Disclaimer
This information collection is a core HTA, i.e. an extensive analysis of one or more health technologies using all nine domains of the HTA Core Model. The core HTA is intended to be used as an information base for local (e.g. national or regional) HTAs.

Structured telephone support (STS) for adult patients with chronic heart failure

Structured telephone support (STS) for adult patients with chronic heart failure compared to Usual care defined as regular schedules of visits of the patient at the heart center/ GP/cardiologist or patient has to move (≠ at home) in the prevention of Chronic cardiac failure in adults and elderly with chronic heart failure (CHF) AND hospitalization due to heart failure at least once AND without implanted devices

(See detailed scope below)

HTA Core Model Application for Medical and Surgical Interventions (2.0)
Core HTA
Published
Tom Jefferson (Agenas - Italy), Marina Cerbo (Agenas - Italy), Nicola Vicari (Agenas - Italy)
Neill Booth (THL - Finland), Plamen Dimitrov (NCPHA - Bulgaria), Mirjana Huic (AAZ - Croatia), Valentina Rupel (IER - Slovenia), Alessandra Lo Scalzo (Agenas - Italy), Ingrid Wilbacher (HVB - Austria)
Agenas - Agenzia nazionale per i servizi sanitari regionali
AAZ (Croatia), Agenas (Italy), ASSR RER (Italy), Avalia-t (Spain), CEM (Luxembourg), GÖG (Austria), HVB (Austria), IER (Slovenia), ISC III (Spain), NCPHA (Bulgaria), NIPH (Slovenia), NSPH (Greece), NSPH MD (Romania), SBU (Sweden), SNHTA (Switzerland), THL (Finland), UTA (Estonia).
9.9.2014 11.18.00
4.12.2015 17.51.00
Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 30 June 2022]. Available from: http://corehta.info/ViewCover.aspx?id=305

Structured telephone support (STS) for adult patients with chronic heart failure

<< Ethical analysisSocial aspects >>

Organisational aspects

Authors: Valentina Prevolnik Rupel, Taja Čokl, Eleftheria Karampli

Summary

ORG1: How does Telemonitoring in home care for patients with chronic cardiovascular diseases affect the current work processes?

As most of the studies are conducted in controlled academic environment or non realistic setting, it might be that additional option should be considered in real setting, like hiring a nurse, use of low cost telephone service, use more time for outcomes dissemination and results discussion in a team. STS can be carried out in very different settings, from primary care to tertiary care. There is little information in the studies on the changes of the workflow – usually for the STS an additional nurse was used who had access to patient data, carried out the STS, monitored the patient, recorded the symptoms and data and reinforced and adapted the plan of care for the patient. The other medical professions did not get involved in STS directly, only indirectly, through the STS nurse, who coordinated all the activities and services around the patient. No study specifically recorded the (decrease or increase of) workload for other specialists in case a STS nurse was involved in the work. One study {6} describes how to manage human resources and the division of roles between nurses. During the 2007 calendar year, there were 1.356 patients visits to the HF clinic and telephone calls accounted for an additional 1.914 patient encounters in 2007. One full-time nurse practitioner, one clinical nurse specialist (working 0,7 of a full-time equivalent), and one registered nurse (vacation replacement) provided the nursing interventions with the telephone visits. Nurse spent 24 % of their working hours doing 1.914 telephone calls in one year.

ORG 2: What kind of patient/participant flow is associated with Telemonitoring in home care for patients with chronic cardiovascular diseases?

 

STS replaced historical program of doctor’s visits for HF patients after discharge. In interventions utilizing STS, the patient is monitored remotely while being at home (including a relative’s home, nursing home or residential care home). The patients are contacted in regular time intervals via telephone by either healthcare personnel (e.g. specialized HF nurses) or an automated telephone-based interactive response system. The STS support starts being planned while the patient is in hospital through education and meeting with the HF nurse. Education and practising with the technology follows and the materials are given to the patients as well as explained to the relatives. At the point of discharge the timing of the first call is agreed. The frequency of calls varies greatly among the studies but in common the calls are weekly at least first two weeks after discharge and then get biweekly until two months after discharge. After that they become monthly. It is not clear how long the intervention should last: there are different periods, going from 3 months up to 2 years after the discharge. It is not clear when the effect is biggest, possibly within first 3 months.

