ORLANDO – A multipronged approach to following and managing heart failure patients closely after they are hospitalized for acute decompensation led to significant reductions in subsequent rehospitalization or death in a randomized trial, but only in the subgroup of patients who actually adhered to the program.
The main message from the study was “this type of telemonitoring should not get used on everyone,” said Dr. Michael K. Ong in an interview at the American Heart Association scientific sessions. “A key issue is who are the people who would benefit” from an intensified at-home monitoring program following hospitalization for an acute heart failure episode.
Mitchel L. Zoler/Frontline Medical News
Dr. Michael K. Ong
Another issue is that new monitoring technologies introduced after launch of the BEAT-HF (Better Effectiveness After Transition–Heart Failure) trial more than 4 years ago have produced unobtrusive and implantable monitoring devices that could help boost monitoring compliance, said Dr. Ong, an internist at the University of California, Los Angeles.
“We all monitor our patients remotely on a variety of ways,” commented Dr. Mariell Jessup, professor of medicine and heart failure specialist and at the University of Pennsylvania in Philadelphia. “Depending on our resources and technology, we might use implantable monitors or have nurses call patients, and have patients send us emails. There is a wide range of telemonitoring available. But we need to find out what works. An enormous effort has been made to enhance patients’ ability to monitor themselves, so they can take charge of their disease,” Dr. Jessup said.
Mitchel L. Zoler/Frontline Medical News
Dr. Mariell Jessup
BEAT-HF randomized 1,437 patients with confirmed heart failure and an index hospitalization to an intensive monitoring and education program or usual care during 2011-2013 at six academic health centers in California. Patients averaged 73 years old, and most patients had class III New York Heart Association heart failure, with three quarters having either class III or IV.
The intensive program included three elements:
• An in-hospital education program.
• A schedule of nine follow-up telephone calls by a registered nurse starting 2-3 days post discharge and continuing out to 6 months. Patients in the intervention arm completed a median of six of these calls.
• Telemonitoring of daily measurement of weight, blood pressure, and heart rate using electronically linked monitoring devices supplied to each patient. The monitoring equipment actually was used by 83% of the 715 patients randomized to this arm, and at 180 days, 52% of the patients in this arm had transmitted more than half of their daily measurement updates.
The study showed no significant benefit from the intensive monitoring arm compared with usual care for the primary endpoint of all-cause hospitalizations after 180 days, Dr. Ong reported. However, in a post hoc analysis that divided the intervention arm patients into those with more than 50% days with monitoring information sent and those with 50% or less, the rehospitalization rate was 61% among the patients who complied 50% or less of the time with daily home monitoring, and 41% in patients with greater than 50% compliance, a one-third relative drop. The more-compliant patients also substantially and significantly reduced their mortality rates at both 30 and 180 days, compared with the less-adherent patients in the intervention arm.
Additional studies must now examine how to optimize adherence and better match patients with various monitoring techniques. “If patients won’t use a treatment, they won’t benefit,” said Dr. Ong. Finding out what makes people adherent and encourage them to participate is the next research issue, he added.
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