Structured telephone support and telemonitoring in the management of patients with chronic heart failure

Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF

Published Online:

June 15, 2011

In the context of limited health funding, and a rapidly expanding population of older patients with chronic heart failure (CHF) it is increasingly difficult for healthcare systems to provide high-quality care to patients with CHF. Multi-disciplinary specialist heart failure clinics are available only to a minority of patients and do not have the capacity for frequent patient review. Patients may be unwilling or unable to make frequent clinic attendance due to financial, transport or disability constraints. Structured telephone support and telemonitoring can provide specialised heart failure care to a large number of patients with limited access to healthcare services. This review demonstrates that CHF interventions utilising information technology can reduce the rates of death and hospitalisation and improve the quality of life. The majority of elderly patients learned to use the technology easily and were satisfied with receiving healthcare in this way.

Abstract (click to read)

Background:

Specialised disease management programmes for chronic heart failure (CHF) improve survival, quality of life and reduce healthcare utilisation. The overall efficacy of structured telephone support or telemonitoring as an individual component of a CHF disease management strategy remains inconclusive.

Objectives:

To review randomised controlled trials (RCTs) of structured telephone support or telemonitoring compared to standard practice for patients with CHF in order to quantify the effects of these interventions over and above usual care for these patients.

Search strategy:

Databases (the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database (HTA) on The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED and Science Citation Index Expanded and Conference Citation Index on ISI Web of Knowledge) and various search engines were searched from 2006 to November 2008 to update a previously published non-Cochrane review. Bibliographies of relevant studies and systematic reviews and abstract conference proceedings were handsearched. No language limits were applied.

Selection criteria:

Only peer reviewed, published RCTs comparing structured telephone support or telemonitoring to usual care of CHF patients were included. Unpublished abstract data was included in sensitivity analyses. The intervention or usual care could not include a home visit or more than the usual (four to six weeks) clinic follow-up.

Data collection and analysis:

Data were presented as risk ratio (RR) with 95% confidence intervals (CI). Primary outcomes included all-cause mortality, all-cause and CHF-related hospitalisations which were meta-analysed using fixed effects models. Other outcomes included length of stay, quality of life, acceptability and cost and these were described and tabulated.

Main results:

Twenty-five studies and five published abstracts were included. Of the 25 full peer-reviewed studies meta-analysed, 16 evaluated structured telephone support (5613 participants), 11 evaluated telemonitoring (2710 participants), and two tested both interventions (included in counts). Telemonitoring reduced all-cause mortality (RR 0.66, 95% CI 0.54 to 0.81, P < 0.0001) with structured telephone support demonstrating a non-significant positive effect (RR 0.88, 95% CI 0.76 to 1.01, P = 0.08). Both structured telephone support (RR 0.77, 95% CI 0.68 to 0.87, P < 0.0001) and telemonitoring (RR 0.79, 95% CI 0.67 to 0.94, P = 0.008) reduced CHF-related hospitalisations. For both interventions, several studies improved quality of life, reduced healthcare costs and were acceptable to patients. Improvements in prescribing, patient knowledge and self-care, and New York Heart Association (NYHA) functional class were observed.

Authors' conclusions:

Structured telephone support and telemonitoring are effective in reducing the risk of all-cause mortality and CHF-related hospitalisations in patients with CHF; they improve quality of life, reduce costs, and evidence-based prescribing.

This record should be cited as:

Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD007228. DOI: 10.1002/14651858.CD007228.pub2

Assessed as up to date:

November 21, 2008

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Primary Review Group:

Heart Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is structured telephone support or telemonitoring for patients with chronic heart failure (HF)?

Bottom line:

Compared with standard practice, structured telephone support and telemonitoring programmes for patients with chronic HF living in the community reduced the risk of all-cause mortality by 12% and more than one-third respectively, reduced the risk of chronic HF hospitalisation by more than one-fifth and may have reduced all-cause hospitalisations by 8% to 9%. For both interventions, there was improved quality of life and reduced healthcare costs, and the technology was acceptable to patients. There were also improvements in prescribing, patient knowledge and self-care, and New York Heart Association functional class.

Caveat:

Although a reduction in the proportion of participants with an allcause or chronic HF-related hospitalisation was observed, the review did not identify a consistent impact of structured telephone support or telemonitoring on length of stay for such admissions. Length of stay was inconsistently reported, thus preventing metaanalysis of this outcome.

Context:

In the context of limited health funding, and a rapidly expanding population of older patients with chronic HF, it is increasingly difficult for healthcare systems to provide high-quality care to patients with chronic HF. Multidisciplinary specialist HF clinics are available only to a minority of patients and do not have the capacity for frequent patient review. Patients may be unwilling or unable to attend frequent clinic appointments due to disability or financial and transport constraints. Structured telephone support and telemonitoring can provide specialised HF care to a large number of patients with limited access to healthcare services.

Cochrane Systematic Review:

Inglis SC et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Reviews, 2010, Issue 8. Article No. CD007228. DOI: 10.1002/14651858.CD007228. pub2. This review contains 25 studies and 5 published abstracts involving 9603 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Heart & circulation > Heart failure > Organization of care

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Structured telephone support and telemonitoring in the management of patients with chronic heart failure

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