ORG3: What kind of involvement has to be mobilized for patients/participants and important others?

Please find the overlapping results also in TEC3: What kind of training and information should be provided for the patient who uses Telemonitoring in home care for patients with chronic cardiovascular diseases, or for his family?

ORG4: What is the process ensuring proper education and training of the staff?

Proper education and training of the staff is ensured through the courses for nurses on HF (formal HF certification) and on the remote monitoring, which is assured by telemedicine providers in case any devices for home symptoms measurements are included. As far as the STS itself, no specific training were found to be offered to staff in the literature.

ORG5: What kind of co-operation and communication of activities have to be mobilised?

In the heart of communication and cooperation strategy in the studies there is always a nurse. A consistent nurse case manager who cares for the patient and connects family, tries to understand goals and specific outcomes, provides information and monitors patient and communicates and cooperates with other members of health team to help them understand the patient {240}. A published communication strategy is important, including patient support strategy, communication between patient: nurse, patient: medical doctor, patient: pharmacist, the brochures, diaries to record daily control measurements, web pages with disease information and with instructions, instructions for family members  to share a best practise.

ORG6: How is the quality assurance and monitoring system of Telemonitoring in home care for patients with chronic cardiovascular diseases organised?

Please find the overlapping results in TEC2: What kind of qualification and quality assurance processes are needed for the use or maintenance of Telemonitoring in home care for patients with chronic cardiovascular diseases?

ORG7: What are the processes ensuring access to care of Telemonitoring in home care for patients with chronic cardiovascular diseases for patients/participants?

In general, RM including STS provides greater access to care in geographical terms. In most of the studies the problems with accessability to phone line were not reported. Careful planning of STS is necessary among specific population that might have issues in moving around and having lower access to phone lines. Also, the number of telephone contacts per week should not be too high, not even in the first week as this may affect adherence. The problems might arise on the side of physicians as patients might relocate to more developed health care centres with remote monitoring programs posing financial risk for smaller providers.

Speaking in terms of financial accessability, no specific problems were mentioned on the side of the patient. On the side of the provider, the current reimbursement structures basically do not support STS and hence act as a disincentive to providers wanting to offer RM incl. STS to patients sustaining HF. Innovative reimbursement schemes such as coverage with evidence in development are suggested in the literature.

ORG8: What are the likely budget impacts of implementing the technologies being compared?

While some studies reported  {2} no statistically significant difference in healthcare costs (either total costs or all-cause hospital costs), other studies reported important and significant reductions in costs. While the average costs of intervention across the studies amounted from $23,6 to $443, the reported savings amounted from $30,9 to $536 per patient per month. The savings across studies were reported in various ways which makes them hardly comparable (percentage reduction in inpatient costs, percentage reduction in overall costs, percentage reduction in total health expenditures, reduction in different currencies per patient, per nurse, per year, per month, per 6 months...). However, more important than this is the method of costs calculation that varies widely across the studies. More or less, only direct costs are included, mostly connected to reduction in hospitalizations. More than 70 % of the studies did not take into account expenses in one of the following categories:  healthcare sector, other sectors, patient/family expenses or productivity losses. None of the studies analyzed a shift of cost, from specialits to HF nurse to GP, for instance. In 80% of the studies the source and methods of the evaluations were not clear. Authors mostly focused on direct costs while omitting indirect and intangible costs {310}. Principally, the costs were missing across majority of the studies and those of the intervention overheads, training of personnel, and patient related costs.  There is a difficulty in capturing all of the effects of telehealth intervention. Thus the cost effectiveness evidence for specific implementations in the field of telehealth is limited. Problems with telehealth interventions reside in absence of quality data and appropriate measures. The quality of economic data is especially questionnable. The quality of evidence in the scientific literature is poor. More studies on all costs are needed to reach the unbiased conclusion. 

ORG9: What management problems and opportunities are attached to Telemonitoring in home care for patients with chronic cardiovascular diseases?

