Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial Linking clinic and home: a randomized, controlled clinical effectiveness trial of real-time, wireless blood pressure monitoring for older patients with kidney disease and hypertension Effects of home telemonitoring to support improved care for chronic obstructive pulmonary diseases. Home telemonitoring and quality of life in stable, optimised chronic obstructive pulmonary disease The Utah Remote Monitoring Project: improving health care one patient at a time. Results of a telehealth-enabled chronic care management service to support people with long-term conditions at home A novel telemonitoring device for improving diabetes control: protocol and results from a randomized clinical trial. A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study Telemonitoring-based service redesign for the management of uncontrolled hypertension (HITS): cost and cost-effectiveness analysis of a randomised controlled trial A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized controlled trial Active Care Management Supported by Home Telemonitoring in Veterans With Type 2 Diabetes Effect of Home Blood Pressure Telemonitoring With Self-Care Support on Uncontrolled Systolic Hypertension in Diabetics The rationale and design of reduction of uncontrolled hypertension by Remote Monitoring and Telemedicine (REMOTE) study Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial A Randomized Trial of Telemonitoring Heart Failure Patients Does Home Telemonitoring after Pulmonary Rehabilitation Reduce Healthcare Use in Optimized COPD?? A Pilot Randomized Trial Technical and compliance considerations for mobile health self-monitoring of glucose and blood pressure for patients with diabetes Telemonitoring in Chronic Obstructive Pulmonary Disease (CHROMED). A Randomized Clinical Trial Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: a qualitative study embedded in a randomized controlled trial. Device monitoring strategies in acute heart failure syndromes Simulated case management of home telemonitoring to assess the impact of different alert algorithms on work-load and clinical decisions Heart Failure 2012 Continuity, but at what cost? The impact of telemonitoring COPD on continuities of care: a qualitative study.
Background Diabetes and hypertension are devastating , deadly , and costly conditions that are very common in seniors . Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications . However , blood pressure ( BP ) must be lowered carefully because seniors are also susceptible to low BP and attendant harms . Achieving “ optimal BP control ” ( ie , avoiding both undertreatment and overtreatment ) is the ultimate therapeutic goal in such patients . Regular BP monitoring is required to achieve this goal . BP monitoring at home is cheap , convenient , widely used , and guideline endorsed . However , major barriers prevent proper use . These may be overcome through use of BP telemonitoring — the secure teletransmission of BP readings to a health portal , where BP data are summarized for provider and patient use , with or without protocol ized case management . Objective To examine the incremental effectiveness , safety , cost-effectiveness , usability , and acceptability of home BP telemonitoring , used with or without protocol ized case management , compared with “ enhanced usual care ” in community-dwelling seniors with diabetes and hypertension . Methods A 300-patient , 3-arm , pragmatic r and omized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors ’ residences in greater Edmonton . Consenting patients will be r and omized to usual care , home BP telemonitoring alone , or home BP telemonitoring plus protocol ized pharmacist case management . Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data . In both telemonitored arms , providers will receive telemonitored BP data summaries . In the case management arm , pharmacist case managers will be responsible for review ing teletransmitted data and initiating guideline -concordant and protocol ized changes in BP management . Results Outcomes will be ascertained at 6 and 12 months . Within- study -arm change scores will be calculated and compared between study arms . These include : ( 1 ) clinical outcomes : proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range ( 110 - 129 mmHg in patients 65 - 79 years and 110 - 139 mmHg in those ≥80 years : primary outcome ) ; additional ambulatory and home BP outcomes ; A1c and lipid profile ; medications , cognition , health care use , cardiovascular events , and mortality . ( 2 ) Safety outcomes : number of serious episodes of hypotension , syncope , falls , and electrolyte disturbances ( requiring third party assistance or medical attention ) . ( 3 ) Humanistic outcomes : quality of life , satisfaction , and medication adherence . ( 4 ) Economic outcomes : incremental costs , incremental cost-utility , and cost per mmHg change in BP of telemonitoring ± case management compared with usual care ( health payor and societal perspectives ) . ( 5 ) Intervention usability and acceptability to patients and providers . Conclusion The potential benefits of telemonitoring remain largely unstudied and unproven in seniors . This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes . Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada . Trial Registration Clinical trials.gov NCT02721667 ; https:// clinical trials.gov/ct2/show/NCT02721667 ( Archived by Webcite at http://www.webcitation.org/6i8tB20Mc Objective Older adults with chronic kidney disease have a high rate of uncontrolled hypertension . Home monitoring of  blood pressure ( BP ) is an integral part of management , but requires that patients bring records to clinic visits . Telemonitoring interventions , however , have not targeted older , less technologically-skilled population s. Methods Veterans with stage 3 or greater chronic kidney disease and uncontrolled hypertension were r and omized to a novel telemonitoring device pairing a Bluetooth-enabled BP cuff with an Internet-enabled hub , which wirelessly transmitted readings ( n=28 ) , or usual care ( n=15 ) . Home recordings were review ed weekly and telemonitoring participants were contacted if BP was above goal . The prespecified primary endpoints were improved data exchange and device acceptability . Secondary endpoint was BP change . Results Forty-three