Combined telemonitoring and telecoaching for heart failure improves outcome

Abstract

Telemedicine has been shown to improve the outcome of heart failure (HF) patients in addition to medical and device therapy. We investigate the effectiveness of a comprehensive telehealth programme in patients with recent hospitalisation for HF on subsequent HF hospitalisations and mortality compared to usual care in a real-world setting. The telehealth programme consists of daily remote telemonitoring of HF signs/symptoms and regular individualised telecoaching sessions. Between January 2018 and September 2020, 119,715 patients of a German health insurer were hospitalised for HF and were eligible for participation in the programme. Finally, 6065 HF patients at high risk for re-hospitalisation were enroled. Participants were retrospectively compared to a propensity score matched usual care group (n = 6065). Median follow-up was 442 days (IQR 309-681). Data from the health insurer was used to evaluate outcomes. After one year, the number of hospitalisations for HF (17.9 vs. 21.8 per 100 patient years, p < 0.001), all-cause hospitalisations (129.0 vs. 133.2 per 100 patient years, p = 0.015), and the respective days spent in hospital (2.0 vs. 2.6 days per year, p < 0.001, and 12.0 vs. 13.4, p < 0.001, respectively) were significantly lower in the telehealth than in the usual care group. Moreover, participation in the telehealth programme was related to a significant reduction in all-cause mortality compared to usual care (5.8 vs. 11.0 %, p < 0.001). In a real-life setting of ambulatory HF patients at high risk for re-hospitalisation, participation in a comprehensive telehealth programme was related to a reduction of HF hospitalisations and all-cause mortality compared to usual care.

Fig. 1. Study flow.

*ACRA-LoH = likelihood of hospitalisation (LoH) calculated with the adaptable, comprehensive, risk assessment methodology (ACRA) based on historical data of patients from the insurance company.

Fig. 2. Kaplan–Meier-plots of the all-cause mortality probability (continuous line) with 95%-confidence interval (dotted line) in the intention-to-treat-analysis.

Hazard ratio 0.62, 95%-confidence interval: 0.56–0.69, p < 0.001, Wald-test. Blue line: Telehealth group (TH). Red line: Usual care group (UC).

Fig. 3. Competing risk curve for time to first hospitalisation with specific main diagnosis and death as competing risk in the telehealth intervention (TH) and usual care (UC) group.

a Hospitalisation with main diagnosis heart failure, b Hospitalisation with main diagnosis cardiovascular disease, c All-cause hospitalisations. Blue line: Telehealth group. Red line: Usual care group.

Fig. 4. Differences in hospitalisations rates (per 100 patient years with 95%-confidence interval) and average length of stay for different main diagnoses of hospitalisation in telehealth (TH) versus usual care (UC) group.

Solid diamonds and bold diagnoses indicate statistical significance (p < 0.05 after adjustment for multiple comparisons, Wald-test), empty diamonds statistically non-significant diagnoses (p > 0.05 after adjustment for multiple comparisons, Wald-test). The bars indicate the 95%-confidence interval for the differences.

Fig. 5. Self-Care Behaviour (EHFScBS-9) at start of programme (black) compared to follow-up after 1 year (blue).

Values standardised to 0–100, with 100 meaning full agreement. The numbers at the top indicate the change after one year. The star indicates statistically significant differences between start of programme and 1-year follow-up with a p-value of <0.001 (paired Wilcoxon tests). Black: Start of programme. Blue: After one year. Questions: 1: I weigh myself every day, 2: If shortness of breath increases, I contact my doctor or nurse, 3: If my legs/feet are more swollen, I contact my doctor or nurse, 4: If I gain weight more than 2 kg in 7 days, I contact my doctor or nurse, 5: I limit the amount of fluids (no more than 1.5–2 litres a day), 6: If I experience fatigue, I contact my doctor or nurse, 7: I eat a low-salt diet, 8: I take my medication as prescribed, 9: I exercise regularly.