure, from a third-party payer's perspective.

METHODS

We developed a Markov model with a 20-year time horizon to analyze the cost effectiveness using the original study (Trans-European Network-Home-Care Management System) and various data sources. A probabilistic sensitivity analysis was performed to assess the decision uncertainty in our model.

RESULTS

In the original scenario (which concerned the cost inputs at the time of the original study), HTM and NTS interventions yielded a difference in quality-adjusted life-years (QALYs) gained compared with UC: 2.93 and 3.07, respectively, versus 1.91. An incremental net monetary benefit analysis showed €7,697 and €13,589 in HTM and NTS versus UC at a willingness-to-pay (WTP) threshold of €20,000, and €69,100 and €83,100 at a WTP threshold of €80,000, respectively. The incremental cost-effectiveness ratios were €12,479 for HTM versus UC and €8,270 for NTS versus UC. The current scenario (including telenurse cost inputs in NTS) yielded results that were slightly different from those for the original scenario, when comparing all New York Heart Association (NYHA) classes of severity. NTS dominated HTM, compared with UC, in all NYHA classes except NYHA IV.

CONCLUSIONS

This modeling study demonstrated that HTM and NTS are viable solutions to support patients with chronic heart failure. NTS is cost-effective in comparison with UC at a WTP of €9000/QALY or higher. Like NTS, HTM improves the survival of patients in all NYHA classes and is cost-effective in comparison with UC at a WTP of €14,000/QALY or higher.

Association between remote implantable cardioverter defibrillator monitoring and beta-blocker utilization: An analysis from the EFFECT study

Introduction

A substantial number of heart failure patients undergoing implantation of implantable cardioverter defibrillators (ICDs) fail to receive beta-blockers, or receive them at a suboptimal dose. Remote monitoring (RM) is becoming the standard means of following up recipients of ICDs. However, the impact of this shift toward remote ICD follow-up on the quality of drug therapy management in current clinical practice is unknown. The present analysis was aimed at investigating the impact of RM on the dose of beta-blockers achieved, and its association with clinical outcome at 12 months.

Methods

Altogether 987 consecutive patients were enrolled and followed up for at least 12 months in 25 Italian centres. RM was adopted by 499 patients.

Results

The number of patients receiving beta-blockers at any dose decreased after 12 months (from 403 (81%) to 370 (74%) for the remote arm and from 389 (80%) to 342 (70%) for the standard arm, both p < 0.02). Nonetheless, the number of patients on beta-blockers at the effective dose increased in both arms (from 60 (12%) to 82 (16%) for remote and from 63 (13%) to 98 (20%) for standard arms respectively, both p < 0.05). At multivariate analysis, RM was not associated with an effective dose of beta-blockers at the follow-up evaluation. However, the adoption of RM ( p = 0.003) and the achievement of the effective dose of beta-blockers ( p = 0.006) were independently and positively associated with an improved outcome.

Discussion

In a ‘real-world’ setting, we did not find an association between RM and the achieved dose of beta-blockers. However, we reported outcome benefits in achieving the effective dose of beta-blockers during follow-up and in adopting RM.

What impact do anxiety, depression, perceived control and technology capability have on whether patients with chronic heart failure take-up or continue to use home tele-monitoring services? Study design of ADaPT-HF

BACKGROUND

Home tele-monitoring (HTM) is used to monitor the clinical signs and symptoms of patients with chronic heart failure (CHF) in order to reduce unplanned hospital admissions. However, not all patients who are referred will agree to use HTM, and some patients choose to withdraw early from its use.

AIMS

ADaPT-HF will investigate whether depression, anxiety, low perceived control, reduced technology capability, level of education, age or the severity or complexity of a patient's illness can predict refusal of, or early withdrawal from, HTM in patients with CHF.

METHODS

The study will recruit 288 patients who have been recently admitted to hospital with heart failure who have been referred for HTM. At the time of referral, patients will complete depression (nine-item Patient Health Questionnaire), anxiety (seven-item Generalised Anxiety Disorder questionnaire), perceived control (eight-item revised Controlled Attitudes Scale) and technology capability (ten-item Technology Readiness Index 2.0) screening questionnaires. In addition, data on demographics, diagnosis, clinical examination, socio-economic status, history of comorbidities, medication, biochemistry and haematology will be recorded. The primary outcome will be a composite of refusal of or early withdrawal from HTM. The principle analysis will be made using logistic regression.

CONCLUSION

By establishing which factors influence a patient's decision to refuse or withdraw early from HTM, it may be possible to redesign HTM referral processes. It may be that patients with CHF who also have depression, anxiety, low control and poor technology skills should not be referred until they receive appropriate support or that they should be managed differently when they do receive HTM. The results of ADAPT-HF may provide a way of making more efficient and cost-effective use of HTM services.