Multicenter randomised trial on home-based telemanagement to prevent hospital readmission of patients with chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) remains a common cause of disability, death and hospital admission. Several investigations support the usefulness of programs of disease management for improving clinical outcomes. However, the effect of home-based telemanagement programs on the rate of hospital readmission is still unclear and the cost-effectiveness ratio of such programs is unknown. The aim of the study was to determine whether a home-based telemanagement (HBT) programme in CHF patients decreased hospital readmissions and hospital costs in comparison with the usual care (UC) follow-up programme over a one-year period. METHODS AND RESULTS: Four hundred-sixty CHF patients (pts), aged 57+/-10 years were randomised to two management strategies: 230 pts to HBT programme and 230 pts to UC programme. The HBT pts received a portable device, transferring, by telephone, a one-lead trace to a receiving station where a nurse was available for interactive teleconsultation. The UC pts were referred to their primary care physicians and cardiologists. The primary objective of the study was one-year hospital readmission for cardiovascular reasons. During one-year follow-up 55 pts (24%) in HBT group and 83 pts (36%) in UC group had at least one readmission (RR=0.56; 95% CI: 0.38-0.82; p=0.01). After adjusting for clinical and demographic characteristics, the HBT group had a significantly lower risk of readmission compared with the UC group (HR=0.50, 95% CI: 0.34-0.73; p=0.01). The intervention was associated with a 36% decrease in the total number of hospital readmissions (HBT group: 91 readmissions; UC group: 142 readmissions) and a 31% decrease in the total number of episodes of hemodynamic instability (101 in HBT group vs 147 in UC group). The rate of hearth failure-related readmission was 19% (43 pts) in HBT group and 32% (73 pts) in UC group (RR=0.49, 95% [CI]: 0.31-0.76; p=0.0001). No significant difference was found on cardiovascular mortality between groups. Mean cost for hospital readmission was significantly lower in HBT group (euro 843+/-1733) than in UC group (euro 1298+/-2322), (-35%, p<0.01). CONCLUSIONS: This study suggests that one-year HBT programme reduce hospital readmissions and costs in CHF patients.

A pilot study of nurse-led, home monitoring for patients with chronic respiratory failure and with mechanical ventilation assistance.

We assessed the feasibility of telemedicine for home monitoring of 45 patients with chronic respiratory failure (CRF) discharged from hospital. The patients transmitted pulsed arterial saturation (pSat) data via a telephone modem to a receiving station where a nurse was available for a teleconsultation. A respiratory physician was also available. Scheduled and ad hoc appointments were conducted. Thirty-five patients were on home mechanical ventilation, 13 with invasive and 22 with non-invasive devices. The main diagnosis was chronic obstructive pulmonary disease (COPD). The follow-up period was 176 days (SD 69). In all, 376 calls for scheduled consultations were received and 83 ad hoc consultations were requested by the patients. The actions taken were: 55 therapy modifications, 19 hospitalizations in a respiratory department for decompensated CRF, three hospitalizations in an intensive care unit (ICU), 22 requests for further investigations, 25 contacts with the general practitioner (GP), 66 demands for respiratory consultations and 10 calls for the emergency department. The mean time recorded for the 459 calls was 16 min/patient/week. In 82% of calls, a pSat recording was received successfully. The nurse time required to train the users in the operation of the pSat instrument was high (mean time 30 min). However, the results showed that home monitoring was feasible, and useful for titration of oxygen, mechanical ventilation setting and stabilization of relapses.

Cardiac event recording yields more diagnoses than 24-hour Holter monitoring in patients with palpitations.

Palpitation is a common symptom that sometimes results from a substantial cardiac arrhythmia. We compared the diagnostic yield of trans-telephonic event monitors with those of Holter monitoring in patients with intermittent palpitations. In all, 310 patients were randomly assigned to receive an event recorder or 24-hour Holter monitoring. Event recorders were used for seven days or until two recordings were obtained while symptoms occurred. The main end-point was an electrocardiogram (ECG) recorded during symptoms. The patients with palpitation recorded the one-lead ECG trace and sent it to a telemedicine call centre, where a nurse responded. There were 119 symptomatic patients in the event recorder group and 74 in the Holter group. The total costs were 6019 for event recording and 9605 for Holter monitoring. The average costs were 51 per symptomatic patient detected by event recorder monitoring and 130 per symptomatic patient detected by Holter monitoring. More patients therefore received a clear diagnosis, and more quickly, when using event recording than with Holter monitoring. For this reason, event recorders are preferable to Holter monitors for patients with palpitations.

Effect of home-based telecardiology on chronic heart failure: costs and outcomes.

