Home Health Care With Telemonitoring Improves Health Status for Older Adults With Heart Failure A systematic review of the cost and cost-effectiveness of telehealth for patients suffering from chronic obstructive pulmonary disease Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial Community-based care for the management of type 2 diabetes: an evidence-based analysis. A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study Home telemonitoring in heart failure patients: the HHH study (Home or Hospital in Heart Failure) 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 Impact of telemonitoring at home on the management of elderly patients with congestive heart failure A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home-HF study. A randomised clinical trial of the effectiveness of home-based health care with telemonitoring in patients with COPD Telemonitoring-based service redesign for the management of uncontrolled hypertension (HITS): cost and cost-effectiveness analysis of a randomised controlled trial A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Assessment of a primary care-based telemonitoring intervention for home care patients with heart failure and chronic lung disease. The TELBIL study Place of care in advanced cancer: a qualitative systematic literature review of patient preferences. A novel telemonitoring device for improving diabetes control: protocol and results from a randomized clinical trial. Cost–effectiveness analysis of telemonitoring versus usual care in patients with heart failure: The TEHAF–study The rationale and design of reduction of uncontrolled hypertension by Remote Monitoring and Telemedicine (REMOTE) study Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. Feasibility of blood pressure telemonitoring in patients with poor blood pressure control Effectiveness of electronic guideline-based implementation systems in ambulatory care settings - a systematic review Randomized trial of Telemonitoring to Improve Heart Failure Outcomes (Tele-HF): study design. Telemonitoring in patients with heart failure. Telemonitoring in fasting individuals with Type 2 Diabetes Mellitus during Ramadan: A prospective, randomised controlled study
Home telemonitoring can augment home health care services during a patient 's transition from hospital to home . Home health care agencies commonly use telemonitors for patients with heart failure although studies have shown mixed results in the use of telemonitors to reduce rehospitalizations . This r and omized trial investigated if older patients with heart failure admitted to home health care following a hospitalization would have a reduction in rehospitalizations and improved health status if they received telemonitoring .  Patients were followed up to 180 days post-discharge from home health care services . Results showed no difference in the time to rehospitalization or emergency visit between those who received telemonitoring versus usual care .  Older heart failure patients who received telemonitoring had better health status by home health care discharge than those who received usual care . Therefore , for older adults with heart failure , telemonitoring may be an important adjunct to home health care services to improve health status We conducted a systematic review of the evidence on the costs and cost-effectiveness of telehealth for patients with chronic obstructive pulmonary disease ( COPD ) . A literature search identified six relevant economic evaluations that were assessed according to the Consensus Health Economic Criteria list ( CHEC list ) . Three studies were from North America and three studies were from Europe . All studies reported the use of home monitoring devices that measured and transmitted different physical indicators to nurses who provided personalised feedback to patients during weekdays . The six studies involved a total of 559 COPD patients of whom 281 were r and omised to telehealth .  The review demonstrated a potential for cost savings . All six studies reported a lower average cost per patient with telehealth plus usual care compared with usual care alone . However , the quality of the economic evidence was poor . Five studies were evaluated as low quality and one study was evaluated as moderate quality , with CHEC list scores of 21–68 % . Caution is advised for healthcare decision-makers seeking large-scale implementation of telehealth in routine clinical practice . The clinical effectiveness of such implementations with follow-up exceeding 12 months has not yet been demonstrated 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 UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes  : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups 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 The Home or Hospital in Heart failure ( HHH ) study was a European Community‐funded , multinational , r and omized controlled clinical trial , conducted in the UK , Pol and , and Italy , to assess the feasibility of a new system of home telemonitoring ( HT ) . The HT system was used to monitor clinical and physiological parameters , and its effectiveness ( compared with usual care ) in reducing cardiac events in heart failure ( HF ) patients was evaluated . Measurements were patient‐managed 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 We studied the effects of home telemonitoring in elderly patients with congestive heart failure ( CHF ) on mortality and rate of hospitalization , compliance with treatment , quality of life and costs of CHF management , by comparison with a group receiving usual care . Fifty-seven elderly CHF patients were r and omized to st and ard care or to home telemonitoring-based care  and followed for 12 months . In the subjects who were monitored , weekly