Home telemonitoring or structured telephone support programmes after recent discharge in patients with heart failure: systematic review and economic evaluation
Open accessAbstract
BACKGROUND: Remote monitoring (RM) strategies have the potential to deliver specialised care and management to patients with heart failure (HF). OBJECTIVE: To determine the clinical effectiveness and cost-effectiveness of home telemonitoring (TM) or structured telephone support (STS) strategies compared with usual care for adult patients who have been recently discharged (within 28 days) from acute care after a recent exacerbation of HF. DATA SOURCES: Fourteen electronic databases (including MEDLINE, EMBASE, PsycINFO and The Cochrane Library) and research registers were searched to January 2012, supplemented by hand-searching relevant articles and contact with experts. The review included randomised controlled trials (RCTs) or observational cohort studies with a contemporaneous control group that included the following RM interventions: (1) TM (including cardiovascular implanted monitoring devices) with medical support provided during office hours or 24/7; (2) STS programmes delivered by human-to-human contact (HH) or human-to-machine interface (HM). REVIEW METHODS: A systematic review and network meta-analysis (where appropriate) of the clinical evidence was carried out using standard methods. A Markov model was developed to evaluate the cost-effectiveness of different RM packages compared with usual care for recently discharged HF patients. TM 24/7 or using cardiovascular monitoring devices was not considered in the economic model because of the lack of data and/or unsuitability for the UK setting. Given the heterogeneity in the components of usual care and RM interventions, the cost-effectiveness analysis was performed using a set of costing scenarios designed to reflect the different configurations of usual care and RM in the UK. RESULTS: The literature searches identified 3060 citations. Six RCTs met the inclusion criteria and were added to the 15 trials identified from the previous systematic reviews giving a total of 21 RCTs included in the systematic review. No trials of cardiovascular implanted monitoring devices or observational studies met the inclusion criteria. The methodological quality of the studies varied widely and reporting was generally poor. Compared with usual care, RM was beneficial in reducing all-cause mortality for STS HH [hazard ratio (HR) 0.77, 95% credible interval (CrI) 0.55 to 1.08], TM during office hours (HR 0.76, 95% CrI 0.49 to 1.18) and TM 24/7 (HR 0.49, 95% CrI 0.20 to 1.18); however, these results were statistically inconclusive. The results for TM 24/7 should be treated with caution because of the poor methodological quality of the only included study in this network. No favourable effect on mortality was observed with STS HM. Similar reductions were observed in all-cause hospitalisations for TM interventions, whereas STS interventions had no major effect. A sensitivity analysis, in which a study was excluded because it provided better-than-usual support to the control group, showed larger beneficial effects for most outcomes, particularly for TM during office hours. In the cost-effectiveness analyses, TM during office hours was the most cost-effective strategy with an estimated incremental cost-effectiveness ratio (ICER) of £11,873 per quality-adjusted life-year (QALY) compared with usual care, whereas STS HH had an ICER of £228,035 per QALY compared with TM during office hours. STS HM was dominated by usual care. Similar results were observed in scenario analyses performed using higher costs of usual care, higher costs of STS HH and lower costs of TM during office hours. LIMITATIONS: The RM interventions included in the review were heterogeneous in terms of monitored parameters and HF selection criteria and lacked detail in the components of the RM care packages and usual care (e.g. communication protocols, routine staff visits and resources used). As a result, the economic model developed scenarios for different RM classifications and their costs were estimated using bottom-up costing methods. Although the users can decide which of these scenarios is most representative of their setting, uncertainties still remain about the assumptions made in the estimation of these costs. In addition, the model assumed that the effectiveness of the interventions was constant over time, irrespective of the duration of deployment, and that the intervention was equally effective in different age/severity groups. CONCLUSION: Despite wide variation in usual care and RM strategies, cost-effectiveness analyses suggest that TM during office hours was an optimal strategy (in most costing scenarios). However, clarity was lacking among descriptions of the components of RM packages and usual care and there was a lack of robust estimation of costs. Further research is needed in these areas. STUDY REGISTRATION: PROSPERO registration no. CRD42011001368. FUNDING: The National Institute for Health Research Health Technology Assessment programme.
