Halting the Revolving Door: Could Remote Monitoring Reduce Heart Failure Rehospitalizations?

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Remote monitoring has emerged as a possible strategy for stemming the costly pattern of repeat hospitalization common among heart failure patients.

Revolving hospital door

Nearly one million hospitalizations for heart failure occur in the United States each year. Unplanned readmissions contribute to these hospitalizations and to the country’s approximately $37.2 billion price tag paid annually on heart failure care. Heart failure rehospitalization rates have continued to rise, approaching 30 percent within 30–90 days post-discharge (J Am Coll Cardiol 2013;61[4]:391-403).

The problem with heart failure is not a lack of best practices guidelines. In an editorial on preventing heart failure hospitalizations, Liviu Klein, MD, MS, of the University of California, San Francisco, noted that the heart failure rehospitalization rate is close to 50 percent over six months despite clinicians’ efforts to manage patients in heart failure clinics, follow-up early after discharge, collect daily weights and stay in frequent contact with patients (JACC Heart Fail 2016;4[5]:345-7).

Neither is there a shortage of incentives for clinicians to halt heart failure’s revolving hospital door. The Hospital Readmissions Reduction Program (HRRP), which was launched in 2012 under the Affordable Care Act, levied penalties totaling $517 million in 2013 and 2014 for above-national-average all-cause readmissions within 30 days of discharge following treatment for heart failure, myocardial infarction or pneumonia, according to a Kaiser Family Foundation analysis.

A major challenge in treating heart failure has been that clinicians often don’t learn that a patient’s condition has worsened until symptoms that require urgent treatment in the hospital—such as shortness of breath or congestion causing the ankles, feet, legs and abdomen to swell—have returned. If cardiologists were able to catch congestion earlier, then they might be able to make medication changes and stave off both the dangerous symptoms and the rehospitalizations.

This is where remote monitoring could play a role, experts say, even though most of the studies reported so far have yielded disappointing results. 

Try, try again 

“In three large trials, telemonitoring did not lead to reductions in hospitalization,” says Gregg Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center at the University of California-Los Angeles. The trials he’s referencing: Tele-HF (Telemonitoring to Improve Heart Failure Outcomes), which in 2010 failed to improve readmissions or reduce all-cause mortality in heart failure patients despite having monitored their general health and heart failure symptoms (N Engl J Med 2010;363[24]:2301-9); TIM-HF (Telemedical Interventional Monitoring in Heart Failure), which tracked daily weights and vital signs but  also failed to decrease all-cause mortality (Circulation 2011;123:1873-80); and BEAT-HF (Better Effectiveness After Transition-Heart Failure), where daily collection of blood pressure, heart rate, weight and symptom data did not improve 180-day readmissions (JAMA Intern Med 2016;174[3]:310-8).

A theme of these trials is that most of the data captured by remotely monitoring heart failure patients has not been “highly actionable,” says Fonarow, who was a BEAT-HF investigator. For example, he explains, “changes in daily weight are neither sensitive nor very specific for [detecting] true congestion that would lead to hospitalization.”

Arrival of a champion?

The ability to deliver information that clinicians can use to take preemptive action to halt the heart failure cycle of hospital admission–discharge–symptomatic congestion–readmission is what differentiated CHAMPION (CardioMEMS [St. Jude Medical] Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in Class III Heart Failure) from the other heart failure monitoring trials. In CHAMPION, participants who had been rehospitalized for heart failure in the previous 12 months were implanted with a CardioMEMS pressure sensor, which collects data on pulmonary artery pressure and heart rate. The patients were then randomized to be remotely monitored and receive the standard of care or to receive only standard care. At six months, there was a 28 percent decrease in heart failure hospitalization rates for the patients whose treatment was guided by the data obtained with the monitoring device compared to the control patients (Lancet 2011;377[9766]:658-66). The monitored patients also had their medications changed