ReviewAccounting for Complexity in Home Telemonitoring: A Need for Context-Centred Evidence
Section snippets
The Effect of HT on HF Outcomes: What Do We Know?
Table 1 presents the results from meta-analyses published in the past 5 years on the effect of HT on 2 critical outcomes: all-cause mortality and HF-related hospitalizations. Whereas meta-analyses have shown that HT reduces all-cause mortality and HF-related hospitalizations, important differences exist in terms of significance of the results as well as the magnitude of the effect. Fewer meta-analyses report on quality of life and other health outcomes. Those that did were unable to draw clear
Evidence Is Plagued by Heterogeneity
Potential reasons for the lack of a clear answer regarding the effect of HT on HF outcomes include heterogeneity of the HF literature in terms of: patient population (eg, disease severity), characteristics of the interventions evaluated, and quality of the trial (eg, degree to which the intervention was used as intended).20, 21, 28, 29, 30 We contend that HT cannot, and should not be considered as a single intervention when attempting to draw conclusions of the effect of HT on HF outcomes.
A Path Forward: Generating Patient and Context-Centred Evidence
The evidence for HT is likely strong enough to convince early adopters who are confident in its potential. However, more robust and consistent evidence is required to convince skeptics and decision-makers who must decide if, and how to fund wide-scale implementation of these systems. In Figure 2, we outline a series of questions on the basis of knowledge gaps identified in the reviewed literature. These questions are categorized in 4 steps that provide a logical plan for how the necessary
Filling in the Gaps
The questions identified in Figure 2 cannot be answered by a single research study, rather, it requires collective action among HT researchers. Following are some examples of how individual researchers can play a role.
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As was done in some of the meta-analyses reviewed,9, 20, 32 subgroup analyses can be performed to understand which patients, and in which circumstances, benefit from different types of HT interventions. However, this approach comes with important methodological limitations9 and
Conclusion
HT has been shown to reduce mortality and HF hospitalizations and improve clinical outcomes in HF patients. Despite this evidence, significant heterogeneity exists in the design of HT interventions, the implementation context, and outcomes of individual studies, leading to ambiguity about the true effect of HT on HF outcomes. HT is not one, but rather a collection of complex interventions for which success or failure is linked to a range of contextual factors. These factors cannot be ignored if
Disclosures
The authors have no conflicts of interest to disclose.
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2021, Canadian Journal of CardiologyCitation Excerpt :Finally, studies were clinically and methodologically diverse in terms of sample size, follow-up, intensity of usual care, care settings, and intervention characteristics. Although there was no statistically significant heterogeneity among the included studies, it is unknown how these clinical, methodological, and contextual differences might affect the results.57 mHealth interventions are complex in nature and their efficacy is directly linked to a range of contextual factors.57,58
Remote monitoring of heart failure patients: A complex proximity
2021, Revista Portuguesa de CardiologiaEvaluation of a heart failure telemonitoring program through a microsimulation model: Cost-utility analysis
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