The use of RM has improved as a possible way to improve the management of patients with HF by allowing more frequent assessment of patients without the need for FTF clinical reviews {100}. When planning the introduction of a RM intervention in general, there are several questions that need to be addressed concerning: the choice of patients targeted by these programmes; the parameters that will be monitored; the more efficient way to monitor them; the training of patients and healthcare personnel; how to organize the response of the health care professionals to data obtained from monitoring to optimize patient care {1430}{1}. Possibly management will need to deal with (de)employment of new resources, new information systems, new equipment for STS provisions, new administrative leadership and new group culture that promotes quality improvement {15}{40}.

CUR3 / ORG10: Who decides which people are eligible for Telemonitoring in home care for patients with chronic cardiovascular diseases and on what basis?

Eligibility to new technology depends on an assessment of the general practitioner of a patient’s condition and the patient's willingness and ability to participate. Access to new technologies depends on support of healthcare providers. In real-world settings, patient selection will be critical for the acceptance and compliance with the programme. Patient selection criteria might include the degree to which the patient is willing to incorporate these technologies into their care or patients at high-risk {40}. Having  an access to a touchtone telephone is an essential inclusion criterion {1} . By Dunagan et al {10} cognitive or psychologic impairment as well as inability to hear and understand English spoken over the telephone were included as non-eligibility criteria.

ORG11: How is Telemonitoring in home care for patients with chronic cardiovascular diseases accepted?

Adherence to STS programs differs in HM to HH STS programs, it seems that interpersonal interaction with a care provider is an important active component of STS (adherence is higher in HH than HM STS) {40}. Adherence is reported from 55,1% to 84% across the studies, adaptation to the technology to 90% or higher, more than 90% of patietns are statisfied with the use of technolgy. Acceptance of automated voice interactive system was poor, mostly due to technical failures. Patients were generally very satisfied with various STS programs across studies.

 

The clinicians, on the other hand, have several reservations, such as potential increased clinical workload, medicolegal issues, and worries of difficulty of use for some patients due to lack of visual acuity or manual dexterity. The clinicians believed that the telephone interactions is as effective as face-to-face interactions. The clinicians fear that system would result in a significant increase in their workload {91}.

ORG12: How are the other interest groups taken into account in the planning / implementation of Telemonitoring in home care for patients with chronic cardiovascular diseases?

No other interest groups except those mentioned in other assessment elements, are taken into account in the planning / implementation of Telemonitoring in home care for patients with chronic cardiovascular diseases.

Introduction

In this domain we aim to explain the impact of STS on providers (their work processes, education and training of staff, management strategies, acceptance), on patients (patient flow, patient involvement, access to STS, eligibility and acceptance) as well as on health care system (budget impact, quality assurance and monitoring). From oragnizational aspect the most important issue is ensuring optimal organization on the side of provider by assigning a trained heart failure (HF) nurse to carry our STS program through proper communication that assures maximum acceptance, adherence and satisfaction by patients. According to the opinion of medical staff, lack of proper reimbursement in most health care systems makes the management of STS programs challenging. It needs to take into account evidence based findings on best result technology, social and organizational issues to achieve maximum results.

Methodology

Frame

The collection scope is used in this domain.

TechnologyStructured telephone support (STS) for adult patients with chronic heart failure
Description

Telemonitoring via structured telephone support with focus on patient reported signs (symptoms of congestion, peripheral edema, pulmonary congestion, dyspnea on exertion, abdominal fullness), medication adherence, physiological data (like heart rate, blood pressure, body weight – measured by the patient with home-device), activity level; done in regular schedules using risk stratification (with fixed algorithm by call center staff or experience-based by specialized staff); done by dedicated call centers, center-based staff, nurses, AND reduced visits to a GP or heart center

Intended use of the technologyPrevention

Remote transmission of information to alleviate symptoms, relieve suffering and allow timely treatment for chronic heart failure

Target condition
Chronic cardiac failure
Target condition description

Heart failure is a condition in which the heart has lost the ability to pump enough blood to the body's tissues. With too little blood being delivered, the organs and other tissues do not receive enough oxygen and nutrients to function properly.

Target population

Target population sex: Any. Target population age: adults and elderly. Target population group: Patients who have the target condition.