reports on their clinical status were obtained and their management was modified accordingly . Home telemonitoring was associated with improvements in the composite endpoint of mortality and rate of hospitalizations ( P = 0.006 ) , a better compliance with therapy , more frequent use of beta-blockers and statins , lower total cholesterol level and a better reported health perception score . The improved results with home telemonitoring in CHF were probably due to better compliance and to closer monitoring of the patients AIMS Heart failure chiefly affects the elderly , with frequent emergency admissions . Telemonitoring can identify worsening heart failure but previous r and omized trials have enrolled selected patient population s. The Home-HF study examined the impact of home telemonitoring on typical heart failure patients discharged from three acute hospitals in North West London , UK . METHODS AND RESULTS Patients hospitalized with heart failure were r and omized to telemonitoring or usual specialist care . Primary outcome measures were days alive and out of hospital . Secondary outcome measures were number and duration of heart failure hospitalizations , clinic visits , and quality of life .  We recruited 182 patients . There was no difference in the primary outcome measure in the two groups , but there were significantly fewer unplanned hospitalizations for heart failure decompensation , and a reduction in clinic and emergency room visits in the telemonitoring group . There was no statistically significant difference in the mean direct health service costs . CONCLUSION Home telemonitoring in a typical elderly population of heart failure patients produces a similar outcome to ' usual ' specialist care , but reduces clinic and emergency room visits and unplanned heart failure rehospitalizations at little additional cost . This method of disease monitoring may allow specialist services to increase the number of patients under their care We studied the effect of telemonitoring in addition to usual care compared to usual care alone in patients with chronic obstructive pulmonary disease ( COPD ) . A total of 110 patients with moderate to severe COPD were recruited from a specialist respiratory service in Northern Irel and . Patients had at least two of : emergency department admissions , hospital admissions or emergency general practitioner ( GP ) contacts in the 12 months before the study . Exclusion criteria were patients who had any respiratory disorder other than COPD , or were cognitively unable to learn the process of monitoring . Patients were r and omised to receive six months of home telemonitoring with usual care , or six months of usual care . The primary outcome measure was disease-specific quality of life , as measured by the St George ’s Respiratory Question naire for COPD patients ( SGRQ-C ) . Of 100 patients completing the study , 48 patients were r and omised to telemonitoring and 52 patients were r and omised to the control group . The SGRQ-C scores improved significantly in the intervention group compared to usual care ( P = 0.001 ) . The HADS anxiety score was significantly higher in the telehealth group compared to the usual care group ( P = 0.01 ) . There were significantly more contacts with the Community Respiratory Team in the telemonitoring group compared to the control group ( P = 0.029 ) . There were no significant between group differences in EQ-5D scores , HADS depression scores , GP activity , emergency department visits , hospital admissions or exacerbations . The total cost to the health service of the intervention over the 6-month study period was £ 2039 , giving an estimated ICER of £ 203,900 . In selected patients with COPD , telemonitoring was effective in improving health-related quality of life and anxiety , but was not a cost-effective intervention 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 Efficiently caring for frail older adults will become an increasingly important part of health care reform;telemonitoring within homes may be an answer to improve outcomes . This study sought to assess differences in hospitalizations and emergency department ( ED ) visits among older adults using telemonitoring vs usual care . METHODS A r and omized controlled trial was performed among adults older than 60 years at high risk for rehospitalization . Participants were r and omized to telemonitoring ( with daily input ) or to patient-driven usual care . Telemonitoring was accomplished by daily biometrics , symptom reporting , and videoconference . The primary outcome was a composite end point of hospitalizations and ED visits in the 12 months following enrollment . Secondary end points included hospitalizations , ED visits , and total hospital days . Intent-to-treat analysis was performed . RESULTS Two hundred five participants were enrolled , with a mean age of 80.3 years . The primary outcome of hospitalizations and ED visits did not differ between the telemonitoring group ( 63.7 % ) and the usual care group(57.3 % ) ( P=.35 ) . No differences were observed in secondary end points , including hospitalizations , ED visits , and total hospital days . No significant group differences in hospitalizations and ED visits were found between the pre-enrollment period vs the post-enrollment period . Mortality was higher in the telemonitoring group (14.7%)than in the usual care group ( 3.9 % ) ( P=.008 ) . CONCLUSIONS Among older patients , telemonitoring did not result in fewer hospitalizations or ED visits . Secondary outcomes demonstrated no significant differences between the telemonitoring group and the usual care group . The cause of greater mortality in the telemonitoring group is unknown Background Telemonitoring technology offers one of the most promising