participants ( average age 68 years , 75 % white ) completed the 6-month study . Average start-of- study BP was 147/78 mmHg . Those in the intervention arm had a median of 29 ( IQR 22 , 53 ) transmitted BP readings per month , with 78 % continuing to use the device regularly , whereas only 20 % of those in the usual care group brought readings to in-person visits . The median number of telephone contacts triggered by the wireless monitoring was 2 ( IQR 1 , 4 ) per patient . Both groups had a significant improvement in systolic BP ( P<0.05 , for both changes ) ; systolic BP fell a median of 13 mmHg in monitored participants compared with 8.5 mmHg in usual care participants ( P for comparison 0.31 ) . Conclusion This low-cost wireless monitoring strategy led to greater sharing of data between patients and clinic and produced a trend toward improvements in BP control over usual care at 6 months OBJECTIVE To assess the impact of a home telemonitoring technology on patients with chronic obstructive pulmonary disease in terms of care satisfaction , patient empowerment , improved quality of life , and utilization of hospital and home care . DESIGN A quasi-experimental retrospective and prospect i ve design was developed with a matched control group to compare the effects of telemonitoring  ( the experimental group , n = 23 ) with the traditional homecare offering  ( the control group , n = 23 ) . MEASUREMENTS Satisfaction , patient empowerment , and quality of life were measured using vali date d Likert scales , whereas the data on care utilization were collected from the participating patients ' medical record . RESULTS Mixed results were observed . The clinical effects of home telemonitoring were very positive in terms of patients ' satisfaction and empowerment . The perceptions of care providers as well as those of patients were congruent in this respect . Also , the study suggests that telemonitoring may have a positive effect on quality of life for patients with chronic obstructive pulmonary diseases . In contrast , the results were disappointing in terms of re source savings for the use of both homecare and hospital care . CONCLUSION Capturing the full potential of these new technologies will require a much more fundamental reorganization of work than just a simple deployment of the technology We conducted a six-month r and omised controlled trial of home telemonitoring for patients with chronic obstructive pulmonary disease ( COPD ) . A total of 40 stable patients with moderate to severe COPD who had completed pulmonary rehabilitation took part . They were r and omised to receive st and ard care ( controls ) or st and ard care plus home telemonitoring ( intervention ) . During the monitoring period , patients in the telemonitoring group recorded their symptoms and physical observations twice daily . The data were transmitted automatically at night via the home telephone line . Nurses could access the data through a website and receive alerting email messages if certain conditions were detected . The patients completed the St George 's Respiratory Question naire , Hospital Anxiety and Depression and the EuroQoL EQ-5D quality of life scores before and after pulmonary rehabilitation , and then periodically during the trial . There were significant and clinical ly important improvements in the scores immediately following pulmonary rehabilitation , but thereafter there were no differences in quality of life scores between the groups at any time , or consistently within either group over time . The study showed that telemonitoring was safe but , despite being well used , it was not associated with changes in quality of life in patients who had stable COPD BACKGROUND The exp and ing role of technology to augment diabetes care and management highlights the need for clinicians to learn about these new tools . As these tools continue to evolve and enhance improved outcomes , it is imperative that clinicians consider the role of telemonitoring , or remote monitoring , in patient care . This article describes a successful  telemonitoring project in Utah . SUBJECTS AND METHODS This was a nonr and omized prospect i ve observational preintervention-postintervention study , using a convenience sample . Patients with uncontrolled diabetes and /or hypertension from four rural and two urban primary care clinics and one urban stroke center participated in a telemonitoring program . The primary clinical outcome measures were changes in hemoglobin A1C ( A1C ) and blood pressure . Other outcomes included fasting lipids , weight , patient engagement , diabetes knowledge , hypertension knowledge , medication adherence , and patient perceptions of the usefulness of the telemonitoring program . RESULTS Mean A1C decreased from 9.73 % at baseline to 7.81 % at the end of the program ( P<0.0001 ) . Systolic blood pressure also declined significantly , from 130.7 mm Hg at baseline to 122.9 mm Hg at the end ( P=0.0001 ) . Low-density lipoprotein content decreased significantly , from 103.9 mg/dL at baseline to 93.7 mg/dL at the end ( P=0.0263 ) . Other clinical parameters improved nonsignificantly . Knowledge of diabetes and hypertension increased significantly ( P<0.001 for both ) . Patient engagement and medication adherence also improved , but not significantly . Per question naires at study end , patients felt the telemonitoring program was useful . CONCLUSIONS Telemonitoring improved clinical outcomes and may be a useful tool to help enhance disease management and care of patients with diabetes and /or hypertension Both congestive heart failure and chronic obstructive pulmonary disease are more common among Māori than non-Māori people , and the cultural acceptability of home-based remote monitoring technology has not been tested . We conducted a 12-month pilot trial of home telemonitoring .  