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One review focused primarily on HF patients who had been recently discharged (within 28 days) from an acute care setting after a recent HF exacerbation and conducted additional analyses to assess whether results differed from studies with stable HF patients.
“One review [37] focused primarily on HF patients who had been recently discharged (within 28 days) from an acute care setting after a recent HF exacerbation and conducted additional analyses to assess whether or not the results from these studies differed markedly from the results of studies that included patients with stable HF.”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
In five reviews, the description of the intervention extracted from the trials was reduced into just a few words presented in a summary table or within the text.
“In five reviews [37,38,45-47], the description of the intervention extracted from the trials was reduced into just a few words presented in a summary table or within the text”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Six reviews reported that most participants in the included studies were NYHA class II-IV.
“Six reviews reported that most participants in the included studies were NYHA class II-IV [34-35,37-39,47].”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Most reviews (8/15, 53%) did not provide sufficient details about the technology used in each of the included primary studies.
“most reviews (8/15, 53%) did not provide sufficient details about the technology used in each of the included primary studies [33,34,36-40,45-47]”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
The majority of systematic reviews (10/15, 67%) summarized and reported relevant information about the type of physiological measures monitored in the included trials.
“While the majority of systematic reviews (10/15, 67%) summarized and reported relevant information about the type of physiological measures monitored in the included trials [33,34,37,38,41-44,47,49]”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Usual care varied across studies from in-person follow-up visits to a general practitioner or primary care provider to attendance at an outpatient clinic-based disease management program.
“Usual care varied across studies from in-person follow-up visits to a general practitioner or primary care provider to attendance at an outpatient clinic-based disease management program [33,34,36,37,47,49].”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Improvements in survival rates with HT are more pronounced in patients who have been recently discharged from the hospital (HR 0.62 [95% CrI 0.42-0.89]; ARR 5% [95% CI -1.4 to -7.8]) than patients without any acute event or deterioration in the past 28 days before randomization (HR 0.85 [95% CrI 0.59-1.20]; ARR 1.4% [95% CI -3.9 to 1.9]).
“Evidence from a more recent review [37] suggests that improvements in survival rates with HT are more pronounced in patients who have been recently discharged from the hospital (HR 0.62 [95% CrI 0.42-0.89]; ARR 5% [95% CI -1.4 to -7.8]) than patients without any acute event or deterioration in the past 28 days before randomization (HR 0.85 [95% CrI 0.59-1.20]; ARR 1.4% [95% CI -3.9 to 1.9]).”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
In patients with stable heart failure, home telemonitoring with clinical support provided during office hours, without home visits for clinical assessment or educational purposes, compared with usual care does not significantly affect all-cause hospitalization (HR 1.17, 95% CI 0.89 to 1.59; 47 more per 1000, from 32 fewer to 148 more) over 6-12 months.
“| | Population: Patients with stable heart failure | 1267 (5 studies) 6-12 months | LOW due to risk of bias, imprecisione,f | HR 1.17 (0.89 to 1.59)h | 357 per 1000 | 47 more per 1000 (from 32 fewer to 148 more) |”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
In recently discharged patients (≤28 days), home telemonitoring with clinical support provided during office hours, without home visits for clinical assessment or educational purposes, compared with usual care reduces all-cause hospitalization (HR 0.67, 95% CI 0.42 to 0.97; 138 fewer per 1000, from 11 fewer to 271 fewer) over 6-12 months.
“| | Population: Recently discharged patients (≤28 days) | 831 (5 studies) 6-12 months | LOW due to risk of bias, inconsistency, imprecisione-g | HR 0.67 (0.42 to 0.97)h | 569 per 1000 | 138 fewer per 1000 (from 11 fewer to 271 fewer) |”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
HT interventions with clinical support during office hours yielded a smaller relative effect for recently discharged patients than patients with stable HF (HR 0.86 [95% CrI 0.61-1.21] versus HR 0.70 [95% CrI 0.34-1.50]).
“HT interventions with clinical support during office hours yielded a smaller relative effect for recently discharged patients than patients with stable HF (HR 0.86 [95% CrI 0.61-1.21] versus HR 0.70 [95% CrI 0.34-1.50]).”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Of them, five pooled study results into a meta-analysis.
