Tele-HF: Yale Heart Failure Telemonitoring Study
- Conditions
- Congestive Heart Failure
- Interventions
- Other: Telemonitoring
- Registration Number
- NCT00303212
- Lead Sponsor
- Yale University
- Brief Summary
The primary purpose of this study is to determine the effectiveness of telemonitoring compared with usual guideline-based care in preventing hospitalization for heart failure patients.
- Detailed Description
Heart failure (HF) is a common, costly condition characterized by recurrent periods of clinical decompensation that often lead to repeated hospitalizations (1, 2). Despite advances in the care of patients with HF, population-based outcomes such as mortality and hospitalization rates have not improved substantially over the past decade (3). Episodic, infrequent, outpatient visits are the only usual opportunities for clinicians to detect and treat early signs of HF decompensation; this constitutes a major gap in the current medical model. Moreover, opportunities for patients to take an active role in managing their own conditions occur infrequently. Disease management has emerged as a possible solution to the need for better patient surveillance and engagement. It typically involves multidisciplinary efforts to improve the quality and efficiency of care for patients with chronic conditions, with interventions designed to foster adherence of clinicians to scientific guidelines and patients to treatment plans. However, traditional disease-management programs are generally resource-intensive (often relying on nurse case management), difficult to scale for a large population, and inefficient in providing daily patient monitoring.
Telemonitoring, which bridges clinicians and patients with communication technology, holds promise for closing the gap in HF care (4). This technology has the potential for standardized, widespread implementation (and long-term maintenance) in the near future because it can be easily applied to large patient populations and integrated into the current medical care system. Supporting this potential, preliminary evaluations have suggested that telemonitoring is feasible across a broad spectrum of typical HF patients, relatively inexpensive on a per-patient basis, and highly effective in improving health outcomes. Thus, this approach is ready for rigorous evaluation.
Accordingly, we propose an office-based, multicenter, randomized controlled trial (Tele-HF study) to determine the effectiveness of a telemonitoring strategy in decreasing hospital readmissions and death in patients with HF. Many HF patients experience deterioration in their health status and an increase in weight and symptoms over a period of days and weeks before ultimately presenting to medical attention and requiring hospitalization. Our premise is that a frequent monitoring system can alert clinicians to the early signs and symptoms of decompensation, providing the opportunity for intervention before the patient becomes severely ill and requires hospitalization. Moreover, such a system can engage patients in their care and provide instruction about beneficial self-care strategies. This intervention is not intended to substitute for communication relating to acute care or acute, sudden changes in health status. In these cases, patients are instructed to make direct and immediate contact with their doctor or hospital.
We will use the Pharos Tel-AssuranceTM, an in-home communication system that allows patients to transmit information to their clinicians and provides education to enable patients to actively participate in managing their condition. The system uses conventional telephone lines and does not require the patient to have Internet access. Patients are asked a pre-programmed series of questions and the system automatically uploads the responses to a secure data center. A clinician in each practice can then log on to a secure Internet site using a Web browser to review the patients' responses. The system thus serves as an interface between patients at home and their clinicians, facilitating monitoring of chronic conditions and patient education. While many vendors have potential tools to implement this study, we chose to use Pharos Tel-AssuranceTM because it is simple to use, does not require any equipment in patients' homes and substantial preliminary data suggest high patient and clinician satisfaction with its use. The investigators have no financial interest in this company.
Primary Aim Our primary aim is to determine whether telemonitoring by community-based cardiology office practices reduces the risk of hospital readmission (for any cause) or death after an initial "index hospitalization" for HF. We hypothesize that, among patients recently discharged after a hospitalization for HF, telemonitoring will decrease the rate of rehospitalization or death over 6 months by at least 15% (relative risk reduction). This would yield an absolute risk reduction of 7.5%, so that 1 major adverse event would be averted for every 13 patients.
We have chosen all-cause readmission as part of our primary outcome because poorly controlled HF can result in admissions for a variety of reasons, as the patient becomes weak and susceptible to falls, mental status changes, renal dysfunction, and other debilitating conditions that can result in hospitalization. In addition, from a societal and health system perspective, the overall risk of readmission is more important than disease-specific readmission. Moreover, prior studies suggest that telemonitoring can reduce this outcome.
