Telemonitoring no more effective than usual care after hospitalization in heart failure patients
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Telemonitoring after hospitalization for heart failure did not improve outcomes compared with usual care, according to a new study.
Researchers performed a six-month multicenter trial in which 1,653 patients recently hospitalized for heart failure were randomly assigned to receive usual care or telemonitoring. All patients were given educational information on heart failure, along with a scale to weigh themselves if needed. Patients in the telemonitoring group also received instructions on how to report their symptoms and weight daily over the phone using an interactive voice-response system; these data were reviewed by the patients' clinicians, who then took action as necessary. The study's primary end point was any hospital readmission or death from any cause up to 180 days after enrollment. Heart failure hospitalizations, hospital days, and number of hospitalizations were secondary end points. The study results were published online Nov. 16 by the New England Journal of Medicine.
Overall, 826 patients were assigned to the telemonitoring group and 827 were assigned to the usual care group. Forty-two percent of the patients were women, 39% were black and the mean age was 61 years. The primary end point did not differ significantly between the groups (52.3% vs. 51.5%; difference, 0.8 percentage point [95% CI, −4.0 to 5.6 percentage points]; P=0.75). In the telemonitoring group, 49.3% of patients were readmitted to the hospital for any reason and 11.1% died, versus 47.4% and 11.4% in the usual care group (differences, 1.9 percentage points [95% CI, −3.0 to 6.7 percentage points]; P=0.45 and −0.2 percentage point [95% CI, −3.3 to 2.8 percentage points]; P=0.88). The study groups also did not differ significantly in rates of the secondary end points. Approximately 14% of patients assigned to the telemonitoring system never used it, and only approximately 55% continued to use the system at least three times a week by the end of the study. No adverse events were reported in either group.
The authors noted that the automated telemonitoring used in their study might have been more effective if it had involved more direct contact between clinicians and patients. However, they also pointed out that even though patients were actively encouraged to participate in telemonitoring and were given considerable support, a significant number did not adhere to instructions or did not use the system at all.
The authors concluded that telemonitoring had no effect on outcomes compared with usual care in patients who had recently been hospitalized for heart failure. Previous studies showing a benefit, they wrote, were probably too small and had methodologic weaknesses that affected their results.
“There remains a need for strategies to improve heart-failure outcomes, and our findings indicate the importance of a thorough, independent evaluation of disease-management strategies before their widespread implementation,” the authors concluded.
An accompanying editorial pointed out other potential reasons why the intervention might not have improved outcomes, including that the symptoms measured may not have accurately predicted clinical deterioration. Although the telemonitoring system was set up to alert clinicians to “variances” indicating a potential clinical problem, they noted, the timeliness and appropriateness of the clinicians' responses were not detailed. The trial's “neutral findings,” the editorialists wrote, “highlight a need for caution before inserting additional loops into disease management.”