Chronic heart failure (CHF) remains a common cause of disability. We have investigated the use of home-based telecardiology (HBT) in CHF patients. Four hundred and twenty-six patients were enrolled in the study: 230 in the HBT group and 196 in the usual-care group. HBT consisted of trans-telephonic follow-up and electrocardiogram (ECG) monitoring, followed by visits from the paramedical and medical team. A one-lead ECG recording was transmitted to a receiving station, where a nurse was available for reporting and interactive teleconsultation. The patient could call the centre when assistance was required (tele-assistance), while the team could call the patient for scheduled appointments (telemonitoring). The one-year clinical outcomes showed that there was a significant reduction in rehospitalizations in the HBT group compared with the usual-care group (24% versus 34%, respectively). There was an increase in quality of life in the HBT group (mean Minnesota Living Questionnaire scores 29 and 23.5, respectively). The total costs were lower in the HBT group (107,494 and 140,874, respectively). The results suggest that a telecardiology service can detect and prevent clinical instability, reduce rehospitalization and lower the cost of managing CHF patients.

[Telecardiology: a new way to manage the relation between hospital and primary care]. / Telecardiologia: una nuova modalità per gestire il territorio.

In medicine, computer-applied technology enables the performance of many diagnostic investigations with their transfer to a receiving station for referral. The use of telemedicine appears particularly promising in cardiovascular disease, because the cost/effectiveness ratio of an early, tailored intervention, in terms of life-saving and functional recovery, is demonstrated. The development of telemedicine represents an advantage for the individual patient in terms of the interaction between primary and secondary care. In addition, general practitioners can gain educationally and so be equipped to handle more advanced medical problems, thus reducing the number of hospital follow-up appointments. Economic savings for the health service are a driving force. Evidence to date is that the patient seems satisfied and the general practitioner gains competence, but the extent to which telemedicine results in reduced follow-up appointments and economic savings is not yet established. The findings of studies, even if preliminary, have important implications for the design and implementation of the telemedicine service center within the health care system. Selection of patients, significant service reorganization and provision of logistic support for the setting up and functioning of the telemedicine center will be required for it to operate efficiently. Future research in this subject needs to be more scientifically organized, in order to achieve informed decisions about the appropriate use of this technology.

[Potential cost reductions for the National Health Service through a telecardiology service dedicated to general practice physicians]. / Riduzione potenziale dei costi per il Servizio Sanitario Nazionale mediante un servizio di telecardiologia dedicato ai medici di medicina generale.

BACKGROUND: Rising health care costs resulted in increasing pressure on the health care system and stimulated new strategies for improving the efficiency of care. A telecardiology service provides a useful support to general practitioners in the management of cardiac patients and contributes to the optimization of health care costs in terms of appropriateness of hospital admission and diagnostic testing. The aim of our study was to evaluate the reduction in the number of referrals to the Emergency Department and to cardiological evaluation resulting from the employment of a telecardiology service by general practitioners. METHODS: Eight hundred and ninety-one consecutive calls arrived to the receiving station of the telecardiology service were analyzed. One hundred and fifty general practitioners received a portable electrocardiographer (Card-Guard 7100, Rehovot, Israel) transferring, by a mobile or fixed telephone, a 12-lead ECG to a receiving station, where a cardiologist was available for reporting and for interactive teleconsultation. At the onset of the phone call, a question was asked to the general practitioner: "What would you have done without the telecardiology service?". The possible answers were: "No actions"; "Referral to the Emergency Department"; "Cardiological consultancy"; "Further investigations". Then we collected the history, risk factors, symptoms and therapy of the patients; the general practitioner sent the ECG tracing by phone. RESULTS: Eight hundred and ninety-one patients were enrolled (402 males, 489 females, mean age 59 +/- 19 years); 465 (52%) patients were symptomatic; 36.4% had no evidence of previous cardiac disease, 35.1% had systemic hypertension, 10.6% had ischemic cardiac disease, 3.7% had atrial fibrillation, and 11.9% other diseases. ECG was normal in 55%. The general practitioners would have sent to the Emergency Department 106 patients (11.9%), and requested further investigations in 717 patients (80.5%). The cardiologist of the telecardiology service solved the problems of the general practitioners in 657 cases (73.7%), sent 56 patients (6.3%) to the Emergency Department, and asked for further investigations in 178 patients (20%), with a reduction of 47% of Emergency Department admission (p < 0.001) and of 95% of further investigations (p < 0.0001) respectively. The cost analysis showed a reduction, between the two modalities, varying from Itl 22,760,000 and Itl 140,060,000 for 891 calls. CONCLUSIONS: Telemedicine is a useful tool for the support of general practitioners' daily activity, with a possible cost reduction due to increased appropriateness of hospital admission and of diagnostic testing.

