By Van Selby, MD
Assistant Professor of Medicine, University of California, San Francisco Cardiology Division, Advanced Heart Failure Section
Dr. Selby reports no financial relationships relevant to this field of study.
SYNOPSIS: In patients with chronic heart failure, adding a remote patient management program to usual care was associated with improvement in unplanned cardiovascular hospitalization or death.
SOURCE: Koehler F, Koehler K, Deckwart O, et al. Efficacy of telemedical interventional management in patients with heart failure
(TIM-HF2): A randomised, controlled, parallel-group, unmasked trial. Lancet 2018;392:1047-1057.
Telemedicine allows healthcare providers to evaluate, diagnose, and treat patients remotely. This could improve the management of chronic diseases such as heart failure (HF) that require regular, frequent monitoring and treatment adjustments. The results of several studies have suggested telemedicine may improve outcomes for patients with HF, but there are no strong guideline recommendations regarding its use. Further, routine telemedicine for HF has not been adopted widely.
The authors of the Telemedical Interventional Management in Heart Failure II (TIM-HF2) trial randomized 1,571 patients with New York Heart Association (NYHA) class II or III chronic HF to receive standard care with or without a telemedicine intervention. Patients with depression were excluded from the study. The telemedicine intervention consisted of daily transmission of body weight, blood pressure, heart rate, heart rhythm analysis, oxygen saturation, and a self-rated health status. This information was transmitted to a telemedical center staffed by nurses and physicians 24 hours per day. The telemedical center was in contact with the patient’s primary care and cardiology providers to make timely recommendations regarding changes to management. The telemedical nurses also provided monthly HF-related educational sessions over the phone.
For the primary outcome of days lost due to unplanned cardiovascular hospitalization or all-cause mortality, the telemedicine group saw a significant reduction (4.9% vs. 6.6%; hazard ratio [HR], 0.80; P = 0.0460). Telemedicine also was associated with a reduction in all-cause mortality (7.9 vs. 11.3 per 100 patient-years; HR, 0.70; P = 0.028). For the secondary outcome of cardiovascular death, there was a trend toward improvement that did not quite reach statistical significance (HR, 0.67; P = 0.056). Ninety-seven percent of patients in the telemedicine group were compliant with daily data transfer to the telemedical center. The authors concluded that a structured remote patient management intervention could reduce the percentage of days lost to unplanned cardiovascular admissions and all-cause mortality.
COMMENTARY
Advances in information technology and remote monitoring have created new opportunities to treat patients outside the hospital or clinic. For a disease like chronic HF, telemedicine is seen as a promising tool to prevent exacerbations or at least identify and treat them early. Koehler et al found that a structured telemedicine intervention reduced the composite of unplanned days hospitalized or mortality, driven primarily by a reduction in mortality. This adds to the growing evidence supporting the use of telemedicine in HF and suggests telemedicine will play a growing role in our management of these patients.
It is important to stress the holistic approach used in this trial. The telemedicine intervention involved a telemedical center that received and interpreted data 24 hours a day and worked closely with healthcare providers to intervene when necessary. The ability to react to abnormal data and promptly intervene with appropriate treatment is crucial to improving outcomes with remote management programs. Previous studies of remote monitoring systems have revealed an association between the number of treatment changes made and improvement in outcomes. In other words, a telemonitoring program is not enough; there must be a system in place to intervene when needed.
Another important finding is the ability to use these remote monitoring technologies in chronic HF patients, who often are elderly (up to 92 years of age in this trial) and less comfortable with technology vs. other patients. It is important to remember that patients with depression (one-third of patients screened for this study) were excluded. The exact reason why depressed patients would not respond to telemedicine could not be answered by this study, although it may be related to lack of engagement with the monitoring platform and their willingness to participate in daily check-ins and communication with the telemedicine center. This issue will require further study. There were a few critical limitations in this study. The telemedicine intervention used requires the availability of a comprehensive telemedical center with 24-hour staffing. Such centers are not widely available today. Furthermore, the intervention studied was tailored to the German healthcare system, where the study took place. Adjustments likely would be required before implementing a similar system in the United States.
Some centers and providers have already started implementing aspects of telemedicine into their management of chronic HF patients, with close monitoring, regular check-ins, and medication adjustments made over the phone rather than waiting for the next visit. There are issues related to billing, integration into the electronic medical record, and general acceptance among healthcare practitioners that must be solved before telemedicine is widely adopted. However, the results of the TIM-HF2 trial and other studies suggest we need to be receptive to incorporating telemedicine into our HF care.
In patients with chronic heart failure, adding a remote patient management program to usual care was associated with improvement in unplanned cardiovascular hospitalization or death.
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