“Of them, five pooled study results into a meta-analysis [33-37].”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
In patients with stable heart failure, home telemonitoring with clinical support provided during office hours, without home visits for clinical assessment or educational purposes, compared with usual care does not significantly affect HF-related hospitalizations (HR 0.70, 95% CI 0.34 to 1.5; 61 fewer per 1000, from 139 fewer to 91 more) over 12 months.
“| | Population: Patients with stable heart failure | 432 (2 studies) 12 months | LOW due to risk of bias and imprecisione,f | HR 0.70 (0.34 to 1.5)g | 221 per 1000 | 61 fewer per 1000 (from 139 fewer to 91 more) |”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Results for HF-related hospitalizations were statistically inconclusive and the overall quality of evidence was low, suggesting that these estimates should be interpreted with caution until more evidence accumulates.
“However, results were statistically inconclusive and the overall quality of evidence was found to be low, suggesting that these estimates should be interpreted with caution until more evidence accumulates.”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Relative effects in meta-analyses that favored HT over usual care for all-cause hospitalizations ranged from 0.99 (95% CI 0.88-1.11) to 0.67 (95% CrI 0.42-0.97).
“Relative effects in meta-analyses that favored HT over usual care ranged from 0.99 (95% CI 0.88-1.11) [36] to 0.67 (95% CrI 0.42-0.97) [37].”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
HT with clinical support provided during office hours increased the risk of all-cause hospitalizations in patients with stable HF by 17% (HR 1.17 [95% CrI 0.89-1.59], with an absolute risk increase of 4.7% [95% -3.2 to 14.8]).
“HT with clinical support provided during office hours increased the risk of all-cause hospitalizations in patients with stable HF by 17% (HR 1.17 [95% CrI 0.89-1.59], with an absolute risk increase of 4.7% [95% -3.2 to 14.8]).”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
In patients with stable heart failure, home telemonitoring with clinical support provided 24/7, without home visits for clinical assessment or educational purposes, compared with usual care does not significantly affect all-cause hospitalization (HR 0.84, 95% CI 0.54 to 1.15; 57 fewer per 1000, from 181 fewer to 48 more) over 12-24 months.
“| | Population: Patients with stable heart failure | 1258 (3 studies) 12-24 months | LOW due to risk of bias, inconsistency, imprecisione-g | HR 0.84 (0.54 to 1.15)h | 474 per 1000 | 57 fewer per 1000 (from 181 fewer to 48 more) |”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
In patients with stable heart failure, home telemonitoring with clinical support provided 24/7, without home visits for clinical assessment or educational purposes, compared with usual care does not significantly affect HF-related hospitalizations (HR 0.64, 95% CI 0.34 to 1.14; 82 fewer per 1000, from 157 fewer to 30 more) over 12-24 months.
“| | Population: Patients with stable heart failure | 1170 (3 studies) 12-24 months | LOW due to risk of bias and imprecisione,f | HR 0.64 (0.34 to 1.14)g | 251 per 1000 | 82 fewer per 1000 (from 157 fewer to 30 more) |”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
HT with 24/7 clinical support yielded beneficial but marginally lower relative effects than those observed in recently discharged patients: HR 0.84 (95% CrI 0.54-1.15); ARR 5.7% (-1.8 to 4.8%).
“While HT with 24/4 clinical support yielded beneficial but marginally lower relative effects than those observed in recently discharged patients: HR 0.84 (95% CrI 0.54-1.15); ARR 5.7% (-1.8 to 4.8%).”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Relative risk reductions in the four reviews that incorporated meta-analysis ranged from 14% (HR 0.86 [95% CI 0.61-1.21)] to 36% (HR 0.64 [95% CrI 0.34-1.14]), while the ARR in HF-related hospitalizations extended from 3.7%-8.2%.
“Relative risk reductions in the four reviews that incorporated meta-analysis ranged from 14% (HR 0.86 [95% CI 0.61-1.21)] [37] to 36% (HR 0.64 [95% CrI 0.34-1.14]), while the ARR in HF-related hospitalizations extended from 3.7%-8.2%.”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
In recently discharged patients (≤28 days), home telemonitoring with clinical support provided during office hours, without home visits for clinical assessment or educational purposes, compared with usual care does not significantly affect HF-related hospitalizations (HR 0.86, 95% CI 0.61 to 1.21; 37 fewer per 1000, from 109 fewer to 52 more) over 6-8 months.
