Circ: Does HF home monitoring improve outcomes or not?
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| Source: St. Vincent Health |
Marvin A. Konstam, MD, of the Tufts Medical Center, and Akshay S. Desai, MD, MPH, of the cardiovascular division at Brigham and Women’s Hospital, both in Boston, agreed that the increasing prevalence of HF and its associated costs strain healthcare. Konstam noted that the prevalence of HF is expected to increase by 25 percent over the next two decades at a projected cost of $77.7 billion (in 2008 dollars). Today, almost a quarter of patients who are admitted for HF are readmitted within 30 days, Desai added, making the identification of modifiable factors that contribute to readmissions a target for clinicians and policy makers.
“If current legislative and regulatory efforts are successful at expanding healthcare access while improving affordability, systematic approaches must be developed and implemented to drive cost-effectiveness,” wrote Konstam, taking the pro-monitoring stance in the debate. “The management of patients with HF will be front and center in efforts to achieve this goal.”
The authors noted that to be effective, disease management through home monitoring involves a loop in which the patient’s physiologic data is collected, transmitted, interpreted and—when there are signs of clinical deterioration—the physician determines proper treatment, contacts the patient to implement the treatment and then monitors for a response, all in a timely fashion. Konstam contended that clinical evidence shows such programs have improved clinical outcomes with some analyses concluding they were cost-effective as well.
In support, he cited several studies, including:
- A landmark 1995 randomized controlled clinical trial on HF patients at high-risk of readmission that found a nurse-directed intervention using home visits and telephone contacts led to a reduction in all-cause and HF-related readmissions and improved quality-of-life scores at an estimated lower cost when compared with a control group (N Engl J Med 1995;333:1190-1195).
- A meta-analysis based on 14 clinical trials of either telemonitoring, telephone support or both, that showed a 21 percent reduction in HF-related readmissions and a 20 percent reduction in mortality. A subsequent analysis gave the edge to telemonitoring over telephone support for having a mortality benefit (BMJ 2007;334:942-950).
- A randomized, controlled trial by Konstam and colleagues with a 90-day nurse-led telephone-based home monitoring program for HF patients with reduced and preserved left ventricular ejection fraction that showed a lower rate of HF hospitalizations per patient-year for the intervention group compared with standard care (Circulation 2004;110:1450-1455); and
- A study that tested an intervention using counseling, education and telephone monitoring by nurses in stable HF patients that found at 16-month follow-up a 29 percent reduction in relative risk for HF hospitalization in the intervention group (BMJ 2005;331:425-430).
“As a number of authors have pointed out, the key to achieving clinical benefit, including reduced hospitalization rates, from a disease management program may be the implementation of patient-centered care—i.e., enlisting the patient's direct participation in his or her own care through both education and involvement in the monitoring and intervention process,” Konstam wrote.
Some studies on home monitoring indicated a residual benefit over time with a persistent reduction in HF readmissions in intervention groups and improved adherence to medication regimes, Konstam added.
“Home monitoring is likely to facilitate improved performance on the recently popularized 30-day rehospitalization metric, which is projected to soon carry significant financial incentives and penalties from both Medicare and commercial payers,” Konstam pointed out.
Desai argued that while there is consensus that disease management works, it is unclear what the best approach may be. He pointed out that the interventions used in clinical trials have not been standardized, differed in terms of intensity and duration and used different patient populations. Many of the trials were insufficiently powered to study clinical outcomes, he wrote, relying on meta-analyses of disparate trials for results.
“[B]ecause many trials have been conducted at single sites (often academic medical centers), it is uncertain whether the results from clinical trials can be generalized to larger community-based populations,” Desai wrote. “Most importantly, even if they are effective, it remains unclear which core components of these multidimensional, multidisciplinary interventions are essential to improvement in clinical outcomes.”
Instead, Desai recommended a strategy to that maximizes the effectiveness of each step in the HF monitoring loop. Measures such as weight gain, while a predictor of HF decompensation, may be too blunt for practical and timely intervention, he said. He pointed out that diagnostics using implantable devices such as cardiac resynchronization therapy and implantable cardioverter-defibrillators may be an option.
“Changes in certain routinely monitored parameters, such as the percentage of ventricular pacing, presence of arrhythmia, activity levels, and mean heart rates at rest or during exertion, may help clinicians to better anticipate impending decompensation, although they do not always illuminate a clear pathway to effective treatment,” Desai wrote.
Invasive hemodynamic monitoring may not be realistic, he noted, nor scalable. And to be successful, a monitoring strategy must include a larger workforce trained to care for the growing number of HF patients and must provide the infrastructure, decision algorithms and a payment system to support the program.
“Finally, because a large proportion of hospitalizations among heart failure patients (in particular among the elderly and those with preserved ejection fraction) are not because of heart failure decompensation but rather because of exacerbations of noncardiovascular illness, a real impact on overall hospitalization rates and mortality may require disease management approaches that focus more comprehensively on the full range of medical comorbidities, not exclusively on heart failure management,” Desai concluded.
Cardiovascular Business explores the workforce requirements for remotely monitoring HF patients in the upcoming March issue. To learn more about this topic, sign up for a free subscription here.