Telemonitoring in patients with heart failure: Is there a long-term effect?

INTRODUCTION: Evidence suggests that telemonitoring decreases mortality and heart failure (HF)-related hospital admission in patients with HF. However, most studies follow their patients for only several months. Little is known about the long-term effects of telemonitoring after a period of application. METHODS: In 2007, the TEHAF study was initiated to compare tailored telemonitoring with usual care with respect to time until first HF-related hospital admission. In total, 301 patients completed the study after a follow-up period of one year. No differences could be found in time to first HF-related admission between intervention and control groups. Here, we performed a retrospective analysis in order to investigate potential long-term effects of telemonitoring. The primary endpoint was time to first HF-related hospital admission. Secondary endpoints were, amongst others, all-cause mortality, hospital admission due to HF and days alive and out of hospital (DAOOH). Electronic files of all included patients were reviewed between October 2007 and September 2015. RESULT: Mean follow-up duration was 1652 days (standard deviation: 1055 days). No significant difference in time to first HF-related hospital admission (log-rank test, p = 0.15), all-cause mortality (log-rank test, p = 0.43), or DAOOH (two-sample t-test, p = 0.87) could be found. However, patients that underwent telemonitoring had significantly fewer HF-related hospital admissions (incident rate ratio 0.54, 95% confidence interval 0.31-0.88). DISCUSSION: Telemonitoring did not significantly influence the long-term outcome in our study. Therefore, extending the follow-up period of telemonitoring studies in HF patients is probably not beneficial.

Effects of tailored telemonitoring on heart failure patients' knowledge, self-care, self-efficacy and adherence: a randomized controlled trial.

BACKGROUND: The education of patients with heart failure (HF) is an essential part of disease management. The perspectives of an increasing number of patients and a shortage of professionals force healthcare to explore new strategies in supporting patients to be better informed and more active. METHODS: Three hundred and eighty-two patients with HF (age 71±SD 11.2 years) were randomly assigned to either a telemonitoring or a usual care group. Patients received four postal questionnaires to assess their levels of self-reported knowledge, self-care, self-efficacy and adherence. Generalized estimating equations analysis was performed to assess the effects of telemonitoring during the 1-year follow-up. Corrections for baseline were performed if needed. RESULTS: Baseline differences between groups were found for self-care (p=0.001) and self-efficacy (p=0.024). Knowledge of patients in the telemonitoring group significantly improved with 0.9 point on a 15-points scale (p<0.001). Their self-care abilities improved with 1.5 point on a 10-item scale whereas no changes were found in patients receiving usual care (p<0.001). Self-efficacy of patients in the intervention group improved significantly after 6 months yet was not significantly different after 3 months and 1 year. For patients in the intervention group adherence improved for daily weighing (p<0.001) during the whole follow-up and for fluid intake (p=0.019) after 3 months and after 12 months (p=0.086). Adherence for activity recommendations improved (p=0.023) after 3 months and importance of medication adherence increased after 6 (p=0.012) and 12 months (p=0.037). No effects were found regarding appointments, diet, smoking and use of alcohol. CONCLUSIONS: Tailored telemonitoring was found to educate patients with HF and to improve their self-care abilities and sense of self-efficacy.

Cost-effectiveness analysis of telemonitoring versus usual care in patients with heart failure: the TEHAF-study.

We examined the incremental cost-effectiveness of telemonitoring (TM) versus usual care (UC) in patients with congestive heart failure (CHF). In one university and two general hospitals, 382 patients were randomised to usual care or telemonitoring and followed for 1 year. Hospital-related and home costs were estimated, based on resource use multiplied by the appropriate unit prices. Effectiveness was expressed as QALYs gained. Information was gathered, using 3 monthly costs diaries and questionnaires. The mean age of the patients was 71 years (range 32-93), 59% were male and 64% lived with a partner. Health related quality of life improved by 0.07 points for the usual care and 0.1 points for the telemonitoring group, but the difference between groups was not significant. There were no significant differences in annual costs per patient between groups. At a threshold of €50,000 the probability of telemonitoring being cost-effective was 48%. The cost effectiveness analysis showed a high level of decision uncertainty, probably caused by the divergence between the participating institutions. It is therefore premature to draw an unambiguous conclusion regarding cost-effectiveness for the whole group.

