Monitoring heart failure patients with either high-tech home monitors or through regular telephone contacts with nurses improves the odds they will survive during the months after a serious hospitalization, according to a new study in the May 17, 2005, issue of the Journal of the American College of Cardiology.
“The difference between usual care and telemonitoring is larger than any other intervention for heart failure,” said John G. F. Cleland, M.D., F.A.C.C., at the University of Hull, Kingston Upon Hull in the United Kingdom. “Telemonitoring helps fewer expert health professionals deliver better quality care to a larger number of patients, thus increasing patients’ well-being and longevity. This makes the best use of scarce human and economic health resources.”
In the largest trial yet of home telemonitoring, researchers in the United Kingdom, Germany and the Netherlands recruited patients who had been recently hospitalized for worsening heart failure. Even though treatment had mostly resolved the symptoms of these patients, they still faced a high risk of relapse, rehospitalizations and death.
The 426 patients enrolled in this trial were randomly assigned to home telemonitoring, nurse telephone support or usual care. The home telemonitoring equipment recorded body weight, blood pressure and basic heart rhythm information. The data were transmitted by telephone to a computer that automatically alerted nurses to abnormal readings. The patients assigned to telephone support received a monthly call from a nurse who assessed their symptoms and medication. Patients in the usual care group were managed by their primary physicians and assessed by researchers every four months. The main outcome measure was days lost to either hospitalization or death during 240 days (eight months) of follow-up; that is, if a patient died, the remaining days in the study period were subtracted, and any days spent in the hospital were also subtracted.
During the 240 days of follow-up, patients in the usual care group lost about 47 days on average (19.5 percent) to death or hospitalization. Patients receiving nurse telephone support lost about 38 days (15.9 percent). Those who were tracked by home telemonitoring equipment lost about 30 days (12.7 percent). These differences were not statistically significant. However, patients receiving either telephone support or home telemonitoring were significantly less likely to die within one year. The one-year mortality rates were 27 percent for the telephone support group, 29 percent for the home telemonitoring group, and 45 percent for the group receiving usual care.
“The most important single thing that any patient with heart failure can do and the most important thing a health care professional can do for such a patient is to get them into an expert ‘Heart Failure Management Program.’ This has a bigger impact on survival than any other single thing that can be done for a patient. Telemonitoring allows more patients to be looked after by fewer experts,” Dr. Cleland said.
Dr. Cleland pointed out that telemonitoring improved the ability of clinicians to adjust medications their patients were taking, even while decreasing the number of face-to-face home and clinic visits.
Although home telemonitoring was not superior to telephone support in this study, it was less expensive overall.
“Home telemonitoring reduces face-to-face contacts versus nurse telephone support. Home telemonitoring was the least expensive option associated with improved survival mostly due to the less expensive outpatient contacts but also due to shorter hospital stays,” Dr. Cleland said.
Usual care was the least expensive option; however, that was largely because patients died sooner and incurred fewer costs.
Although this was the largest heart failure telemonitoring trial yet, Dr. Cleland noted that the number of patients was still modest compared to major trials of other heart failure interventions. He said further work needs to be done to refine telemonitoring equipment and methods and compare it to telephone support, but he emphasized that this study found that either method is better than usual care.
“Ultimately, more randomized, controlled trials comparing expert health care support with and without home telemonitoring are warranted. “Usual care” may no longer be ethical, even though it is still standard practice in the U.S. and Europe,” he said.
Edward P. Havranek, M.D.,F.A.C.C., at the University of Colorado and Denver Health Medical Center, who wrote an editorial in the journal, said that even though home telemonitoring was not superior to telephone support in this trial, cardiologists should remain open to the idea of using technology to support patient care, while focusing their attention on maintaining contact with patients.
“From my perspective, the most important thing this study teaches us is that the key aspect of improved care is a stronger working relationship between patient and provider. Technology should be viewed as a useful tool for enhancing care, not as the centerpiece of care. Also, the article is another important piece of evidence supporting the concept that reorganizing the system for delivering care to patients with heart failure is having as great an effect on improving patient outcomes as some recent advances in drug treatment,” Dr. Havranek said.
Roger M. Mills, M.D., F.A.C.C., at the Henry Ford Hospital and Wayne State University in Detroit, Mich., who was not connected with this study, noted that this trial was remarkably large for a trial of its type and so was the size of the benefit of monitoring heart failure patients.
“In summary, if outpatient support were a drug, it would represent a major breakthrough. These findings should receive equal attention. These data provide unequivocal support for the concept that heart failure patients benefit substantially from continued interaction with health care providers after discharge. Certainly, the telemetry system offers more hard data, but access to a nurse appears to be the critical element of the system,” Dr. Mills said.
Dr. Mills said in his experience some patients like using high-tech monitors, while others prefer getting telephone calls from nurses.
The American College of Cardiology, a 31,000-member nonprofit professional medical society and teaching institution, is dedicated to fostering optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and guidelines, and the formulation of health care policy.