Structured telephone support or non-invasive telemonitoring for patients with heart failure
Open accessAbstract
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; I² = 24%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.71, 95% CI 0.60 to 0.83; participants = 2148; studies = 8; I² = 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; I² = 0%, GRADE: moderate-quality evidence) and heart failure-related hospitalisations (RR 0.85, 95% CI 0.77 to 0.93; participants = 7030; studies = 16; I² = 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; I² = 47%, GRADE: very low-quality evidence; non-invasive telemonitoring: RR 0.95, 95% CI 0.89 to 1.01; participants = 3332; studies = 13; I² = 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%
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Heart failure hospitalizations, but not all-cause hospital admissions, were significantly lower with either telemonitoring or telephone support.
“Heart failure hospitalizations, but not all-cause hospital admissions, were also significantly lower with either telemonitoring or telephone support.”
Both structured telephone support and telemonitoring reduced all-cause mortality in heart failure.
“Self-management support was explicitly hypothesized as a mechanism by which these interventions might exert their effect, and both interventions reduced all-cause mortality.”
Nine reviews analyzed telehealth interventions for heart failure.
“A total of 9 reviews analyzed telehealth interventions for heart failure [16,20,28,55-60].”
Inglis et al separately analyzed structured telephone support and telemonitoring of physiological parameters.
“This review separately analyzed structured telephone support and telemonitoring of physiological parameters.”
The highest-weighted heart failure meta-analysis was Inglis et al.
“The highest-weighted meta-analysis was Inglis et al [58].”
A sensitivity analysis of telephone-based interventions showed no difference between symptom monitoring and education-focused telephone calls.
“A sensitivity analysis of the telephone-based interventions showed no difference between symptom monitoring and education-focused telephone calls.”
Physiological telemonitoring and telephone support for heart failure were associated with reduced mortality and heart failure-specific hospital admissions.
“Physiological telemonitoring and telephone support for heart failure were associated with reduced mortality and heart failure-specific hospital admissions [58].”
Inglis et al. showed no significant impact on mortality of an exploratory subgroup analysis based on intensity of telemonitoring in heart failure.
“By contrast, Inglis et al showed no significant impact on mortality of an exploratory subgroup analysis based on intensity of telemonitoring in heart failure [58].”
Monitoring and feedback was associated with improved clinical outcomes in diabetes and heart failure.
“This was the most commonly described telehealth component in the included systematic reviews and was associated with improved clinical outcomes in diabetes and heart failure [33,35,36,38,42,44,54,58]; however, findings for asthma and COPD were mostly neutral or inconsistent [61-63,65,66,68,69].”
The highest-quality evidence for heart failure showed an overall improvement in mortality in meta-analyses of telemonitoring and telephone support.
“The highest-quality evidence for heart failure showed an overall improvement in mortality in meta-analyses of telemonitoring and telephone support [58].”
Teleconsultations, videoconferencing, and telephone follow-up designed to review symptoms or clinical course were important aspects of telehealth interventions described by Inglis et al for heart failure, whose meta-analysis showed reduced mortality and heart failure hospital admission with telemonitoring and telephone review.
“Teleconsultations, videoconferencing, and telephone follow-up designed to review symptoms or clinical course were important aspects of telehealth interventions described by Inglis et al for heart failure, whose meta-analysis showed reduced mortality and heart failure hospital admission with telemonitoring and telephone review [58].”
It is not clear whether the association between more intensive interventions and greater improvements in glycemic control applies to other disease areas.
“and it is not clear whether this applies to other disease areas [58].”
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Flagged first, then by citations
17 of the 559 references couldn’t be matched to a known paper.
Research works printed but not linked: 11
- trial (the TEHAFstudy). Journal of the American College of Cardiology 2011;1:E389.
- Boyne JJ, Vrijhoef HJM, Spreeuwenberg M, Weerd GD, Kragten J, Gorgels APM. The effects of telemonitoring on heart failure patients' knowledge, self-care, self-efficacy and adherence: a randomized controlled trial [European Journal of Cardiovascular Nursing]. European Journal of Cardiovascular Nursing 2013; Vol. 13, issue 3:243-52.
