ABSTRACT
BACKGROUND: Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption. OBJECTIVE: We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF. METHODS: We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use. RESULTS: Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring. CONCLUSIONS: The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.
Subject(s)
Heart Failure , Telemedicine , Humans , Male , Female , Aged, 80 and over , Adolescent , Young Adult , Adult , Middle Aged , Telemetry/methods , Retrospective Studies , Chronic Disease , Heart Failure/therapy , Research DesignABSTRACT
Objective: Noninvasive telemonitoring aims to improve healthcare for patients with chronic heart failure (HF) by reducing hospitalizations and improving patient experiences. Yet, sustainable adoption seems to be limited. Therefore, the goal of our study is to gain insight in the processes that support sustainable adoption of telemonitoring for patients with HF. Methods: We conducted semi-structured interviews with 25 stakeholders that were involved with the adoption of telemonitoring, such as healthcare professionals, policymakers and healthcare insurers. We analyzed the interviews by using a combination of open-coding and the themes of the Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability framework. Results: We found that telemonitoring projects have moved beyond initial pilot phases despite a high level of complexity on multiple topics. The patient selection, the business case, the evidence, the aims of telemonitoring, integration of telemonitoring in the care pathway, reimbursement, and future centralization were items that yielded different and sometimes contradictory opinions. Conclusions: This study showed that the sustainable adoption of telemonitoring for HF is a complex endeavor. Different aims and perspectives play an important role in the patient selection, design, evaluations and envisioned futures of telemonitoring. High conviction among participants of the added value that telemonitoring may support further adoption of telemonitoring. Structural evaluations will be needed to guide cyclical improvement and adapt programs to employ telemonitoring in such a manner that it contributes to collectively supported aims.
ABSTRACT
BACKGROUND: Chronic heart failure (CHF) poses a major challenge for healthcare systems. As these patients' needs vary over time in intensity and complexity, the coordination of care between primary and secondary care is critical for them to receive the right care in the right place. To support the continuum of care needed, Dutch regional transmural agreements (RTAs) between healthcare providers have been developed. However, little is known about how the stakeholders have experienced the development and use of these RTAs. The aim of this study was to gain insight into how stakeholders have experienced the development and use of RTAs for CHF and explore which factors affected this. METHODS: We interviewed 25 stakeholders from 9 Dutch regions based on the Measurement Instrument for Determinants of Innovations framework. Interview recordings were transcribed verbatim and analysed through open thematic coding. RESULTS: In most cases, the RTA development was considered relatively easy. However, the participants noted that sustainable use of the RTAs faced different complexities and influencing factors. These barriers concerned the following themes: education of primary care providers, referral process, patients' willingness, relationships between healthcare providers, reimbursement by health insurance companies, electronic health record (EHR) systems and outcomes. CONCLUSION: Some complexities, such as reimbursement and EHR systems, are likely to benefit from specialised support or a national approach. On a regional level, interregional learning can improve stakeholders' experiences. Future research should focus on quantitative effects of RTAs on outcomes and potential financing models for projects that aim to transition care from one setting to another.
ABSTRACT
BACKGROUND: Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear. OBJECTIVE: This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs. METHODS: We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant. RESULTS: We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization. CONCLUSIONS: Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.