NIHR Signal Telehealth can help people with heart failure avoid hospital admission

Published on 18 January 2016

Home telephone or telemonitoring support can bring some aspects of specialised care and monitoring into the homes of people with heart failure. This updated Cochrane review confirmed that people with heart failure who received home telehealth support were less likely to die or go into hospital for problems relating to their heart failure than those getting usual care.

Usual care involved visiting a GP surgery or hospital for care and monitoring, which may be difficult for frail people with limited mobility. The review included seventeen new trials since the last review was published five years ago. More evidence is needed on which people would gain most benefit, particularly considering that people with heart failure can have different underlying health problems, multiple conditions and care needs.

Data on cost of the interventions compared to usual care was mixed (some found it more expensive and some less expensive overall). Information on the cost effectiveness of telehealth support for people living with heart failure in the UK context was not covered by this review.

Telehealth can help people with heart failure avoid hospital admission

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Why was this study needed?

Heart failure is a condition with various underlying causes where the heart muscle is usually weak or stretched and not able to pump blood to meet the body’s needs. It causes symptoms such as breathlessness, tiredness and ankle swelling.

Heart failure affects over half a million people in the UK - mainly older adults - with an average of 30 heart failure patients per GP. In hospital, heart failure accounts for 5% of all emergency medical admissions and 2% of all NHS inpatient bed-days.

As well as the cost implications of this care, attending clinic appointments can be difficult for a predominantly elderly, frail population. Telephone or telehealth support, where a person’s health (e.g. weight and heart rate) is monitored at home via phone calls or other technology, has shown promising results in earlier research.

This review is an update of a 2010 Cochrane review, as 17 new trials had been published in the interim. The 2010 Cochrane review had found that structured telephone support or non-invasive home telemonitoring (see Definitions) reduced the risk of death from any cause and heart failure-related hospital admissions. However, some recent trials had not found reduced risk for these outcomes. An update to the review was carried out to clarify the effectiveness of the interventions.

What did this study do?

This Cochrane systematic review included 41 trials that compared structured telephone support or non-invasive home telemonitoring to usual care at clinic appointments, for people living at home with chronic heart failure. Care could not include home visits or clinic follow-up that was more intensive than usual.

The main outcomes were death from all causes, and rates of admission to hospital, for all causes or for heart failure-related reasons. The review also assessed costs, patient satisfaction with the interventions, and their knowledge of heart failure, ability to care for themselves and quality of life changes.

The study was carried out to a high standard and its methods were reliable. However, the quality of the included evidence was assessed as very low for all-cause hospital admissions, to moderate for all-cause mortality and heart failure-related hospital admissions. This was largely because of a risk that studies reporting positive findings were more likely to be published and suggests the overall finding and balance might be influenced by the exclusion of negative findings. All but two took place in non-UK countries with similar healthcare systems, such as the US or Europe.

What did it find?

  • Non-invasive telemonitoring reduced deaths from all causes by 20% (relative risk [RR] 0.80, 95% confidence interval [CI] 0.68 to 0.94; pooled data from 17 studies including 3,740 participants) this was equivalent to about 31 deaths avoided per 1000 patients.
  • Non-invasive telemonitoring reduced heart failure-related admissions to hospital by 29% (RR 0.71, 95% CI 0.60 to 0.83; pooled data from eight studies including 2,148 participants).
  • Structured telephone support also reduced deaths from all causes by 13% (RR 0.87, 95% CI 0.77 to 0.98; pooled data from 22 studies including 9,222 participants) this was equivalent to about 15 admissions avoided per 1000 patients. Heart failure-related admissions to hospital were reduced by 15% (RR 0.85, 95% CI 0.77 to 0.93; pooled data from 16 studies including 7,030 participants).
  • Neither structured telephone support nor telemonitoring had any effect on the risk of all-cause admissions to hospital.
  • Participant adherence with telephone support or telemonitoring was between 55% and 99% in studies that reported this outcome. Participant acceptance of the interventions was 76% to 97%, and seven out of nine studies reported improved heart failure knowledge and participants’ ability to care for themselves.
  • Three of nine studies telephone support studies reported that it decreased costs. In six telemonitoring studies one reported that it reduced costs, two increased costs.

What does current guidance say on this issue?

