Home Heart Failure Symptoms Home Telemonitoring Cut HF Mortality at 6 Months - MedPage Today

Home Telemonitoring Cut HF Mortality at 6 Months - MedPage Today

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Home telemonitoring following hospitalization for heart failure was associated with significant reductions in mortality within the first 6 months, but mortality reductions were not seen after a year of monitoring, according to a meta-analysis.

In 26 randomized controlled trials that evaluated the effectiveness of home telemonitoring (HTM) in the setting of heart failure, the latter was associated with a 40% decrease in the odds of all cause mortality (odds ratio 0.60) at 180 days, reported Renee Pekmezaris, PhD, of Northwell Health in Manhasset, New York, and colleagues.

At 365 days, the mortality decrease was not significant (HTM intervention OR 0.85, P=0.461), they wrote in Health Affairs.

Home telemonitoring was also associated with an increase in all-cause emergency department (ED) visits, possibly because telemonitoring made patients more aware of heart failure symptoms that warranted medical attention.

The finding of a waning effect on mortality over time suggested that competing factors, such as illness progression and adherence decline, may reduce the effectiveness of home telemonitoring over time, the authors noted.

"We found that while home telemonitoring or telemedicine decreases mortality 6 months after hospitalization for heart failure, this benefit does not continue a year after hospitalization," Pekmezaris said in a statement, adding that there may be several reasons for this.

"Patients may become less adherent to monitoring their vital sings, like weight and blood pressure, over time," she said. "Whether they are too sick to adhere, or they just don't make it as much of a priority as they did right after their hospitalization, we don't know. But, these findings are important because, as scientists and providers, we need to understand when to rely on telemedicine and how to create a program that most benefits patients."

The researchers noted that since the passage of the Affordable Care Act, which required the Centers for Medicare & Medicaid Services to reduce payments to hospitals with high heart failure readmission ratios, "health systems have struggled to find ways to decrease readmissions."

Telehealth technology, including home telemonitoring, has been considered a promising approach to do this, but the widespread implementation of home telemonitoring in heart failure populations has been slowed by reimbursement issues, along with regulations and policy issues.

In 2018, the Bipartisan Budget Act relaxed Medicare restrictions on home telemonitoring services as a supplemental benefit, and agreed to allow accountable care groups to include the home in telehealth services in limited circumstances.

"Given these recent changes in federal legislation, HTM is clearly poised for widespread implementation," the researchers wrote. "To date, over 1,200 studies, including both primary HTM studies and meta-analyses, have explored the potential impacts of HTM for heart failure patients on hospital use, costs, and quality of life. The results have been astonishingly varied: some studies found benefits (reductions in all-cause mortality and heart- failure-related quality of life), while others did not."

Pekmezaris and colleagues sought to better understand the impact of the duration of home telemonitoring on mortality and hospitalization in the setting of heart failure. The analysis included only home telemonitoring randomized controlled trials that used vital signs monitoring and transmission from home to healthcare center as part of the heart failure intervention. Control groups were patients receiving usual care that might or might not include home care.

To ensure that the results would be relevant to current practice, the search was limited to trials conducted after the year 2000. Of the 26 studies, 12 reported all-cause mortality at 180 days and six at 365 days.

Seven studies reported all-cause hospitalization at 180 days and three at 90 days. Home telemonitoring did not have a significant impact on the odds of all-cause hospitalization at 180 days (OR 0.97, P=0.002) or at 90 days (OR, 0.81 P=0.472).

Three studies reported all-cause ED visits at 180 days, and they found a significant effect in favor of the control group (OR 1.51).

Pekmezaris characterized the increase in ED visits among the home telemonitoring patients as a positive study finding.

"This is actually a good thing, because if a patient is determined to be experiencing a serious episode -- the emergency room is the right place to be," she said.

The researchers noted that the findings have potential implications for policymakers to determine how to best utilize home telemonitoring services in heart failure.

"Early on, home telemonitoring was heralded as a potential intervention to decrease hospital use and costs while improving patient outcomes. Perhaps the time has come for researchers, clinicians, and policymakers to adjust these expectations," they wrote. "While HTM clearly has the potential to decrease both all-cause and heart failure related mortality, it may be unrealistic to expect a technology developed to address symptoms of heart failure to reduce all-cause hospitalization."

They added that while home telemonitoring can facilitate access to care, "there is no evidence that it is effective in improving care access for disparity populations living with heart failure."

"As HTM transitions to common use, a value framework should be considered," they wrote. "Specifically, the balance between the cost of HTM implementation and improvements in length and quality of life, decreases in travel time for patients and providers, and increases in provider efficiency, must be constantly assessed."

The study was funded by Northwell Health. Co-authors are company employees.

2018-12-04T16:30:00-0500

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