September 26, 2011

September 23, 2011 (Boston, Massachusetts) — Remote monitoring remains an appealing option for following patients after a heart-failure (HF) hospitalization, although the strategy--which takes different forms--has turned in mixed results when tested in clinical trials. In a meta-analysis of 25 such trials, two common telemonitoring strategies--simple phone calls with a nurse, and automatic monitoring and data transmission by specialized devices--achieved highly significant improvements in survival and risk of readmission for HF [1].

But it may be that both have strengths and weaknesses in different types of patients or care-delivery settings, and both can be used by the same clinic, according to Robyn A Clark (Queensland University of Technology, Brisbane, Australia), who presented the analysis here this week at the Heart Failure Society of America 2011 Scientific Meeting .

Her group doesn't have data on it, but "It could be that simple telephone calls and 'complex telemonitoring' [by specialized equipment] are implemented by the same HF clinic at different times in the patient's trajectory of disease," she speculated for heartwire .

"A phone call could be best at the early stages, when they're getting their heads around what's happening to them, and how they need to self-manage," she said. Complex telemonitoring, which involves the least participation by the patient, "could be more suited to people with regular admissions or who are very fragile."

The analysis included 25 published HF telemonitoring studies involving 8323 patients: 16 trials of structured telephone support and 11 of complex device-oriented telemonitoring (compared with "usual care," and including two studies that involved both forms of telemonitoring). Patients did not receive regular home visits by HF specialist nurses in any of the studies.

Hazard Ratios (HRs) for Clinical End Points; Telemonitoring vs Usual Care

Monitoring technology

All-cause mortality

HR (95% CI), p

All-cause hospitalization

HR (95% CI), p

HF hospitalization

HR (95% CI), p

Telephone call

0.86 (0.75–1.00), 0.04

0.91 (0.84–0.97), 0.008

0.77 (0.68–0.87), <0.0001

Interactive voice recognition

0.70 (0.24–2.11), 0.53

1.18 (0.83–1.66), 0.35

1.03 (0.60–1.78), 0.91

"Complex" telemonitoring

0.63 (0.51–0.77), <0.0001

0.91 (0.84–0.99), 0.02

0.79 (0.67–0.94), 0.008

Standing out in the analysis was a third variation on telemonitoring--interactive voice recognition--whereby patients called in to access an automated question-response menu tree. Patients responded to questions about their status and replied by pressing phone buttons (eg, "Please enter your weight in pounds then press the hash key," or "Have you taken your medications today? Press 1 for yes and 2 for no").

Not only was that unpopular, Clark said, it seemed to have no effect on outcomes.

The phone call was most often preferred. Explanations may include that the current age group with HF is more comfortable with the human contact and/or is technophobic and less enthusiastic about complex monitoring. If it is the latter, "that won't last much longer. The elders that are with us now are the end of a generation. The baby boomers won't be that way at all," she predicted. "They're already online and using cell phones."

Phone calls have special advantages anyway, she noted. "Speaking to a HF patient on the telephone is a highly sensitive way of measuring their current breathlessness. You can't talk on the phone well if you're breathless, so we can tell how they're doing from day to day."

Clark had no disclosures.

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