An Integrative Review of Interventional Designs in Studies Utilizing Home Telehealth to Reduce Hospital Admissions for Heart Failure Patients

Problem:  Home telehealth monitoring (HTM) uses home-based electronic stations to monitor heart failure (HF) patients in community settings.  Randomized control trials (RCTs) examining the efficacy of HTH in reducing hospital admissions show conflicting results.  While a few studies have shown significant improvement in HF patient admissions, many HTM studies have not shown any significant reduction in HF admission rates. To date, the interventional designs of these studies have not been compared or fully explained.

Purpose:   Interventional designs used in HTH studies for HF patients vary, including frequency of data input, type of data monitored provider availability to monitor the input, and interventional duration. This review examines whether differences in design are related to HF admission rates in HTM studies.

Search Strategies: A literature search was conducted using PubMed, EBSCO, and CINHL. Key words included HF, telehealth, telemonitoring, telemedicine, and remote patient monitoring. RCTs of HF patients, HTH, and hospital admissions published from 2004 to 2014 were included for analysis.  Excluded studies used synchronous telephone support, web-based journaling, or implantable medical devices.

Search Results:  172 publications were identified for review. 59 articles did not include HTM, 37 did not include admissions data, 26 were based on remote monitoring using implantable devices, 16 were not RCTs, 8 were mixed morbidity studies that did not include separate admission data for heart failure, 5 only included the study protocol, and 18 studies met the criteria for review.   The remaining 3 studies were duplicates.

Synthesis of the Literature: Three studies showed consistent, significant reductions in admissions; two of those studies included daily input of heart rate and symptom ratings. The third included daily diseased based symptom and medication adherence questions. All three included daily provider monitoring, and lasted from 90 to 365 days. One 120 day study reduced admissions at 60 days when controlled for days in home healthcare. None of the studies with significant findings tracked pulse oximetry.   Fourteen studies had no significant improvements in admissions; of those fourteen only two included daily heart rate, symptom monitoring, and provider monitoring. 

Due to the small number of studies with significant findings, and the variations in study designs it is difficult to definitively determine the optimal combination of interventional design components to reduce hospital admissions in heart failure patients. Analysis of the interventional design of these studies was also hampered by incomplete descriptions of the intervention components, especially provider monitoring frequency, description of usual care and descriptions of disease based questioning for patients.

Implications: The three HTM studies that consistently reduced hospital admission for HF patients included daily input of symptom ratings, and daily provider monitoring. Two of the studies also included daily heart rate monitoring.  Daily monitoring of symptoms and heart rate should be prioritized when designing HTM interventions for HF patients in the clinical setting.   More research is indicated to determine optimal design of HTH programs to reduce admissions in HF patients.