Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk for Recurrent Admission and Death

Abstract. Objectives. We sought to identify whether home telemonitoring (HTM) improves outcomes compared with nurse telephone support (NTS) and usual care (UC) for patients with heart failure (HF) who are at high risk for hospitalization or death. Background. HF is associated with a high rate of hospitalization and poor prognosis. Telemonitoring could help implement and maintain effective therapy and promptly detect worsening HF and its cause to prevent medical crises. Methods. Patients with a recent admission for HF and left ventricular ejection fraction <40% were randomly assigned to HTM, NTS, or UC in a 2:2:1 ratio. HTM consisted of twice-daily patient self-measurement of weight, blood pressure, heart rate, and rhythm with automated devices linked to a cardiology center. The NTS consisted of specialist nurses who were available to patients by telephone. Primary care physicians delivered UC. The primary end point was number of days dead or hospitalized with NTS vs. HTM at 240 days. Results. Of 426 patients who were randomly assigned, 48% were older than 70 years of age, with a mean left ventricular ejection fraction of 25% (SD, 8%) and a median plasma N-terminal pro-brain natriuretic peptide of 3070 pg/mL (interquartile range, 1285–6749 pg/mL). During 240 days of follow-up, 19.5%, 15.9%, and 12.7% of days were lost as a result of death or hospitalization for UC, NTS, and HTM, respectively (no significant difference). The number of admissions and mortality were similar among patients randomly assigned to NTS or HTM, but the mean duration of admissions was reduced by 6 days (95% confidence interval 1–11) with HTM. Patients randomly assigned to receive UC had higher 1-year mortality (45%) than patients assigned to receive NTS (27%) or HTM (29%) (p=0.032). Conclusion. Further investigation and refinement of the application of HTM are warranted because it may play a valuable role in the management of HF in select patients.—Cleland JG, Louis AA, Rigby AS, et al, for the TEN-HMS Investigators. Noninvasive home telemonitoring for patients with heart failure at high risk of recurrent admission and death: the Trans-European Network-Home-Care Management System (TEN-HMS) study. J Am Coll Cardiol. 2005;45(W):1654–1664 Comment. Chronic HF is the only major cardiovascular disease that is increasing in incidence and prevalence in the United States. This rising chronic HF disease burden in the developed world is driven partly by the aging of the population; however, the burden is also a legacy of our substantial progress in thwarting deadly cardiac events. Many acute deaths have been averted with increased use of thrombolytics and primary angioplasty, for example, and many acute events have been avoided completely with expanded use of primary and secondary prevention for high-risk patients with agents such as β blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, spironolactone, and defibrillating devices. While treating CHF, at first glance, disease management would not appear to be a primary issue to address. It is not based on new insights into the biology of HF and, indeed, is not a new concept at all. Yet evidence continues to emerge that the reorganization of the delivery of care to patients with HF may have the impact on outcomes that new drug treatments have not. In the present study, authors report results from a randomized trial of a uniquely structured disease-management program from 12 hospitals in Germany, the Netherlands, and the United Kingdom. The intervention they tested consisted of monthly telephone contact with a nurse, augmented by daily transmission of information on patients' weight, blood pressure, and cardiac rhythm using innovative phone line technology. The study was rigorously conducted and analyzed and contained comparisons of both UC and nurse contact without the addition of the telemonitoring technology. The study was terminated early because patients in the control arm had statistically higher mortality than patients in the disease-management arms and because benefit was statistically unlikely for the telemonitoring arm. The results were durable over a median of 484 days of follow-up. This study strongly suggests that HTM or a nurse-based HF service, using more conventional telephone support (i.e., NTS), can substantially reduce mortality in patients with HF and left ventricular systolic dysfunction who have recurrent HF admissions. The reduction in mortality is achieved without an increase in the duration of time spent in the hospital. Compared with NTS, HTM substantially reduced the duration of hospital admissions and the number of home or office visits. The combined benefits on mortality and consumption of health care resources suggest that HTM may have an important role in the management of HF. Although the primary hypothesis was not proved, this study suggests that HTM may be the most cost effective solution for the delivery of expert care to patients with HF. This is one of the first substantial, prospective, randomized trials on HTM for patients with HF. The results are sufficiently encouraging to warrant both service development and further research. Improved selection of patients and tailoring of the duration of HTM to the patient's needs could enhance the benefits and lower the costs of therapy. With limitations, this study suggests that intensive monitoring by “telenurses” or by telemanagement may reduce hospital stay and improve mortality compared with usual care.