Patients were r and omly assigned to the control and intervention groups . Patients in the control group showed no clear differences in quality of life at the end of the trial . The telehealth group showed a consistent trend towards improved quality of life on several instruments , including the SF-36 , the St George Respiratory Question naire and the K10 question naire ; the improvement in the latter was significant . Hospitalizations were reduced in both the control ( −19 % ) and telehealth group ( −25 % ) . Patient interviews indicated that the technology was acceptable to most patients and their families , including the Māori . The results from the pilot trial suggest that wider implementation with a cost benefit evaluation could be worthwhile BACKGROUND Telemedicine is one approach to managing patients with chronic illness . Several telephone-based monitoring studies of diabetes patients have shown improved glycosylated hemoglobin ( HbA1c ) , blood pressure ( BP ) , and low-density lipoprotein ( LDL ) levels . The purpose of this study was to evaluate an investigational in-home telemetry device for improving glucose and BP control over 6 months for patients with type 2 diabetes . The device was used to transmit weekly blood glucose , weight , and BP readings to a diabetes care manager . SUBJECTS AND METHODS We conducted a two-arm , parallel-comparison , single-blind , r and omized controlled trial among Kaiser Permanente Northern California members 18 - 75 years old with type 2 diabetes mellitus and entry HbA1c levels between 7.5 % and 10.0 % . Participants were r and omly assigned to either the telemonitoring arm or the usual care arm . RESULTS We observed very small , nonsignificant changes in fructosamine ( telemonitoring , -54.9 μmol ; usual care , -59.4 μmol ) and systolic BP ( telemonitoring , -6.3 mm Hg ; usual care , -3.2 mm Hg ) from baseline to 6 weeks in both groups . At 6 months , we observed no significant intergroup differences in change from baseline for HbA1c , fructosamine , or self-efficacy . However , LDL cholesterol in the telemonitoring arm decreased more than in the usual care arm ( -17.1 mg/dL versus -5.4 mg/dL ; P=0.045 ) . CONCLUSIONS Although HbA1c improved significantly over 6 months in both groups , the difference in improvement between the groups was not significant . This lack of significance may be due to the relatively healthy status of the volunteers in our study and to the high level of care provided by the care managers in the Santa Rosa , CA clinic . Further study in subgroups of less healthy diabetes patients is recommended Background Older adults with multiple chronic illnesses are at risk for worsening functional and medical status and hospitalization . Home telemonitoring may help slow this decline . This protocol of a r and omized controlled trial was design ed to help determine the impact of home telemonitoring on hospitalization . The specific aim of the study reads as follows : to determine the effectiveness of home telemonitoring compared with usual care in reducing the combined outcomes of hospitalization and emergency department visits in an at-risk population 60 years of age or older . Methods / Design Two-hundred patients with the highest 10 % Mayo Clinic Elder Risk Assessment scores will be r and omly assigned to one of two interventions . Home telemonitoring involves the use of a computer device , the Intel Health Guide , which records biometric and symptom data from patients in their homes . This information is monitored by midlevel providers associated with a primary care medical practice . Under the usual care scenario , patients make appointments with their providers as problems arise and use ongoing support such as a 24-hour nurse line . Patients will have initial evaluations of gait and quality of life using instruments such as the SF-12 Health Survey , the Kokmen Short Test of Mental Status , and the PHQ-9 health question naire . Patients will be followed for 1 year for primary outcomes of hospitalizations and emergency department visits . Secondary analysis will include quality of life , compliance with the device , and attitudes about telemonitoring . Sample size is based on an 80 % power to detect a 36 % difference between the two groups . The primary analysis will involve Cox proportional time-to-event analysis . Secondary analysis will use t-test comparisons for continuous variables and the chi square test for proportional analysis . Discussion Patients r and omized to home telemonitoring will have daily assessment s of their health status using the device . Registered nurse monitoring will assess any change in status followed by videoconferencing by a mid-level provider . We obtained trial registration and Institutional Review Board approval . Trial registration Trial registration number through http://www . clinical trials.gov:%20NCT01056640 Objectives To compare the costs and cost-effectiveness of managing patients with uncontrolled blood pressure ( BP ) using telemonitoring versus usual care from the perspective of the National Health Service ( NHS ) . Design Within trial post hoc economic evaluation of data from a pragmatic r and omised controlled trial using an intention-to-treat approach . Setting 20 socioeconomically diverse general practice s in Lothian , Scotl and . Participants 401 primary care patients aged 29–95 with uncontrolled daytime ambulatory blood pressure ( ABP ) ( ≥135/85 , but < 210/135 mm Hg ) . Intervention Participants were central ly r and omised to 6 months of a telemonitoring service comprising of self-monitoring of BP transmitted to a secure website for review by the attending nurse/doctor and patient , with optional automated patient decision-support by text/email ( n=200 ) or usual care ( n-201 ) . R and omisation was undertaken with minimisation for age , sex , family practice , use of three or more hypertension drugs and self-monitoring history . Main outcome measures Mean difference in total NHS costs between trial arms and blinded assessment of mean cost per 1 mm Hg systolic BP point reduced .  