Remote patient monitoring for chronic conditions such as hypertension, diabetes and chronic obstructive pulmonary disease (COPD) have demonstrated successful outcomes. The evidence for heart failure (HF) monitoring, however, is less definitive. Yet, newer approaches may turn things around.
Complexity of heart failure
The Centers for Disease Control and Prevention estimate that remote patient monitoring of congestive HF, diabetes, COPD and chronic wounds or skin ulcers could reduce costs to the U.S. healthcare system by nearly $200 billion over the next 25 years. For HF telemonitoring to contribute its fair share to the savings, researchers will need to strengthen the evidence.
Klersy et al found cost savings associated with remote HF monitoring from 21 randomized controlled trials between 2000 and 2009 (mostly driven by reduced hospital admissions). However, they said the economic data were “scanty” and the approach to economic analyses were not uniform. They also noted the follow-up time was “limited" (Eur J Heart Fail 2011;online Feb 1).
Guy Paré, PhD, research chair of healthcare IT and professor of IT at HEC Montreal, found similar challenges with telemonitoring HF studies. He and colleagues analyzed 62 randomized controlled studies spanning from 1966 through 2008 (J Med Internet Res 2010;12:e21). Overall, diabetics, asthmatics and hypertensive patients were able to improve their health, but findings for HF patients were “equivocal” and researchers called for larger and better designed trials.
Heart failure is the most complex and perhaps the most unpredictable condition among those studied, which could explain the disparity in telemonitoring success; however, the literature is inconclusive, Paré says.
He notes several problems with HF telemonitoring studies. First, most do not extend beyond six months, “a considerable limitation.” Second, patients are typically compared with a control group, rather than their prior use of healthcare resources pre-intervention. Finally, the telemonitoring feedback does not usually empower patients to take appropriate actions for their health. “These systems need more than just preprogrammed protocols. They need to react in real time to the patient’s condition,” Paré says.
Paré and colleagues are planning two randomized controlled trials where patients will be followed for 12 months prior to the intervention and 12 months post-intervention. The technology being used has certain intelligent features that could impact self-care, Paré says. “My hypothesis is that the patients who are involved in managing their health will see a greater improvement in quality of life and clinical conditions, with reduced hospital readmissions.”
Following 50,000 patients remotely
In 2009, the Medicare Payment Advisory Commission estimated that 17.6 percent of all Medicare hospital admissions are readmissions, and a majority of them are avoidable. Readmissions cost $15 billion annually and if successfully prevented, could save Medicare $12 billion annually (Frontiers Health Serv Mgmt 2009;25:3-10). The Veterans Health Administration (VHA) has shown remote patient monitoring saves money and reduces hospital admissions, albeit on a very large scale.
Between July 2003 and December 2007, the VHA introduced a home telehealth program across the U.S. During that time, the population being served increased from 2,000 to more than 31,000, and is expected to reach 50,000 this year (Telemed e-Health 2008;14:1118-1126). Echoing Paré, Darkens et al wrote that “promoting patient self-management is a fundamental underpinning” of the telehealth model.
|Implantable Devices Send Signals of Success|
|Studies of implantable cardioverter-defibrillators (ICDs) and cardiac resychronization therapy devices with defibrillators (CRT-Ds) that can wirelessly transmit diagnostic information from heart failure patients to providers are promising.
In the CONNECT trial, Crossley et al randomized 1,997 patients to wireless remote data transmission with clinician alerts or in-office visits (J Am Coll Cardiol 2011;online Jan 19). The median time from a clinical event to a decision per patient was reduced from 22 days in the in-office arm to 4.6 days in the remote arm, and length of stay per hospitalization was reduced from four days to 3.3 days, respectively, an estimated savings of $1,659 per hospitalization. There was no difference in mortality between the two arms.
In the ALTITUDE trial, Saxon et al examined a