NICE guidance (2010) advises on the monitoring required for people with chronic heart failure (e.g. reviewing their clinical status and treatment) and its frequency. NICE also recommend that patients who wish to be involved in monitoring their condition should be provided with sufficient education and support from their healthcare professional to do this, with clear guidance on what to do in the event of deterioration. However, there is currently no specific guidance on the use of telehealth interventions or how this compares with face to face monitoring.

What are the implications?

Telephone support or other forms of telehealth monitoring could be an acceptable option for people living at home with chronic heart failure, who tend to be elderly and frail and who may find frequent clinic visits difficult. The reviews’ findings add further evidence that these interventions can reduce mortality and heart failure-related hospital admissions in these people. This may inform the 2010 NICE guidance on heart failure, which is being scheduled for an update.

The trials included in the current review covered various interventions. All but two took place in non-UK countries such as the US or Europe. More research is needed to understand which specific interventions work best in UK contexts, and which people would gain most benefit – particularly considering that older people with chronic heart failure can also have other underlying illnesses and care needs. Information on the cost effectiveness in the NHS is also needed. Commissioners will be considering relative costs of different approaches. Unfortunately cost-effectiveness information is not provided in this review.

Citation

Inglis SC, Clark RA, Dierckx R, et al. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev. 2015;(10):CD007228.

Bibliography

British Heart Foundation. Cardiovascular disease statistics 2015. Oxford: British Heart Foundation Centre on Population Approaches for Non‑Communicable Disease Prevention. Nuffield Department of Population Health, University of Oxford; 2015.

NHS Choices. Heart failure. London: NHS Choices; 2014.

NHS Choices. Telecare and telehealth technology. London: NHS Choices; 2014.

NICE. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. CG108. London: National Institute for Health and Care Excellence; 2010.

Centre for Reviews and Dissemination. Telehealth for patients with long term conditions. York: University of York; 2013.

Why was this study needed?

Heart failure is a condition with various underlying causes where the heart muscle is usually weak or stretched and not able to pump blood to meet the body’s needs. It causes symptoms such as breathlessness, tiredness and ankle swelling.

Heart failure affects over half a million people in the UK - mainly older adults - with an average of 30 heart failure patients per GP. In hospital, heart failure accounts for 5% of all emergency medical admissions and 2% of all NHS inpatient bed-days.

As well as the cost implications of this care, attending clinic appointments can be difficult for a predominantly elderly, frail population. Telephone or telehealth support, where a person’s health (e.g. weight and heart rate) is monitored at home via phone calls or other technology, has shown promising results in earlier research.

This review is an update of a 2010 Cochrane review, as 17 new trials had been published in the interim. The 2010 Cochrane review had found that structured telephone support or non-invasive home telemonitoring (see Definitions) reduced the risk of death from any cause and heart failure-related hospital admissions. However, some recent trials had not found reduced risk for these outcomes. An update to the review was carried out to clarify the effectiveness of the interventions.

What did this study do?

This Cochrane systematic review included 41 trials that compared structured telephone support or non-invasive home telemonitoring to usual care at clinic appointments, for people living at home with chronic heart failure. Care could not include home visits or clinic follow-up that was more intensive than usual.

The main outcomes were death from all causes, and rates of admission to hospital, for all causes or for heart failure-related reasons. The review also assessed costs, patient satisfaction with the interventions, and their knowledge of heart failure, ability to care for themselves and quality of life changes.

The study was carried out to a high standard and its methods were reliable. However, the quality of the included evidence was assessed as very low for all-cause hospital admissions, to moderate for all-cause mortality and heart failure-related hospital admissions. This was largely because of a risk that studies reporting positive findings were more likely to be published and suggests the overall finding and balance might be influenced by the exclusion of negative findings. All but two took place in non-UK countries with similar healthcare systems, such as the US or Europe.

What did it find?

