A meta-analysis from ESC Heart Failure shows the effects of home telemonitoring in patients with decompensated heart failure.
Noninvasive home telemonitoring (TM) had a neutral effect on all-cause hospitalization and all-cause mortality in patients with decompensated heart failure (HF), according to a systematic review published in ESC Heart Failure.
HF is associated with rising health care expenses, predominantly due to hospital readmission and pharmacological treatments. Additionally, mortality and hospitalization rates are equally high among patients with HF with preserved ejection fraction or HF with reduced ejection fraction. The review’s authors proposed a possible intervention: noninvasive home TM using telehealth devices and other new technology to self-monitor and self-manage HF symptoms.
They conducted a meta-analysis of data regarding specifically noninvasive home TM to study its impact on the treatment of patients with recently decompensated HF. The study used randomized controlled trials (RCTs) that compared TM with standard care.
Their database search was conducted on October 4, 2020, and only included articles published after January 1, 2004. Eleven articles were included in the final analysis.
In the 11 articles, 4291 patients were analyzed across all-cause hospitalization studies and 4521 were analyzed across all-cause mortality studies. Compared with standard-of-care treatment, the pooled estimate of relative risk (RR) in all-cause hospitalization was 0.95 (95% CI, 0.84-1.08; P = .43) and in all-cause mortality, 0.83 (95% CI, 0.63-1.09; P = .17).
Two studies resulted in all-cause hospitalization rates being significantly lower in the TM group than in the standard care group. These 2 studies adjusted the patients’ medications, with one using more beta-blockers, statins, and aldosterone antagonists in the follow-up than in the standard care group. However, different population samples, lack of adherence reporting, and nonuniform definitions of HF subtypes made it difficult to draw concrete conclusions.
Another study showed a lower all-cause mortality rate in the TM group than the standard care group (4 vs 14 deaths). The authors mention that this study also showed “a relatively high number of hospitalizations and deaths per patient year in the standard care group during follow-up.”
Regarding at-home HF medication management, 4 studies allowed study personnel to alter diuretic doses when necessary, and 3 had study personnel or technology inform a physician of a potential need for adjustments in overall HF medication.
Quality of life showed the most positive change, with 4 studies reflecting a significant improvement in the TM group’s follow-up and only 1 study with a neutral effect.
There was evidence of substantial heterogeneity in the effect estimates between all-cause hospitalization in TM and standard care (P = .0003; I2 = 73%), but there was nonsignificant evidence of moderate heterogeneity in the effect estimates between all-cause mortality in TM and standard care.
The study authors acknowledge that the scarcity of published trials on noninvasive home TM interventions in patients with recently decompensated HF could be the cause of heterogeneity among the studies. There was also varying adherence to the TM intervention between studies, with those with positive effects of TM intervention showing stronger adherence.
Studies with positive results also showed higher levels of prescribed HF medication at the end of follow-up in the TM group or direct ways for the TM intervention to affect HF medication. Because of these differences between studies, more weight was placed on qualitative data than quantitative data.
The authors’ findings echo previous studies that found most patients with HF are prescribed guideline-directed medications. Ninety-two percent of patients are prescribed an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) and 93% are prescribed a beta-blocker. However, only 29% of ACE inhibitors and 18% of beta-blocker users hit their target doses, while 50% to 60% of patients in RCTs achieved target doses of these medications.
“It is likely that the treatment effect of a TM intervention depends on the details of the intervention and on how the general health care system has been included in the study setup,” the authors noted. “TM interventions should be tailored to the local health care environment.”
According to the study’s findings, patient adherence is higher with interventions relatively simple and easier to use at home.
“It is likely that noninvasive home TM in recently decompensated HF has provided proof of concept, but the most feasible system and environment for implementing a TM intervention remain to be established,” the authors concluded.
Drews TEI, Laukkanen J, Nieminen T. Non-invasive home telemonitoring in patients with decompensated heart failure: a systematic review and meta-analysis. ESC Heart Fail. Published online June 24, 2021. doi:10.1002/ehf2.13475