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- C O N T R I B U T I O N S O F A U T H O R S Sally C Inglis: Responsible for conception and design of this study and the previous versions of this review (Clark 2007a; Inglis 2010). Responsible for co-ordinating and completing the review. Responsible for all data included in the review including designing, undertaking searches, retrieving search results, screening studies for inclusion, assessing risk of bias of studies, extracting data from papers, contacting study authors for information, entering data into Review Manager 5, analysis and interpretation of data, drafting of the review or revising it critically for important intellectual content and final approval of the version to be published. Performed previous work that was the foundation of this study.
- Robyn A Clark: Responsible for conception and design of this study and the previous version of this review (Clark 2007a; Inglis 2010). Responsible for conceiving the initial idea for Clark 2007a. Responsible for all data included in the review including designing, undertaking searches, screening studies for inclusion, assessing risk of bias of studies, extracting data from papers, entering data into Review Manager 5, analysis and interpretation of data, drafting of the review or revising it critically for important intellectual content and final approval of the version to be published. Performed previous work that was the foundation of this study. Riet Dierckx: Responsible for all data included in the review including undertaking handsearching of conference abstracts, retrieving search results, screening studies for inclusion, assessing risk of bias of studies, extracting data from papers, entering data into Review Manager 5, interpretation of data, drafting of the review or revising it critically for important intellectual content and final approval of the version to be published.
- David Prieto-Merino: Responsible for undertaking the heterogeneity tests between predefined subgroups and the meta-regression, review of statistical analyses undertaken in the review and drafting of sections of the review relevant to the heterogeneity analysis and meta-regression findings and approval of the version to be published.
- John GF Cleland: Consulted on design of review. Responsible for adjudicating study inclusion, interpretation of data (providing a methodological and clinical view), revising the review critically for important intellectual content and final approval of the version to be published. Guarantor for this review.
- D E C L A R A T I O N S O F I N T E R E S T Sally C Inglis: no disclosures Robyn A Clark was a PhD student involved in patient telemonitoring, data collection and tool development, analysis and publication of the CHAT Study which is included in this review (Krum 2013 (CHAT)). She was funded from NHMRC-funded grant for the CHAT study for one year then a Heart Foundation/NICS Scholarship.
- Cleland 2005 (Telemon) (TENS-HMS)) and other research related to telemonitoring. He has received honoraria from Philips for speaking on the subject of telemonitoring (this funding is not connected with this review). As this author was a lead investigator of an included study in this review (Cleland 2005 (Struct Tele) (TENS-HMS);
- Cleland 2005 (Telemon) (TENS-HMS)) he did not undertake any risk of bias assessment or GRADE assessment of studies included in this review. Performed previous work that was the foundation of this study Clark 2007a and Inglis 2010.
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The year in cardiology 2018: heart failure
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- Authors
- Inglis, S. C., Clark, R. A., Dierckx, R., Prieto-Merino, D., & Cleland, J. G.
- Affiliations
- University of Technology Sydney (AU)
- Flinders University (AU)
- Onze Lieve Vrouwziekenhuis Hospital (BE)
- London School of Hygiene & Tropical Medicine; Department of Non-communicable Disease Epidemiology; Keppel Street London UK WC1E 7HT
- Imperial College London (GB)
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2015-10-31
- Volume
- 2015
- Issue
- 10
- Pages
- CD007228-CD007228
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC8482064
- OpenAlex
- W3081832434
- Cited by
- 453
- References
- 559
- Citations by year
- 2026: 41 · 2025: 36 · 2024: 45 · 2023: 46 · 2022: 53 · 2021: 53 · 2020: 56 · 2019: 42 · 2018: 40 · 2017: 27 · 2016: 13
- FWCI
- 4.58
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion)
- Funders
- National Institute for Health and Care Research (NF-SI-0611-10227)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
- Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
- Keywords
- heart failure, home health monitoring, remote patient monitoring, disease management programs, hospitalization, mortality, health-related quality of life, self-care, acceptability, cost, health care utilization, usual care comparison, subgroup analysis, meta-regression
- MeSH terms
- Aged, Chronic Disease, Heart Failure, Hospitalization, Humans, Length of Stay, Quality of Life, Telemetry, Telephone, Randomized Controlled Trials as Topic
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