{"id":4565,"date":"2010-11-16T16:51:44","date_gmt":"2010-11-16T21:51:44","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=4565"},"modified":"2011-07-19T17:45:11","modified_gmt":"2011-07-19T21:45:11","slug":"%e2%80%9cphone-it-in%e2%80%9d-heart-failure-monitoring-offers-no-advantage-over-usual-care","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2010\/11\/16\/%e2%80%9cphone-it-in%e2%80%9d-heart-failure-monitoring-offers-no-advantage-over-usual-care\/","title":{"rendered":"\u201cPhone It In\u201d Heart-Failure Monitoring Offers No Advantage Over Usual Care"},"content":{"rendered":"

CardioExchange welcomes Sarwat I. Chaudhry, first author of an NHLBI-funded trial in which 1653 recently hospitalized heart-failure patients were randomized to telemonitoring or usual care. The findings, published in the New England Journal of Medicine<\/a>, failed to show an advantage of telemonitoring in the primary endpoint: rehospitalization for any reason or death from any cause within 180 days after enrollment (52.3% for telemonitored patients, 51.5% for usual-care patients).<\/em><\/p>\n

Telemonitoring was conducted via a telephone-based voice-response system. Every day, patients in the telemonitoring group phoned in information about their symptoms and weight, which was reviewed on weekdays by site coordinators. Predetermined, clinically relevant \u201cvariances\u201d in patients\u2019 responses flagged clinicians\u2019 attention. Here, Chaudhry answers questions about the trial, posed by CardioExchange editor Anju Nohria, MD<\/a>.<\/em><\/p>\n

Q: You report that adherence to the telemonitoring system deteriorated over time: Only 55% of patients were still using it at least 3 times per week by the end of the trial. Physicians\u2019 rate of adherence (attention) to the flagged \u201cvariances\u201d is not reported \u2014\u00a0can you share that information with us? Also, how often did the physicians actually change therapy in response to a variance, and how often did they simply document a noted variance and choose not to intervene?<\/strong><\/p>\n

A: Our protocol required clinicians to check the telemonitoring information every business day and to document their responses to variances. The study Coordinating Center examined this documentation every 2 to 3 weeks to ensure that the variances were being reviewed. Therefore, we can say with confidence that the information was being carefully considered in a timely manner. Although physicians were required to document their management of variances, they didn\u2019t record the information systematically. We do know that the cardiologists responsible for clinical management of patients\u2019 heart failure made purposeful decisions about medication adjustments, education about dietary indiscretions, referrals for office visits, and so on.<\/p>\n

Q: Do you think the findings might have been different if the telemonitoring system had required patients to call in weekly rather than daily? For example, might a once-a-week protocol have improved both patient and physician adherence, and also allowed patients a chance to perceive changes in how they felt, such that their responses would trigger a variance?<\/strong><\/p>\n

A: It is difficult to know whether less frequent monitoring would have produced a different result. Part of the goal of a daily monitoring intervention is that it becomes part of a patient’s daily habit. In fact, patients were instructed to phone into the telemonitoring system shortly after measuring their body weight in the morning, so that the call would become routine. Also, the opportunity to detect early changes in health may be lost with a less frequent intervention.<\/p>\n

Q: The article does not describe the \u201cusual care.\u201d\u00a0Did it typically involve a nurse-based heart-failure management program, or individual physicians who responded to patient calls as needed?<\/strong><\/p>\n

A: Similar to national practice patterns, \u201cusual care\u201d did not typically include nurse-based heart-failure management programs. Our sites were general cardiology practices, and such resources are not widely available. As in standard clinical settings, patients in usual care contacted physicians when they felt they needed to do that. There were no proactive contacts by clinicians.<\/p>\n

Q: Does your study allow you to draw any broader conclusions about clinical management?<\/strong>
\n<\/em>
\nA:\u00a0It\u2019s important to keep in mind that our study was a rigorous examination of one approach to telemonitoring. It should not be misapplied to telemonitoring or disease management in general. Other components \u2014<\/em> such as patient education, medication support, or interventions aimed at patients\u2019 caregivers \u2014<\/em> may ultimately prove to be more effective. Such strategies for supporting patients and physicians must be carefully tested before they are adopted widely.<\/p>\n

CardioExchange readers, what conclusions do you draw from the telemonitoring in heart failure trial and its negative findings?<\/p>\n

Editorial Note: CardioExchange editor Dr. Harlan Kumholz was the senior investigator on this trial.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

CardioExchange welcomes Sarwat I. Chaudhry, first author of an NHLBI-funded trial in which 1653 recently hospitalized heart-failure patients were randomized to telemonitoring or usual care. The findings, published in the New England Journal of Medicine, failed to show an advantage of telemonitoring in the primary endpoint: rehospitalization for any reason or death from any cause […]<\/p>\n","protected":false},"author":196,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[14],"tags":[287],"class_list":["post-4565","post","type-post","status-publish","format-standard","hentry","category-heart-failure","tag-heart-failure-2"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/4565","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/196"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=4565"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/4565\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=4565"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=4565"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=4565"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}