alternatives for the provision of health care services at the patient 's home . The primary aim of this study is to evaluate the impact of a primary care-based telemonitoring intervention on the frequency of hospital admissions . Methods / design A primary care-based r and omised controlled trial will be carried out to assess the impact of a telemonitoring intervention aim ed at home care patients with heart failure ( HF ) and /or chronic lung disease ( CLD ) . The results will be compared with those obtained with st and ard health care practice . The duration of the study will be of one year . Sixty patients will be recruited for the study . In-home patients , diagnosed with HF and /or CLD , aged 14 or above and with two or more hospital admissions in the previous year will be eligible . For the intervention group , telemonitoring will consist of daily patient self- measurements of respiratory-rate , heart-rate , blood pressure , oxygen saturation , weight and body temperature . Additionally , the patients will complete a qualitative symptom question naire daily using the telemonitoring system . Routine telephone contacts will be conducted every fortnight and additional telephone contacts will be carried out if the data received at the primary care centre are out of the established limits . The control group will receive usual care . The primary outcome measure is the number of hospital admissions due to any cause that occurred in a period of 12 months post-r and omisation . The secondary outcome measures are : duration of hospital stay , hospital admissions due to HF or CLD , mortality rate , use of health care re sources , quality of life , cost-effectiveness , compliance and patient and health care professional satisfaction with the new technology . Discussion The results of this study will shed some light on the effects of telemonitoring for the follow-up and management of chronic patients from a primary care setting . The study may contribute to enhance the underst and ing of alternative modes of health care provision for medically unstable elderly patients , who bear a high degree of physical and functional deterioration . Trial Registration IS RCT N : IS RCT BACKGROUND It is commonly written that more patients wish to die at home than currently achieve this . However , the evidence for preferences for place of terminal care and death has not been systematic ally review ed . AIM To carry out a systematic literature review of the preferences for  place of care and death  among advanced cancer patients . METHOD Studies were identified using systematic data base search es of MEDLINE ( 1966 - 1999 ) , PsychLit ( 1974 - 1999 ) , and Bath Information Data Service ( BIDS ) ( 1981 - 1999 ) . Studies were assessed and data extracted and synthesis es following the NHS Centre for Review s and Dissemination guidelines , grading studies according to design and rigor of methods . Studies of preferences in the general population and of groups including cancer patients and /or their caregivers were included . RESULTS Eighteen studies determining preferences in either the general population or groups including cancer patients were identified . Views were obtained prospect ively and retrospectively from patients , the general population , families , and professionals . Respondents indicated preferences for home death ( range 49%-100 % ) , except one study of patients in the care of a continuing care team in London where only 25%-29 % of patients wanted a home death , and inpatient hospice was the most favored option . However , the response rate of this study was not known . Among the general public there was a higher preference for  inpatient hospice care among in people with recent experience of a close friend or relative 's death or dying . Where the views of patients , families , and professionals were compared , all respondents broadly agreed although patients expressed the strongest home preferences . Only 2 of the studies provided longitudinal data , and 9 of the 18 had major deficits in design or reporting , such as poor or unknown response rate , unclear or un systematic methods of eliciting preferences or other sample or measurement bias . However , sensitivity analysis of only the more robust and larger studies did not alter the finding of a preference for home care at the end of life in over 50 % of patients . CONCLUSIONS Home care is the most common preference , with inpatient hospice care as second preference in advanced illness . Meeting these preferences could be important outcomes for services . Study design s in this area need to be improved 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 Summary We examined the incremental cost – effectiveness of telemonitoring ( TM ) versus usual care ( UC ) in patients with congestive heart failure ( CHF ) . In one university and two general hospitals , 382 patients were r and omised to usual care or telemonitoring  and followed for 1 year . Hospital-related and home costs were estimated , based on re source use multiplied by the appropriate unit prices . Effectiveness was expressed as QALYs gained . Information was gathered , using 3 monthly costs diaries and question naires . The mean age of the patients was 71 years ( range 32–93 ) , 59 % were male and 64 % lived with a partner . Health related quality of life improved by 0.07 points for the usual care and 0.1 points for the telemonitoring group , but the difference between groups was not significant . There were no significant differences in annual costs per patient between groups . At a threshold of € 50,000 the probability of telemonitoring  being cost-effective was 48 % . The cost effectiveness analysis showed a high level of decision uncertainty , probably caused by the divergence between the