Results Home telemonitoring of BP costs significantly more than usual care ( mean difference per patient £ 115.32 ( 95 % CI £ 83.49 to £ 146.63 ; p<0.001 ) ) . Increased costs were due to telemonitoring service costs , patient training and additional general practitioner and nurse consultations . The mean cost of systolic BP reduction was £ 25.56/mm Hg ( 95 % CI £ 16.06 to £ 46.89 ) per patient . Conclusions Over the 6-month trial period , supported telemonitoring was more effective at reducing BP than usual care but also more expensive . If clinical gains are maintained , these additional costs would be very likely to be compensated for by reductions in the cost of future cardiovascular events . Longer-term modelling of costs and outcomes is required to fully examine the cost-effectiveness implication s. Trial registration International St and ard R and omised Controlled Trials , number IS RCT N72614272 Background Heart failure is a prevalent health problem associated with costly hospital readmissions . Transitional care programs have been shown to reduce readmissions but are costly to implement . Evidence regarding the effectiveness of telemonitoring in managing the care of this chronic condition is mixed . The objective of this r and omized controlled comparative effectiveness study is to evaluate the effectiveness of a care transition intervention that includes pre-discharge education about heart failure and post-discharge telephone nurse coaching combined with home telemonitoring of weight , blood pressure , heart rate , and symptoms in reducing all-cause 180-day hospital readmissions for older adults hospitalized with heart failure . Methods / Design A multi-center , r and omized controlled trial is being conducted at six academic health systems in California . A total of 1,500 patients aged 50 years and older will be enrolled during a hospitalization for treatment of heart failure . Patients in the intervention group will receive intensive patient education using the ‘ teach-back ’ method and receive instruction in using the telemonitoring equipment . Following hospital discharge , they will receive a series of nine scheduled health coaching telephone calls over 6 months from nurses located in a central ized call center . The nurses also will call patients and patients ’ physicians in response to alerts generated by the telemonitoring system , based on predetermined parameters . The primary outcome is readmission for any cause within 180 days . Secondary outcomes include 30-day readmission , mortality , hospital days , emergency department ( ED ) visits , hospital cost , and health-related quality of life . Discussion BEAT-HF is one of the largest r and omized controlled trials of telemonitoring in patients with heart failure , and the first explicitly to adapt the care transition approach and combine it with remote telemonitoring . The study population also includes patients with a wide range of demographic and socioeconomic characteristics . Once completed , the study will be a rich re source of information on how best to use remote technology in the care management of patients with chronic heart failure . Trial registration Clinical Trials.gov # NCT01360203 OBJECTIVE We compared the short-term efficacy of home telemonitoring coupled with active medication management by a nurse practitioner with a monthly care coordination telephone call on glycemic control in veterans with type 2 diabetes and entry A1C ≥7.5 % . RESEARCH DESIGN AND METHODS Veterans who received primary care at the VA Pittsburgh Healthcare System from June 2004 to December 2005 , who were taking oral hypoglycemic agents and /or insulin for ≥1 year , and who had A1C ≥7.5 % at enrollment were r and omly assigned to either active care management with home telemonitoring ( ACM+HT group , n = 73 ) or a monthly care coordination telephone call ( CC group , n = 77 ) . Both groups received monthly calls for diabetes education and self-management review . ACM+HT group participants transmitted blood glucose , blood pressure , and weight to a nurse practitioner using the Viterion 100 TeleHealth Monitor ; the nurse practitioner adjusted medications for glucose , blood pressure , and lipid control based on established American Diabetes Association targets . Measures were obtained at baseline , 3-month , and 6-month visits . RESULTS Baseline characteristics were similar in both groups , with mean A1C of 9.4 % ( CC group ) and 9.6 % ( ACM+HT group ) . Compared with the CC group , the ACM+HT group demonstrated significantly larger decreases in A1C at 3 months ( 1.7 vs. 0.7 % ) and 6 months ( 1.7 vs. 0.8 % ; P < 0.001 for each ) , with most improvement occurring by 3 months . CONCLUSIONS Compared with the CC group , the ACM+HT group demonstrated significantly greater reductions in A1C by 3 and 6 months . However , both interventions improved glycemic control in primary care patients with previously inadequate control Lowering blood pressure reduces cardiovascular risk , yet hypertension is poorly controlled in diabetic patients . In a pilot study we demonstrated that a home blood pressure telemonitoring system , which provided self-care messages on the smartphone of hypertensive diabetic patients immediately after each reading , improved blood pressure control . Messages were based on care paths defined by running averages of transmitted readings . The present study tests the system 's effectiveness in a r and omized , controlled trial in diabetic patients with uncontrolled systolic hypertension . Of 244 subjects screened for eligibility , 110 ( 45 % ) were r and omly allocated to the intervention ( n=55 ) or control ( n=55 ) group , and 105 ( 95.5 % ) completed the 1-year outcome visit . In the intention-to-treat analysis , mean daytime ambulatory systolic blood pressure , the primary end point , decreased significantly only in the intervention group by 9.1±15.6 mmHg ( SD ; P<0.0001 ) , and the mean between-group difference was 7.1±2.3 mmHg ( SE ; P<0.005 ) . Furthermore , 51 % of intervention subjects achieved the guideline recommended target of < 130/80 mmHg compared with 31 % of control subjects ( P<0.05 ) . These improvements were obtained without the use of more or different antihypertensive medications or additional clinic visits to physicians . Providing self-care support did not affect anxiety but worsened depression on the Hospital Anxiety and Depression Scale ( baseline , 4.1±3.76 ; exit , 5.2±4.30 ; P=0.014 ) . This study demonstrated that home blood pressure telemonitoring combined with automated self-care support reduced the blood pressure of diabetic patients with uncontrolled systolic hypertension  and improved hypertension control . Home blood pressure monitoring alone had no effect on blood pressure . Promoting patient self-care may have negative psychological effects Abstract Purpose : Although self-measurement of home blood pressure ( HBP ) is common in Japan and HBP telemonitoring via the Internet is possible , whether telemonitoring improves HBP control better than conventional practice remains unclear . Furthermore , hypertension care with online communication using telemonitored HBP is feasible , whereas the efficacy and safety of such telemedicine have not been established . We aim to