Taking a Look at Telemonitoring Use in Patients with Heart Failure

When Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM, FAAN, and colleagues reviewed literature on telemonitoring use in adults with chronic heart failure, they were surprised by the results. Reports on randomized, controlled, multicenter studies indicated that telemonitoring did not improve clinical outcomes.

“Heart failure is a chronic, complex condition, and telemonitoring can help simplify communications with patients,” says Dr. Albert, ACNO of Nursing Research and Innovation at Cleveland Clinic. “So my research collaborators and I were intrigued when telemonitoring research did not lead to improved clinical outcomes, for example, improved hospitalization, quality of life or survival.” Albert and nine other researchers from Denmark, the University of California at Berkeley and University of California, Davis Medical Center decided to explore factors associated with telemonitoring use among patients with mild to severe heart failure.

Study methods and procedures

Before initiating the study, researchers spent three days hypothesizing and discussing factors that were thought to be associated with telemonitoring use. The list was far-reaching, from age and education level of the patient to history of using devices such as smart phones. Albert and her colleagues grouped factors into four categories for study purposes – patient characteristics, global health factors, heart failure factors and device factors.

The international study used a cross-sectional design with convenience sampling and questionnaire methods. Three sites were used to increase the generalizability of the findings – Cleveland Clinic, UC Davis Medical Center and Vendsyssel Hospital in Denmark.

Prior to completing a questionnaire, all 206 participants watched a six-minute video that explained three remote telemonitoring device solutions. These included a tabletop tablet, a smartphone and a key fob. The video described the ease of use, features and potential telemonitoring capabilities of all three devices. Immediately following the video, participants completed a 27-item device questionnaire and 74-item multiple themes questionnaire.

Results of the study

Dr. Albert shared some of the most noteworthy findings within three of the four factor groupings:

• Device Factors – Two primary findings stood out: Patients desired two-way communication and preferred a smartphone device over other options. “We hypothesize that adults are just more comfortable with smartphones because they already use them in daily life,” says Dr. Albert. Two-way communication was an important finding as most telemonitoring studies collected data from patients, but did not always provide information back to patients. When patients do not know or understand what happens to the data that was transmitted, they may not trust that telemonitoring holds value for them.
• Patient Characteristics – Very few patient characteristics significantly affected the potential use of telemonitoring devices. One interesting finding was related to the type of insurance patients had. For example, patients with government insurance (such as Medicare and Medicaid or Danish insurance) were less likely to have and use device applications, were less likely to believe that telemonitoring could help prevent worsening of heart failure and were less likely to track measured values and communicate with nurses using a device. “More research is needed to learn if results were primarily reflecting U.S. patients, who were older and had more severe heart failure, or Danish patients, who were enrolled from home and had milder heart failure,” says Dr. Albert.
• Heart Failure Factors – If patients had 12 or more symptoms of heart failure, they were less likely to prefer any device. “We interpreted this finding to mean that patients with multiple symptoms wanted to discuss their condition face-to-face with healthcare providers rather than deal with a telemonitoring device,” says Dr. Albert. Similarly, participants who had the least number of symptoms – patients in New York Heart Association Functional Class I and II – had the highest self-confidence using devices. “Most device companies gear telemonitoring toward adults with moderate symptoms of heart failure in an effort to reduce symptoms,” says Dr. Albert. “Our findings might explain why previous research studies did not achieve the effects they were hoping for.”

Complete results of the study were published as an EPub ahead of print in February in the Journal of Telemedicine and Telecare.

The future of telemonitoring

Examining the factors that affect telemonitoring use in patients with heart failure is an important step in ultimately using the technology to effectively care for patients. “Population health is important, and down the road people are going to want to take care of themselves from their home,” says Dr. Albert. “In the future, interactions [with healthcare professionals] will happen remotely, whether by telephone, Skype or some other mode of communication. We need to learn how to make telemonitoring beneficial so it can match the needs of our patients.”