E-Health in Self-Care of Heart Failure Patients: Promises Become Reality

This article refers to “Effectiveness of the European Society of Cardiology/Heart Failure Association website ‘heartfailurematters.org’ and an e-health adjusted care pathway in patients with stable heart failure: results of the ‘e-Vita HF’ randomized controlled trial” by K.P. Wagenaar et al., published in this issue on pages xxx. With important gains in mortality achieved through pharmacological and device therapy in patients with heart failure (HF) over the past decade, the focus is increasingly shifting towards reducing recurrences, rehospitalization and therefore optimizing health-related quality of life (HRQoL). HF patients are prepared to trade off longevity for an improvement in HRQoL.1 Meta-analyses of exercise-based cardiac rehabilitation (CR) in patients with HF reported important improvements in HRQoL and a reduction in rehospitalizations,2 and therefore international guidelines consistently recommend group or centre-based CR.3 However, less than 50% of HF patients in Europe actually participate in CR and secondary prevention programmes, prompting a call to identify newer strategies to improve participation and to explore the effectiveness of more accessible alternatives to group- or centre-based interventions.4 Home-based intervention programmes can widen the access and have been shown to be as effective as group- or hospital-based CR after myocardial infarction and coronary revascularization, and with similar costs. In a randomized multicentre trial, participants with HF who received the novel REACH-HF home-based CR intervention for 12 weeks in addition to usual care had superiority in disease-specific HRQoL and self-management at 12 months compared with usual care alone. The cost of the REACH-HF intervention (GBP 418.39 per participant) falls within the National Health Service tariff for CR in England of GBP 477 per patient.5 Self-management interventions could have a beneficial effect on hospitalization, mortality, and HF-related quality of life, an effect that may act through better adherence to evidence-based treatment.6 Incorporation of computing technologies in healthcare (so called e-health) may be particularly patient-friendly as it enables self-care activities at a time and place convenient for the individuals, with elimination of travel time to the hospital. An example of the implementation of e-health is the e-Vita platform, an interactive platform for HF disease management with telemonitoring facilities, created in the Netherlands with the aim at replacing routine consultations. Another e-health tool is the Heart Failure Association website ‘heartfailurematters.org’ (HFM website), which provides information targeted at patients and their family/carers to improve self-care. Although the site is used intensively and translated in several languages, its effect on patient outcomes has never been evaluated.7 In this issue of the Journal, a study evaluated both the e-Vita platform and the HFM website in comparison to usual care alone in stable HF patients. The primary outcome was self-care [assessed by the European Heart Failure Self-care Behaviour (EHFScB) scale] and the secondary outcomes were health status, hospitalizations and all-cause mortality.8 An improvement in self-care at 3 months when received the HFM website compared to usual care alone (mean score on EHFScB scale 73.5 vs. 70.8; difference 2.7, 95% confidence interval 0.6–6.2) was observed. The e-Vita platform resulted in an even higher improvement when compared to usual care (mean 78.2 vs. 70.8; difference 7.4, 95% confidence interval 3.8–9.4). These effects attenuated during the following 9 months, and no clear differences were seen at 12 months between groups. Secondary outcomes such as HRQoL and HF knowledge showed a similar trend, but mortality and hospitalizations did not clearly differ between groups. A shortcoming of applying a scale such as the EHFScB scale is that its clinical relevance is unclear and that a significant difference was detected only in the first 3 months. The secondary outcomes of all-cause and HF-related mortality and hospitalizations were not significant, but the study was designed and powered for the primary outcome self-care, and the sample size was insufficient (underpowered) to formally compare these outcomes between groups. Regarding generalization of the results, the mild severity of HF (79% New York Heart Association class I or II) of the study population should be acknowledged. We may assume that the effects of the studied interventions could be larger in patients with more severe HF, and in settings with a lower level of care as usual for HF as in the Netherlands. Nevertheless, based on these study results, the use of the HFM website may be recommended to educate HF patients. The website may positively effects self-care, is freely accessible, and the use by patients or their relatives followed by discussion with the HF nurse does not require serious changes in the infrastructure of the healthcare system. In this light, it is noteworthy to mention that recently a combined telerehabilitation and centre-based programme, followed by transitional telerehabilitation, induced persistent health benefits and remained cost-efficient up to 2 years after the end of the intervention. Telerehabilitation is defined as the remote delivery of rehabilitation services via telecommunication technologies, including the phone, the internet and videoconference communication between the patient and healthcare provider. It encompasses a comprehensive programme with multiple components such as telemonitoring, telecoaching, and e-learning.9 A partial decline of the benefits originally achieved did occur once the tele-intervention ended. Healthcare professionals should reflect on how innovative cost-efficient care models could be implemented on the long term in standard care. Future research should focus on key behaviour change techniques in technology-based interventions that enable full persistence of long-term behaviour change and health benefits. To decide on implementation of an e-health adjusted care pathway, further research on sustainability of the effect and cost-effectiveness would also be needed. Conflict of interest: none declared.