8 Jan, 11 | by Alistair Lindsay
Despite a decade of incremental advances in the treatment of heart failure, readmission rates remain persistently high at 50% at 6 months. Telemonitoring has been championed as a potential strategy to improve outcomes so that clinicians can intervene early if there is evidence of clinical deterioration. Small studies have suggested that this strategy works, and a recent Cochrane review concluded that telemonitoring was able to reduce death from any cause by 44% and the rate of heart-failure related re-admission by 21%. Despite this promise and its early adoption by some US based healthcare organisations, telemonitoring has not been definitively tested in the setting of a large scale prospective randomised controlled study.
In the Tele-HF study the authors randomised 1653 patients who had recently been hospitalized for heart failure to undergo either telemonitoring (826 patients) or usual care (827 patients). Telemonitoring was accomplished by means of a commercially provided telephone-based interactive voice-response system that collected daily information about symptoms and weight. Variances in responses were automatically flagged and the clinician’s reaction to these logged. Centres were provided with thorough training on the use of the system and ways were sought in which to integrate it into their usual out-patient care structures. The primary end point was readmission for any reason or death from any cause within 180 days after enrolment. Secondary end points included hospitalization for heart failure, number of days in the hospital, and number of hospitalizations. At 6 months, the telemonitoring group and the usual-care group did not differ significantly with respect to the primary end point, which occurred in 52.3% and 51.5% of patients, respectively (95% CI, -4.0 to 5.6; P=0.75). Readmission for any reason occurred in 49.3% of patients in the telemonitoring group and 47.4% of patients in the usual-care group (95% CI, -3.0 to 6.7; P=0.45). Death occurred in 11.1% of the telemonitoring group and 11.4% of the usual care group (95% CI, -3.3 to 2.8; P=0.88). There were no significant differences between the two groups with respect to the secondary end points or the time to the primary end point or its components.
Among patients recently hospitalised for heart failure, telemonitoring did not improve outcomes even as part of an integrated programme of community-based heart failure management. It is unclear whether this is intrinsic to telemonitoring or a wider inability of physicians to identify and forestall acute deteriorations in heart failure. The results underscore the importance of a thorough, independent evaluation of disease-management strategies before their adoption.
- Chaudhry SI, Mattera JA, Curtis JP et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010 Dec 9;363(24):2301-9.