  • Non-invasive telemonitoring reduced deaths from all causes by 20% (relative risk [RR] 0.80, 95% confidence interval [CI] 0.68 to 0.94; pooled data from 17 studies including 3,740 participants) this was equivalent to about 31 deaths avoided per 1000 patients.
  • Non-invasive telemonitoring reduced heart failure-related admissions to hospital by 29% (RR 0.71, 95% CI 0.60 to 0.83; pooled data from eight studies including 2,148 participants).
  • Structured telephone support also reduced deaths from all causes by 13% (RR 0.87, 95% CI 0.77 to 0.98; pooled data from 22 studies including 9,222 participants) this was equivalent to about 15 admissions avoided per 1000 patients. Heart failure-related admissions to hospital were reduced by 15% (RR 0.85, 95% CI 0.77 to 0.93; pooled data from 16 studies including 7,030 participants).
  • Neither structured telephone support nor telemonitoring had any effect on the risk of all-cause admissions to hospital.
  • Participant adherence with telephone support or telemonitoring was between 55% and 99% in studies that reported this outcome. Participant acceptance of the interventions was 76% to 97%, and seven out of nine studies reported improved heart failure knowledge and participants’ ability to care for themselves.
  • Three of nine studies telephone support studies reported that it decreased costs. In six telemonitoring studies one reported that it reduced costs, two increased costs.

What does current guidance say on this issue?

NICE guidance (2010) advises on the monitoring required for people with chronic heart failure (e.g. reviewing their clinical status and treatment) and its frequency. NICE also recommend that patients who wish to be involved in monitoring their condition should be provided with sufficient education and support from their healthcare professional to do this, with clear guidance on what to do in the event of deterioration. However, there is currently no specific guidance on the use of telehealth interventions or how this compares with face to face monitoring.

What are the implications?

Telephone support or other forms of telehealth monitoring could be an acceptable option for people living at home with chronic heart failure, who tend to be elderly and frail and who may find frequent clinic visits difficult. The reviews’ findings add further evidence that these interventions can reduce mortality and heart failure-related hospital admissions in these people. This may inform the 2010 NICE guidance on heart failure, which is being scheduled for an update.

The trials included in the current review covered various interventions. All but two took place in non-UK countries such as the US or Europe. More research is needed to understand which specific interventions work best in UK contexts, and which people would gain most benefit – particularly considering that older people with chronic heart failure can also have other underlying illnesses and care needs. Information on the cost effectiveness in the NHS is also needed. Commissioners will be considering relative costs of different approaches. Unfortunately cost-effectiveness information is not provided in this review.

Citation

Inglis SC, Clark RA, Dierckx R, et al. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev. 2015;(10):CD007228.

Bibliography

British Heart Foundation. Cardiovascular disease statistics 2015. Oxford: British Heart Foundation Centre on Population Approaches for Non‑Communicable Disease Prevention. Nuffield Department of Population Health, University of Oxford; 2015.

NHS Choices. Heart failure. London: NHS Choices; 2014.

NHS Choices. Telecare and telehealth technology. London: NHS Choices; 2014.

NICE. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. CG108. London: National Institute for Health and Care Excellence; 2010.

Centre for Reviews and Dissemination. Telehealth for patients with long term conditions. York: University of York; 2013.

Structured telephone support or non-invasive telemonitoring for patients with heart failure

Published on 1 November 2015

Inglis, S. C.,Clark, R. A.,Dierckx, R.,Prieto-Merino, D.,Cleland, J. G.