Target population description

Patients with chronic heart failure (CHF; defined as I50 http://www.icd10data.com/ICD10CM/Codes/I00-I99/I30-I52/I50-/I50 ) AND hospitalization due to heart failure at least once  AND without implanted devices

ComparisonUsual care defined as regular schedules of visits of the patient at the heart center/ GP/cardiologist or patient has to move (≠ at home)
Description

Usual care defined as regular schedules of visits of the patient at the heart center/ GP/cardiologist; patient has to move (≠ at home)

Outcomes

Mortality (disease specific and all cause) progressions, admissions, re-admissions, QoL or HRQoL, harms

Assessment elements

TopicIssue RelevantResearch questions or rationale for irrelevance
G0001Health delivery processHow does the technology affect the current work processes?yesHow does structured telephone support (STS) for adult patients with chronic heart failure affect the current work processes?
G0100Health delivery processWhat kind of patient/participant flow is associated with the new technology?yesWhat kind of patient/participant flow is associated with structured telephone support (STS) for adult patients with chronic heart failure?
G0002Health delivery processWhat kind of involvement has to be mobilized for patients/participants and important others?yesWhat kind of involvement has to be mobilized for patients/participants and important others?
G0003Health delivery processWhat is the process ensuring proper education and training of the staff?yesWhat is the process ensuring proper education and training of the staff?
G0004Health delivery processWhat kind of co-operation and communication of activities have to be mobilised?yesWhat kind of co-operation and communication of activities have to be mobilised?
G0012Health delivery processHow is the quality assurance and monitoring system of the new technology organised?yesHow is the quality assurance and monitoring system of structured telephone support (STS) for adult patients with chronic heart failure organised?
G0101Structure of health care systemWhat are the processes ensuring access to care of the new technology for patients/participants?yesWhat are the processes ensuring access to care of structured telephone support (STS) for adult patients with chronic heart failure for patients/participants?
G0005Structure of health care systemHow does de-centralisation or centralization requirements influence the implementation of the technology?noAs telemonitoring is provided at patients' home and is monitored by the unit defined in the system, the level of de/centralization has no impact on the implementation.
G0007Process-related costsWhat are the likely budget impacts of implementing the technologies being compared?yesWhat are the likely budget impacts of implementing the technologies being compared?
G0006Process-related costsWhat are the processes related to purchasing and setting up the new technology?noInvestments in premises and equipment (except phone lines/broadbands) are not necessary and not mentioned in the literature, which clearly follows from TEC domain. This is the reason we find this question irrelevant.
G0008ManagementWhat management problems and opportunities are attached to the technology?yesWhat management problems and opportunities are attached to structured telephone support (STS) for adult patients with chronic heart failure?
G0009ManagementWho decides which people are eligible for the technology and on what basis?yesWho decides which people are eligible for structured telephone support (STS) for adult patients with chronic heart failure and on what basis?
G0010CultureHow is the technology accepted?yesHow is structured telephone support (STS) for adult patients with chronic heart failure accepted?
G0011CultureHow are the other interest groups taken into account in the planning / implementation of the technology?yesHow are the other interest groups taken into account in the planning / implementation of structured telephone support (STS) for adult patients with chronic heart failure?

Methodology description

To answer the questions in the assessment elements we mainly used the basic literature search provided for the whole project. Additionally, two more systematic searches were used: one performed by ORG and ECO domains (described in methodology of ECO domain) and one perfomed by EFF, SAF and ECO domains (described in SAF domain). For some answers (ORG4) an additional handsearch was performed.  

Information sources

·         Common basic project literature search

·         Specific literature search performed together with ECO domain

·         Specific literature search performed in SAF, EFF and ECO domain

·         Handsearch (additional reference found/ provided)

·         Google

Quality assessment tools or criteria

We did not rate the quality of the included studies, but mentioned whether the information was extracted from systematic reviews or single studies (i.e. RCTs) or other resources. The basis for inclusion and exclusion of the studies is described in other domains with whom the search was perfomed and was based on the contents of the abstract (we checked the relevance of topic for our AEs and PICO). Quality assessment of the literature was not performed in ORG domain - however, no separate search was performed within the domain as well. We found the opposing results based on the same articles cited in 2 articles – in such cases the original articles was searched for and the results were checked.

