Hospitals that face penalties from CMS for failing to reduce readmission rates have looked to telehealth as a potential tool to keep track of patients after discharge. A study presented by a UCLA researcher did not meet its end point but offered some insights for future work.
In the scientific sense, Michael K. Ong, MD, PhD, did not have positive results to report. A trial had tested whether heart failure patients who’d been hospitalized could be monitored remotedly, and a telemonitoring approach had not made a difference in reducing hospital admission rates.
But beyond the overall results, Ong, associate professor of medicine at the University of California, Los Angeles, found seeds for future attempts at telehealth: a subset of the patients who had better adherence had better results. Better integration of an intervention with a patient’s primary care practice might have helped.
Most of all, Ong said, technology has made leaps since the study period, which occurred between October 2011 and September 2013. At a news conference ahead of the presentation on the findings, he said telemonitoring that is less intrusive, perhaps through an electronic wristband, might prove superior to the form used in the intervention. This study relied on patients to take calls from nurses.
The issue of great importance to managed care since CMS and commercial payers are increasingly moving to value-based reimbursement models, and 30-day readmission rates are a prime measure for which hospitals face financial penalties if they fail to meet targets. Ong said that while readmission rates for other conditions have improved, heart failure is an area where “the needle hasn’t moved very much.” Thus, researchers had hoped that an intervention with telemonitoring would make a difference.
Only recently has CMS acknowledged that reimbursement formulas and hospital star ratings may need to reflect patients’ socioeconomic status. Poverty is known to affect health status, adherence, and health outcomes. Ong said 3 of the 6 hospitals taking part in the study were safety net hospitals, but he did not break out data by socioeconomic status.
How the study worked. The study randomized 1437 patients who had been hospitalized for heart failure to either an intervention or control group. Those receiving the intervention were educated prior to discharge that they would receive 9 telephone calls from registered nurses (RNs) that would start 2 to 3 days after discharge. Patients would receive weekly calls for the first month, then monthly calls for 6 months. The study would measure readmission rates for 30-day and 180-day periods, comparing the intervention and control groups.
Use of Bluetooth technology and a blood pressure and heart rate monitor allowed the RNs to daily check patient data, and the RNs could call if certain parameters were exceeded. Patients’ physicians were notified if there were significant symptoms, and patients were sent to the emergency department if necessary.
Results. Curves for the 30-day and 180-day readmission for the intervention and control groups overlapped almost exactly. Hazard ratio for 30-day readmission with intervention was 1.03 (95% CI 0.83-1.29). Adjusted hazard ratio for 30-day readmission with intervention was 1.01 (95% CI 0.80-1.28).
Of the 722 patients in the control group, 106 died during the study; of the 715 in the intervention, 92 died. The hazard ratio for the 180-day mortality with the intervention was 0.88 (95% CI 0.67-1.15); the adjusted hazard ratio for 180-day mortality with the intervention was 0.85 (95% CI 0.64-1.13).
One clear challenge was getting patients in the intervention group to complete the calls: while 82.7% of the participants used the equipment, at the 180-day mark only 68% had completed >50% of the calls, and the average number of completed calls was 6. Just over half—51.7%—of the telemonitoring was completed.
Percentages of both 30-day and 180-day readmissions, as well as mortality rates, were lower among those in the intervention group who completed >50% of the calls. When asked if he could say what set the most adherent patients apart—and what researchers might learn from them—Ong smiled and said he could not discuss that just yet, suggesting that perhaps this was an article for another day.
Ong M, Auerback AD, Black JT, et al. Remote patient management after discharge of hospitalized heart failure patients: the Better Effectiveness After Transition - Heart Failure (BEAT-HF) study. Presented at the American Heart Association Scientific Sessions; Orlando, Florida; November 8, 2015; Abstract 20282.