Home Heart Failure (HF) Care: Comparing Patient-Driven Technology Models

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Project Details -
Completed

This study assessed the impact of health information technologies (health IT) on clinical and financial outcomes for patients with symptomatic heart failure (HF). Nearly 5 million Americans have HF (the leading cause of hospitalization) with an estimated $40 billion annual cost. The information technologies we used include remote monitoring (telemonitoring) of vital signs and symptoms, an electronic health record system and clinical decision support systems. We tested a reproducible model for technology-supported HF management and assist purchasers, payers and policy makers in selecting health IT to improve clinical and financial outcomes. Patients were recruited from rural and urban primary care practices. We evaluated two different configurations of health IT. One was Technology Supported Case Management, a combination of telemonitoring and telephone nurse case management. The other was Technology Supported Self Management, a novel combination of telemonitoring plus an expert system that assesses vital signs and symptoms for risk of decompensation and guides patients through an individually-tailored self-care algorithm. The study used a two-stage, randomized, open-label, multi-site, controlled trial design. In Stage 1, the incidence of hospitalization and/or ER visits with Standard Care were compared to the incidence with Case Management to test the hypothesis that Case Management will have a lower incidence of ER visits and/or hospitalization than Standard Care. In Phase 2, Case Management was compared to Self Management to test the hypothesis that both interventions are equivalent in reducing ER visits and/or hospitalization. Secondary outcomes included total cost of HF care, functional and psychosocial status and satisfaction with care.

Lee Goldberg, MD
Every day, Joseph gets a check-up -- without even leaving his house. 

He is taking part in an important project funded by the Agency for Healthcare Research and Quality (AHRQ) aimed at evaluating how a new, cutting-edgetechnology can help patients with congestive heart failure (CHF) to better manage their condition.

Joseph records his vital signs, including weight, blood pressure, and blood sugar, and sends the data across phone lines with the simple touch of a button. He responds to a series of prompts generated by the data he enters, asking, for example, about his food and medication intake and activity during the previous day.

The data are monitored in real time at St. Vincent Hospital (SVH) in Billings, Mont., and if something is wrong -- if his readings are outside normal limits -- Joseph is immediately prompted to speak to his doctor. Often, these readings give him the first warning signs that he should see his doctor right away. Frequently, Joseph says, those warning signs were more difficult to observe before.  In addition, daily reports are faxed to Joseph's doctor.

"It's like having a doctor right there in your house!" he says.

Remote telemonitoring holds the potential to greatly improve the treatment and management of chronic conditions. Lee Goldberg, MD, and his colleagues at the St. Vincent Healthcare Foundation (SVHF) in Montana, the University of Pennsylvania (UPenn), Billings Area Indian Health Services and the University of Louisville are exploring that potential, comparing two types of telemonitoring with standard care.

Thanks to the AHRQ grant, SVHF and UPenn have launched a two-year project to evaluate whether this technology can improve clinical outcomes for patients with CHF, enhance clinical decision support, and prove a cost-effective aid in treating CHF, which costs the health care system $40 billion annually. The grant is part of AHRQ's Transforming Healthcare Quality through Health Information Technology initiative.

"The hope is that this project will help us educate patients about their conditions, to learn what some of the triggers are, and what some the barriers to better care are," says Goldberg, Assistant Professor of Medicine, at UPenn. Goldberg and his colleagues are also poised to examine potential cost efficiency of a new type of technology-enhanced case management. In their study, the cost to monitor patients hovers just below or above $2,000 per patient.  Contrast that to the costs of an emergency room visit and admission to an inpatient unit from CHF-related complications, which can loom into the tens of thousands of dollars.

CHF affects 5 million people in the United States. People living with CHF must actively manage their condition, or risk facing serious complications, frequent hospitalizations, or even death.

"This treatment gives me the details I need about how my body is doing," says Mona, an energetic grandmother who, following chemotherapy, was diagnosed with cardiomyopathy, a disease that often leads to heart failure. "I've seen how the things I used to do--like eating salt--affected my condition, even when I couldn't see any symptoms," she said. "It's really changed my behavior."

The study is comparing two types of disease management that use telemonitoring technology and clinical case management -- either by a nurse at the SVH call center or through an automated voice response system managed directly by the healthcare provider. Patients track and transmit their vitals -- using a small machine that connects to a home phone line. What's created is an electronic medical record for each patient that gets updated daily.

"We've developed a sophisticated system based on an algorithm tailored to each individual patient," says Goldberg. "To the patient on the other end of the phone, that algorithm translates to an automated series of questions that they answer. Any triggers or signs that there is a problem will result in immediate feedback, and an instant alert to the patient's physician."

"Mydoctor really likes the reports," Joseph says. Prior to treatment, his physician needed to see him every week to monitor him. Now, thanks to the daily updates he gets on Joseph's condition, he only needs to see Joseph every four to six weeks.

"And I don't get sick and end up at the emergency room as often," says Joseph. "I can know what's going on before I get sick."

Goldberg and his colleagues are quite encouraged by the data they've received so far. "With the support of the AHRQ, we're looking forward to moving closer to uncovering whether this emerging technology can make a real difference in improving the outcomes and lives of people with CHF," he says.