Analysis and synthesis

Three investigators divided the amount of studies among themselves, each scanned one third of the studies and double-checked the other two thirds. The investigators in the further process divided the questions (each investigator 4 questions) and we wrote and wrapped them up based on the findings from the literature. The whole document was checked before sent to internal reviewers. The comments from internal reviewers were divided among investigators according to the separate questions and reacted to accordingly. The whole process was coordinated with ECO, TEC and LEG domain through PI s of each domain. The classification of literature was prepared in other domains and not in Org and is therefore not presented here. 

Result cards

Health delivery process

Result card for ORG1: "How does structured telephone support (STS) for adult patients with chronic heart failure affect the current work processes?"

View full card
ORG1: How does structured telephone support (STS) for adult patients with chronic heart failure affect the current work processes?
Method
Short Result
Result

Importance: Critical

Transferability: Completely

Result card for ORG2: "What kind of patient/participant flow is associated with structured telephone support (STS) for adult patients with chronic heart failure?"

View full card
ORG2: What kind of patient/participant flow is associated with structured telephone support (STS) for adult patients with chronic heart failure?
Method
Short Result
Result

Importance: Critical

Transferability: Completely

Result card for ORG3: "What kind of involvement has to be mobilized for patients/participants and important others?"

View full card
ORG3: What kind of involvement has to be mobilized for patients/participants and important others?
Method
Short Result
Result

Importance: Critical

Transferability: Completely

Result card for ORG4: "What is the process ensuring proper education and training of the staff?"

View full card
ORG4: What is the process ensuring proper education and training of the staff?
Method
Short Result
Result

Importance: Critical

Transferability: Completely

Result card for ORG5: "What kind of co-operation and communication of activities have to be mobilised?"

View full card
ORG5: What kind of co-operation and communication of activities have to be mobilised?
Method
Short Result
Result

Importance: Critical

Transferability: Completely

Result card for ORG6: "How is the quality assurance and monitoring system of structured telephone support (STS) for adult patients with chronic heart failure organised?"

View full card
ORG6: How is the quality assurance and monitoring system of structured telephone support (STS) for adult patients with chronic heart failure organised?
Method
Short Result
Result

Importance: Critical

Transferability: Partially

Structure of health care system

Result card for ORG7: "What are the processes ensuring access to care of structured telephone support (STS) for adult patients with chronic heart failure for patients/participants?"

View full card
ORG7: What are the processes ensuring access to care of structured telephone support (STS) for adult patients with chronic heart failure for patients/participants?
Method
Short Result
Result

Importance: Critical

Transferability: Completely

Process-related costs

Result card for ORG8: "What are the likely budget impacts of implementing the technologies being compared?"

View full card
ORG8: What are the likely budget impacts of implementing the technologies being compared?
Method
Short Result
Result

Importance: Critical

Transferability: Partially

Management

Result card for ORG9: "What management problems and opportunities are attached to structured telephone support (STS) for adult patients with chronic heart failure?"

View full card
ORG9: What management problems and opportunities are attached to structured telephone support (STS) for adult patients with chronic heart failure?
Method
Short Result
Result

Importance: Important

Transferability: Partially

Result card for CUR3 / ORG10: "Who decides which people are eligible for structured telephone support (STS) for adult patients with chronic heart failure and on what basis?"

View full card
CUR3 / ORG10: Who decides which people are eligible for structured telephone support (STS) for adult patients with chronic heart failure and on what basis?
Method
Short Result
Result

Importance: Important

Transferability: Partially

Culture

Result card for ORG11: "How is structured telephone support (STS) for adult patients with chronic heart failure accepted?"

View full card
ORG11: How is structured telephone support (STS) for adult patients with chronic heart failure accepted?
Method
Short Result
Result

Importance: Critical

Transferability: Completely

Result card for ORG12: "How are the other interest groups taken into account in the planning / implementation of structured telephone support (STS) for adult patients with chronic heart failure?"

View full card
ORG12: How are the other interest groups taken into account in the planning / implementation of structured telephone support (STS) for adult patients with chronic heart failure?
Method
Short Result
Result

Importance: Optional

Transferability: Completely

Discussion

ORG1: How does Telemonitoring in home care for patients with chronic cardiovascular diseases affect the current work processes?

