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Long-Term Outcomes of Remote Patient Monitoring After Acute HF
Quick Takes
- In this randomized controlled trial of patients after a heart failure hospitalization, there is no difference in a composite outcome of all-cause death and hospitalization with a post-discharge telephone-based remote patient management strategy with usual care compared to usual care alone.
- Long-term outcomes after completion of intervention suggests a possible mortality benefit with the telephone-based remote patient management strategy with usual care, though the exact reason for this observation is unclear.
Study Questions:
In the E-INH (Extended Interdisciplinary Network Heart Failure) trial, does an 18-month use of a remote patient management (RPM) strategy in addition to usual care after a hospitalization for heart failure improve outcomes?
Methods:
The original INH (Interdisciplinary Network Heart Failure) trial was a prospective, randomized, multicenter study that examined the effect of a telephone-based, nurse-coordinated RPM strategy in patients after a heart failure (HF) hospitalization. There was no difference in the primary outcome of time to all-cause death or hospitalization at 6 months. E-INH is an extension of this original study including a larger cohort of patients and longer duration of intervention and follow-up.
Patients were enrolled between March 2004 and December 2008. Eligible patients were age ≥18 years, hospitalized for an acute HF exacerbation, and had a left ventricular ejection fraction (LVEF) ≤40%. Exclusion criteria included new-onset structural heart disease and inability to participate in telephone-based interventions. Enrolled patients were randomized to intervention (RPM along with usual care) or control (usual care) arms. RPM included specialized nursing education during hospitalization and post-discharge monitoring of vital signs and symptoms, frequent telephone communication, medication titration, education on medications and lifestyle modifications, action plans for evidence of worsening HF, and coordination of multidisciplinary comorbidity management. Less frequent telephone calls occurred in months 7-18. The RPM intervention ended at 18 months. Usual care included standard discharge planning, recommendations for HF therapies, and a clinic visit in 7-14 days.
Follow-up visits occurred at baseline and 6, 12, 18, 36, 60, and 120 months. The primary composite outcome was time to all-cause death or all-cause hospitalization assessed at 18 and 60 months. Secondary outcomes included all-cause death, all-cause hospitalization, cardiovascular mortality and hospitalizations, and changes to health-related quality of life (QOL).
Results:
A total of 1,022 patients were included in this study, with 509 in the intervention (RPM along with usual care) and 513 in the control (usual care) group. There was no difference between the intervention and control groups for the primary outcome at 18 months (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.82-1.13; p = 0.63) and 60 months (HR, 0.88; 95% CI, 0.77-1.01; p = 0.077). At 18 months, when active intervention ended, all-cause mortality rates were similar between groups at approximately 20%. All-cause mortality was lower in the intervention compared to control arm at 60 months (HR, 0.82; 95% CI, 0.68-0.99; p = 0.040) and 120 months (HR, 0.83; 95% CI, 0.72-0.97; p = 0.019). Similar mortality trends were noted when looking at cardiovascular death alone. Health-related QoL was better at all study follow-up visits in the intervention group.
Conclusions:
Following a hospitalization for HF, RPM with usual care compared to usual care alone did not significantly reduce the primary outcome of all-cause death or hospitalization at 18 and 60 months.
Perspective:
HF continues to pose a significant challenge to patients and the health care system. Following an HF hospitalization, risk of death and rehospitalization, and impact on QOL remain key issues. Research efforts into RPM strategies have tried to address these issues, though with varying success and some conflicting evidence. In practice, post-discharge care is complex and usually requires a multidisciplinary effort and a group of interventions. The authors took impressive steps to design a comprehensive intervention with these challenges in mind. The lack of difference in the primary outcome of the original INH trial and now this E-INH trial suggest there is still more work to be done to determine the ideal RPM strategy and what components of the strategy have the biggest impact. The associated long-term reduction in all-cause mortality long after the active intervention ended is intriguing and may suggest a late benefit to this particular RPM strategy. However, more research is needed to examine this observation.
Clinical Topics: Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: Aftercare, Ambulatory Care, Comorbidity, Heart Failure, Life Style, Patient Care Team, Patient Discharge, Quality of Life, Remote Consultation, Secondary Prevention, Stroke Volume, Telemedicine, Ventricular Function, Left, Vital Signs
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