Tailored telemonitoring in patients with heart failure: results of a multicentre randomized controlled trial.

AIMS: Recent increases in heart failure tend to overload the healthcare system. Consequently, there is a need for innovative strategies to reduce heart failure hospitalizations. METHODS AND RESULTS: A multicentre randomized controlled trial was carried out to test the hypothesis that telemonitoring reduces heart failure hospitalizations during 1 year follow-up. The mean age of the 382 participating patients was 71.5 (32-93) years; the mean left ventricular ejection fraction was 0.38, and in 61% it was ≤0.45%. Mean time to first heart failure-related hospitalization was 161 days for the intervention group and 139 days for the usual-care group; hospitalizations occurred in 18 (9.1%) compared with 25 (13.5%) patients, with a total number of 24 and 43 hospitalizations, respectively [Kaplan-Meier P = 0.151, hazard ratio (HR) 0.65, 95% confidence interval (CI) 0.35-1.17]. Subgroup analysis of the primary endpoint showed benefits for three subgroups: duration of heart failure, having a pacemaker, and co-habiting. The combined endpoint of heart failure admission and all-cause mortality was similar for both groups (Kaplan-Meier P = 0.641, HR 0.89, 95% CI 0.69-1.83). No differences were found regarding secondary endpoints, except for the reduced number of face to face contacts with the heart failure nurse (Mann-Whitney P < 0.001). Mortality was 18 (9.1%) in the intervention group and 12 (6.5%) in the usual-care group (Mann-Whitney P = 0.34, Cox regression analysis P = 0.82). CONCLUSION: No significant differences were found regarding the primary endpoint, possibly caused by a relative underpowering of the population combined with well-treated study groups. However, telemonitoring tends to reduce heart failure (re)admissions and significantly decreases contacts with specialized nurses. Further research with pre-specified groups, as found in the subgroup analysis, is needed. TRIAL REGISTRATION: NCT00502255.

Reduction of atrial fibrillation burden by atrial overdrive pacing: experience with an improved algorithm to reduce early recurrences of atrial fibrillation.

AIMS: Two independent studies have revealed a potential limitation of post-mode switch overdrive pacing (PMOP), which is its delayed start. METHODS AND RESULTS: We conducted a prospective, randomized, single blind, crossover design study (the post-long pause overdrive pacing study) to test the efficacy of an improved version of PMOP (PMOP(enhanced)). A total of 45 patients were enrolled, of whom 41 were analysed. The median number of atrial tachycardia/atrial fibrillation (AT/AF) episodes per day (1.38 vs. 1.19), the median number of early recurrences of atrial fibrillation (ERAF) per day (0.56 vs. 0.51), and the median AT/AF burden (time per day spent in AT/AF) (2.47 vs. 2.51 h) were not significantly different during the control and active study periods. Based on the median number of episodes per week recorded 90 days prior to enrollment, the patients were stratified by the median and then split into two groups, Group A (lower 2-Quartiles) and Group B (upper 2-Quartiles). The median AT/AF burden was significantly lower in Group B during the active study period (3.71 vs. 1.71 h, P = 0.02).The median number of AT/AF episodes per day and the median number of ERAF per day in Group B showed a trend towards reduction when the algorithm was turned on (3.79 vs. 2.44 and 2.77 vs. 1.86, respectively). In contrast, in Group A we did not demonstrate any difference in AT/AF frequency, ERAF frequency, or burden. CONCLUSION: The main finding of this study is that temporary overdrive pacing at 90 bpm for 10 min starting just prior to device-classified AT/AF termination does not show a positive effect on the overall study population. However, when enabled in patients who suffer from a high percentage of ERAF, a significant reduction in the AT/AF burden could be demonstrated. Based on these findings, further prospective studies on a more targeted patient population are needed to confirm our results.