“| | Population: Recently discharged patients (≤28 days) | 755 (2 studies) 6-8 months | LOW due to risk of bias and imprecisione,f | HR 0.86 (0.61 to 1.21)g | 315 per 1000 | 37 fewer per 1000 (from 109 fewer to 52 more) |”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Relative risk reductions in meta-analyses that achieved the highest AMSTAR score in each group of the taxonomy ranged from 15% (HR 0.85, 95% CrI 0.59-1.2) to 40% (RR 0.60, 95% CI 0.45-0.81).
“As shown in Table 7, relative risk reductions in meta-analyses that achieved the highest AMSTAR score in each group of the taxonomy ranged from 15%, with hazard ratio (HR) 0.85 (95% credible interval [CrI] 0.59-1.2) [37] to 40%, with risk ratio (RR) 0.60 (95% CI 0.45-0.81) [35].”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
One review incorporated a network meta-analysis to determine the effectiveness of different remote monitoring strategies versus usual care on adult HF patients who had been recently discharged home (≤28 days) from an acute care setting and also on patients with stable HF.
“One of the reviews [37] incorporated a network meta-analysis to determine the effectiveness of different remote monitoring strategies versus usual care on adult HF patients who had been recently discharged home (≤28 days) from an acute care setting and also (in additional analyses) on patients with stable HF.”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Improvements in HF-related hospitalizations might be more pronounced in patients with stable HF receiving telemonitoring with clinical support during 24/7 (HR 0.64 [95% CrI 0.34-1.14]).
“Findings from a recent review [37] suggest that improvements in HF-related hospitalizations might be more pronounced in patients with stable HF receiving telemonitoring with clinical support during 24/7 (HR 0.64 [95% CrI 0.34-1.14]).”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Quality of evidence was low for the finding that improvements in survival rates with HT are more pronounced in recently discharged patients.
“However, quality of evidence was low for this finding, suggesting that further research is very likely to have an important impact on this estimate.”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
The bulk of the literature consists of low-quality and inconsistent evidence about the beneficial effects of HT on all-cause hospitalizations.
“Yet the bulk of the literature consists of low-quality and inconsistent evidence about the beneficial effects of HT on all-cause hospitalizations [34,37].”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
Three reviews, all of which focused on RCTs, concluded that the impact of HT on length of stay was ambivalent.
“Three reviews, all of which focused on RCTs, concluded that the impact of HT on length of stay was ambivalent [34,36,37].”
From Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews (2015) · cites this paper as [37]
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- Authors
- Pandor, A., Thokala, P., Gomersall, T., Baalbaki, H., Stevens, J., Wang, J., Wong, R., Brennan, A., & Fitzgerald, P.
- Affiliations
- University of Sheffield (GB)
- Venue
- Health Technol Assess
- Published
- 2013-08
- Volume
- 17
- Issue
- 32
- Pages
- 1-207, v
- ISSN
- 1366-5278 (ISSN-L)
- 2046-4924
- PMC
- PMC4781365
- OpenAlex
- W2058910331
- Cited by
- 159
- References
- 273
- Citations by year
- 2026: 2 · 2024: 10 · 2023: 11 · 2022: 18 · 2021: 14 · 2020: 12 · 2019: 11 · 2018: 26 · 2017: 15 · 2016: 6 · 2015: 17 · 2014: 15 · 2013: 2
- FWCI
- 2.28
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- Health Technology Assessment (publishedVersion, cc-by)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- National Institute for Health Research
- 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 monitoring, hospital readmission, all-cause mortality, cost-effectiveness, post-discharge care, Markov model, network meta-analysis, usual care comparison, quality of life, patient satisfaction
- MeSH terms
- Cost-Benefit Analysis, Heart Failure, Home Care Services, Humans, Markov Chains, Monitoring, Physiologic, Patient Discharge, Patient Readmission, Telephone, Telemedicine
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