Long-term Effects of Telemonitoring on Healthcare Usage in Patients with Heart Failure or COPD (Preprint)
Authors: van der Burg Jorien Maria Margaretha , Aziz Nasir Ahmad , Kaptein Maurits C. , Breteler Martine J.M. , Jansen Joris H. , van Vliet Lisa , Winkeler Daniel , van Anken Anneke , Kasteleyn Marise J. , Chavannes Niels H. 
Published: May 2018

UNSTRUCTURED

Objective
The aim of this study was to evaluate the effectiveness of home telemonitoring in reducing healthcare usage and costs in patients with heart failure or chronic obstructive pulmonary disease (COPD).

Design
The study was a retrospective observational study with a pre-post research design and a follow-up duration of up to 3 years, based on hospital data collected in the period 2012-2016.

Setting
Data was collected at the Slingeland Hospital in Doetinchem, The Netherlands.

Participants
In 2012 the Slingeland Hospital in The Netherlands started a telemonitoring program for patients with COPD or heart failure as part of their usual care. Patients were eligible for the telemonitoring program if they were in an advanced disease stage (New York Heart Association (NYHA) functional class 3 or 4; COPD gold stage 3 or 4), received treatment for their condition by a cardiologist or pulmonary specialist at the Slingeland Hospital, were proficient in Dutch and capable of providing informed consent. Exclusion criteria were absence of the cognitive, physical or logistical ability required to fully participate in the program. Hundred seventy-seven patients with heart failure and 83 patients with COPD enrolled the program between 2012 and 2016.

Intervention
Using a touchscreen, participants with heart failure recorded their weight (daily), blood pressure and heart rate (once a week) through connected instruments, and completed a questionnaire about their symptoms (once a week). Symptoms in patients with COPD were monitored via the Clinical COPD Questionnaire (CCQ), which participants were asked to complete twice per week. All home registrations were sent via a telemonitoring application (cVitals, FocusCura, Driebergen-Rijssenburg) on the iPad to a medical service center were a trained nurse monitored the data and contacted the patient by video chat or a specialised nurse in the hospital in case of abnormal results, such as deviations from a preset threshold or alterations in symptom score.

Outcome measures
The primary outcome was the number of hospitalisations; the secondary outcomes were total number of hospitalisation days and healthcare costs during the follow-up period. Generalised Estimating Equations were applied to account for repeated measurements, adjusting for sex, age and length of follow-up.

Results
In heart failure patients (N=177), after initiation of home telemonitoring both the number of hospitalisations and the total number of hospitalisation days significantly decreased (incidence rate ratio of 0.35 (95% CI: 0.26-0.48) and 0.35 (95% CI: 0.24-0.51), respectively), as did the total healthcare costs (exp(B) = 0.11 (95% CI: 0.08-0.17)), all p < 0.001. In COPD patients (N=83) neither the number of hospitalisations nor the number of hospitalisation days changed compared to the pre-intervention period. However, the average healthcare costs were about 54% lower in COPD patients after the start of the home telemonitoring intervention (exp(B) = 0.46, 95% CI 0.25-0.84, p = 0.011).

Conclusion
Integrated telemonitoring significantly reduced the number of hospital admissions and days spent in hospital in patients with heart failure, but not in patients with COPD. Importantly, in both patients with heart failure and COPD the intervention substantially reduced the total healthcare costs.