Review
Accounting for Complexity in Home Telemonitoring: A Need for Context-Centred Evidence

https://doi.org/10.1016/j.cjca.2018.01.022Get rights and content

Abstract

Heart failure represents a significant burden for patients and the Canadian health care system. Home telemonitoring is proposed as an intervention that can improve heart failure outcomes by identifying opportunities for earlier clinical intervention and by providing patients with self-management support between scheduled clinic visits. The objective of this review is to provide clarity with respect to the most recent evidence of the effect of home telemonitoring on heart failure outcomes. Despite some strong evidence that telemonitoring can reduce the risk of mortality and heart failure-related hospitalizations, important inconsistencies exist in the evidence. This article proposes that much of the inconsistency results from differences in the patient population being studied, the type of home telemonitoring intervention, and the implementation setting. Also important is the degree to which intervention fidelity is maintained throughout the course of a study; this is emphasized through a review of the factors that influence the degree to which patients and health care providers use home telemonitoring interventions as intended. In this article we propose that for researchers to produce definitive answers regarding the effect of home telemonitoring on heart failure outcomes, interventions and studies need to be designed and tailored according to the characteristics of the target patient population and the implementation context.

Résumé

L’insuffisance cardiaque représente un fardeau important pour les patients et le système de soins de santé canadien. La télésurveillance à domicile est proposée en tant qu’intervention susceptible d’améliorer les résultats dans les cas d’insuffisance cardiaque, du fait qu’elle permet de cerner les possibilités d’intervention clinique précoce et procure aux patients une assistance en matière d’autoprise en charge entre les rendez-vous en clinique. Le présent article de synthèse vise à faire la lumière sur les preuves les plus récentes de l’effet de la télésurveillance à domicile sur les résultats dans les cas d’insuffisance cardiaque. Des données convaincantes montrent que la télésurveillance peut réduire le risque de mortalité et d’hospitalisations liées à l’insuffisance cardiaque. Néanmoins, ces données présentent d’importantes incohérences. Ces incohérences sont, selon nous, attribuables en grande partie aux différences touchant la population de patients étudiée, le type de télésurveillance à domicile et le cadre de mise en œuvre. Le degré d’observance des modalités de l’intervention tout au long d’une étude a aussi de l’importance; ce fait ressort de l’examen des facteurs qui influent sur le degré de concordance entre la mise en œuvre effective de la télésurveillance à domicile par les patients et les professionnels de la santé, et la mise en œuvre prévue. Pour que les chercheurs puissent caractériser de façon définitive l’effet de la télésurveillance à domicile sur les résultats dans les cas d’insuffisance cardiaque, nous estimons que les interventions et les études doivent être conçues en fonction des caractéristiques de la population de patients cible et du contexte de mise en œuvre, et y être adaptées.

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.

  • 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.

References (57)

  • L.M. Collins et al.

    Factorial experiments: efficient tools for evaluation of intervention components

    Am J Preventive Med

    (2014)
  • J.E. Yun et al.

    Comparative effectiveness of telemonitoring versus usual care for heart failure: a systematic review and meta-analysis

    J Card Fail

    (2018)
  • Heart and Stroke Foundation. The Burden of Heart Failure. 2017. Available at:...
  • T. Greenhalgh et al.

    Understanding heart failure; explaining telehealth–a hermeneutic systematic review

    BMC Cardiovasc Disord

    (2017)
  • J.S. Ross et al.

    Recent national trends in readmission rates after heart failure hospitalization

    Circ Heart Fail

    (2010)
  • Y.H. Jeon et al.

    The experience of living with chronic heart failure: a narrative review of qualitative studies

    BMC Health Serv Res

    (2010)
  • A.S. Desai et al.

    Rehospitalization for heart failure

    Circulation

    (2012)
  • N.H. Jonkman et al.

    Do self-management interventions work in patients with heart failure?

    An individual patient data meta-analysis

    (2016)
  • S. Kitsiou et al.

    Effects of home telemonitoring interventions on patients with chronic heart failure: an overview of systematic reviews

    J Med Internet Res

    (2015)
  • A.M. Clark et al.

    A systematic review of the main mechanisms of heart failure disease management interventions

    Heart

    (2016)
  • I. Vassilev et al.

    Assessing the implementability of telehealth interventions for self-management support: a realist review

    Implement Sci

    (2015)
  • R. Dierckx et al.

    Telemonitoring in heart failure: Big Brother watching over you

    Heart Fail Rev

    (2015)
  • N. Bashi et al.

    Remote monitoring of patients with heart failure: an overview of systematic reviews

    J Med Internet Res

    (2017)
  • R.C. Mohan et al.

    Remote monitoring in heart failure: the current state

    Curr Treat Options Cardiovasc Med

    (2017)
  • C. Palaniswamy et al.

    Remote patient monitoring in chronic heart failure

    Cardiol Rev

    (2013)
  • E. Piotrowicz

    The management of patients with chronic heart failure: the growing role of e-Health

    Exp Rev Med Dev

    (2017)
  • R. Purcell et al.

    Telemonitoring can assist in managing cardiovascular disease in primary care: a systematic review of systematic reviews

    BMC Fam Pract

    (2014)
  • N. Nakamura et al.

    A meta-analysis of remote patient monitoring for chronic heart failure patients

    J Telemed Telecare

    (2014)
  • Cited by (12)

    • Effectiveness of Mobile Health Technology Interventions for Patients With Heart Failure: Systematic Review and Meta-analysis

      2021, Canadian Journal of Cardiology
      Citation 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

    View all citing articles on Scopus

    See page 902 for disclosure information.

    View full text