Cochrane Database Syst Rev Volume 10 , 2015

BACKGROUND: Specialised disease management programmes for heart failure aim to improve care, clinical outcomes and/or reduce healthcare utilisation. Since the last version of this review in 2010, several new trials of structured telephone support and non-invasive home telemonitoring have been published which have raised questions about their effectiveness. OBJECTIVES: To review randomised controlled trials (RCTs) of structured telephone support or non-invasive home telemonitoring compared to standard practice for people with heart failure, in order to quantify the effects of these interventions over and above usual care. SEARCH METHODS: We updated the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology AsseFssment Database (HTA) on the Cochrane Library; MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Science Citation Index Expanded (SCI-EXPANDED), Conference Proceedings Citation Index- Science (CPCI-S) on Web of Science (Thomson Reuters), AMED, Proquest Theses and Dissertations, IEEE Xplore and TROVE in January 2015. We handsearched bibliographies of relevant studies and systematic reviews and abstract conference proceedings. We applied no language limits. SELECTION CRITERIA: We included only peer-reviewed, published RCTs comparing structured telephone support or non-invasive home telemonitoring to usual care of people with chronic heart failure. The intervention or usual care could not include protocol-driven home visits or more intensive than usual (typically four to six weeks) clinic follow-up. DATA COLLECTION AND ANALYSIS: We present data as risk ratios (RRs) with 95% confidence intervals (CIs). Primary outcomes included all-cause mortality, all-cause and heart failure-related hospitalisations, which we analysed using a fixed-effect model. Other outcomes included length of stay, health-related quality of life, heart failure knowledge and self care, acceptability and cost; we described and tabulated these. We performed meta-regression to assess homogeneity (the null hypothesis) in each subgroup analysis and to see if the effect of the intervention varied according to some quantitative variable (such as year of publication or median age). MAIN RESULTS: We include 41 studies of either structured telephone support or non-invasive home telemonitoring for people with heart failure, of which 17 were new and 24 had been included in the previous Cochrane review. In the current review, 25 studies evaluated structured telephone support (eight new studies, plus one study previously included but classified as telemonitoring; total of 9332 participants), 18 evaluated telemonitoring (nine new studies; total of 3860 participants). Two of the included studies trialled both structured telephone support and telemonitoring compared to usual care, therefore 43 comparisons are evident.Non-invasive telemonitoring reduced all-cause mortality (RR 0.80, 95% CI 0.68 to 0.94; participants = 3740; studies = 17; I(2) = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I(2) = 20%, GRADE: moderate-quality evidence). Structured telephone support reduced all-cause mortality (RR 0.87, 95% CI 0.77 to 0.98; participants = 9222; studies = 22; I(2) = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I(2) = 27%, GRADE: moderate-quality evidence).Neither structured telephone support nor telemonitoring demonstrated effectiveness in reducing the risk of all-cause hospitalisations (structured telephone support: RR 0.95, 95% CI 0.90 to 1.00; participants = 7216; studies = 16; I(2) = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I(2) = 71%, GRADE: very low-quality evidence).Seven structured telephone support studies reported length of stay, with one reporting a significant reduction in length of stay in hospital. Nine telemonitoring studies reported length of stay outcome, with one study reporting a significant reduction in the length of stay with the intervention. One telemonitoring study reported a large difference in the total number of hospitalisations for more than three days, but this was not an analysis of length of stay per hospitalisation. Nine of 11 structured telephone support studies and five of 11 telemonitoring studies reported significant improvements in health-related quality of life. Nine structured telephone support studies and six telemonitoring studies reported costs of the intervention or cost effectiveness. Three structured telephone support studies and one telemonitoring study reported a decrease in costs and two telemonitoring studies reported increases in cost, due both to the cost of the intervention and to increased medical management. Adherence was rated between 55.1% and 98.5% for those structured telephone support and telemonitoring studies which reported this outcome. Participant acceptance of the intervention was reported in the range of 76% to 97% for studies which evaluated this outcome. Seven of nine studies that measured these outcomes reported significant improvements in heart failure knowledge and self-care behaviours. AUTHORS' CONCLUSIONS: For people with heart failure, structured telephone support and non-invasive home telemonitoring reduce the risk of all-cause mortality and heart failure-related hospitalisations; these interventions also demonstrated improvements in health-related quality of life and heart failure knowledge and self-care behaviours. Studies also demonstrated participant satisfaction with the majority of the interventions which assessed this outcome.

In this review ’structured telephone support’ was defined as monitoring or self-care management delivered using simple telephone technology (data may have been collected and stored by a computer), sometimes also known as remote health coaching. It was categorised as ’telemonitoring’ if there was digital/broadband/satellite/wireless or blue-tooth transmission of physiological and other non-invasive data to the carer/hospital.

Telehealth is a broad term used to describe communication and information technologies that provide healthcare at a distance. It can be used to enable people to either self-monitor their own health at home or self-manage their condition, where they take more responsibility for deciding any changes to treatment. This can include measuring vital signs – such as blood pressure or blood oxygen levels – and uploading results to a system for health professionals to monitor and change treatment accordingly. Telehealth packages can also include support like remote consultations or peer group support via videoconference. Telehealth can help people to feel in control of their condition, rather than controlled by it, and to have greater engagement with their treatment.

Expert commentary

Whether telehealth can improve outcomes for people with long term conditions is unclear. However, interventions in heart failure patients often seem to show more benefits than similar initiatives in other patient groups. This Cochrane review is an example of this, showing that supporting people with heart failure at home using telehealth can reduce the rates of death and heart failure-related hospitalisation but not overall hospitalisation. This is encouraging but we need to better understand how to provide effective support for patients with multi-morbidities to realise the benefits of this sort of intervention in an ageing population. 

Professor Sarah Purdy, Associate Dean, Professor of Primary Care, Faculty of Health Sciences, University of Bristol