compare traditional care , care with office visits using HBP telemonitoring , and antihypertensive telemedicine based on HBP telemonitoring . Methods and design : In total , 444 patients with uncontrolled hypertension will be recruited and r and omly assigned to three groups : ( 1 ) control : usual care with office visits and HBP self-report , ( 2 ) telemonitoring : weekly assessment of transmitted HBP by physicians and treatment adjustment upon office visits , or ( 3 ) telemedicine : online communication instead of office visits to adjust medication using telemonitored HBP . Primary outcome is the time to control of HBP , and secondary outcomes include achieved HBP levels , adherence , treatment intensity , adverse events , patient satisfaction and cost-effectiveness . Discussion : Hypertension care with telemonitoring and telemedicine are expected to require shorter time to achieve HBP control compared to usual care . Combining HBP telemonitoring with telemedicine may lower the hurdles for starting and persisting to hypertension treatment and eventually reduce cardiovascular events BACKGROUND Control of blood pressure is a key component of cardiovascular disease prevention , but is difficult to achieve and until recently has been the sole preserve of health professionals . This study assessed whether self-management by people with poorly controlled hypertension result ed in better blood pressure control compared with usual care . METHODS This r and omised controlled trial was undertaken in 24 general practice s in the UK . Patients aged 35 - 85 years were eligible for enrolment if they had blood pressure more than 140/90 mm Hg despite antihypertensive treatment and were willing to self-manage their hypertension . Participants were r and omly assigned in a 1:1 ratio to self-management , consisting of self-monitoring of blood pressure and self-titration of antihypertensive drugs , combined with telemonitoring of home blood pressure measurements or to usual care . R and omisation was done by use of a central web-based system and was stratified by general practice with minimisation for sex , baseline systolic blood pressure , and presence or absence of diabetes or chronic kidney disease . Neither participants nor investigators were masked to group assignment . The primary endpoint was change in mean systolic blood pressure between baseline and each follow-up point ( 6 months and 12 months ) . All r and omised patients who attended follow-up visits at 6 months and 12 months and had complete data for the primary outcome were included in the analysis , without imputation for missing data . This study is registered as an International St and ard R and omised Controlled Trial , number IS RCT N17585681 . FINDINGS 527 participants were r and omly assigned to self-management ( n=263 ) or control ( n=264 ) , of whom 480 ( 91 % ; self-management , n=234 ; control , n=246 ) were included in the primary analysis . Mean systolic blood pressure decreased by 12.9 mm Hg ( 95 % CI 10.4 - 15.5 ) from baseline to 6 months in the self-management group and by 9.2 mm Hg ( 6.7 - 11.8 ) in the control group ( difference between groups 3.7 mm Hg , 0.8 - 6.6 ; p=0.013 ) . From baseline to 12 months , systolic blood pressure decreased by 17.6 mm Hg ( 14.9 - 20.3 ) in the self-management group and by 12.2 mm Hg ( 9.5 - 14.9 ) in the control group ( difference between groups 5.4 mm Hg , 2.4 - 8.5 ; p=0.0004 ) . Frequency of most side-effects did not differ between groups , apart from leg swelling ( self-management , 74 patients [ 32 % ] ; control , 55 patients [ 22 % ] ; p=0.022 ) . INTERPRETATION Self-management of hypertension in combination with telemonitoring of  blood pressure measurements represents an important new addition to control of hypertension in primary care . FUNDING Department of Health Policy Research Programme , National Coordinating Centre for Research Capacity Development , and Midl and s Research Practice s Consortium EXECUTIVE SUMMARY The purpose of this study was to measure the ability of telemonitoring to reduce hospital days and total costs for Medicare managed care enrollees diagnosed with heart failure . Patients were recruited and r and omly assigned for six months to either  telemonitoring or st and ard care . Telemonitoring transmitted vital signs and clinical alerts daily to a central nursing station . Utilization of covered services was analyzed for the six‐month telemonitoring period to test for hypothesized reductions in hospital days and changes in utilization of the emergency department ( ED ) , urgent care , and primary care . Negative binomial regressions adjusted for gender , age , co‐occurring diabetes , co‐occurring chronic obstructive pulmonary disease , and residence neighborhood were used to analyze units of service , and two‐part ( hurdle ) multivariable models were used for expenditures . The main finding was a tendency for lower total number of hospital days for patients assigned to telemonitoring . Results for other covered services were generally consistent with hypothesized direction and magnitude ; however , statistical power was reduced because of lowerthan‐expected recruitment rates into the study . Within a managed‐care environment , telemonitoring appears to facilitate better ambulatory management of heart failure patients  , including fewer ED visits , which were offset by more frequent primary care and urgent care visits ABSTRACT Aim . To see if home telemonitors reduce healthcare use in those with optimized chronic obstructive pulmonary disease ( COPD ) . Methods . We r and omized 40 stable patients with moderate to severe COPD , who had completed at least 12 sessions of outpatient pulmonary rehabilitation ( PR ) , to receive st and ard care ( Controls ) for 52 weeks or st and ard care plus Docobo HealthHUB monitors at home for 26 weeks followed by 26 weeks st and ard care ( Tm Group ) . During the monitoring period , the Tm Group completed  symptoms and physical observations  twice daily which were stored and then uploaded at 2 am through a freephone l and line . Nurses could access the data through a secure web site and received alerting e-mails if certain combinations of data occurred . Results . There were fewer primary care contacts for chest problems ( p < 0.03 ) in the Tm group , but no differences between the groups in emergency room visits , hospital admissions , days in hospital