participating institutions . It is therefore premature to draw an unambiguous conclusion regarding cost-effectiveness for the whole group 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 IMPORTANCE Only about half of patients with high blood pressure ( BP ) in the United States have their BP controlled . Practical , robust , and sustainable models are needed to improve BP control in patients with uncontrolled hypertension . OBJECTIVES To determine whether an intervention combining home BP telemonitoring with pharmacist case management improves BP control compared with usual care and to determine whether BP control is maintained after the intervention is stopped . DESIGN , SETTING , AND PATIENTS A cluster r and omized clinical trial of 450 adults with uncontrolled BP recruited from 14,692 patients with electronic medical records across 16 primary care clinics in an integrated health system in Minneapolis-St Paul , Minnesota , with 12 months of intervention and 6 months of postintervention follow-up . INTERVENTIONS Eight clinics were r and omized to provide usual care to patients ( n = 222 ) and 8 clinics were r and omized to provide a telemonitoring intervention ( n = 228 ) . Intervention patients received home BP telemonitors and transmitted BP data to pharmacists who adjusted antihypertensive therapy accordingly . MAIN OUTCOMES AND MEASURES Control of systolic BP to less than 140 mm Hg and diastolic BP to less than 90 mm Hg ( < 130/80 mm Hg in patients with diabetes or chronic kidney disease ) at 6 and 12 months . Secondary outcomes were change in BP , patient satisfaction , and BP control at 18 months ( 6 months after intervention stopped ) . RESULTS At baseline , enrollees were 45 % women , 82 % white , mean ( SD ) age was 61.1 ( 12.0 ) years , and mean systolic BP was 148 mm Hg and diastolic BP was 85 mm Hg .  Blood pressure was controlled at both 6 and 12 months in 57.2 % ( 95 % CI , 44.8 % to 68.7 % ) of patients in the telemonitoring intervention group vs 30.0 % ( 95 % CI , 23.2 % to 37.8 % ) of patients in the usual care group ( P = .001 ) . At 18 months ( 6 months of postintervention follow-up ) , BP was controlled in 71.8 % ( 95 % CI , 65.0 % to 77.8 % ) of patients in the telemonitoring intervention group vs 57.1 % ( 95 % CI , 51.5 % to 62.6 % ) of patients in the usual care group ( P = .003 ) . Compared with the usual care group , systolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months ( -10.7 mm Hg [ 95 % CI , -14.3 to -7.3 mm Hg ] ; P<.001 ) , at 12 months ( -9.7 mm Hg [ 95 % CI , -13.4 to -6.0 mm Hg ] ; P<.001 ) , and at 18 months ( -6.6 mm Hg [ 95 % CI , -10.7 to -2.5 mm Hg ] ; P = .004 ) . Compared with the usual care group , diastolic BP decreased more from baseline among patients in the telemonitoring intervention group at 6 months ( -6.0 mm Hg [ 95 % CI , -8.6 to -3.4 mm Hg ] ; P<.001 ) , at 12 months ( -5.1 mm Hg [ 95 % CI , -7.4 to -2.8 mm Hg ] ; P<.001 ) , and at 18 months ( -3.0 mm Hg [ 95 % CI , -6.3 to 0.3 mm Hg ] ; P = .07 ) . CONCLUSIONS AND RELEVANCE Home BP telemonitoring and pharmacist case management achieved better BP control compared with usual care during 12 months of intervention that persisted during 6 months of postintervention follow-up . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00781365 We examined the feasibility of using home blood pressure ( BP ) telemonitoring devices for managing patients with poor BP control .  We enrolled 591 subjects with a diagnosis of hypertension . Patients were r and omized to usual care ( n = 147 ) or to the intervention arm ( n = 441 ) . Those in the intervention arm were issued with a home BP telemonitoring device . The device transmitted BP readings automatically via the home telephone line . Technical alerts were generated if patients did not transmit their BP readings according to the protocol . During the first six months , 693 technical alerts were generated by 267 patients . About half of these patients ( 112 ) generated more than two technical alerts . Resolution of the alerts showed that 61 % were caused by patient non-adherence . Patients who generated > 2 technical alerts were younger ( 61 vs. 64 years ; P = 0.001 ) and were more likely to be non-Caucasian  ( 64 % vs. 47 % , P = 0.002 ) than those generating 2 or fewer alerts . Despite the potential for improving health care using home BP telemonitoring , certain patients will require more support to use the equipment successfully Background Electronic guideline -based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines . A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services . Methods A systematic literature search ( 1990 to December 2008 ) of the English literature indexed in the Medline data base , Embase , the Cochrane Central Register of Controlled Trials , and CRD ( DARE , HTA and NHS EED data bases ) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care setting s. Important inclusion criterions were the multidimensionality of the guideline ( the guideline needed to consist of several aspects or steps ) and real-time interaction with the system during consultation . Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier review s were excluded . Two comparisons were considered : electronic multidimensional guidelines versus usual care ( comparison one ) and electronic multidimensional guidelines versus other guideline implementation methods ( comparison two ) . Results Twenty-seven publications were selected for analysis in this systematic review . Most design s were cluster r and omized controlled trials investigating process outcomes more than patient outcomes . With success defined as at least 50 % of the outcome variables being significant , none of the studies were successful in improving patient outcomes . Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group ( comparison one ) . No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found , neither for the patient outcomes nor for the process outcomes ( comparison two ) . Conclusions There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines . After more than a decade of development of numerous electronic systems , research on the most effective implementation strategy for this kind of guideline -based decision support systems is still lacking . This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care BACKGROUND Telemonitoring , the use of communication technology to monitor clinical status , is gaining attention as a strategy to improve the care of patients with heart failure . A system of frequent monitoring could alert clinicians to early heart failure decompensation , providing the opportunity for intervention before patients become severely ill and require hospitalization . Moreover , patients ' participation in a daily monitoring program could have a favorable effect on their health behaviors . The literature on telemonitoring for heart failure , however , is quite limited . METHODS AND MATERIAL S Telemonitoring to Improve Heart Failure Outcomes ( Tele-HF ) is a r and omized , controlled , trial design ed to compare an automated , daily symptom , and self-reported weight monitoring intervention with usual care in reducing ( all-cause ) hospital readmissions and mortality among patients recently hospitalized with decompensated heart failure . The intervention will be implemented and all outcomes will be assessed over a 6-month period . The purpose of the intervention is to collect information about symptoms , clinical status and weight and to engage participants in their own self-care .  Participants are recruited from general cardiology , heart failure specialty , and primary care practice s across the United States . CONCLUSIONS The results of this study may inform future policy decisions regarding implementation of telemonitoring in treatment of heart failure BACKGROUND Small studies suggest that telemonitoring may improve heart-failure outcomes , but its effect in a large trial has not been established . METHODS We r and omly assigned 1653 patients who had recently been hospitalized for heart failure to undergo either telemonitoring ( 826 patients ) or usual care ( 827 patients ) .  Telemonitoring was accomplished by means of a telephone-based interactive voice-response system that collected daily information about symptoms and weight that was review ed by the patients ' clinicians . The primary end point was readmission for any reason or death from any cause within 180 days after enrollment . Secondary end points included hospitalization for heart failure , number of days in the hospital , and number of hospitalizations . RESULTS The median age of the patients was 61 years ; 42.0 % were female , and 39.0 % were black . The telemonitoring group and the usual-care group did not differ significantly with respect to the primary end point , which occurred in 52.3 % and 51.5 % of patients , respectively ( difference , 0.8 percentage points ; 95 % confidence interval [ CI ] , -4.0 to 5.6 ; P=0.75 by the chi-square test ) . Readmission for any reason occurred in 49.3 % of patients in the telemonitoring group and 47.4 % of patients in the usual-care group ( difference , 1.9 percentage points ; 95 % CI , -3.0 to 6.7 ; P=0.45 by the chi-square test ) . Death occurred in 11.1 % of the telemonitoring group and 11.4 % of the usual care group ( difference , -0.2 percentage points ; 95 % CI , -3.3 to 2.8 ; P=0.88 by the chi-square test ) . There were no significant differences between the two groups with respect to the secondary end points or the time to the primary end point or its components . No adverse events were reported . CONCLUSIONS Among patients recently hospitalized for heart failure , telemonitoring did not improve outcomes . The results indicate the importance of a thorough , independent evaluation of disease-management strategies before their adoption . ( Funded by the National Heart , Lung , and Blood Institute ; Clinical Trials.gov number , NCT00303212 . ) We determined the impact of a remote blood glucose telemonitoring program with feedback in type 2 diabetes mellitus patients fasting during Ramadan compared to conventional self-monitoring method . A twelve-week cluster r and omised study , with 85 participants who wish to fast for at least 15 days during Ramadan was conducted . Self-measurement and transmission of blood glucose results were performed six times daily during Ramadan . Results were transmitted to a secure website for review with feedback from case manager if necessary . The control group received usual care . The main outcome was the number of participants experiencing hypoglycaemia during Ramadan and at the end of the study . During Ramadan , the number of participants reporting hypoglycaemia was significantly lower in the telemonitoring group [ Odds ratio ( OR ) : 0.186 , 95 % confidence interval : 0.04–0.936 ; p = 0.04 ] . Similarly , the proportion of participants reporting symptomatic hypoglycaemia at the end of the study was significantly lower in the telemonitoring group ( OR : 0.257 , 95 % CI : 0.07–0.89 ; p = 0.03 ) . A reduction of 1.07 % in glycated haemoglobin levels was observed in the telemonitoring group compared to 0.24 % in the control group ( p < 0.01 ) . Overall , telemonitoring was a useful adjunct to reduce the risk of hypoglycaemia during Ramadan with no deterioration in glycaemic
Patient quality of life and satisfaction with home telemonitoring were similar or better than with usual care .
We conducted a systematic review of the literature about home telemonitoring compared with usual care .