The Future of Telehealth in HF

Fraiche AM, Eapen ZJ, McClellan MB
Moving Beyond the Walls of the Clinic: Opportunities and Challenges to the Future of Telehealth in Heart Failure. JACC Heart Fail 2017;5:297-304.

The following are 10 key points from this review, which is intended to provide an overview of the opportunities and challenges of telehealth in heart failure (HF):

  1. HF is becoming increasingly more prevalent and is associated with a significant financial burden on the health care system.
  2. Telehealth uses both traditional technologies (e.g., landline telephones) and emerging technologies (e.g., wearable and implantable devices and smartphone apps) to collect health information that is communicated from the patient to the health care system with the goal of redesigning and improving care outside the hospital and outpatient clinic.
  3. Evidence to support the effectiveness of telehealth on clinical outcomes varies widely, with smaller studies suggesting that telehealth reduces rehospitalization rates and mortality and larger, higher-quality randomized controlled trials suggesting no benefit in patients with HF.
  4. In the Tele-HF (Telemonitoring to Improve Heart Failure Outcomes) and BEAT-HF (Better Effectiveness After Transition–Heart Failure) studies, patient adherence to telemonitoring and phone calls decreased by nearly half within the first 30 days. Patient activation, defined as the knowledge and ability of a patient to perform a task regardless of the situation, is a key factor that must be considered when developing and implementing a telehealth strategy.
  5. One meta-analysis of 11 randomized controlled trials involving over 3,700 patients showed that device monitoring in patients with HF reduced health care utilization by 15-20%, but other analyses have been unable to conclude whether telehealth interventions are cost-effective.
  6. Logistical barriers to implementing telehealth are significant because many health systems are not currently designed for these technologies to be integrated with existing information systems. Additional personnel and specific protocols are also necessary and often must be funded out of existing resources or external grants.
  7. Reimbursement remains a major issue because much of the care delivered by telehealth is not covered by traditional fee-for-service payment models. However, the growth of value-based payment models may provide incentives to implement telehealth as a strategy to provide high-quality, cost-effective, and coordinated care.
  8. Variations at the state level in practice laws, restrictions on how telehealth can be delivered, and which patients should receive these services also limit the applicability of telehealth. For example, the state of Maine requires two-way video and audio, and there must be an indication for the service (e.g., physical or geographical barrier).
  9. Future research should focus on the accessibility and practicality of telehealth interventions.
  10. Large-scale, pragmatic clinical trials are needed to better inform health systems and clinicians on how to implement telehealth in the real-world setting.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Ambulatory Care Facilities, Cellular Phone, Heart Failure, Motivation, Outpatient Clinics, Hospital, Patient Acceptance of Health Care, Patient Compliance, Patient Participation, Telemedicine, Telephone

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