or contacts to the specialist COPD community nurse team , during the monitoring period . After the monitors were removed , there were no differences between the groups for any of the health care contacts ( p > 0.20 throughout ) . Conclusion . In stable , optimized COPD patients who have already completed PR , telemonitoring in addition to best care , reduces primary care chest contacts but not hospital or specialist team utilization Self-monitoring of blood glucose is an integral part of diabetes care which may be extended to other biometrics . Cellular and short range communication technologies will be important for the routine usage of these systems . However , the issues of follow-up and patient compliance with these emerging systems have not been yet studied evaluated but could be critical to the adoption of these technologies . We evaluated the impact of mobile telemonitoring on the intensification of care on blood pressure control and exposure to hyperglycaemia in patients with diabetes . We r and omised 137 patients with diabetes to either mobile telemonitoring  ( n = 3D72 ) or usual care patients ( n = 3D65 ) for 9 months . In this paper we present some of the clinical results with focus on blood pressure control hypertension and highlight some of the technical and compliance issues that were encountered Rationale : Early detection of chronic obstructive pulmonary disease ( COPD ) exacerbations using telemonitoring of physiological variables might reduce the frequency of hospitalization . Objectives : To evaluate the efficacy of home monitoring of lung mechanics by the forced oscillation technique and cardiac parameters in older patients with COPD and comorbidities . Methods : This multicenter , r and omized clinical trial recruited 312 patients with Global Initiative for Chronic Obstructive Lung Disease grade s II to IV COPD ( median age , 71 yr [ interquartile range , 66‐76 yr ] ; 49.6 % grade II , 50.4 % grade s III‐IV ) , with a history of exacerbation in the previous year and at least one nonpulmonary comorbidity . Patients were r and omized to usual care ( n = 158 ) or telemonitoring ( n = 154 ) and followed for 9 months . All telemonitoring patients self‐assessed lung mechanics daily , and in a subgroup with congestive heart failure ( n = 37 ) cardiac parameters were also monitored . An algorithm identified deterioration , triggering a telephone contact to determine appropriate interventions . Measurements and Main Results : Primary outcomes were time to first hospitalization ( TTFH ) and change in the EuroQoL EQ‐5D utility index score . Secondary outcomes included : rate of antibiotic/corticosteroid prescription ; hospitalization ; the COPD Assessment Tool , Patient Health Question naire‐9 , and Minnesota Living with Heart Failure question naire scores ; quality ‐adjusted life years ; and healthcare costs . Telemonitoring did not affect TTFH , EQ‐5D utility index score , antibiotic prescriptions , hospitalization rate , or question naire scores . In an exploratory analysis , telemedicine was associated with fewer repeat hospitalizations ( −54 % ; P = 0.017 ) . Conclusions : In older patients with COPD and comorbidities , remote monitoring of lung function by forced oscillation technique and cardiac parameters did not change TTFH and EQ‐5D . Clinical trial registered with www . clinical trials.gov ( NCT 01960907 ) OBJECTIVE To explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease ( COPD ) . METHODS Semi-structured interviews with patients with COPD and healthcare professionals participating in a r and omized controlled trial of telemonitoring in Lothian , Scotl and , explored experiences of using telemonitoring , and dynamics in patient-practitioner relationships . Transcribed data were analyzed using the Framework approach . RESULTS 38 patients ( mean age 67.5 years ) and 32 professionals provided 70 interviews . Patients considered that telemonitoring empowered self-management by enhancing their underst and ing of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice . Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters , but expressed concerns about promoting the sick role and creating dependence on telemonitoring . CONCLUSION Telemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered . A medical model of ' compliant self-management ' may paradoxically have promoted dependence on professionals . PRACTICE IMPLICATION S Patients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD . Care is needed , however , to minimize the risk in some patients , of telemonitoring increasing dependence on practitioner support Acute heart failure syndromes ( AHFS ) represent the most common discharge diagnoses in adults over age 65 and translate into dramatically increased heart failure – associated morbidity and mortality . Conventional approaches to the early detection of pulmonary and systemic congestion have been shown to be of limited sensitivity . Despite their proven efficacy , disease management and structured telephone support programs have failed to achieve widespread use in part due to their re source intensiveness and reliance upon motivated patients . While once thought to hold great promise , results from recent prospect i ve studies on telemonitoring strategies have proven disappointing . Implantable devices with their capacity to monitor electrophysiologic and hemodynamic parameters over long periods of time and with minimal reliance on patient participation may provide solutions to some of these problems . Conventional electrophysiologic parameters and intrathoracic impedance data are currently available in the growing population of heart failure patients with equipped devices . A variety of implantable hemodynamic monitors are currently under investigation . How best to integrate these devices into a systematic approach to the management of patients before , during , and after AHFS  is yet to be established Background Home telemonitoring ( HTM ) of chronic heart failure ( HF ) promises to improve care by timely indications when a patient ’s condition is worsening . Simple rules of sudden weight change have been demonstrated to generate many alerts with poor sensitivity . Trend alert algorithms and bio-impedance ( a more sensitive marker of fluid change ) , should produce fewer false alerts and reduce workload . However , comparisons between such approaches on the decisions made and the time spent review ing alerts has not been studied . Methods Using HTM data from an observational trial of 91 HF patients , a simulated telemonitoring station was created and used to present virtual caseloads to clinicians experienced with HF HTM systems . Clinicians were r and omised to either a simple ( i.e. an increase of 2 kg in the past 3 days ) or advanced alert method ( either a moving average weight algorithm or bio-impedance cumulative sum algorithm ) . Results In total 16 clinicians review ed the caseloads , 8 r and omised to a simple alert method and 8 to the advanced alert methods .  