As most of the studies are conducted in controlled academic environment or non realistic setting, it might be that additional option should be considered in real setting, like hiring a nurse, use of low cost telephone service, use more time for outcomes dissemination and results discussion in a team. STS can be carried out in very different settings, from primary care to tertiary care. There is little information in the studies on the changes of the workflow – usually for the STS an additional nurse was used who had access to patient data, carried out the STS, monitored the patient, recorded the symptoms and data and reinforced and adapted the plan of care for the patient. The other medical professions did not get involved in STS directly, only indirectly, through the STS nurse, who coordinated all the activities and services around the patient. No study specifically recorded the (decrease or increase of) workload for other specialists in case a STS nurse was involved in the work. One study {6} describes how to manage human resources and the division of roles between nurses. During the 2007 calendar year, there were 1.356 patients visits to the HF clinic and telephone calls accounted for an additional 1.914 patient encounters in 2007. One full-time nurse practitioner, one clinical nurse specialist (working 0,7 of a full-time equivalent), and one registered nurse (vacation replacement) provided the nursing interventions with the telephone visits. Nurse spent 24 % of their working hours doing 1.914 telephone calls in one year.

ORG 2: What kind of patient/participant flow is associated with Telemonitoring in home care for patients with chronic cardiovascular diseases?

 

STS replaced historical program of doctor’s visits for HF patients after discharge. In interventions utilizing STS, the patient is monitored remotely while being at home (including a relative’s home, nursing home or residential care home). The patients are contacted in regular time intervals via telephone by either healthcare personnel (e.g. specialized HF nurses) or an automated telephone-based interactive response system. The STS support starts being planned while the patient is in hospital through education and meeting with the HF nurse. Education and practising with the technology follows and the materials are given to the patients as well as explained to the relatives. At the point of discharge the timing of the first call is agreed. The frequency of calls varies greatly among the studies but in common the calls are weekly at least first two weeks after discharge and then get biweekly until two months after discharge. After that they become monthly. It is not clear how long the intervention should last: there are different periods, going from 3 months up to 2 years after the discharge. It is not clear when the effect is biggest, possibly within first 3 months.

ORG3: What kind of involvement has to be mobilized for patients/participants and important others?

Please find the overlapping results also in TEC3: What kind of training and information should be provided for the patient who uses Telemonitoring in home care for patients with chronic cardiovascular diseases, or for his family?

ORG4: What is the process ensuring proper education and training of the staff?

Proper education and training of the staff is ensured through the courses for nurses on HF (formal HF certification) and on the remote monitoring, which is assured by telemedicine providers in case any devices for home symptoms measurements are included. As far as the STS itself, no specific training were found to be offered to staff in the literature.

ORG5: What kind of co-operation and communication of activities have to be mobilised?

In the heart of communication and cooperation strategy in the studies there is always a nurse. A consistent nurse case manager who cares for the patient and connects family, tries to understand goals and specific outcomes, provides information and monitors patient and communicates and cooperates with other members of health team to help them understand the patient {240}. A published communication strategy is important, including patient support strategy, communication between patient: nurse, patient: medical doctor, patient: pharmacist, the brochures, diaries to record daily control measurements, web pages with disease information and with instructions, instructions for family members  to share a best practise.

ORG6: How is the quality assurance and monitoring system of Telemonitoring in home care for patients with chronic cardiovascular diseases organised?

Please find the overlapping results in TEC2: What kind of qualification and quality assurance processes are needed for the use or maintenance of Telemonitoring in home care for patients with chronic cardiovascular diseases?

ORG7: What are the processes ensuring access to care of Telemonitoring in home care for patients with chronic cardiovascular diseases for patients/participants?

In general, RM including STS provides greater access to care in geographical terms. In most of the studies the problems with accessability to phone line were not reported. Careful planning of STS is necessary among specific population that might have issues in moving around and having lower access to phone lines. Also, the number of telephone contacts per week should not be too high, not even in the first week as this may affect adherence. The problems might arise on the side of physicians as patients might relocate to more developed health care centres with remote monitoring programs posing financial risk for smaller providers.

Speaking in terms of financial accessability, no specific problems were mentioned on the side of the patient. On the side of the provider, the current reimbursement structures basically do not support STS and hence act as a disincentive to providers wanting to offer RM incl. STS to patients sustaining HF. Innovative reimbursement schemes such as coverage with evidence in development are suggested in the literature.

ORG8: What are the likely budget impacts of implementing the technologies being compared?

