Telemonitoring for heart failure: the only feasible option for good universal care?

Telecarewillbecomethepreferredmethodformanagingmostlongterm medical conditions and this revolution may well be as seismic for health care as the industrial revolution was to Western economies 200 years ago. When and how this revolution will occur is not yet clear. The change will be driven by the increasing numbers of patients with long-term conditions because of the triad of: earlier diagnosis, longer survival after diagnosis and population ageing. This increasing prevalence of chronic illness will occur in the context of fewer people of working age who may be reluctant to pay the higher taxes required in order to fulfil all of society’s needs. Increasing expectations from care, increasingly complex but effective treatment, improved sensors that detect more problems and ubiquitous, secure, familiar means of telecommunications, will create new incentives and pressures to deliver more expert care. Reaping the benefits of the telecare revolution is not going to be easy. Telecare is not only an immature technology, but a whole new set of medical disciplines. No one who has conducted a trial so far has ever received more than theoretical training and so telecare information is being used in the same conventional way that it would be in a hospital clinic. This is not good use of potentially smart technology. Training programmes for health professionals are only now being set-up. Monitoring alone probably achieves little. Monitoring should be integrated with expert decision-support systems and diagnostic alerts that identify both the nature and optimal response to a problem rather than just its mere existence. 1 The sheer density of information provided by telecare changes its nature and ensures that health professionals unsupported by computer technology are ill-equipped to make best use of it. Many sensors are not really appropriate for telecare and merely mimic the bad habits of routine clinical practice. Further work is required to establish the optimal sensors for inclusion in telecare systems. Fragmented health-care organizations that are not interested in unified services are a further impediment to innovation. A recent systematic review identified seven randomized trials of telemonitoring that included 807 patients, and suggested that telemonitoring reduced mortality substantially (hazard ratio 0.620; 95% confidence intervals 0.45‐0.85; P ¼ 0.003). 2 However, hospitalization rather than mortality was the primary target of these studies, but no reduction in hospitalization was observed. The lack of effect on hospitalization could simply reflect a lack of benefit. However, timely hospitalization may have been the reason for the reduction in mortality and keeping patients alive means they have a chance of being hospitalized again. In this sense, hospitalization is a good outcome rather than evidence of disease progression and casts doubt on the wisdom of hospitalization as an endpoint in clinical trials. Telemonitoring may also generate false alerts leading to inappropriate hospitalization. 1 This might be reduced by training, the development of robust clinical pathwaysintegratedwith existing services and the development of smart decision-support software. However, sceptics may consider that the reduction in mortality merely reflects the play of chance or bias in what are inevitably unblinded studies. Clearly, more data from randomized controlled trialsarerequired,butarewereallyreadyandabletoconductthem? ThisissueoftheEuropeanJournalofHeartFailurereportstwowellconducted randomized controlled trials of telemonitoring for heart failure. 3,4 Both were neutral and sceptics might even suggest that they showed some evidence of harm from telemonitoring. In HOME-HF, 3 182 patients with a recent hospitalization for heart failurewererandomlyassignedtodailytelemonitoringofsymptoms, weight,bloodpressure,heartrateandbloodoxygensaturationorto a control group that received a package of intensive, conventional, expert care. Patient characteristics differed from previous studies. A large proportion had new-onset heart failure (44%) and a normal left ventricular ejection fraction (40%). The 91 patients in the control group were seen, on average, each month by a specialist and once every two weeks by some health-care professional (1136 visits) during the study’s six-month follow-up. In addition, patients in the control group had access to advice by telephone during usual