Total time to review the caseloads was lower in the advanced arms than the simple arm ( 80 ± 42 vs. 149 ± 82 min ) but agreements on actions between clinicians were low ( Fleiss kappa 0.33 and 0.31 ) and despite having high sensitivity many alerts in the bio-impedance arm were not considered to need further action . Conclusion Advanced alerting algorithms with higher specificity are likely to reduce the time spent by clinicians and increase the percentage of time spent on changes rated as most meaningful . Work is needed to present bio-impedance alerts in a manner which is intuitive for clinicians Heart failure has been named “ the growing epidemic . ” Over the last decade , the annual number of heart failure hospitalizations has almost doubled with approximately 50 % of patients being rehospitalized within 6 months of discharge [ 1 ] . The complex array of physiologic , psychological , social , and health care delivery issues makes it a challenging chronic disease to manage . Underst and ing the epidemiology and pathophysiology of the syndrome , identifying the predictors and their strength of association with outcomes , and using the available diagnostic modalities cost-effectively are essential in order to devise effective prevention interventions and implement novel therapeutic approaches to curb this epidemic . In this special issue , we have invited a few papers that address such issues and explain why despite the emergence of novel therapeutic approaches , that promise life prolongation and hospital length reduction , this patient population will still be needing rehospitalization and will often have a poor prognosis . This special issue is the extension of an effort that was initiated in 2011 with the first heart-failure-focused issue [ 2 ] . In the pathophysiology section , S. M. R. Kazemi-Bajestani et al. describe the opportunities and challenges of targeting the angiotensin converting enzyme 2 (ACE2)/Ang II/Ang1–7 and apelin/APJ pathways as novel therapeutic modalities in heart failure [ 3 ] . ACE2 and the apelin/APJ are two important peptide systems which exert diverse effects on the cardiovascular system . Dysregulation of such systems may be involved in the predisposition to cardiovascular diseases whereas enhancing their action may have important therapeutic effects . In the same section , D. Lindner et al. provide a comprehensive review on the protective function of signal transducer and activator of transcription 3 ( STAT3 ) in CVB3-induced myocarditis [ 4 ] . The transcription factor ( STAT3 ) is an important mediator of the inflammatory process , and in this original research the investigators examine the role of STAT3 in viral myocarditis and its possible role in the development to dilated cardiomyopathy . Considering the high mortality rate and the availability of life-saving therapies like transplantation and left ventricular assist devices , accurate prognosis determination in HF is clinical ly important . Taking into account the mediocre performance of current established prediction models , such as the Seattle Heart Failure Model [ 5–7 ] , the work by H. Fukuta et al. [ 8 ] on the prognostic value of left ventricular diastolic dysfunction in patients undergoing cardiac catheterization for coronary artery disease sheds light on this extremely important topic . A shared underst and ing of medical conditions between patients and their health care providers has been shown to improve self-care and outcomes [ 9 ] . In the comorbidity section , we demonstrate how certain comorbid conditions may affect patients ' decision-making capacity and interfere with their ability to comply with treatment requirements , recognize and self-manage disease worsening symptoms . Among others , cognitive impairment is increasingly recognized as a common adverse consequence of HF , whereby phenomena such as microembolism , chronic or intermittent cerebral hypoperfusion , and /or impaired cerebral vessel reactivity may lead to cerebral hypoxia and ischemic brain damage . Cognitive decline in HF is characterized by deficits in one or more cognition domains , including attention , memory , executive function , and psychomotor speed . E. Dardiotis et al. [ 10 ] , in a comprehensive review , underscore the importance for healthcare professionals to become familiar with assessment of cognitive performance using st and ardized screening instruments in their routine evaluations of HF patients . Another comorbidity gaining increasing attention in HF patients is depression . There are several pathophysiological mechanisms as well as behavioral processes linking depression and HF . Equally important is screening for depression and there are several valid and reliable screening tools to identify patients at greater risk . Consultation should be provided by a multidisciplinary team , consisting of cardiologists , psychiatrists , and hospital or community nurses so as to carefully plan , execute , and evaluate medical intervention and implement lifestyle changes . D. Mastrogiannis et al. [ 11 ] systematic ally review the existing knowledge regarding current definitions , prognostic implication s , pathophysiological mechanisms , and current and future treatment options in patients with depression and HF . Evidence from the literature supports the possibility of a pathophysiological relationship between cognitive impairment , depression , and HF . Yet , very few studies have sought to investigate this relationship . The paper by Z. N. Sohani and Z. Samaan review s current literature on the association between depression and cognitive impairment  in persons with HF and explores possible mechanisms explaining this complex triad [ 12 ] . Heart failure through neurohumoral activation induces alterations of cardiac metabolism , such as insulin resistance , and promotes increased utilization of noncarbohydrate substrates for energy production [ 13 , 14 ] . Fasting blood ketone bodies as well as fat oxidation have been shown to be increased in this patient population . The result is depletion of myocardial ATP , phosphocreatine , and creatine kinase , leading to decreased efficiency of mechanical work . A direct approach to manipulate cardiac energy metabolism consists in modifying substrate utilization by the failing heart . Trimetazidine , perhexiline , and ranolazine directly inhibit fatty acid oxidation and have been used to increase the ischemic threshold in patients with effort angina . Current research is supporting the concept that shifting the energy substrate preference away from fatty acid metabolism and toward glucose metabolism could be an effective adjunctive treatment in patients with HF . These agents have been shown to improve both glucose metabolism and left ventricular function in diabetic patients with left ventricular dysfunction . In the pharmacotherapy section , we provide a systematic review , in which N. Signoretta et al. [ 15 ] discuss the beneficial therapeutic effects of modulation of cardiac metabolic substrates utilization in patients with HF . In the advanced heart failure section , we provide a thorough review on the current status of mechanical circulatory support in patients with advanced HF . Management of the advanced HF patients with the numerous comorbidities [ 16 , 17 ] requires a significant amount of health care re sources and is becoming a major public health problem . As therapeutical strategies for HF have been refined , the number of patients suffering from the end-stage disease has exp and ed dramatically . Although heart transplantation still represents the gold st and ard therapeutical approach , the shortage of donors universally has made the implantation of mechanical circulatory support devices a well-established management for this disease . The systematic review by K. Spiliopoulos et al. [ 18 ] , outlines the current status of mechanical circulatory support in this patient population . In the chronic follow-up section , we deal with telemonitoring , a novel diagnostic modality that has been suggested to be beneficial for HF patients , targeting optimization of their chronic followup . Telemonitoring is viewed as a means of recording physiological data ( such as body weight , heart rate , arterial blood pressure electrocardiogram recordings , and other data ) by portable devices and transmitting these data remotely ( via a telephone line , a mobile phone , or a computer ) to a server where they can be stored , review ed , and analyzed by the research team . In a systematic review of all r and omized clinical trials evaluating telemonitoring in chronic HF , G. Giamouzis et al. [ 19 ] assess whether telemonitoring provides any substantial benefit in this patient population . We hope that the readers of the journal will find the topics as interesting and important as we did . Gregory Giamouzis George Giannakoulas Javed Butler John A. Elefteriades Carsten Tschope Filippos BACKGROUND Continuity of care is widely regarded as an important marker of quality in the management of patients with long-term conditions . New services that integrate telemonitoring into care pathways have potential to change aspects of continuity in both positive and negative ways . AIMS A telemonitoring service for patients with chronic obstructive pulmonary disease ( COPD ) was introduced in Lothian , Scotl and , in 2009 . A qualitative study , nested within the TELESCOT COPD r and omised control trial , was undertaken to explore the views of patients and professionals on  telemonitoring . The perceived impact of telemonitoring on continuity of care was investigated as part of the research . METHODS Semi-structured interviews were undertaken with 38 patients ( 47 % male , mean age 67.5 years ) . A maximum variation sample in relation to age , sex , socio-economic background , disease severity , and compliance with telemonitoring was recruited . Thirty-two stakeholders ( healthcare professionals and managers ) were interviewed . Transcribed coded data were analysed thematically using the framework approach . Interpretation was supported by multidisciplinary discussion . RESULTS Patients and healthcare professionals considered that relationship-based continuity of care was important in the delivery of telemonitoring services . Managers placed emphasis on improved continuity of clinical management as a means of reducing healthcare costs . However , professionals described many operational challenges arising from the ' bolting-on ' of telemonitoring provision to existing usual care provision which , they considered , result ed in the proliferation of additional managerial discontinuities . CONCLUSIONS Managers and healthcare professionals face major challenges in meeting dem and s for both relationship continuity and continuity of clinical management in the development of telemonitoring services
RESULTS The magnitude and significance of the telemonitoring effects on patients ' conditions ( e.g. , early detection of symptoms , decrease in blood pressure , adequate medication , reduced mortality ) still remain inconclusive for all four chronic illnesses .
However , the results of this study suggest that regardless of their nationality , socioeconomic status , or age , patients comply with telemonitoring programs and the use of technologies .
Importantly , the telemonitoring effects on clinical effectiveness outcomes ( e.g. , decrease in the emergency visits , hospital admissions , average hospital length of stay ) are more consistent in pulmonary and cardiac studies than diabetes and hypertension .
Home telemonitoring of chronic diseases seems to be a promising patient management approach that produces accurate and reliable data , empowers patients , influences their attitudes and behaviors , and potentially improves their medical conditions .
OBJECTIVE Home telemonitoring represents a patient management approach combining various information technologies for monitoring patients at distance .
This study presents a systematic review of the nature and magnitude of outcomes associated with telemonitoring of four types of chronic illnesses : pulmonary conditions , diabetes , hypertension , and cardiovascular diseases .