Secondary Aims
In our secondary aims we will determine whether telemonitoring will:
1. Reduce the rate of all-cause hospital readmission
2. Reduce the rate of hospital readmission for HF
3. Reduce the total number of all-cause and HF-specific hospital readmissions
4. Increase office visits with the clinician receiving information from the telemonitoring system
5. Improve survival after index hospitalization
6. Reduce the cost of inpatient medical care
7. Improve health status
8. Improve patient satisfaction with care
9. Improve patients' self-management of HF
Sub-Group Analyses
The following sub-group analyses will be conducted:
1. Age
2. Sex
3. Race
4. HFPEF vs depressed EF
5. Education
6. Insurance status
7. Self-reported access to care
8. Baseline self-efficacy and self-care
9. Socioeconomic Status
10. Site characteristics
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 1660
- age 18 years or older
- hospitalized for heart failure within the past 30 days
- access to telephone line
- not expected to survive 6 months due to irreversible, life-threatening condition
- has or scheduled for cardiac transplant or LVAD
- scheduled for CABG or PCI within 90 days
- severe valvular disease
- Folstein MMSE score less than 20
- resident of a nursing home
- currently a prisoner
- does not speak English or Spanish
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description TM Telemonitoring Telemonitoring group plus usual guideline-based HF care
- Primary Outcome Measures
Name Time Method Rate of all-cause hospital readmission or death during the 6-month follow-up period. 6 months
- Secondary Outcome Measures
Name Time Method Number of office visits with clinician receiving information from the telemonitoring system 6 months Survival after index hospitalization 6 months Post index discharge hospital days/follow up days alive 6 months Rate of all-cause hospital readmissions 6 months Cost of inpatient medical care 6 months Health status 6 months Patient satisfaction with care 6 months Patients' self-management of heart failure 6 months Post index discharge hospital days 6 months
Trial Locations
- Locations (33)
Morehouse School of Medicine/Cardiology
🇺🇸Atlanta, Georgia, United States
Heart Clinic of Louisiana
🇺🇸Marrero, Louisiana, United States
Cardiology Specialists, Ltd.
🇺🇸Westerly, Rhode Island, United States
The Dayton Heart Center
🇺🇸Dayton, Ohio, United States
Howard University Hospital
🇺🇸Washington, District of Columbia, United States
Sentara Cardiology Consultants, Ltd.
🇺🇸Norfolk, Virginia, United States
Iowa City Heart Center
🇺🇸Iowa City, Iowa, United States
Integrated Care / Cardiovascular Consultants of South Florida
🇺🇸Tamarac, Florida, United States
Cooper Health System Cardiology
🇺🇸Camden, New Jersey, United States
Chabert Medical Center
🇺🇸Houma, Louisiana, United States
New York University/Cardiology
🇺🇸New York, New York, United States
Cardiology Associates
🇺🇸Mobile, Alabama, United States
Department of Cardiology at Bridgeport Hospital
🇺🇸Bridgeport, Connecticut, United States
Piedmont Hospital Research Institute
🇺🇸Atlanta, Georgia, United States
Emory University
🇺🇸Atlanta, Georgia, United States
Loyola University Medical Center
🇺🇸Maywood, Illinois, United States
Cardiology Associates, LLC
🇺🇸Tupelo, Mississippi, United States
Hackensack University Medical Center
🇺🇸Hackensack, New Jersey, United States
Baylor University Medical Center
🇺🇸Dallas, Texas, United States
UC Irvine Medical Center
🇺🇸Orange, California, United States
UCLA Harbor Medical Center
🇺🇸Torrance, California, United States
Cardiology Diagnostics
🇺🇸Saint Louis, Missouri, United States
Washington University
🇺🇸Saint Louis, Missouri, United States
St. Joseph's Regional Medical Center / Cardiology Associates
🇺🇸Paterson, New Jersey, United States
Indiana Heart Physicians
🇺🇸Indianapolis, Indiana, United States
MetroHealth Medical Center, Heart & Vascular Center
🇺🇸Cleveland, Ohio, United States
University of Pittsburgh
🇺🇸Pittsburgh, Pennsylvania, United States
Forsyth Medical Center
🇺🇸Winston-Salem, North Carolina, United States
Oregon Health and Science University
🇺🇸Portland, Oregon, United States
Cardiology Associates of New Haven
🇺🇸New Haven, Connecticut, United States
The Queen's Medical Center
🇺🇸Honolulu, Hawaii, United States
Truman Medical Center/Cardiology
🇺🇸Kansas City, Missouri, United States
St. Luke's Hospital / Mid-America Heart Institute
🇺🇸Kansas City, Missouri, United States