[Appropriateness of referral to the emergency department through a telecardiology service. "Boario Home-Care" researchers]. / Appropriatezza dell'invio in Pronto Soccorso mediante un servizio di telecardiologia sul territorio. Ricercatori "Boario Home-Care".

BACKGROUND: The use of telemedicine appears particularly promising in cardiovascular diseases; it may reduce the decisional time during an acute myocardial infarction, which is the greater part of the so-called "avoidable delay" and the inappropriate admission to the Emergency Department with the possibility of ruling out an acute pathology. The aim of our study was to show the diagnostic accuracy of a telecardiology service in the daily activity of general practitioners. METHODS: From February 1998 to February 1999, 150 general practitioners received a portable electrocardiographer (Card-Guard 7100) transferring, by a mobile or fixed telephone, a 12-lead ECG to a receiving station, where a cardiologist was available for the reporting and interactive teleconsultation. RESULTS: During 1 year 3456 calls took place. At the time of the ECG recording 44% of patients were symptomatic. Chest pain was present in 669 patients (44%), dyspnea in 21%, palpitation in 18%, dizziness in 7%, and asthenia in 13%. ECG and teleconsultation solved all the problems for 2452 patients (71%) and further diagnostic tests were requested in 862 patients (25%); 142 patients (4%) were sent to the Emergency Department. Cardiological diagnosis was confirmed in 95 patients (73%), while anxiety or gastritis were presumed in 35 patients (27%). In the group of patients (n = 3314) for whom the cardiologist solved the problem without admission to the Emergency Department, there were 5 patients who were admitted to the Emergency Department for myocardial ischemia in the following 48 hours after the teleconsultation. Telecardiology service showed versus Emergency Department admission a sensitivity of 95%, a specificity of 97.5%, and a diagnostic accuracy of 92.5%. CONCLUSIONS: These data confirm a good diagnostic value to the service and a useful support to the general practitioners' activity.

Telecardiology community: a new approach to take care of cardiac patients. "Boario Home-Care" Investigators.

BACKGROUND: Cardiovascular diseases are the leading cause of morbidity and mortality in Western countries and represent, in terms of diagnostic and treatment measures, a large amount of health care expenses. A telecardiology service may offer to general practitioners, in real time, a useful diagnostic tool and the possibility of an accurate screening of patients with suspected ischemic heart disease. METHODS: From February to July 1998, in the provinces of Bergamo and Brescia (Italy), 178 general practitioners received a portable Card Guard 7100 electrocardiographer transferring, by a mobile or fixed telephone, a 12 lead ECG to a receiving station, where a cardiologist was available for the reporting and interactive teleconsultation. RESULTS: During the first 6 months a total 2800 calls took place. Due to incompleteness of requested data only 2254 traces, corresponding to 2254 subjects (mean age 63 +/- 18 years) were entered in the study. In 27% of patients (n = 609) there was a history of systemic hypertension, in 12.5% (n = 283) there was a history of coronary artery disease, and in 38% (n = 834) there was no history of cardiovascular diseases. At the time of ECG recording, 42% of patients (n = 949) were symptomatic: more common symptoms were chest pain (39%), dyspnea (23%), palpitation (19%), dizziness or faint (10%), and asthenia (9%). No action was suggested by cardiologists in 74% of cases. Of the remaining patients, 16% (n = 92) were referred to the Emergency Department, 27% (n = 158) were offered further diagnostic tests as an out patient, and 56% (n = 328) were started on medication or had their treatment changed. CONCLUSIONS: A telecardiology system provides a useful support to general practitioners in the management, in real time, of patients with cardiovascular conditions, and possibly contributes to optimization of health care costs in terms of appropriateness of hospital admissions and diagnostic tests.

Intra- and paraprosthetic valve regurgitation. A color Doppler echocardiographic study.

We prospectively followed a cohort of 64 patients bearing an aortic or mitral prosthetic valve (mean follow-up 5.2 +/- 3.2 months) in order to evaluate if color-coded two-dimensional Doppler echocardiography (CFD) could provide some major advantages with respect to pulsed (PW) and continuous wave (CW) Doppler in the diagnostic accuracy of detection of intra-, and paraprosthetic leaks. During follow-up 4 cases of pathologic prosthetic regurgitation ensued and were all correctly and easily identified by CFD while one of them was missed both by PW and CW Doppler. Based on our results we conclude that CFD is the best noninvasive tool actually available for the correct identification of prosthetic valvular regurgitation because it can provide useful accessory information difficult to obtain with other echocardiographic techniques.