While some studies reported  {2} no statistically significant difference in healthcare costs (either total costs or all-cause hospital costs), other studies reported important and significant reductions in costs. While the average costs of intervention across the studies amounted from $23,6 to $443, the reported savings amounted from $30,9 to $536 per patient per month. The savings across studies were reported in various ways which makes them hardly comparable (percentage reduction in inpatient costs, percentage reduction in overall costs, percentage reduction in total health expenditures, reduction in different currencies per patient, per nurse, per year, per month, per 6 months...). However, more important than this is the method of costs calculation that varies widely across the studies. More or less, only direct costs are included, mostly connected to reduction in hospitalizations. More than 70 % of the studies did not take into account expenses in one of the following categories:  healthcare sector, other sectors, patient/family expenses or productivity losses. None of the studies analyzed a shift of cost, from specialits to HF nurse to GP, for instance. In 80% of the studies the source and methods of the evaluations were not clear. Authors mostly focused on direct costs while omitting indirect and intangible costs {310}. Principally, the costs were missing across majority of the studies and those of the intervention overheads, training of personnel, and patient related costs.  There is a difficulty in capturing all of the effects of telehealth intervention. Thus the cost effectiveness evidence for specific implementations in the field of telehealth is limited. Problems with telehealth interventions reside in absence of quality data and appropriate measures. The quality of economic data is especially questionnable. The quality of evidence in the scientific literature is poor. More studies on all costs are needed to reach the unbiased conclusion. 

ORG9: What management problems and opportunities are attached to Telemonitoring in home care for patients with chronic cardiovascular diseases?

The use of RM has improved as a possible way to improve the management of patients with HF by allowing more frequent assessment of patients without the need for FTF clinical reviews {100}. When planning the introduction of a RM intervention in general, there are several questions that need to be addressed concerning: the choice of patients targeted by these programmes; the parameters that will be monitored; the more efficient way to monitor them; the training of patients and healthcare personnel; how to organize the response of the health care professionals to data obtained from monitoring to optimize patient care {1430}{1}. Possibly management will need to deal with (de)employment of new resources, new information systems, new equipment for STS provisions, new administrative leadership and new group culture that promotes quality improvement {15}{40}.

CUR3 / ORG10: Who decides which people are eligible for Telemonitoring in home care for patients with chronic cardiovascular diseases and on what basis?

Eligibility to new technology depends on an assessment of the general practitioner of a patient’s condition and the patient's willingness and ability to participate. Access to new technologies depends on support of healthcare providers. In real-world settings, patient selection will be critical for the acceptance and compliance with the programme. Patient selection criteria might include the degree to which the patient is willing to incorporate these technologies into their care or patients at high-risk {40}. Having  an access to a touchtone telephone is an essential inclusion criterion {1} . By Dunagan et al {10} cognitive or psychologic impairment as well as inability to hear and understand English spoken over the telephone were included as non-eligibility criteria.

ORG11: How is Telemonitoring in home care for patients with chronic cardiovascular diseases accepted?

Adherence to STS programs differs in HM to HH STS programs, it seems that interpersonal interaction with a care provider is an important active component of STS (adherence is higher in HH than HM STS) {40}. Adherence is reported from 55,1% to 84% across the studies, adaptation to the technology to 90% or higher, more than 90% of patietns are statisfied with the use of technolgy. Acceptance of automated voice interactive system was poor, mostly due to technical failures. Patients were generally very satisfied with various STS programs across studies.

 

The clinicians, on the other hand, have several reservations, such as potential increased clinical workload, medicolegal issues, and worries of difficulty of use for some patients due to lack of visual acuity or manual dexterity. The clinicians believed that the telephone interactions is as effective as face-to-face interactions. The clinicians fear that system would result in a significant increase in their workload {91}.

ORG12: How are the other interest groups taken into account in the planning / implementation of Telemonitoring in home care for patients with chronic cardiovascular diseases?

No other interest groups except those mentioned in other assessment elements, are taken into account in the planning / implementation of Telemonitoring in home care for patients with chronic cardiovascular diseases.

References

  1. Acosta-Lobos A, Riley JP, Cowie MR. Current and future technologies for remote monitoring in cardiology and evidence  from trial data. Future Cardiol 2012; 8(3):425-37. {100}
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